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WORKERS' COMPENSATION <br /> CERTIFICATE OF COVERAGE <br /> ISSUED BY OR ON BEHALF OF THE'VOLUNTEER SAFETY <br /> WORKERS' COMPENSATION FUND. <br /> NAME AND ADDRESS OF FUND PARTICIPANT <br /> WHITE CROSS VOLUNTEER FIRE DEPARTMENT <br /> ATTN: TONY BLAKE <br /> 5722 OLD GREENSBORO RD <br /> CHAPEL HILL, NC 27516-0000 <br /> This company is a qualified self-insured in the state of North Carolina for its <br /> Workers'Compensation liabilities._pursuant to all statutory requirements under <br /> section 97-93 of the North Carolina Workers Compensation Act. <br /> CLIENT NUMBER: 911-463-0 <br /> COVERAGE PERIOD FROM: 07/01/13 TO 07/01/14 <br /> RENEWAL PREMIUM: $ 5,355 <br /> EMPLOYERS LIABILITY LIMITS: $100,000 Each Accident <br /> $500,000 Disease-Policy;Limit <br /> $100,000 . Disease-Each Employee <br /> .AUTHORIZED AGENT: <br /> DATE: 08/0112013 <br /> KEY RISK MANAGEMENT SERVICES, INC. <br /> P.O. BOX 49129 <br /> GREENSBORO, NC 27419 <br /> AGENCY: <br /> Business Insurers of the Carolinas, Inc., 213 <br /> P. O. Box 2536 <br /> Chapel Hill, NC 27515-0000 <br /> VOLUNTEER SAFETY <br /> WORKERS'COMPENSATION FUND <br />