Orange County NC Website
onnuS• 111672Fo-E5A1 1oonecr <br /> 4Hanover <br /> n° <br /> Insurance Group. <br /> WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY <br /> EXTENSION OF INFORMATION PAGE <br /> RENEWAL OF WZ6-A004288-03 <br /> CARRIER CODE NO. 30937 <br /> Policy Number Policy Period Coverage is Provided in the Agency Code <br /> From To <br /> VYZ6`A004288'04 06/25/2017 06/25K2018 THE HANOVER AMERICAN INSURANCE COMPANY 1902820 <br /> ITEM 1. Named |nowredo and n Address Agent Telephone: 866-635'3736 <br /> TRIANGLE UROLOGY ASSOCIATES PA MOORE &JOHNSON AGENCY <br /> ATTN: DAVIN BROWN CL HANOVER CSC/STE 350 <br /> 205 FRASIER ST 4505 FALLS OF NEUSE RD <br /> DURHAM, NC 27704 RALE|GH, NC 27809 <br /> Federal ID No. 561205850 <br /> POLICY ** A D D I T I O N A L L O C A T I O N S ** SCHEDULE <br /> PAGE 2 <br /> PAGE 1 <br /> LOCATION ADDRESS <br /> NUMBER <br /> 001 205 FRASIER STREET <br /> DURHAM NC <br /> 27704 <br /> -------------------------------------------------------------------- <br /> Q�Q — <br /> 331-0226 VVCU00081B <br /> --Deta Issued: 04/26/2017 ORIGINAL/INSURED Payment Type: CUST SERV CTR-DIRECT BILL <br /> "~"~'' <br />