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DocuSign Envelope ID:COE92964-1 D40-431E-B3C2-48EE5F39527D <br /> �• Hanover <br /> Insumlicc Group- <br /> WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY <br /> 32 EXTENSION OF INFORMATION PAGE <br /> RENEWAL OF WZ6-AO04288-04 <br /> CARRIER CODE NO. 30937 <br /> Policy Number Policy Period Coverage is Provided in the Agency Code <br /> From To <br /> WZ6-AO04288-05 06/25/2018 06/25/2019 THE HANOVER AMERICAN INSURANCE COMPANY 1902820 <br /> ITEM 1. Named Insured and Address Agent Telephone: 844-367-7899 <br /> TRIANGLE UROLOGY ASSOCIATES PA ASSUREDPARTNERS OF NC LLC <br /> ATTN: ❑AVIN BROWN CL HANOVER CSCISTE 350 <br /> 205 FRASIER ST 4505 FALLS OF NEUSE R❑ <br /> ❑URHAM, NC 27704 RALEIGH, NC 27609 <br /> Federal ID No. 561205950 <br /> POLICY ** A D D I T I 0 N A L L O C A T I O N S ** SCHEDULE <br /> PAGE 2 PAGE I <br /> LOCATION ADDRESS <br /> NUMBER <br /> -__.._------------------------------------------------------------------ <br /> 001 205 FRASIER STREET <br /> DURHAM NC <br /> 27704 <br /> --------------------------------------------------------------------- <br /> wc,8a arm 331-0226 0-03) WC000601B <br /> Date Issued: 03/27/2018 ORIGINAL/INSURED Payment Type: CUST SERV CTR-DIRECT BILL <br /> wcaEC1 <br />