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DocuSign Envelope ID: FlE99030-036D-407F-B588-94BC3741A806 <br /> BERKSHIRE HATHAWAY Worker';:,CornuensatiOn acid A > . i . ,QIli <br /> INSURANCE AmGLIAttb Insuran a Company-A Stack Company <br /> COMPANIES Policy Number PRWC663376 <br /> Renewal of PRWC552943 <br /> NCCI No. (21873) <br /> Policy Information Page <br /> 1]Named Insured and Mailing Address Lawson€nsutancri any Financial <br /> lioPRO NET SYSTEMS INC. �:aa:�.ki:r:-r:ia'•u:air:x <br /> 3200407 Glen Royal Road ""` ,•ersur:�� <br /> 017.-101$in i•GrT:?VW <br /> Raleigh, NC 27617 ;i„ic;,in '1 ;+,s s�15 <br /> 'ref:aIa-8 6.;:as <br /> it?t 10:V Sic\ i'io:,al i°<i4>-24tS <br /> Federal Employer's ID Insured is Corporation <br /> Elj Risk ID Number 6049357 <br /> [2] Policy Period <br /> From April 3, 2015 to AprIl 3, 2036, 12:1)1 AM,standard time at the insured's mailing address. <br /> [3) Coverage <br /> A. Workers'Compensation Insurance-Part One of this policy applies to the Workers'Compensation <br /> Law of the following states: North Carolina <br /> B. Employer's Liability Insurance-Part Two of this policy applies to work in each of the states listed <br /> in item(31A, The limits of our liability under Part Two are: <br /> Bodily injury by Accident-each accident $1,000,000 <br /> Bodily Injury by Disease-each employee $1,000,000 <br /> Bodily Injury by Disease-policy limit $1,000,000 <br /> C. Other States Insurance- Part Three of this policy applies to all states,except any state listed In <br /> Item(3)A,and the states of North Dakota,Ohio,Washington,and Wyoming. <br /> D. This policy Includes these endorsements and schedules: <br /> See Extension of Information Page-Schedule of Forms ” Y <br /> [4) Premium <br /> The Premium Basis and,therefore,the premium will be determined by our Manual of Rules, <br /> Classifications,Rates,and Rating Plans. All required Information is subject to verification and change by <br /> audit. (Continued on another page) �..._..,.....•,..........,>._ <br /> Total Estimated Policy Premium $ 6,558 <br /> Total Surcharges/Assessments $ 0.00 <br /> Total Estimated Cost $ 6,558.00 <br /> INTERNAL USE Y,X Page-1- Information Page <br /> MGA ;PRWC663376 p WC 000001A <br /> Date :04/02/2015 <br /> is&uing Office;P.Q.Box A-N,16 S.River Street,Wilkes-Barre,PA 18703-0020•www.guard.carn <br />