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DocuSign Envelope ID: 72574FBA-38BB-482F-A711-18C4CFEC2EDF <br /> Issued by The Stock Insurance Company WC 00 00 01 A <br /> POLICY NUNIBER PREVIOUS POLICY NUNIBER <br /> WC 7227674 WC 7227674 <br /> SELECTIVE INSURANCE COMPANY OF AMERICA <br /> 40 WANTAGE AVE, BRANCHVILLE, NJ 07890 <br /> INFORMATION PAGE NCCI COMPANY NO. 11169 <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> ITEM 1.NAME OF INSURED&MAILING ADDRESS PRODUCER'S NAME AND nL1ILING ADDRESS <br /> RALEIGH PATHOLOGY LABORATORY ASSOCIATES MMIC AGENCY, LLC <br /> PA & WAKE MED LABORATORY CORP PO BOX 98028 <br /> PO BOX 14045 <br /> RALEIGH, NC 27620-4045 RALEIGH, NC 27624-8028 <br /> INSURED IS: CORPORATION FED ID NO. 561230477 AGENT NIIAIBER: 31-00-07265-00000 <br /> ITEM 2.POLICY PERIOD The Policy Period is from JUNE 7, 2014 To JUNE 7, 2015 <br /> 12:01 AAL,standard time at the insured's mailing address. <br /> ITEM 3.COVERAGE <br /> A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation law of the states listed here: <br /> NC <br /> B. Employers Liability Insurance: Part Two of the policy applies to work in each stated listed in Item 3.A. <br /> The limits of our liability raider Part Two are: Bodily Injury By Accident $10 0,0 0 0 each accident <br /> Bodily Injury By Disease $10 0,0 0 0 each employee <br /> Bodily Injury By Disease $5 0 0,0 0 0 policy limit <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. <br /> ITEM 4.PREAIIUAI: The premiurn for this policy will be determined by our manuals of rules,classifications,rates and rating plans. All <br /> information required below is subject to verification and change by audit. <br /> Code Premiurn Basis Rate Per Estimated <br /> CLASSIFICATION No. Total Estimated $100 of Animal <br /> Animal Renrtuieration Remuneration Premium <br /> SEE ATTACHED SCHEDULE(S) <br /> EXPENSE CONSTANT 0900 - <br /> TERRORISM - NC $.010 9740 - <br /> CATASTROPHE - NC $.010 9741 - <br /> Minimum Premium Total Estimated Cost <br /> If indicated below,interim adjustments of premium shall be made: <br /> ❑ Semi-Armually ❑ Quarterly ❑ Monthly Deposit Premium This policy includes these endorsements and schedules: REFER TO WC-52 <br /> D/B - 4 - 770655299 <br /> Issue Date: MAY 13, 2014 Issuing Office: SERVICE CENTER, 23225-0325 <br /> Authorized Representative <br /> Form-64(07/08) Copyright 1987 National Council on Compensation Insurance. <br /> INSURED'S COPY <br />