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DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980 41-lanover <br /> Insurance Group_ <br /> WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY <br /> ^2 EXTENSION OF INFORMATION PAGE - AMENDED POLICY <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 /> POLICY ** A D D I T I O N A L L O C A T I O N S ** SCHEDULE <br /> PAGE 2 PAGE 1 <br /> LOCATION ADDRESS <br /> NUMBER <br /> 001 205 FRASIER STREET <br /> DURHAM NC <br /> 27704 <br /> Form 331-0226 (9-03) WC000001B <br /> Date Issued: 04/29/2016 ORIGINAL/INSURED Payment Type: CUST SERV CTR-DIRECT BILL <br /> WCOEC1 <br /> 493 <br />