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DocuSign Envelope ID:273B24CC-D965-44DO-A589-37C63CDFC6B6
<br /> M11
<br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
<br /> Original Printing Issued November 9,2015 WC000001A
<br /> INFORMATION PAGE
<br /> Insurer. '""""" '""
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<br /> Markel Insurance Company "`""/ // /
<br /> Ten Parkway North
<br /> Deerfield, IL 60015-2526
<br /> 800-431-1270
<br /> 1. The Insured: Individual Partnership
<br /> Family Centered Healthcare INC
<br /> Corporation or X Corporation
<br /> Mailing address:
<br /> PO Box 1119
<br /> Hillsborough, NC 27278-1119
<br /> Other workplaces not shown above: See attached Location Schedule
<br /> 2. The policy period is from 11/17/2015 to 11/17/2016 at the insured's mailing address
<br /> 3. A. Worker Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states
<br /> listed here: NORTH CAROLINA
<br /> B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3 A.The limits of
<br /> our liability under Part Two are:
<br /> Bodily Injury by Accident $100,000 each accident
<br /> Bodily Injury by Disease $500,000 policy limit
<br /> Bodily Injury by Disease $100,000 each employee
<br /> C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
<br /> All states except those listed in Item 3A of the Information Page and the following states or territories: AZ, District
<br /> of Columbia, ID, ME,MA, MT,NJ, NY, ND,OH, OR,WA,WY, Puerto Rico and US Virgin Islands.
<br /> D. This policy includes these endorsements and schedules:MJWC1000, MPIL 1007,WCOOOOOOC,WC000308,
<br /> WC000404,WC000406,WC000414,WC000419,WC000421D,WC000422B,WC320301C,WC890600B,
<br /> WC990601,WC990602,WC990603
<br /> 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
<br /> verification and change by audit
<br /> Code Premium Basis Rate Per Estimated
<br /> Classifications No Total Estimated $100 of Annual
<br /> Annual Remuneration Remuneration Premium
<br /> Total Estimated Annual Premium:$1,288.00
<br /> Minimum Premium:$304.00 Expense Constant$210.00
<br /> Countersigned by
<br /> WC000001A
<br /> ©1987 National Council on Compensation Insurance
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