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DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 <br /> Berkivy^ North Carolina Workers' Compensation Insurance Plan <br /> t' Riverport Insurance Company NCCI Carrier Code 27995 <br /> Administered by Berkley Assigned Risk Services <br /> ASSIGNED RISK SERVICES P.O. Box 59143,Minneapolis,Minnesota 55459-4143 <br /> Toll Free(888)548-7431 Fax(866)215-8118 <br /> www.berkleyassignedrisk.com policyservices @berkleyrisk.com <br /> PARTNERS OFFICERS AND OTHERS EXCLUSION ENDORSEMENT <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 <br /> Policy Period: From: 218I2015 <br /> To: 218/2016 <br /> Endorsement Eff. Date: 2/8/2015 <br /> Date of Mailing: 1/7/2015 <br /> This policy does not cover bodily injury to any person described in the schedule. <br /> The Premium basis for the policy does not include the remuneration of such persons. <br /> You will reimburse us for any payment we must make because of bodily injury to such persons. <br /> SCHEDULE <br /> Partners Officers Others <br /> Jack Chesnut <br /> Jerry Passmore <br /> Ed Flowers <br /> Mary Ann Peter <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 hairy RD Ste F <br /> Greensboro, NC 27409 <br /> WC 00-03-08 <br /> 315 <br />