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DocuSign Envelope ID:78BE6605-1 CDA-4976-978A-2870E79AD11 E <br /> SUMMARY OF INSURANCE <br /> HE <br /> I "FORD„ <br /> FOR: <br /> EL FUTURO Prepared:7/12/2017 <br /> 136 E CHAPEL HILL ST <br /> DURHAM NC 27701 <br /> Phone: FAX: <br /> BY: HOME OFFICE <br /> PAYCHEX INSURANCE AGENCY INC/PAC 250881 <br /> PO BOX 33015 <br /> SAN ANTONIO TX 78265 <br /> Phone: FAX: (888) 443-6112 <br /> ACCOUNT POLICY RECAP Policy Number Eff Date Exp Date Premium <br /> . Workers' Compensation 76 WBG ZS2911 11122016 11122017 $2, 987 .00 <br /> Trumbull Ins Co <br /> POLICY DETAIL Policy . Workers' Compensation <br /> Policy States: NC <br /> Location 01 Premises Address <br /> 136 E CHAPEL HILL ST <br /> DURHAM, NC 27701 <br /> Location 02 Premises Address <br /> 319 A EAST 3RD STREET <br /> SILER CITY, NC 27344 <br /> Worker's Compensation Coverages <br /> Employer's Liability Limits Limit <br /> Disease - Policy Limit $1, 000, 000 <br /> Disease - Each Employee $1, 000, 000 <br /> Each Accident $1, 000, 000 <br /> Individual Included/Excluded <br /> Class/Payroll Detail Class Description Class code Payroll #of Emp <br /> Location 01 - NC °oo000°m`79'97 m,, '9'9'9'9'9'9'9'9 0930 <br /> Location 01 - NC PHYSICIAN & CLERICAL 8832 883719 <br /> Location 02 - NC '?'?'?'?'?`'`'`'`'`'` 7-?7'>7-?7-?????'?'?'�'? 0930 <br /> Location 02 - NC PHYSICIAN & CLERICAL 8832 714 <br /> This summary and its attachments provides high level overview of policy coverages and does <br /> not include all conditions, limitation or exclusion. Please refer to the actual policy <br /> forms for detailed coverages, limits and deductibles. <br />