Orange County NC Website
Browse       Search
DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 14 <br /> (Ed.7-90) <br /> NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT <br /> Experience rating is mandatory for all eligible insureds. The experience rating modification factor, if any, <br /> applicable to this policy, may change if there is a change in your ownership or in that of one or more of the <br /> entities eligible to be combined with you for experience rating purposes. Change in ownership includes sales, <br /> purchases, other transfers, mergers, consolidations, dissolutions, formations of a new entity and other changes <br /> provided for in the applicable experience rating plan manual. <br /> You must report any change in ownership to us in writing within 90 days of such change. Failure to report such <br /> changes within this period may result in revision of the experience rating modification factor used to <br /> determine your premium. <br /> This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br /> (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br /> Endorsement Effective 02/08/2017 Policy No. MWC0106102.01 Endorsement No. <br /> Insured: Senior Care of Orange County no Premium(See Attached) <br /> Insurance Company: Markel insurance Company Countersigned by <br /> W0000414 <br /> Ed.7-90 <br /> outgo National Council on Compensation Insurance. <br /> 14 of 24 <br />