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60 (Policy Provisions: WC 00 00 00 B) <br /> 63 <br /> BV INFORMATION PAGE <br /> WEC WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br /> INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY <br /> ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 <br /> NCCI Company Number: 10456 THE <br /> Company Code: 6 HARTFORD <br /> N <br /> co <br /> O <br /> Suffix <br /> LARS RENEWAL <br /> POLICY NUMBER: 122 WEC BV6360� 20 <br /> °o Previous Policy Number: 122 WEC BV6360 <br /> w <br /> M HOUSING CODE: SA <br /> 1. Named Insured and Mailing Address: ORANGE CONGREGATIONS IN MISSION, <br /> Nro (No., Street,Town,State,Zip Code) INC. <br /> N <br /> O <br /> O 300 MILLSTONE DR <br /> rn FEIN Number: 580058650 HILLSBOROUGH, NC 27278 <br /> State Identification Number(s): <br /> The Named Insured is: CORPORATION <br /> Business of Named Insured: THRIFT STORE - NON-PROFIT <br /> Other workplaces not shown above: 300 MILLSTONE DR. <br /> HILLSBOROUGH NC 27278 <br /> 2. Policy Period: From 08/18/14 To 08/18/15 <br /> 12:01 a.m., Standard time at the insured's mailing address. <br /> Producer's Name: HIGH & RUBISH INSURANCE AGENCY <br /> _ PO BOX 3040 <br /> CHAPEL HILL, NC 27515 <br /> Producer's Code: 270281 <br /> Issuing Office: THE HARTFORD <br /> 8711 UNIVERSITY EAST DRIVE <br /> CHARLOTTE NC 28213 <br /> _ (877) 853-2582 <br /> Total Estimated Annual Premium: $2,243 <br /> Deposit Premium: <br /> Policy Minimum Premium: $696 NC <br /> —' Audit Period: ANNUAL Installment Term: <br /> The policy is not binding unless countersigned by our authorized representative. <br /> Countersigned byc <br /> Authorized Repres ntative Date <br /> Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) <br /> Process Date: 06/14/14 Policy Expiration Date; 08/18/15 <br /> ORIGINAL <br />