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DocuSign Envelope ID:32C22978-D1B8-4515-AD1A-21853E88FAA8 <br /> r r • r r <br /> NEW HAMPSHIRE INSURANCE COMPANY 0008042-00 WC 015-42-5152 <br /> 13080 __..____..____..-------------------------------- <br /> 055-02-0118-10 <br /> •• • • PENN YLVAN! <br /> •• A PLANNED PARENTHOOD SOUTH ATLANTIC I G <br /> 100 SOUTH BOYLAN AVE <br /> RALEIGH, NC 27603-0000 <br /> An AIG company <br /> EXECUTIVE OFFICES; <br /> SEE EXTENSION OF ITEM-1. OF THE INFORMATION PAGE - WC990610 175 Water Street <br /> New York, NY 10038 <br /> LD# 911810018 PRODUCERS NAME AND ADDRESS <br /> MARSH USA INC. <br /> WORKERS COMPENSATION AND EMPLOYERS 1166 AVENUE OF THE AMERICAS <br /> LIABILITY POLICY INFORMATION PAGE NEW YORK, NY 10036-3712 <br /> INSURED IS PREVIOUS POLICY NUMBER <br /> CORPORATION RENEWAL 015425152 <br /> OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1, OF THE INFORMATION PAGE - WC990610 <br /> ITEM 2 POLICY PERIOD 12:01 A.M.standard time at the insured's <br /> mailing address FROM 01 /01 /18 TO 01/01/19 <br /> ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed <br /> here: <br /> NC SC VA WV <br /> B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. <br /> The limits of our liability under Part Two are: <br /> Bodily Injury by Accident $ 1 ,000,000 each accident <br /> Bodily injury by Disease $ 1 .000.000 policy limit <br /> Bodily Injury by Disease $ 1 .000.000 each employee <br /> C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: <br /> AK AL AR AZ CA CO CT DC DE FL GA HI .IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NE NH <br /> NJ NM NV NY OK OR PA RI SD TN TX UT VT WI <br /> D. This policy includes these endorsements and schedules: <br /> SEE EXTENSION OF ITEM 3.D. OF THE INFORMATION PAGE - WC990612 <br /> ITEM The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. <br /> All information required below is subject to verification and change by audit. <br /> Premium Basis Rate Per Estimated <br /> classifloatlons Code Number Total Remuneration S100 OF Re- Premium <br /> N Annual El 3 Year mimeration Annual ❑3 Year <br /> SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7754 <br /> TAXES/ASSESSMENTS/SURCHARGES $30 <br /> EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) $26o VA <br /> MINIMUM PREMIUM $750 NC TOTAL ESTIMATED ANNUAL PREMIUM $31 ,o74 <br /> If indicated below, interim adjustments of premium shall be made: <br /> ❑ Semi-Annually ❑ Quarterly ❑ Monthly DEPOSIT PREMIUM $31 ,074 <br /> 0110211$ CHICAGO 02 � <br /> Issue Date Issuing Office Authorized Representative WC 00 00 01A <br /> 39967(Rev'd 04108) <br />