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DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B <br /> • <br /> THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br /> WORKERS' COMPENSATION BROAD FORM ENDORSEMENT <br /> Policy Number: 22 WBC 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 /> Section I of this endorsement expands coverage provided under WC 00 00 00. <br /> Section II of this endorsement provides additional coverage usually only provided by endorsement. <br /> Section III of this endorsement is a Schedule of Covered States. <br /> You may use the index to locate these coverage features quickly: <br /> INDEX <br /> SUBJECT PAGE <br /> SECTION I 2 <br /> PARTS ONE and TWO 2 <br /> 01 We Will Also Pay 2 <br /> PART-THREE 2 <br /> 02 How This Insurance Works 2 <br /> PART-SIX 2 <br /> 03 Transfer of Your Rights and Duties 2 <br /> 04 Liberalization 2 <br /> SECTION II 2 <br /> VOLUNTARY COMPENSATION INSURANCE 2 <br /> 05 Voluntary Compensation Insurance 2 <br /> A. How This Insurance Applies 2 <br /> B. We will Pay 3 <br /> C. Exclusions 3 <br /> D. Before We Pay 3 <br /> E. Recovery From Others 3 <br /> F. Employers' Liability Insurance 3 <br /> EMPLOYERS'LIABILITY STOP GAP COVERAGE 3 <br /> 06 Employers' Liability Stop Gap Coverage 3 <br /> A. Stop Gap Coverage Limited Montana, North Dakota, Ohio, Washington, 3 <br /> West Virginia and Wyoming <br /> B. Part One does not Apply 3 <br /> C. Application of Coverage 3 <br /> D. Additional Exclusions 3 <br /> E. West Virginia 3 <br /> SECTION III 4 <br /> 07 Schedule of Covered States 4 <br /> Form WC 99 03 02 B Printed in U.S.A. (Ed. 8/00) Page 1 of 4 <br /> Process Date: 08/01/15 Policy Expiration Date: 10/01/16 <br /> ©2000, The Hartford <br />