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DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED <br /> WC 00 04 22 B WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> (Ed. 1-15) <br /> 2. Notwithstanding item I above,the United States Government will not make any payment under the Act for any <br /> portion of Insured Losses that exceed $100,000,000,000. <br /> 3. The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in <br /> Item 4 of the Information Page or in the Schedule below. <br /> Schedule <br /> State Rate Premium <br /> NC 0.02 $40.00 <br /> This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br /> (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br /> Endorsement Effective 02/08/2017 Policy No. MWCO106102-01 Endorsement No. <br /> Insured Senior Care of Orange County Inc Premium:$(See Attached) <br /> Insurance Company Markel Insurance Company Countersigned by <br /> WC 00 04 22 B <br /> (Ed.1-15) <br /> ®Copyright 2015 National Council on Compensation Insurance,Inc.All Rights Reserved. <br /> 18 of 24 <br />