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DocuSign Envelope ID: 8FFCF3D9- 3AF5- 4C83 -9 982_9- AC9D49_75107_C_ -J9 EMPLOYERS LIAOUTY INSURANCE POLICY 1A 00 00 01A <br />Erie INCLU ®ES CDP'fFMGWf MAT €f rLL FHE NATIONAL CIxUNCiL DR COMPENSATION INSURA CE. usC7 ' ini I T $ PF w1swN <br />Insuarce' INFQRMATIOM PAGE <br />x'74 arc; -•+.a,�' ° =i += :e. +_ '� , �, R <br />PRIOR POLICY NUMBER. - Q92 2200715 <br />Agent Insurance Is Provided By Po I i cy Num ber ' a: <br />J31010 THE B I I ARD AGENCY ERIE INSURANCL EXCHANGE 18457 Q9.2 2100215 <br />ITEM 1. Named Insured 2nd Address <br />THE HISTORICAE FOUNDATION OF <br />HZ l- L.!5B1)P()UGH & ORANGE CTY INC <br />201 N CHURTON ST <br />HILLSBOROUGH NC 272' 78-2535 <br />AMENDMENT 02 *4* EFFECTIVE R$ /, /17 <br />REASON FOR AMENDMENT- AMENDED REMUN <br />CORPORATION ORANGE CO <br />OTHER WORKPLACES NOT SHOWN ABOVE - <br />* ** ATTACH THIS TO Y04JE POLICY <br />DUE TO AUDIT` <br />AS SCHEDULED <br />ITEM Z. THE POLICY PERIOD IS FROMM G312 X17 TO 08/22118 AT THE INSUREDS <br />MAILING ADDRESS- <br />ITFM 3.A. WORKERS COYIPENSATION INSURANCE- PART ONE OF THE POLICY APPLIES TO THE <br />WORKERS COMPENSATION LAW OF THE STATES LISTED !HERE- NC, <br />ITEM 3 -B_ EMPLOYLR5 LIAPILIT'Y INSURANCE- PART TWO OF THE POLICY APPLIES TO WORK <br />IN EA(H STATE LISTED IN <br />ITEM 3-A. THE <br />LIMITS OF <br />OUR LIABILITY UNDER PART TWO ARE- <br />BODILY INDURY <br />BY ACCIDENT <br />$1,000,000 <br />EACH ACCIDLNT <br />BODILY IN3URY <br />BY DISEASE <br />$1,0$0,000 <br />POLICY LIMIT <br />BODILY INJURY <br />BY DISEASE <br />$1,000,000 <br />EACH EMPLOYEE <br />TTEM 3,C, OTHER STATES INSURANCE- PART THREE OF THE POLICY APPLIES TO THE <br />STATE5, IF ANY, LISTED MERE- ALL STATES EXCEPT ND, CH, WA, WY, STATES <br />DESIGNATED IN ITEM 3.A., <br />ITEM 3,0,. SEE ATTACHED ENDORSEMENT SCHEDULE. <br />ITEM 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINE[i UY OUR MANUALS OF RULES, <br />CLASSIFICATIONS, RATES AND RATING PLANS. ALL INFORMATION R E QUI RED BELOW IS <br />SUBJECT TO VFAIPTCATTON AND CKAN-GE BY .AUDIT_ <br />SEE A7TACHED SCHEDULE OF OPERATIONS <br />9312 PREMIUM FOR IJNCREASED COV TWO LIMITS 10110 <br />9343 AMT FOR INE R EA5 EU COV TWO NINE PREMIUM <br />CODE 0990 AMOUNT TO SATISFY POLICY MIN PREMIUM <br />EXPENSE CONSTANT <br />TOTAL ESTIMATED ANNUM_ PREMIUM <br />DEP05IT PREMIUM <br />CHANGE IN PREMIUM FOR REMAINDER OF POLICY PERIOD <br />MINIMUM (PREMIUM $643 <br />RETURNED PAYMENT FEES WILL BE ADDED TO YOUR ACCOUNT.. <br />PAGE 01 HOME OFFICE 02/22/18 SEE REVERSE SXDE DEC <br />68 <br />1 <br />119 <br />425 <br />160 <br />►773 <br />$7'7 <br />$010.0 <br />