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DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B <br /> INFORMATION PAGE (Continued) Policy Number: 22 WBC CN3905 <br /> 3.A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the <br /> states listed here:NC (SPO ) . <br /> B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. <br /> The limits of our liability under Part Two are: <br /> Bodily injury by Accident $100,000 each accident <br /> Bodily injury by Disease $500,000 policy limit <br /> Bodily injury by Disease $100,000 each employee <br /> C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: <br /> ALL STATES EXCEPT ND, OH, WA, WY, US TERRITORIES, AND <br /> STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. <br /> D. This policy includes these endorsements and schedule: <br /> WC 99 00 05 WC 00 04 21D WC 00 04 22B WC 99 03 02B WC 99 03 66 <br /> WC 00 04 14 WC 00 04 19 WC 32 03 01C WC 99 02 77 <br /> 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating <br /> Plans. All information required below is subject to verification and change by audit. <br /> Premium Basis <br /> Classifications Total Estimated Rates Per Estimated <br /> Code Number and Annual $100 of Annual <br /> Description Remuneration Remuneration Premium <br /> (SEE ATTACHED SCHEDULES) <br /> TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 2,224 <br /> EXPENSE CONSTANT (0900) 250 <br /> TERRORISM (9740) 885,600 .010 89 <br /> CATASTROPHE (9741) 885,600 .010 89 <br /> TOTAL ESTIMATED ANNUAL PREMIUM 2,652 <br /> Total Estimated Annual Premium: $2,652 <br /> Deposit Premium: <br /> Policy Minimum Premium: $352 NC <br /> Interstate/Intrastate Identification Number: <br /> NAICS: <br /> Labor Contractors Policy Number: SIC: 8641 <br /> Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 <br /> Process Date: 08/01/15 Policy Expiration Date: 10/01/16 <br />