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DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 24 <br /> (Ed. 1-17) <br /> AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT <br /> Part Five—Premium, Section G. (Audit) of the Workers Compensation and Employers Liability Insurance Policy is <br /> revised by adding the following: <br /> If you do not allow us to examine and audit all of your records that relate to this policy, and/or do not provide audit <br /> information as requested,we may apply an Audit Noncompliance Charge. The method for determining the Audit <br /> Noncompliance Charge by state, where applicable, is shown in the Schedule below. <br /> If you allow us to examine and audit all of your records after we have applied an Audit Noncompliance Charge, we will <br /> revise your premium in accordance with our manuals and Part 5—Premium, E. (Final Premium)of this policy. <br /> Failure to cooperate with this policy provision may result in the cancellation of your insurance coverage, as specified <br /> under the policy. <br /> Note: <br /> For coverage under state-approved workers compensation assigned risk plans, failure to cooperate with this policy <br /> provision may affect your eligibility for coverage. <br /> Schedule <br /> State(s) Basis of Audit Noncompliance Maximum Audit Noncompliance <br /> Charge Charge Multiplier <br /> NC $1,782.00 0.25 <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 Inc Premium(See Attached) <br /> Insurance Company: Markel insurance Company Countersigned by <br /> wC000424 <br /> WC 00 04 24 <br /> (Ed,1-17) <br /> ®Capyslght 2015 NetIonel Council on Compensation Insurance.Inc.AM Rights Reserved. <br /> 19 of 24 <br />