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DocuSign Envelope ID: 2515BC90- 5A17- 40B2- 87EF- 09EE03B78730 <br />(Policy Provisions: uv U� <br />94 <br />xK INFORMATION PAGE <br />W13C WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br />INSURER: TWIN CITY FIRE INSURANCE COMPANY <br />ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 <br />NCCI Company Number: 14974 <br />Company Code: 7 <br />L- <br />N <br />CD <br />H POLICY NUMBER: 22 WBC KK9485 <br />,° Previous Policy Number: 122 WBC KK9485 <br />co <br />HOUSING CODE: SA <br />x 1. Named Insured and Mailing Address: KENNON, CRAVER, PLLC <br />�., (No., Street, Town, State, Zip Code) <br />N <br />c-I <br />o° PO BOX 51579 <br />M FEIN Number:. 562341325 DURHAM, NC 27717 <br />State Identification Number(s): <br />UIN: <br />The Named Insured is: PARTNERSHIP <br />Business of Named Insured: LAWYERS <br />Other workplaces not shown above: 4011 UNIVERSITY DR, STE 300 <br />DURHAM NC 27717 <br />2. Policy Period: From 05/05/14 To 05/05/15 <br />12:01 a.m., .Standard time at the insured's mailing address. <br />Suffix <br />L4RS RENEWAL <br />11 <br />Producer's Name: FIRST INSURANCE SERVICES INC <br />5417 SOUTH MIAMI BLVD <br />DURHAM, NC 27703 <br />Producer's Code: 270387 <br />Issuing Office: THE HARTFORD <br />8711 UNIVERSITY EAST DRIVE <br />CHARLOTTE NC 28213 <br />(877) 853 -2582 <br />Total Estimated Annual Premium: $3,661 <br />Deposit Premium: <br />Policy Minimum Premium: $373 NC (INCLUDES INCREASED LIMIT MIN. PREM. ) <br />Audit Period: ANNUAL Installment Term: <br />The policy is not binding unless countersigned by our authorized representative. <br />Countersigned by ` M <br />Aut orized Representative (j Date <br />Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on. next page) <br />Process Date: 03/01/14 Policy Expiration Date: 05/05/15 <br />