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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 **E N D O R S E M E N T /F O R M S C H E D U L E **SCHEDULE <br />PAGE 4 PAGE 1 <br />STATE NUMBER EFFECTIVE <br />DATE <br />---------------------------------------------------------------------------------- <br />NC *000308 0484 PARTNERS,OFFICERS AND OTHERS EXCLUSION END.06/25/20 <br />NC *000313 0484 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS 06/25/20 <br />NC *000424 0117 AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT 06/25/20 <br />NC *320301D0718 NORTH CAROLINA AMENDED COVERAGE ENDORSEMENT 06/25/20 <br />NC *000414A0119 NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT 06/25/20 <br />NC *000419 0101 PREMIUM DUE DATE ENDORSEMENT 06/25/20 <br />NC *000422B0115 TRIPRA DISCLOSURE ENDORSEMENT 06/25/20 <br />NC *990612 0216 TRADE OR ECONOMIC SANCTIONS ENDT 06/25/20 <br />NC *000311A0891 VOLUNTARY COMP.&EMPL.LIAB.COV.END.06/25/20 <br />NC *000115 0120 NOTIFICATION ENDT OF PENDING LAW CHANGE TO TRIPRA 06/25/20 <br />NC *000000C0115 WORKERS COMP AND EMPLOYERS LIABILITY INS POLICY 06/25/20 <br />NC *000404 0484 PENDING RATE CHANGE END.06/25/20 <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