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DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B <br /> 05 (Policy Provisions: wC o0 00 0o B) <br /> 39 <br /> CN INFORMATION PAGE <br /> WBC WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br /> INSURER: HARTFORD FIRE INSURANCE COMPANY <br /> ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 <br /> tea• <br /> NCCI Company Number: 13269 THE 40'Company Code: 1 HARTFORD <br /> Suffix <br /> LARS RENEWAL <br /> POLICY NUMBER: 22 WBC CN3905 I 02 <br /> Previous Policy Number: 22 WBC CN3905 <br /> HOUSING CODE: DV <br /> 1. Named Insured and Mailing Address: NORTH CAROLINA PUBLIC HEALTH <br /> (No., Street, Town, State, Zip Code) FOUNDATION <br /> PO BOX 18763 <br /> FEIN Number: 470921425 RALEIGH, NC 27619 <br /> State Identification Number(s): <br /> The Named Insured is: NON-PROFIT ORGANIZATION <br /> Business of Named Insured: ASSOCIATION - CIVIC NON PROFIT <br /> Other workplaces not shown above: SEE ATTACHED SCHEDULES <br /> 2. Policy Period: From 10/01/15 To 10/01/16 <br /> 12:01 a.m., Standard time at the insured's mailing address. <br /> Producer's Name: BB&T INSURANCE SERVICES INC/PHS <br /> PO BOX 29611 <br /> CHARLOTTE, NC 28229 <br /> Producer's Code: 273438 <br /> Issuing Office: THE HARTFORD <br /> 8711 UNIVERSITY EAST DRIVE <br /> CHARLOTTE NC 28213 <br /> (866) 467-8730 <br /> Total Estimated Annual Premium: $2,652 <br /> Deposit Premium: <br /> Policy Minimum Premium: $352 NC <br /> Audit Period: ANNUAL Installment Term: <br /> The policy is not binding unless countersigned by our authorized representative. <br /> Countersigned by 08/01/15 <br /> Authorized Representative Date <br /> Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) <br /> Process Date: 08/01/15 Policy Expiration Date: 10/01/16 <br />