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DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB ;urance Company WC 00 00 01 A <br /> POLICY NUMBER PREVIOUS POLICY NUMBER <br /> MC 7227674 WC 7227674 <br /> SELECTIVE INSURANCE COMPANY OF SOUTH CAROLINA <br /> 3426 TORIMGDON NAY, CHARLOTTE, NC 28277 <br /> .. t <br /> INFORMATION PAGE NCCI COMPANY NO. 23937 <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> p l�iL.M In NAME OF INSURED & MAILING ADDRESS �� PItODUCEtt'S NAME AND MAILING ADDRESS <br /> RALEIGH PATHOLOGY LABORATORY ASSOCIATES SENT It r L ADVISORS, LLC <br /> PA& WAKE MED LABORATORY CORP 4700 SIX FORKS RD STE 200 <br /> PO BOX 14045 RALEIGH, NC 27609-5244 <br /> RA I.F'IGH,NC 27, 1-4045 <br /> INSURED Is: CORPORATION I FED ID NO 561230477 AGENT NUMBER: 31-00-07265-00000 <br /> ITEM Z. POLICY PERIOD The Policy Period Is from JUNE 7, 2017 TO JUNE 7, 2018 <br /> 12:01 A.M.,otondnrd!Imo at the Insured's mailing address. <br /> polio applies to Workers Compensation law of the states <br /> ITEM 3. CO Di AGE A. Wo Compensation 1 ce'Part One of the <br /> policy pp p listed here: <br /> NC <br /> B. Employers Liability Insurance: Part Two of the policy applies to worK in each stated listed In item 3.A. <br /> limits of our liability under Part'iWo are: Bodily Injury By Accident $100.000 each accident <br /> Bodily Injury By Disease $100,000 each employee <br /> r,.,.ily Injury By Di ..se $500,000 policy limit <br /> C. Other States Insurance: Part Three of the policy applies to the states,it any,listed here: <br /> ALL STATES EXCEPT NO,OH,NA 8 KY. <br /> ITEM 4. PR IUM: The premium for this policy will Le determined by our manuals of rules,classifications,rates and rating plans. All <br /> Information required bend° is subject to verification and change by audit. <br /> Code Premium Basis Rate Per Estimated <br /> CLASSIFICATION No. Total Estimated $1013 of Annual <br /> Annual Remuneration Remuneration Premium <br /> SEE ATTACHED SCHEDULES) <br /> EXPENSE CONSTANT 0900 <br /> TERRORISM - NC $.010 9740 <br /> CATASTROPHE - NC $.010 9741 <br /> IIII <br /> Minimum Premium NORTH CAROLINA Total._Estimated Cost <br /> If Indicated below, interim adjusI :nts of premium shall be made: <br /> Semi- ualiy [1:1 Quarterly [] Monthly De• ;,it Premium <br /> This policy includes the:: endorsements and schedules: REFER TO NC-52 <br /> D/B - 4 - 7706552991 <br /> Issue Date: APRIL 22, 2017 issuing office: SERVICE CENTER, 23225-0325 <br /> Authorized Representative <br /> Form-64 (07/08) Copyright 1987 National Council on Compensation insurance, <br /> INSURED'S COPY <br />