Orange County NC Website
Browse       Search
DocuSign Envelope ID:48D95A50-1183-4EB9-9997-46BD3A0D7724 <br /> StafeFarm WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY <br /> INFORMATION PAGE <br /> 07- 1010-FB5D <br /> POLICY NO. 93-CV-P475-7 COVERAGE IS PROVIDED BY <br /> REPLACES NO . 93-CV-J391 -2 STATE FARM FIRE AND CASUALTY COMPANY <br /> 3 RAVINIA DRIVE , ATLANTA GA 30346-2117 <br /> NCCI CARRIER CODE NO . 14842 <br /> 1 . NAMED INSURED & MAILING ADDRESS RISK ID NO . 006219515 <br /> ANALYTICAL CONSULTANTS INC FEIN 201186981 <br /> 125 KINGSTON DR STE 206 LOCATION : <br /> CHAPEL HILL NC 27514- 1649 125 KINGSTON DR STE 206 <br /> CHAPEL HILL NC 27514- 1649 <br /> INSURED IS A CORPORATION <br /> COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE <br /> ------ ------- ---------------- - ------- - - - ------ - ------------ <br /> 2 . THE POLICY PERIOD IS FROM 10/01 /2018 TO 10/01 /2019 -12 : 01 A . M . STANDARD TIME <br /> AT THE INSURED' S MAILING ADDRESS . <br /> ---------- - ------ - - ------------- - -------- - - --- - - ----- -- <br /> 3A . WORKERS COMPENSATION INSURANCE : PART ONE OF THE POLICY APPLIES TO THE <br /> WORKERS COMPENSATION LAW OF THE STATES LISTED HERE : NC <br /> B . EMPLOYERS LIABILITY INSURANCE : PART TWO OF THE POLICY APPLIES TO <br /> WORK IN EACH STATE LISTED IN ITEM 3A . THE LIMITS OF OUR LIABILITY <br /> UNDER PART TWO ARE : BODILY INJURY BY ACCIDENT $ 1 , 000 , 000 EACH ACCIDENT <br /> BODILY INJURY BY DISEASE $ 1 , 000 , 000 EACH EMPLOYEE <br /> BODILY INJURY BY DISEASE $ 1 , 000 , 000 POLICY LIMIT <br /> C . OTHER STATES INSURANCE : PART THREE OF THE POLICY APPLIES TO ALL STATES <br /> EXCEPT ME , MT , ND , OH , RI , WA , WV , WY AND STATES LISTED IN 3A . <br /> D . THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES : WC320301D* <br /> WC000414 WC000419 WC000308 WC000000C WC000422B* WC000421D WC000404 <br /> WC000424 <br /> *EFFECTIVE 10/01 / 18 <br /> --------------- - - - ------ - -------- - - ----- - - ------------------------ ----- - ------ <br /> 4 . THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF <br /> RULES, CLASSIFICATIONS, RATES AND RATING PLANS . ALL INFORMATION <br /> REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT . <br /> PREMIUM BASIS TO- RATE/$ 100 ESTIMATED <br /> CODE NOS . AND TAL ESTIMATED AN- REMUNERA- ANNUAL <br /> CLASSIFICATIONS NUAL REMUNERATION TION PREMIUM <br /> - ------ -------- - - -------- - -------- - - ----- - ---------------- ----- -- -- -- - - ----- <br /> 8721 473 , 929 . 40 1 , 896 <br /> REAL ESTATE APPRAISAL COMPANIES - <br /> OUTSIDE EMPLOYEES <br /> 8810 80 , 471 . 15 121 <br /> CLERICAL OFFICE EMPLOYEES NOG <br /> EMPLOYERS LIABILITY INCREASED LIMITS 120 <br /> CATASTROPHE (OTHER THAN TERRORISM) 9741 554 , 400 . 01 55 <br /> TERRORISM 9740 554 , 400 . 01 55 <br /> MINIMUM PREMIUM $ 400 NO . CAROLINA TOTAL ESTIMATED ANNUAL PREMIUM $ 2 . 247 <br /> ------ ------------- - --------- - - ------ ------ - -------------- - - ------ - - ------- - -- <br /> PREMIUM ADJUSTMENT PERIOD SHALL BE ANNUAL DEPOSIT PREMIUM $ 2 , 247 <br /> PREPARED 08/20/2018 <br /> WC 00 00 01 A COUNTERSIGNED <br />