Orange County NC Website
Browse       Search
DocuSign Envelope ID: 5D924F8F- OA84- 4ECE- 95C8- E82E8DA18036 <br />Hanover <br />Insurance Group.. <br />WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY <br />32 EXTENSION OF INFORMATION PAGE <br />RENEWAL OF WZ6- AO04288 -04 <br />CARRIER CODE NO 30937 <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 <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 ** S C H E D U L E <br />PAGE 3 <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 />OF O P E R A T I O N S ** SCHEDULE <br />PAGE 1 <br />ITEM 4. CLASSIFICATION OF OPERATIONS EST RATE EST <br />ST LOCT CODE TYP TOT -ANN PER$100 ANNUAL <br />Y NO RSK REMUNERATION PREMIUM <br />---------------------------------------------------------------------------- - - - - -- <br />NC 001 8832 H PHYSICIAN & CLERICAL <br />PREMIUM SUBJECT TO MODIFICATION <br />0930 PREMIUM FOR WAIVER OF SUBROGATION <br />9807 PREMIUM FOR INCREASED COV B LIMITS <br />9848 BALANCE TO MINIMUM FOR COV B LIMITS <br />9887 NC SCHEDULE MODIFICATION <br />0032 LOSS CONSTANT <br />734,2001 .27 <br />.050'i <br />.00801 <br />.8401 <br />I <br />--------- - - - - -- TOTAL - FOR - NORTH - CAROLINA----------------------- I - - - - -- <br />TOTAL SCHEDULE OF <br />OPERATIONS PREMIUM <br />9740 TERRORISM .0061 <br />9741 CATASTROPHE (OTHER THAN TERRORISM) .0101 <br />---------------------------------------------------------------- - - - - -- <br />R <br />00084 orm 331 -0226 (9 -03) <br />ate Issued: 03/27/2018 <br />$1,982 <br />1,982 <br />100 <br />16 <br />59 <br />345 - <br />0 <br />------ 1,812- <br />$1,812 <br />44 <br />73 <br />WC000001 B <br />ORIGINAL /INSURED Payment Type: CUST SERV CTR- DIRECT BILL <br />WCDECI <br />