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DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 <br /> rklNorm uaronna vvorlKers- Compensation Insurance Plan exy, Riverport Insurance Company NCCI Carrier Code 27995 <br /> Administered by Berkley Assigned Risk Services <br /> ASSIGNED RISK SERVICES P.O. Box 59143, Minneapolis, Minnesota 55459-0143 <br /> Toll Free(888)548-7431 Fax(866)215-8118 <br /> www.berkleyassignedrisk.com .policyservices @berkleyrisk.com <br /> INFORMATION SCHEDULE <br /> Renewal Of No, WC-32-90-015265-03 <br /> 1. The Insured: WCIP Policy Number: WC-32-90-015265-04 <br /> Risk ID: <br /> Senior Care of Orange County <br /> PO Box 8181 Attn Health Center Tax ID#: <br /> Hillsborough, NC 27278 Policy Period: From: 2/8/2015 <br /> To: 218/2016 <br /> Endorsement Eff. Date: 218/2015 <br /> Date of Mailing: 1/7/2015 <br /> Changes as set forth below are hereby made,with respect to the estimated remuneration, premium and/or rates. <br /> Total Estimated Annual Premium $3,185.00 <br /> Policy Summary 2/8/2015- 2/8/2016 <br /> Manual Premium $2,783.00 <br /> Increased Limits 1.008 $22.00 <br /> Increased Limits Minimum $53.00 <br /> Subject Premium $2,858.00 <br /> Modified Premium $2,858.00 <br /> Standard Premium $2,858.00 <br /> Expense Constant $250.00 <br /> Terrorism 0.02 $51.00 <br /> Catastrophe 0.01 $26.00 <br /> Total Estimated Annual Premium $3,185.00 <br /> Total Fees&Premium $3,185.00 <br /> Net Deposit Premium Required $3,185.00 <br /> Premium Paid to Date ($3,185.00) <br /> Refund $0.00 <br /> All other terms and conditions of this policy remain unchanged. <br /> Agency Name and Address <br /> BB&T Ins Services Inc <br /> 414 Gallimore Dairy RD Ste F <br /> Greensboro, NC 27409 <br /> Page 2 of 2 WC990001A <br />