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<br /> li'' DocuSiqn Envelope ID: 155D1985-9FE0-4EA7-1367C-F2531BFF9621 " Jrance Company WC 00 00 01 A
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<br /> POLICY NL
<br /> lc 7227674 227iiiER 67B PREV10S 0
<br /> 4 WC 7P221-71C 67Y N4BER
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<br /> TORINGDON WAY,CTIVE INSURANCE COMPANY OF SOUTH CAROLINA
<br /> 4,4'2.6
<br /> SELE CHARLOTTE, NC 28277
<br /> II7...."I
<br /> ATioN PAGE
<br /> AHA' ORM- NC(."1 COMPANY NO. 23957
<br /> NOFR K ER S COMPENSATION AND EMPLOYERS ,LIABILITY INSURANCE POLICY
<br /> 1,-,,, 1 NAME OF INSURED & MAILING ADDRESS I l'OA11,IN G1' AI)DRIf,SS
<br /> 3° /71111° EM1111*(111 PA'EHOLC)(3Y I.A,11,(1RA,' ,RSSC/f-IATES SPRENOTDINUECLER;ISSKNAADMVIISI:'OARSN,1 LLC
<br /> JtAl'''''- kir,'D I,A BC)RA I 0 RN CORP.,
<br /> &WAKE —-:
<br /> NFCORK2S76R0D9-5ST24E4200
<br /> , /0,1107 045
<br /> If 40 Box 14 4RA7L0E0IGSHIX,
<br /> /Ozz
<br /> FiCill,NC 276204045
<br /> I %01!,1,A111" '
<br /> $iuRED is: CORPORATION JUNE NO. AGENT NUMBER: 31-00-07265-00000
<br /> Z. POI,ICY PERIOD The Policy Period is fromFEJDU
<br /> To JUNE 7, 2017
<br /> ,... 12.01..A.y.,standard time at the in7s,ure2c0's1m6ailing address.
<br /> 0:00\ /00,/J0 1( /film 3 COVERAGE •• ,
<br /> jiz %0010 1101101,010k,j Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation law of the states listed here:
<br /> —
<br /> "11F/ 0K00 NL; . ce:
<br /> _ es Liability insuran • Part Two of fbeBopdoilllycyinajupripliBesytAecwciodreknitn each statesdlloisote,doion0Item 3e.Aac.
<br /> Employers under Part Two are:, f our liability un
<br /> ' 'he omits 0
<br /> Bodily Injury By Disease each accident
<br /> $$51 0000,,000000 epoacnchyernonpIttoyee
<br /> '088 fii /8 _ Bodily Injury By Disease
<br /> 11/CI'/8/i1 (//00,ii r• other States insurance: Part Three of the policy applies to the states,if any, listed here:
<br /> '
<br /> ALL STATES EXCEPT ND,OH,WA & WY.
<br /> looltf/),i'l'fl,,,;IIIliiIII
<br /> IIIIll IIIIIIIIIIIIIII,II:01 „Il A;/
<br /> IIIIti;,,,IIIIDal'iclit,11 (
<br /> //11;01(#1'11111.1141 4.. PREMIUM:
<br /> change by audit.
<br /> verification and c
<br /> Estimated
<br /> 111111111 88°0
<br /> li / The premium for this policy will be determined by our manuals of rules,classifications,rates and rating plans. All
<br /> Rate Per
<br /> Premium Basis
<br />„, 14:"'04111IIIII0000 /j information required below is subject torymi
<br /> CoL.d•e• ..,.
<br /> Annual
<br /> $100 of
<br /> Total Estimated
<br /> 10/100041000 \11111, i*
<br /> Na.
<br /> 0 I0t',:00(0000000\Pil fe
<br /> (
<br /> , 1 Premium
<br /> \ill
<br /> CLASSIFICATION
<br /> Remuneration
<br /> 1001111/00f1101401(400.0 Annual Remuneration
<br /> '''''''''11:''''''''''''''1■AlrI,01)k11110`fl0z1r0;ATTACKED SCHEDULE(S)
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<br /> l'11111111111‘1. /I°\ ,11;i /"' '
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<br /> 160
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<br /> ,':'1111111,1yfip, * CONSTANT NT 0900
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<br /> - NC $.010 9740 285
<br /> PI
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<br /> 9741 285
<br /> VIIIH!IIIAt04,11;:IPE
<br /> - NC $.010
<br /> $8,954
<br /> '181/11\10,810014,(000((/ ,
<br /> IIIIIIihl)1111\ 11!IIIIIIIIIIIIII414,(Iiilplioltliii/i0},,,P remolV7interim adjustments$217
<br /> NORTH CAROLINA T
<br /> Eloil Monthly Cost
<br /> . $z,954
<br /> ''illo ,„0 loitlov / -
<br /> cr tments of premium shall be made:
<br /> '11tV1') )°koli iftlftg iv/ -, IN Semi-Annually El
<br /> '"All 4,1 lonoilitof/ i',‘, Quarterly onthly Deposit Premium
<br /> 'Ill/11011110111111111'1',r,',171//le'',:'/14,PclUdes these endorsements and schedules: REFER TO WC-52
<br /> IIIIIIIrill 11,111,1,1,1000000008,1,„„:14,,,,,,fi i i„,,,,/, *
<br /> ,oluy, 0,111,111,111,111,11,17,,,,,:,,,00,00 4/1/ 770655299
<br /> "Ii1 1,4iii116IllivoNfie „,,
<br /> 6, 2016
<br /> IIIIIIIIIIIIIIIA\,tfII\IIIII"",IlIlitiltftire//% Issuing Office: SERVICE CENTER, 23225-0325
<br /> 11!1,1,1,1,1,1,1,10, Authorized Representative
<br /> 11IIIIIIIIIIIIIi11litir:01000000 it,,1000)„.,/ /jj Copyright 1987 National Council on Compensation Insurance.
<br /> II,III,IIIIIIIIIIIIIIIII,IIIIIIIIIIIIIIIIIIIIIIIIIIIII'IIIII1111'1,11),),,),.:!!!Int:1,11,11111rer) 7,;z' INSUREDS COPY
<br /> ol 1,1,1,1,IIIIIII1IIIIIIIIII11,„,lm,, ;;;/
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