2015-326-E DEAPR - Sandhills Turf, Inc. to improve health and conditions of turf $6,500

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DocuSign Envelope ID: 3D3AB4C7-848F-42C0-875C-052115404CDE f1miffast Benefits i a g Insurance Mutual, Inc. r No-tii Cat-olit7a Workers'Coinpetisatioti WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 01 B INFORMATION PAGE POLICY NO: WC-6476-2015 Insurer; First Benefits Insurance Mutual Agent: Jake A.Parrott Ins.Agency, Inc. Carrier Code:49422 PO Box 3547 PO Box 1951 Kinston,NC 28502 Raleigh,NC 27602-1951 (252)523-1041 (855)228-4931 (252)523-0145 I. The Insured: Sandhill Turf Inc Entity type: Corporation FEIN: Interstate/lntrastate Risk ID: 4198924 Mailing address; PO Box 819 Candor,NC 27229 Other workplaces not shown above: Location 1: 255 NC Hevy 211,CANDOR,NC 27229 2. The policy period is from 07/01/2015 12:01mn.to 07/01/2016 12:01 a.m.at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here:North Carolina B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident$ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease S 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:None D, This policy includes these endorsements and schedules: WCOOOOOOC,W0000308, WC000404, WC000406A, WC000414, WC000419, WC00042ID,WC000422B,WC320301C 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. (See Attached Schedule) Total Estimated Annual Premium:$19,688 Minimum Premium: $1,500 Expense Constant: $210 Servicing Office: PO Box 1951 Raleigh,NC 27602-1951 05126i20 l 5 Date Issued: Co€intersigned by Insured Copy