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DocuSign Envelope ID:26CB3394-9EF5-42C1-8EAB-432A9B415AA4 <br /> Staferarm <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br /> INFORMATION PAGE ENDORSEMENT <br /> PAGE 01 <br /> THIS FORMS A PART OF COVERAGE IS PROVIDED BY 07-6379-FB5D <br /> POLICY NO, 93-BX-U625-7 STATE FARM FIRE AND CASUALTY COMPANY <br /> 3 RAVINIA DRIVE , ATLANTA GA 30346-2117 <br /> NAMED INSURED AND MAILING ADDRESS RISK ID NO. 006219515 <br /> ANALYTICAL CONSULTANTS INC FEIN <br /> 125 KINGSTON DR STE 206 <br /> CHAPEL HILL NC 27514- 1649 <br /> THE EFFECTIVE DATE IS 10/01/2015 YOUR POLICY AMENDED AS <br /> THE EXPIRATION DATE IS 10/01/2016 <br /> POLICY CODE NOS. , CLASSIFICATIONS, PREMIUM BASIS, RATES AND ESTIMATED <br /> PREMIUMS ARE AMENDED AS FOLLOWS: <br /> THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF <br /> REQUIIREDLBELOWIISTSUBJECTATOSVERDIFICATIONPANDSCHANGEIBYOAUDITON <br /> CODE NOS. AND ITAL ESTIMATEDTIN- REMUNERA- ANNUAL <br /> CLASSIFICATIONS <br /> 8721 508 , 580 . 44 2, 238 <br /> REAL ESTATE APPRAISAL COMPANIES - <br /> OUTSIDE EMPLOYEES <br /> 8810 93 , 395 .24 224 <br /> CLERICAL OFFICE EMPLOYEES NOC <br /> EMPLOYERS LIABILITY INCREASED LIMITS <br /> PREMIUM PRIOR TO EXPERIENCE MODIFICATION 2 , 537 <br /> EXPERIENCE MODIFICATION : 980 <br /> PREMIUM AFTER EXPERIENCE MODIFICATION 2 , 486 <br /> CATASTROPHE (OTHER THAN TERRORISM) 9741 601 , 975 , 01 60 <br /> TERRORISM 9740 601 , 975 .01 60 <br /> MINIMUM PREMIUM $ 240 NO. CAROLINA TOTAL ESTIMATED ANNUAL PREMIUM $ 2 , 606 <br /> ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED . <br />