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WC000001B <br />04/06/2020 ORIGINAL/INSURED DIRECT BILL <br />WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY <br />32 EXTENSION OF 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 />POLICY ** S C H E D U L E O F O P E R A T I O 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 />|| | <br />NC 001 8832 H PHYSICIAN & CLERICAL | 734,200|| <br />|| | <br />PREMIUM SUBJECT TO MODIFICATION || | <br />--------------------------------------------------------------|------|------------ <br />0930 PREMIUM FOR WAIVER OF SUBROGATION || <br />9807 PREMIUM FOR INCREASED COV B LIMITS || <br />9848 BALANCE TO MINIMUM FOR COV B LIMITS | | <br />9887 NC SCHEDULE MODIFICATION || <br />0032 LOSS CONSTANT | | <br />| | <br />TOTAL FOR NORTH CAROLINA | <br />---------------------------------------------------------------------|------------ <br />| <br />TOTAL SCHEDULE OF | <br />OPERATIONS PREMIUM | $ <br />9740 TERRORISM| <br />9741 CATASTROPHE (OTHER THAN TERRORISM)| <br />---------------------------------------------------------------------------------- <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