Orange County NC Website
Browse       Search
rarr one of the policy applies to the Workers Compensation <br />DocuSign Envelope ID: 2515BC90- 5A17- 40B2- 87EF- 09EE03B78730 <br />�t <br />B. Employers Liability Insurance: Part Two of the olio applies to work in each state listed in Item 3,A. �4 <br />The limits of our liability under Part Two are: Policy pp <br />Bodily injury by Accident $500, 000` <br />each accident n <br />Bodily injury by Disease $500,000 <br />Bodily injury by Disease Policy limit <br />$500, 000 each employee <br />C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here: <br />ALL STA'T'ES 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 01 14 WC 00 03 10 WC 00 04 04 WC 00 04 12 WC 00 04 21C <br />SEE ENDT <br />4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating <br />Plans. All information required below is subject to verification and change by audit. <br />Classifications Premium Basis <br />Code Number and Total Estimated Rates Per Estimated <br />Description Annual $900 of Annual <br />8820 <br />Remuneration Remuneration Premium <br />ATTORNEY - ALL EMPLOYEES & CLERICAL, 1,202,400 24 2,886 <br />MESSENGERS, DRIVERS <br />INCREASED LIMITS PART TWO (9807) .80 PERCENT <br />TO EQUAL INCREASED'LIMITS MINIMUM PREMIUM (9848) 23 <br />TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 52 <br />NC - INTRA EXPERIENCE MODIFICATION 326075114 (CONTINGENT) 2,961 <br />PREMIUM ADJUSTED By APPLICATION OF EXPERIENCE MODIFICATION .990 <br />TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 2,931. <br />EXPENSE CONSTANT (0900) 2,931 <br />TERRORISM (9740) 250 <br />CATASTROPHE (9741) 1,202,400 ,020 240 <br />TOTAL ESTIMATED ANNUAL PREMIUM 1,202,400 .020 240 <br />3,661 <br />Total Estimated Annual Premium: <br />Deposit Premium: <br />Policy Minimum Premium: <br />$3,661 <br />$373 NC (INCLUDES INCREASED LIMIT MIN, PREM.) <br />Interstate /Intrastate Identification Number: <br />Labor Contractors Policy Number: <br />Form WC 00 00 01 A (1) Printed in U.S.A. <br />Process Date; 03/01/14 <br />/ 326075114 <br />NAI.CS: <br />SIC: 8111 <br />UIN: <br />NO. OF EMP: 000021 <br />Page 2 <br />Policy Expiration Date: 05/05/15 <br />