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DocuSign Envelope ID: 5D924F8F- OA84- 4ECE- 95C8- E82E8DA18036 <br />The <br />Li <br />C11 iwvwl <br />Insurance Group.. <br />WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY <br />32 EXTENSION OF INFORMATION PAGE <br />RENEWAL OF WZ6- A004288 -04 <br />rAPPIFR rf)nF NO RAM7 <br />Policy Number <br />Policy Period <br />Coverage is Provided in the <br />Agency Code <br />From To <br />WZ6- A004288 -05 <br />06/25/2018 06/25/2019 <br />THE HANOVER AMERICAN INSURANCE COMPANY i <br />1902820 <br />ITEM 1. Named Insured and Address <br />TRIANGLE UROLOGY ASSOCIATES PA <br />ATTN: DAVIN BROWN <br />205 FRASIER ST <br />DURHAM, NC 27704 <br />Federal ID No. 561205950 <br />POLICY ** A D D I T I 0 N A L <br />PAGE 2 <br />LOCATION <br />NUMBER <br />Agent Telephone: 844 - 367 -7899 <br />ASSUREDPARTNERS OF NC LLC <br />CL HANOVER CSC /STE 350 <br />4505 FALLS OF NEUSE RD <br />RALEIGH, NC 27609 <br />L O C A T I O N S ** SCHEDULE <br />PAGE 1 <br />Fill 1111 :41 1-1 <br />-------------------------------------------------------------------- <br />001 205 FRASIER STREET <br />DURHAM NC <br />27704 <br />-------------------------------------------------------------- - - - - -- <br />y <br />00084 orm 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 />