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DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B <br /> THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br /> CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) <br /> PREMIUM ENDORSEMENT <br /> Policy Number: 22 WEC CN3905 Endorsement Number: <br /> Effective Date: 10/01/15 Effective hour is the same as stated on the Information Page of the policy. <br /> Named Insured and Address: NORTH CAROLINA PUBLIC HEALTH <br /> FOUNDATION <br /> PO BOX 18763 <br /> RALEIGH, NC 27619 <br /> This endorsement is notification that your insurance Terrorism Risk Insurance Act of 2002 (as <br /> carrier is charging premium to cover the losses that amended) but that meets all of the following <br /> may occur in the event of a Catastrophe (other than criteria: <br /> Certified Acts of Terrorism) as that term is defined a. It is an act that is violent or dangerous to <br /> below. Your policy provides coverage for workers human life, property, or infrastructure; <br /> compensation losses caused by a Catastrophe <br /> (other than Certified Acts of Terrorism). This b. The act results in damage within the United <br /> premium charge does not provide funding for States, or outside of the United States in the <br /> Certified Acts of Terrorism contemplated under the case of the premises of United States <br /> Terrorism Risk Insurance Program Reauthorization missions or air carriers or vessels as those <br /> Act Disclosure Endorsement (WC 00 04 22 B), terms are defined in the Terrorism Risk <br /> attached to this policy. Insurance Act of 2002(as amended);and <br /> c. It is an act that has been committed by an <br /> For purposes of this endorsement, the following individual or individuals as part of an effort to <br /> definitions apply: coerce the civilian population of the United <br /> o Catastrophe (other than Certified Acts of States or to influence the policy or affect the <br /> Terrorism): Any single event, resulting from an conduct of the United States Government by <br /> Earthquake, Noncertified Act of Terrorism, or coercion. <br /> Catastrophic Industrial Accident, which results in o Catastrophic Industrial Accident: A chemical <br /> aggregate workers compensation losses in release, large explosion, or small blast that is <br /> excess of$50 million. localized in nature and affects workers in a small <br /> o Earthquake: The shaking and vibration at the perimeter the size of a building. <br /> surface of the earth resulting from underground The premium charge for the coverage your policy <br /> movement along a fault plane or from volcanic provides for workers compensation losses caused by <br /> activity. a Catastrophe (other than Certified Acts of <br /> o Noncertified Act of Terrorism: An event that is Terrorism) is shown in Item 4 of the Information <br /> not certified as an Act of Terrorism by the Page or in the Schedule below. <br /> Secretary of Treasury pursuant to the <br /> Schedule <br /> State Rate Premium <br /> Form WC 00 04 21 D Printed in U.S.A. <br /> Process Date: 08/01/15 Policy Expiration Date: 10/01/16 <br />