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/� PAGE 1 <br /> �o , Owners WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY <br /> INSURANCE COMPANY 16144 <br /> 6101 ANACAPRI BLVD. , LANSING, MI 48917-3999 <br /> INFORMATION PAGE -RENEWAL AGREEMENT RENEWAL EFF. 06-17-2015 <br /> AGENCY HIGH & RUBISH INSURANCE AGENCY — <br /> 15-0936-00 PO BOX 3040 (919) 913-1144 POLICY NUMBER <br /> ITEM 1 CHAPEL HILL NC 27515 MKT TERR 050 041715 35022549 <br /> INSURED ORANGE COUNTY LITERACY COUNCIL INC ITEM 2 POLICY PERIOD <br /> COMPANY FROM 12:01 A.M. 06-17-2015 <br /> ADDRESS 200 N GREENSBORO ST STE C2 BILL TO 12:01 A.M. 06-17-2016 <br /> CARRBORO NC 27510-1849 AT THE INSURED'S <br /> MAILING ADDRESS <br /> INSURED IS - CORPORATION <br /> OTHER WORK PLACES NOT SHOWN ABOVE: <br /> ITEM 3 A. WORKERS' COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO WORKERS' <br /> COMPENSATION LAW OF THE STATES LISTED HERE: NC <br /> B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE <br /> LISTED IN ITEM 3. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE: <br /> BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT <br /> BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE <br /> BODILY INJURY BY DISEASE $500,000 POLICY LIMIT <br /> C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY, <br /> LISTED HERE: AL, AR, AZ, CO, FL, GA, IA, ID, IL, IN, KS, KY, MI, MN, MO, NC, NE, <br /> PA, SC, SD, TN, UT, VA 8 WI UNLESS ALREADY LISTED IN ITEM 3A. <br /> ITEM 4 THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS RULES, CLASSIFICATIONS, <br /> RATES AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION <br /> AND CHANGE BY AUDIT. <br /> CLASSIFICATIONS OF OPERATIONS PREMIUM BASIS RATES <br /> ESTIMATED RATE ESTIMATED <br /> CLASS TOTAL ANNUAL PER ANNUAL <br /> CODE REMUNERATION $100 PREMIUM <br /> STATE OF NORTH CAROLINA <br /> IDB 0010 (SEE FED NUM 001) DESC 001 <br /> CLERICAL OFFICE EMPLOYEES NOC 8810 151,938 .28 425 <br /> TOTAL 425 <br /> EXPENSE CONSTANT 250 675 <br /> TERRORISM-SEE FORM 27317 15 690 <br /> CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) 15 705 <br /> SEE FORM 27322 <br /> TOTAL ESTIMATED ANNUAL PREMIUM 705 <br /> FEDERAL ID - 561433933 <br /> NC EMPLOYER CODE - 08138060 <br /> ISSUED 5-07-2015 <br /> 27777 (10-88)(WC000001A) 1228 <br />