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WC000001B <br />04/06/2020 ORIGINAL/INSURED DIRECT BILL <br />WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY <br />32 WORKERS COMPENSATION RENEWAL INFORMATION PAGE <br />RENEWAL OF WZ6-A004288-06 <br />CARRIER CODE NO.11002 <br />WB6-A004288-07 06/25/2020 06/25/2021 CITIZENS INSURANCE COMPANY OF AMERICA 1902820 <br />919-781-0200 <br />TRIANGLE UROLOGY ASSOCIATES PA <br />ATTN:DAVIN BROWN <br />205 FRASIER ST <br />DURHAM,NC 27704 <br />ASSUREDPARTNERS OF NC LLC <br />CL HANOVER CSC/STE 350 <br />4505 FALLS OF NEUSE RD <br />RALEIGH,NC 27609 <br />561205950 <br />SEE ATTACHED SCHEDULE OF ADDITIONAL LOCATIONS FOR OTHER <br />WORKPLACES NOT SHOWN ABOVE. <br />IF APPLICABLE SEE CONTINUATION OF NAMED INSURED SCHEDULE. <br />ENTITY OF INSURED - CORPORATION <br />ITEM 2. POLICY PERIOD- 06/25/20 TO 06/25/21 12:01 AM STANDARD TIME AT <br />THE ADDRESS OF THE INSURED AS STATED HEREIN. <br />---------------------------------------------------------------------------------- <br />ITEM 3A. PART ONE OF THIS POLICY APPLIES TO THE WORKERS' COMPENSATION LAW AND <br />ANY OCCUPATIONAL DISEASE LAW OF EACH OF THE FOLLOWING STATES- <br />NC. <br />-------------------------------------------------------------------- <br />B. PART TWO OF THIS POLICY APPLIES TO EMPLOYERS' LIABILITY INSURANCE FOR <br />WORK IN EACH STATE LISTED IN ITEM 3A: <br />BODILY INJURY BY ACCIDENT $500,000 EACH ACCIDENT <br />BODILY INJURY BY DISEASE $500,000 EACH EMPLOYEE <br />BODILY INJURY BY DISEASE $500,000 POLICY LIMIT <br />-------------------------------------------------------------------- <br />C. PART THREE OF THIS POLICY APPLIES TO OTHER STATES INSURANCE FOR THE FOL- <br />LOWING STATES- ALL STATES EXCEPT ND,OH,WA,WY, <br />AND THOSE STATES SPECIFICALLY NAMED IN ITEM 3A. <br />-------------------------------------------------------------------- <br />D. SEE ATTACHED SCHEDULE FOR LIST OF ENDORSEMENTS AND SCHEDULES FORMING <br />PART OF THIS POLICY. <br />---------------------------------------------------------------------------------- <br />ITEM 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, <br />CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW <br />IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. <br />ADJUSTMENT OF PREMIUM SHALL BE MADE ANNUALLY. <br />--------------------------------------------------------------------------- <br />CLASSIFICATION OF OPERATIONS | EST <br />| ANNUAL <br />| PREMIUM <br />SEE ATTACHED SCHEDULE OF OPERATIONS | <br />| <br />| <br />MINIMUM PREMIUM $EXPENSE CONSTANT| <br />PREMIUM FOR TERRORISM |$ <br />PREMIUM FOR CATASTROPHE |$ <br />TOTAL ESTIMATED ANNUAL PREMIUM | $ <br />DEPOSIT PREMIUM| $ <br />COUNTERSIGNED THIS DAY OF ,- - - - - - - - - - - - - - - <br />AUTHORIZED REPRESENTATIVE <br />BRANCH OFFICE:13840 BALLANTYNE CORP PL SUITE 100 CHARLOTTE NC 28277 <br />IF THE BILL FOR YOUR POLICY IS NOT ENCLOSED, IT WILL BE SENT TO YOU SEPARATELY. <br />Form 331-0226 (9-03) <br />Date Issued:Payment Type: <br />WCDEC1 <br />Policy Number Policy Period <br />From To <br />Coverage is Provided in the Agency Code <br />ITEM 1.Named Insured and Address Agent Telephone: <br />Federal ID No. <br />DocuSign Envelope ID: F746D5BF-EF42-497A-9B83-D263FC4E623D