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DocuSign Envelope ID: 8FFCF3D9- 3AF5- 4C83 -9 982_9_- AC9D49_75107_C .�0 EMPLOYERS LIABILITY INSURANCE POLICY WC DO 09 01A <br />Erie INCLUDES CDF'YRICEii MATEMIL OF ilk 103CINRL COUNCIL CONY ERSATIDN INSURMCF. USED wan 1 I's PEFIK15Z1% <br />/04- n <br />E74.DM l'3U'jx0:7S_a FINAL AUDIT STATEMENT <br />hm P.4 ith ll <br />Agent Insurance to Provided By P-0I icy dumber �"':° <br />J31010 THE BALLARD A6ENI;Y ERIE INSURANCE EXCHANGL' 18457 Q92 2200215 <br />ITE -M 1. Named Insured and Address <br />THE HISTORICAL FOUNDAT TON OF <br />HILLSBOf{OOGI -11 & ORANGE CTY INC <br />2 -01 N CHURTON ST <br />HILLSBR}ROUGH ]NC 27275 -2535 <br />WHEN THIS POLICY WAS ISSUED, THE PREM -XUM WAS aASED ON AN 'ESTIMIATED' P'AYR01L. <br />RECENTLY, WE RECEIVED AN AUDIT WH M1 CAVE US THE 'ACTUAL' PAYFROL L . RE LOW WE <br />SHOW THE INFORMATION FROM THE AUDIT AND HIE ! N V ICATE :' - E 'ACTUAL ' PREMIUM A1.40 <br />THE 'ESTIMATED' PREMIUM AND NOW THE 'CHANGE IN PREMIUM' AFFECTS YOUR ACCOUNT. <br />AUDIT PERIOD 08/22116 TO GS/ 22, 17 <br />ST LOC CODE CLA5SIFICATIOPIS AUDITED RATE <br />NU PAYROLL PER 1$$ PAEMIUM <br />SEE ATTACHED SCHEDULE OF OPERATIONS 85 <br />0990 AMOUNY 1'0 SATISFY POLICY MIN PREMIU °M 265 <br />EXPENSE CONSTANT 16e <br />ACTUAL PREMIUM 51$ <br />ESTIMATED P REM!9M 797 <br />CHANCE IN PREMIUM DUE TO AUDIT $277 CFR <br />RETURNED PAYMENT FEES WILL BE ADDED TO FOUR ACCOUNT_ <br />PAGE 01 HOME OFFICE 02/22119 SERE REVERSE SIDE DEC <br />