Orange County NC Website
Browse       Search
DocuSign Envelope ID:COE92964-1 D40-431E-B3C2-48EE5F39527D <br /> r„ <br /> Hanover <br /> Insurance 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-A004288-05 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: DAVIN BROWN CL HANOVER CSCISTE 360 <br /> 205 FRASIER ST 4505 FALLS OF NEUSE RD <br /> DURHAM, NC 27704 RALEIGH, NC 27609 <br /> Federal ID No. 561205950 <br /> POLICY ** S C H E D U L E O F 0 P E R A T I 0 N S ** SCHEDULE <br /> PAGE 3 PAGE 1 <br /> ITEM 4. CLASSIFICATION OF OPERATIONS EST RATE EST <br /> ST LOCT CODE TYP TOT-ANN PER$100 ANNUAL <br /> Y NO RSK REMUNERATION PREMIUM <br /> ----------------------------------------------------------------------------------- <br /> I I I <br /> NC 001 8832 H PHYSICIAN & CLERICAL 1 734,2001 .271 $1 ,982 <br /> 1 1 1 <br /> PREMIUM SUBJECT TO MODIFICATIDN I I 1 1 ,982 <br /> -------------------------------------------------------------- I ------ I - <br /> 0930 PREMIUM FOR WAIVER OF SUBROGATION 1 .0501 100 <br /> 9807 PREMIUM FOR INCREASED COV B LIMITS 1 .00801 16 <br /> 9848 BALANCE TO MINIMUM FOR COV B LIMITS 1 1 59 <br /> 9887 NC SCHEDULE MODIFICATION 1 .8401 345- <br /> 0032 LDSS CONSTANT 1 1 0 <br /> I I <br /> TOTAL FOR NORTH CAROLINA 1 I 1,812 <br /> ---------------------------------------------------------------------- <br /> I <br /> TOTAL SCHEDULE OF I <br /> OPERATIONS PREMIUM I $1,812 <br /> 9740 TERRORISM .0061 44 <br /> 9741 CATASTROPHE (OTHER THAN TERRORISM) . 0101 73 <br /> ---------------------------------------------------------------------------------- <br /> 000a, orm 331-0226 {9-03) WC000001B <br /> Date Issued: 03/27/2018 ORIGINAL/INSURED Payment Type: CUST SERV CTR-DIRECT BILL <br /> wcoEcl <br />