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DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B <br /> POLICYHOLDER NOTICE - NORTH CAROLINA <br /> Date: 08/01/15 <br /> Policy Number: 22 WBC CN3905 THE <br /> Renewal Date: 10/01/15 HARTFQRD <br /> Your Hartford Agent: BB&T INSURANCE SERVICES INC/PHS (866) 467-8730 <br /> NORTH CAROLINA PUBLIC HEALTH <br /> PO BOX 18763 <br /> RALEIGH NC 27619 <br /> Dear Valued Hartford Customer, <br /> Your current policy provided by The Hartford will expire shortly. The purpose of this notice is to advise you of <br /> changes to your policy for the upcoming policy term. This is not a bill. You will receive a separate bill for all or part of <br /> the premium due for your upcoming policy. <br /> A. Policy Premium <br /> The premium indicated below is based on the underwriting information that we currently have on file and may be <br /> subject to change based on additional information that may be developed during the underwriting process. If you <br /> desire additional information regarding your premium determination, please contact your agent or broker, or you <br /> may contact us directly. <br /> Renewal Premium=$ 2,652.00 <br /> B. Coverage Changes(if applicable) <br /> Your policy for the upcoming term will include certain reductions or additional restrictions in coverage, as <br /> indicated by an (x)below. <br /> ( ) Increase in Deductible to: <br /> ( ) Reduction in Limits to: <br /> ( ) Reductions in Coverage: <br /> ( ) Other Changes, Clarifications or Restrictions in Coverage: <br /> You may receive other notices of coverage changes for the upcoming policy term under separate cover. Those <br /> other changes will apply in addition to the changes described above. <br /> Some states consider the change(s)described in this notice to be a nonrenewal of your prior policy, in which case this <br /> is our notice to you in compliance with the applicable law. <br /> If you would like more information about this notice or your policy, please contact your agent or broker, or you may <br /> contact us directly. We look forward to continuing our relationship and fulfilling your insurance needs. <br /> Thank you for your business. <br /> Form IH 70 41 01 13 (WC 66 03 27 F) <br />