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DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980 <br /> Hanover <br /> Insurance Group_ <br /> WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY <br /> 2 WORKERS COMPENSATION AMENDED INFORMATION PAGE <br /> ENDORSEMENT EFFECTIVE 06/25/2016 NUMBER 01 <br /> REASON AMENDED: EFF 06/25/16 DELETE BUREAU FILLING# <br /> SUPERSEDES ANY PREVIOUS DECLARATIONS BEARING THE SAME NO. FOR THIS POLICY PERIOD <br /> CARRIER CODE NO. 29661 <br /> Policy Number Policy Period Coverage is Provided in the Agency Code <br /> From To <br /> W26-A004288-03 06/25/2016 06/25/2017 _ ALLMERICA FINANCIAL BENEFIT INSURANCE 1902820 <br /> ITEM 1. Named Insured and Address Agent Telephone: 866-635-9736 <br /> TRIANGLE UROLOGY ASSOCIATES PA MOORE &JOHNSON AGENCY <br /> ATTN: DAVIN BROWN CL HANOVER CSC <br /> 205 FRASIER ST PO BOX 17867 <br /> DURHAM, NC 27704 RALEIGH, NC 27619 <br /> Federal ID No. <br /> SEE ATTACHED SCHEDULE OF ADDITIONAL LOCATIONS FOR OTHER <br /> WORKPLACES NOT SHOWN ABOVE. <br /> IF APPLICABLE SEE CONTINUATION OF NAMED INSURED SCHEDULE. <br /> ENTITY OF INSURED - CORPORATION <br /> ITEM 2. POLICY PERIOD- 06/25/16 TO 06/25/17 12:01 AM STANDARD TIME AT <br /> THE ADDRESS OF THE INSURED AS STATED HEREIN. <br /> ITEM 3A. PART ONE OF THIS POLICY APPLIES TO THE WORKERS' COMPENSATION LAW AND <br /> ANY OCCUPATIONAL DISEASE LAW OF EACH OF THE FOLLOWING STATES- <br /> , <br /> NC. <br /> B. PART TWO OF THIS POLICY APPLIES TO EMPLOYERS' LIABILITY INSURANCE FOR <br /> WORK IN EACH STATE LISTED IN ITEM 3A: <br /> BODILY INJURY BY ACCIDENT $500,000 EACH ACCIDENT <br /> BODILY INJURY BY DISEASE $500,000 EACH EMPLOYEE <br /> BODILY INJURY BY DISEASE $500,000 POLICY LIMIT <br /> C. PART THREE OF THIS POLICY APPLIES TO OTHER STATES INSURANCE FOR THE FOL- <br /> LOWING STATES- ALL STATES EXCEPT ND,OH,WA,WY, <br /> AND THOSE STATES SPECIFICALLY NAMED IN ITEM 3A. <br /> D. SEE ATTACHED SCHEDULE FOR LIST OF ENDORSEMENTS AND SCHEDULES FORMING <br /> PART OF THIS POLICY. <br /> ITEM 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, <br /> CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW <br /> IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. <br /> ADJUSTMENT OF PREMIUM SHALL BE MADE ANNUALLY. <br /> CLASSIFICATION OF OPERATIONS EST <br /> ANNUAL <br /> PREMIUM <br /> SEE ATTACHED SCHEDULE OF OPERATIONS <br /> 3,684 <br /> MINIMUM PREMIUM $261 EXPENSE CONSTANT 210 <br /> PREMIUM FOR TERRORISM $123 <br /> PREMIUM FOR CATASTROPHE $123 <br /> TOTAL ESTIMATED ANNUAL PREMIUM $4,140 <br /> DEPOSIT PREMIUM $4,140 <br /> THE FOREGOING AMENDMENT RESULTS IN AN ADDITIONAL PREMIUM OF $0 <br /> COUNTERSIGNED THIS DAY OF <br /> AUTHORIZED REPRESENTATIVE <br /> BRANCH OFFICE:13840 BALLANTYNE CORP PL SUITE 100 CHARLOTTE NC 28277 <br /> Form 331-0226 (9-03) WC000001 B <br /> Date Issued: 04/29/2016 ORIGINAL/INSURED Payment Type: CUST SERV CTR-DIRECT BILL <br /> 492 WCDEC1 <br />