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DocuSign Envelope ID:COE92964-1 D40-431E-B3C2-48EE5F39527D <br /> Hanover <br /> 111suralice Group- <br /> WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY <br /> 32 EXTENSION OF INFORMATION PAGE <br /> RENEWAL, OF WZ6-A004288-04 <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 INC LLC <br /> ATTN: DAVIN BROWN CL HANOVER CSCISTE 350 <br /> 205 FRASIER ST 4505 FALLS OF NEUSE RD <br /> DURHAM, NC 27704 RALEIGH, NC 27609 <br /> Federal ID No. 561205950 <br /> POLICY * E N D 0 R S E M E N T ■ F 0 R M S C H E D U L E * SCHEDULE <br /> PAGE 4 PAGE I <br /> STATE NUMBER EFFECTIVE <br /> DATE <br /> ---------------------------------------------------------------------------------- <br /> NC *000308 0484 PARTNERS, OFFICERS AND OTHERS EXCLUSION END. 06/25/18 <br /> NC *000424 0117 AUDIT NONC❑MPLIANCE CHARGE ENDORSEMENT 06/25/18 <br /> NC *320301C0114 NORTH CAROLINA AMENDED COVERAGE ENDT 06/25/18 <br /> NC *000414 0790 NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT 06/25/18 <br /> NC *000419 0101 PREMIUM DUE DATE ENDORSEMENT 06/25/18 <br /> NC *000422BO115 TRIPRA DISCLOSURE ENDORSEMENT 06/25/18 <br /> NC *000311A0891 VOLUNTARY COMP. 8 EMPL , LIAR. COV. END. 06/25/18 <br /> NC *000313 0484 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS 06/25/18 <br /> NC *00000000115 WORKERS COMP AND EMPLOYERS LIABILITY INS POLICY 06/25/18 <br /> NC *000404 0484 PENDING RATE CHANGE END. 06/25/18 <br /> NC *000421D0115 CATASTROPHE (NON-TERRORISM) PREMIUM ENDT 96/25/18 <br /> ---------------------------------------------------------------------------------- <br /> S arm 331-0226 (9-03) WC000001B <br /> ate Issued: 03/27/2018 ORIGINAL/INSURED Payment Type: CUST SERV CTR-DIRECT BILL <br /> WCOECI <br />