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2018-494-E Health - Triangle Urology vasectomy services
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2018-494-E Health - Triangle Urology vasectomy services
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Last modified
8/28/2018 11:41:24 AM
Creation date
8/27/2018 10:51:20 AM
Metadata
Fields
Template:
Contract
Date
7/1/2018
Contract Starting Date
7/1/2018
Contract Ending Date
6/30/2019
Contract Document Type
Contract
Amount
$3,400.00
Document Relationships
2019-253-E Health - Triangle Urology vasectomy services amendment
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Path:
\Board of County Commissioners\Contracts and Agreements\General Contracts and Agreements\2010's\2019
R 2018-494 Health - Triangle Urology vasectomy services
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Path:
\Board of County Commissioners\Contracts and Agreements\Contract Routing Sheets\Routing Sheets\2018
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DocuSign Envelope ID: 5D924F8F- OA84- 4ECE- 95C8- E82E8DA18036 <br />The <br />anover <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 />CARRIFR r0DF NO Rn927 <br />Policy Number <br />Policy Period <br />Coverage is Provided in the <br />Agency Code <br />NC <br />From To <br />AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT <br />06/25/18 <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* E N D 0 R S E M E N T / F O R M <br />PAGE 4 <br />STATE 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 />S C H E D U L E ** SCHEDULE <br />PAGE 1 <br />EFFECTIVE <br />DATE <br />---------------------------------------------------------------------------------- <br />NC <br />*000308 0484 <br />PARTNERS, OFFICERS AND OTHERS EXCLUSION END. <br />06/25/18 <br />NC <br />*000424 0117 <br />AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT <br />06/25/18 <br />NC <br />*320301CO114 <br />NORTH CAROLINA AMENDED COVERAGE ENDT <br />06/25/18 <br />NC <br />*000414 0790 <br />NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT <br />06/25/18 <br />NC <br />*000419 0101 <br />PREMIUM DUE DATE ENDORSEMENT <br />06/25/18 <br />NC <br />*000422BO115 <br />TRIPRA DISCLOSURE ENDORSEMENT <br />06/25/18 <br />NC <br />X000311AO891 <br />VOLUNTARY COMP. & EMPL. LIAB. COV. END. <br />06/25/18 <br />NC <br />*000313 0484 <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />06/25/18 <br />NC <br />*O0000000115 <br />WORKERS COMP AND EMPLOYERS LIABILITY INS POLICY <br />06/25/18 <br />NC <br />*000404 0484 <br />PENDING RATE CHANGE END. <br />06/25/18 <br />NC <br />*000421DO115 <br />CATASTROPHE (NON - TERRORISM) PREMIUM ENDT <br />06/25/18 <br />00085 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 />
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