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DocuSign Envelope ID: D246BF38-3F94-4A4B-B6B9-C4F5BAC37487 <br /> 4, SYNERGY <br /> my URANCC COMPANY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> INFORMATION PAGE RENEWAL AGREEMENT <br /> Insurer: PRODUCER: Agent 15 <br /> Synergy Insurance Company Granite Insurance Inc. <br /> 217 South Tryon Street PO Box 620 <br /> Charlotte, NC 28202-3201 Granite Falls, NC 28630 <br /> (Carrier Code: 66998) Carrier Policy #: WC100-000481-116 <br /> Carrier Prior Policy #: WC100-000481-115 <br /> 1. The Insured: KAH Care, LLC <br /> Right at Home <br /> Mailing Address: Ken Helmuth <br /> 4905 Pine Cone Drive, Suite 2 <br /> Durham, NC 27707 <br /> File #: 100000000481116 <br /> Fein: <br /> Other workplaces not shown above: Type of Business: Limited Liability Co <br /> SEE SCHEDULE OF OPERATIONS Risk ID: <br /> 2 . The policy period is from 12:01 a.m. on 5/05/2016 to 12 :01 a.m. on 5/05/2017 <br /> at the insured' s mailing address. <br /> 3 . A. Workers Compensation Insurance: Part One of the policy applies to the Workers <br /> Compensation Law of the states listed here: <br /> NC <br /> B. Employers Liability Insurance: Part Two of the policy applies to work in each <br /> state listed in Item 3 .A. The limits of our liability under Part Two are: <br /> Bodily Injury by Accident $ 1, 000, 000 each accident <br /> Bodily Injury by Disease $ 1, 000, 000 policy limit <br /> Bodily Injury by Disease $ 1,000,000 each employee <br /> C. Other States Insurance: <br /> D. This policy includes these endorsements and schedules: <br /> WC000000C(01/15) WC000310 (04/84) WC000402 (04/84) WC000406 (08/84) WC000414 (07/90) <br /> WC000419(01/01) W0000421D(01/15) WC000422B(01/15) WC320301C(01/14) <br /> 4. The premium for this policy will be determined by our Manuals of Rules, <br /> Classifications, Rates and Rating Plans . All information required below is subject <br /> to verification and change by audit. <br /> Classifications Code Premium Basis Rate Per Estimated <br /> No. Total Estimated $100 of Annual <br /> Annual Remuneration Remuneration Premium <br /> SEE SCHEDULE OF OPERATIONS <br /> Total Estimated Annual Premium $ 54, 513.00 <br /> Minimum Premium $ 1, 120.00 Expense Constant 250.00 Deposit Premium .00 <br /> WC 00 00 01 A <br /> Copyright 1994 National Council on Compensation Insurance Inc. Countersigned by <br />