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Y. <br /> INFORMATION PAGE (Continued) Policy Number: 22 WBC KK9485 <br /> 3.A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the <br /> states listed here:NC (SPO <br /> B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. <br /> The limits of our liability under Part Two are: <br /> Bodily injury by Accident $500,000 each accident <br /> Bodily injury by Disease $500,000 policy limit <br /> Bodily injury by Disease $500,000 each employee <br /> C. Other States Insurance., Part Three of the policy applies to the states, if any , listed here: <br /> ALL STATES EXCEPT ND, OH, WA, WY, AND <br /> STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. <br /> D. This policy includes these endorsements and schedule: <br /> WC 00 03 10 WC 00 04 04 WC 00 04 12 WC 00 04 21C WC 00 04 22A <br /> wc 99 03 02B WC 00 04 14 WC 00 04 19 WC 32 03 GIB WC 99 02 77 <br /> 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Ratirfig <br /> Plans. All information required below is subject to verification and change by audit. <br /> Premium Basis <br /> Classifications Total Estimated Rates Per Estimated <br /> Code Number and Annual $100 Of Annual <br /> Description- —_—Remuneration Remuneration Premium <br /> 8820 1,027,800 .26 2,672 <br /> ATTORNEY - ALL EMPLOYEES & CLERICAL, <br /> MESSENGERS, DRIVERS <br /> INCREASED LIMITS PART TWO (9807) .80 PERCENT 21 <br /> TO EQUAL INCREASED LIMITS MINIMUM PRRK= (9848) 54 <br /> TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 2,747 <br /> NC - INTRA EXPERIENCE MODIFICATION 326075114 (CONTINGENT) .990 <br /> PREMIUM ADJUSTED BY APPLICATION OF EXPERIENCE MODIFICATION 2,720 <br /> TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 2,720 <br /> EXPENSE CONSTANT (0900) 250 <br /> TERRORISM (9740) 1,027,800 .020 206 <br /> CATASTROPHE (9741) 1,027,800 .020 206 <br /> TOTAL ESTIMATED ANNUAL PREMIUM 3,382 <br /> Total Estimated Annual Premium: $3,382 <br /> Deposit Premium: <br /> Policy Minimum Premium: $373 NC (INCLUDES INCREASED LIMIT MIN. PREM. ) <br /> interstatelintrastate Identification Number: 326075114 <br /> NAILS: <br /> Labor Contractors Policy Number: SIC: Bill <br /> UIN: <br /> NO. OF EMP- 000021 <br /> Form WC,00 00 01 A (1) Printed in U.S.A. Page 2 05/05/14 <br /> Process Date: 03/09/13 Policy Expiration Date: <br /> ....................................... <br />