Orange County NC Website
Browse       Search
DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED <br /> MARKEL' <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSLR2ANCE POLICY <br /> Original Printing Issued January 20,2017 WC000001A <br /> INFORMATION PAGE <br /> Insurer. <br /> Markel Insurance Company <br /> Ten Parkway North <br /> Deerfield, IL 60015-2526 <br /> 800-431-1270 <br /> >r'a�:77 -a 7 gi jrn m <br /> a�+'��� � dum:-�,...,.i, �?-4�'ad.,.. rev wF tY",r r.��d�r.o✓ r� M a.!`w fwkn S.U.�.�� ,.� �-n,ti.y.�y.�-�s <br /> 1. The Insured: individual ■Partnership <br /> Senior Care of Orange County Inc <br /> Corporation or ©Corporation <br /> Mailing address: <br /> 105 Meadowlands Dr <br /> Hillsborough, NC 27278-8500 <br /> Other workplaces not shown above:See attached Location Schedule <br /> 2. The policy period is from 02/08/2017 to 02/08/2018 at the insured's mailing address <br /> 3. A. Worker Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the states <br /> listed here: NORTH CAROLINA <br /> B. Employers Liability Insurance:Part Two of the policy applies to work in each state listed in Item 3 A.The limits of <br /> our liability under Part Two are: <br /> Bodily Injury by Accident $500,000 each accident <br /> Bodily Injury by Disease $500,000 policy limit <br /> Bodily Injury by Disease $500,000 each employee <br /> C. Other States Insurance:Part Three of the policy applies to the states,if any,listed here: <br /> All states except those listed In Item 3A of the Information Page and the following states or territories: AZ,District <br /> of Columbia,ID,ME,MT, NJ,NY,ND,OH,OR,WA,WY,Puerto Rico and US Virgin Islands. <br /> D. This policy includes these endorsements and schedules:WC990601,WC990602,WC990603,WC000000C, <br /> WC000308,WC000404,WC000406,WC000414,WC000419,WC000421 D,WC0004228,WC000424, <br /> WC320301 C,MJWC1000,MPIL 1007 <br /> 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans.All information required below is subject to <br /> verification and change by audit <br /> Code Premium Basis Rate Per Estimated <br /> Classifications No Total Estimated $100 of Annual <br /> Annual Remuneration Remuneration Premium <br /> Total Estimated Annual Premium:$1,782.00 <br /> Minimum Premium:$389.00 Expense Constant$210.00 <br /> Countersigned by <br /> WC000001 A <br /> 01987 National Council on Compensation Insurance <br /> II 111111111 111111111 0111111[I1I III 11111 111111111 1 of 24 1111 11011 11 11 1I 110111111[1 1111101 0111 1111 01 11111 <br /> 007598-012071-39321687-91202017 M WC0106102-01 <br />