Orange County NC Website
Browse       Search
DocuSign Envelope ID:7D69FBBF-740D-461 F-894A-506C56B8C2AA <br /> BERKSHIRE HATHAWAY Workar,k C9n1uensaJl!Qn��tEt�lL�_�ai�t#lty�'cal1�5E <br /> INSURANCE AtstGl3AFfl�Insurar�r�e Policy Nu^A Mack Company <br /> 636 <br /> NGUARDCOMPANIES qt`�' Policy��untiter PRV►tC663�76 <br /> Renewal of 11MC562943 <br /> NCCI No. [x1573] <br /> Policy information Pago <br /> ..._........ <br /> I]Named Inisurtsd INC. Mailing Address I.mvlan lnfurance and Finn=dif <br /> PRO NET SYSTEMS INC <br /> 3200-107 Glen Royal Ruad a,�1•so�..<.°rxR'tr ai a :s <br /> Ralelgh,NC 27617 Rr:s�!;� C:2»;,• s�;. <br /> rci:9 tr isiC,•;!ava <br /> e,.nt'otHSW �.x.?i43ar�R3rs <br /> Federal Employer's ID 56-2234077 Insured is Corporation <br /> Risk ID Number 6049357 <br /> _......,......, <br /> 12] Policy Period <br /> From Aprll 3,2015 to April 3,2016, 3 t:t31 AM,standard time at the Insured'S rnalling address. <br /> [3! Coverage <br /> A. Workers'Gnmperssation insurance-Part one of this policy applies to the Workers,Compensation <br /> Law of the following states: North Carolina <br /> B. Employer's Liability Insurance-f art Two of this policy applies to work In Each of the states IlskeQ <br /> in Item(3,}A. The limits of our liability under Part Two are: <br /> Bodily injury by Accident-each accident $1,000,000 <br /> Bodily Injury by Disease-each employee $1,000,000 <br /> Bodily Injury by Disease-Policy limit $1,000,000 <br /> C. Other States Insurance-Part Three of this polity applies to all states,except any state llsted In <br /> Item 131A,and the states of north Dakota,Ohio,Washingtonr and Wyoming, <br /> D. This policy Includes these endorsements and schedules; <br /> See Extension of Information Page-Schedule of Forms <br /> .......... <br /> . <br /> 141 Premium <br /> The Premium basis and,therefore,the premium will be determined by our Manual of Rules, <br /> Classifications,Rates,and Rating Plans. All required Infsarmation is subject to verification and change by <br /> _.. audit. (Continued an another page)._,.. � .e......._......... ......�...., W..�,..wT..._�...,,,........... <br /> Total Estimated Policy Premium $ 6,558 <br /> Total surcharges/Assessments $ 0.00 <br /> Total EStintAt6d Chat $ 6,558.00 <br /> INTERN t14E__r.3 Page-I- Information Page. <br /> MGA S PR►VC663376 WC 0000 1A <br /> Date ¢04t82/2035 <br /> Issuing Offica,P.Q.Box A-N,16 S.River Street,llHiikets-Barrer PA 2.6703-0020 0 WWW,9UerthCnr0 <br />