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DocuSign Envelope ID: 5D924F8F- OA84- 4ECE- 95C8- E82E8DA18036 <br />The <br />Hanover <br />Insurance Group.. <br />WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY <br />32 WORKERS COMPENSATION RENEWAL INFORMATION PAGE <br />RENEWAL OF WZ6- AO04288 -04 <br />CORRIFR CnnF NA 3(1937 <br />Policy Number <br />Policy Period <br />Coverage is Provided in the <br />Agency Code <br />From To <br />WZ6- AO04288 -05 <br />06/25/2018 06/25/2019 <br />THE HANOVER AMERICAN INSURANCE COMPANY <br />1902820 <br />11 EM 1. Named Insured and Address Agent Telephone: 844 - 367 -7899 <br />TRIANGLE UROLOGY ASSOCIATES PA ASSUREDPARTNERS OF NC LLC <br />ATTN: DAVIN BROWN CL HANOVER CSC /STE 350 <br />205 FRASIER ST 4505 FALLS OF NEUSE RD <br />DURHAM, NC 27704 RALEIGH, NC 27609 <br />Federal ID No. 561205950 <br />SEE ATTACHED SCHEDULE OF ADDITIONAL LOCATIONS FOR OTHER <br />WORKPLACES NOT SHOWN ABOVE. <br />IF APPLICABLE SEE CONTINUATION OF NAMED INSURED SCHEDULE. <br />ENTITY OF INSURED - CORPORATION <br />ITEM 2. POLICY PERIOD- 06/25/18 TO 06/25/19 12:01 AM STANDARD TIME AT <br />THE ADDRESS OF THE INSURED AS STATED HEREIN. <br />---------------------------------------------------------------------------------- <br />ITEM 3A. PART ONE OF THIS POLICY APPLIES TO THE WORKERS' COMPENSATION LAW'AND <br />ANY OCCUPATIONAL DISEASE LAW OF EACH OF THE FOLLOWING STATES - <br />NC. <br />-------------------------------------------------------------------- <br />B. PART TWO OF THIS POLICY APPLIES TO EMPLOYERS' LIABILITY INSURANCE FOR <br />WORK IN EACH STATE LISTED IN ITEM 3A: <br />BODILY INJURY BY ACCIDENT $500,000 EACH ACCIDENT <br />BODILY INJURY BY DISEASE $500,000 EACH EMPLOYEE <br />BODILY INJURY BY DISEASE $500,000 POLICY LIMIT <br />-------------------------------------------------------------------- <br />C. PART THREE OF THIS POLICY APPLIES TO OTHER STATES INSURANCE FOR THE FOL- <br />LOWING STATES- ALL STATES EXCEPT ND,OH,WA,WY, <br />AND THOSE STATES SPECIFICALLY NAMED IN ITEM 3A. <br />D. SEE ATTACHED SCHEDULE FOR LIST OF ENDORSEMENTS AND SCHEDULES FORMING <br />PART OF THIS POLICY. <br />ITEM 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, <br />CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW <br />IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. <br />ADJUSTMENT OF PREMIUM SHALL BE MADE ANNUALLY. <br />--------------------------------------------------------------------- - - - - -- <br />CLASSIFICATION OF OPERATIONS EST <br />ANNUAL <br />I PREMIUM <br />SEE ATTACHED SCHEDULE OF OPERATIONS <br />MINIMUM PREMIUM $261 EXPENSE CONSTANT <br />PREMIUM FOR TERRORISM <br />PREMIUM FOR CATASTROPHE <br />TOTAL ESTIMATED ANNUAL PREMIUM <br />DEPOSIT PREMIUM' <br />1,812 <br />210 <br />$44 <br />$73 <br />$2,139 <br />$2,139 <br />COUNTERSIGNED THIS DAY OF - - - - - - - - - - - - - - - <br />AUTHORIZED REPRESENTATIVE <br />BRANCH OFFICE:13840 BALLANTYNE CORP PL SUITE 100 CHARLOTTE NC 28277 <br />IF THE BILL FOR YOUR POLICY IS NOT ENCLOSED, IT WILL BE SENT TO YOU SEPARATELY. <br />00084form 331 -0226 (9 -03) <br />Date Issued: 03/27/2018 <br />WC000001 B <br />ORIGINAL /INSURED Payment Type: CUST SERV CTR- DIRECT BILL <br />WCDECI <br />