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DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B <br /> (Ed 7-01) <br /> POLICY INFORMATION PAGE ENDORSEMENT <br /> The following item(s) <br /> Insured's Name(WC 89 06 01) Item 3.13. Limits (WC 89 06 12) <br /> Policy Number(WC 89 06 02) Item 3.C. States (WC 89 06 13) <br /> Effective Date(WC 89 06 03) Item 3.D. Endorsement Numbers (WC 89 06 14) <br /> Expiration Date(WC 89 06 04) Item 4. Class, Rate, Other(WC 89 04 15) <br /> X Insured's Mailing Address (WC 89 06 05) Interim Adjustment of Premium(WC 89 04 16) <br /> Experience Modification(WC 89 04 06) Carrier Servicing Office(WC 89 06 17) <br /> Producer's Name(WC 89 06 07) Interstate/Intrastate Risk ID Number(WC 89 06 18) <br /> Change in Workplace of Insured(WC 89 06 08) Carrier Number(WC 89 06 19) <br /> Insured's Legal Status (WC 89 06 10) Issuing Agency/Producer Office Address (WC 89 06 25) <br /> Item 3.A. States (WC 89 06 11) <br /> is changed as follows: <br /> Action Type Previous Value New Value <br /> Change Mailing Address:400 Millstone Dr Address:PO Box 1119 <br /> Address Ste 100 City:Hillsborough <br /> City:Hillsborough State:NC <br /> State:NC Postal Code:27278-1119 <br /> Postal Code:27278-9006 Phone#:919-619-3018 <br /> Phone#:9196193018 <br /> Total Estimated Annual Premium $1,288.00 Premium Adjustment $0.00 <br /> Minimum Premium $ 304.00 Deposit Premium $210.00 <br /> All other terms and conditions of this policy remain unchanged. <br /> This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br /> (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br /> Endorsement Effective 11/17/2015 Policy No. MWC0071930-02 Endorsement No. <br /> Insured: Family Centered Healthcare INC Premium(See Attached) <br /> Insurance Company: Markel Insurance Company Countersigned by <br /> WC890600B <br /> Ed.7-01 <br /> ©2001 National Council on Compensation Insurance,Inc. <br /> 111111111111111111111111111111111111111111111111111111111111111111111111111111111 1 of 6 <br /> 005274-011459-36588592-11112015 MWC0071930-02 <br />