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DocuSign Envelope ID: 313DA256-1 EDE-4396-A716-4C53B809027E <br />NORTH CAROLINA <br />WORKERS COMPENSATION INSURANCE <br />EXPERIENCE RATING <br />j?P.'fj1,1G DATE: D7/01/1 ! I` OiP�1111, <br />i.,N)UP TI); <br />?jr,1606 <br />0:3 1 3V 3 5 b <br />CORVORATIOU <br />f wl <br />Da t <br />4_('V NUIAbe-f <br />Lo�is e '5 <br />6 <br />?7 SO <br />II <br />ii;, 1966 <br />0 1 /.1 3 <br />1� 8 J7; <br />I <br />16, <br />/0 1 i 4 <br />wc,3 0 0 0 <br />I., P I E N, C1, <br />cv F A I <br />A,jua.l <br />t, V,1 1uc- <br />PC, I lal] <br />( j0 ,000 <br />wui "'.1-iQ J I . 0 <br />ARM, 5j1,,:h,12 �4. <br />l) I <br />zP1 (,f�pj,j f Ap <br />Lxpe,kl t 11 i <br />PC_ i IEWO Y <br />60 ,, 5 1 � � <br />" 81 1 <br />3 ft 3 <br />T:, a tacn <br />Experience Modi£icatiorr 1,22 <br />p, C: t. i I rj I C:a .j L I I i: 3 C1 t 1 <br />