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DocuSign Envelope ID: BBE2812E-C8CC-4A62-A991-7B4A2DC9F2F3 <br /> BERKSHIRE HATHAWAY +;tar er'S ComVerrs <br /> INSURANCE AMGIIARD Insuran a Company- A Stock Company <br /> KOGUARDCOMPANIES policy Number PRWC663376 <br /> Renewal of PRWC552943 <br /> NGCI No. [21873] <br /> Policy Information Page <br /> I Whiling Address <br /> ]Named Insured and ...._._ _ ._ <br /> PRO NET SYSTEMS INC. i.:,sz sci2 il:xae=<:t?sr:<i?�Fina::c:i;r; <br /> 3200-107 Glen Royal Road <br /> Raleigh, NC 27617 :. <br /> .;?t"bow__R"' .•`Tic' <br /> Federal Employer's Ill Insured Is Corporation <br /> t <br /> Risk ID Number 6049357 <br /> 1.--....... _. ...._......_. - ........... _....,.,....- - .......... .. _._.. .-..-.j <br /> [2I Policy Period <br /> From April 3, 2015 to April 3, 2016, 12.:01 AM,standard time At the Insured's mailing address. <br /> L_--_-___.__..........�................. ..--------......................... _.._ . __. —•.. ................ •..................--- -- .....-......... . .......-..-...------ - _ <br /> .........................._.... ._.. _... ............_ <br /> [3j Coverage <br /> A. Workers' (compensation Insurance -Part One of this policy applies to Lhe Workers' Compensation <br /> Law of the following states: North Carolina <br /> B. Employer's Liability Insurance-Part Two of this policy applies to work in each of the states listed <br /> in item[3.)A. The limits of our liability under Part Two are: <br /> Bodily Injury by Accident-each accident $1,000,000 <br /> Bodily Injury by Disease- each employee 11,000,000 <br /> Bodily Injury by Disease- policy limit $1,000,000 <br /> C. Other States Insurance- part Three of this policy applies to all states,except any state listed In <br /> item [3]A. and the states of North Dakota,Ohio, Washington,and Wyoming. <br /> D. This policy Includes these endorsements and schedules: <br /> See Extension of Information Page -Schedule of Forms <br /> - . _.._.. •- -----------------------------------------...... <br /> [4] Premium <br /> The Premium Basis and,therefore,the premium will be determined by our Manual of Rules, <br /> Classifications, Rates, and Rating Plans. All required information is subject to verification and change by <br /> audit. (Continued on another page) <br /> Total Estimated Policy Premium $ 5,558 <br /> Total Surcharges/Assessments $ 0.00 <br /> Total Estimated Cost $ 6,558.00 <br /> INTERNAL USE Y, rage- 1 - Information Page <br /> MGA : PRWC663376 WC 00000IA <br /> Date :04102!2015 <br /> Issuing Office,Q.Q.Box A-i4,16 S.River Street,Wilkes-Barre,PA 1$703-0020•vvww.guard.com <br />