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DocuSign Envelope ID: DF078B63-CCED-42B9-8016-A67D8F6DF779 WORKERS COMPENSATION&EMPLOYERS LIABILITY <br /> BUILDERS MUTUAL INSURANCE CO. <br /> Post Office Box 150005 Policy Number: WCP 0044355 13 <br /> Raleigh, North Carolina 27624-0005 Named Insured: BROWN BROTHERS PLUMBING <br /> &HEATING CO INC <br /> Agent: DIVERSIFIED INSURANCE SOLUTION 0000443 <br /> EXTENSION OF INFORMATION PAGE <br /> ENDORSEMENT SCHEDULE - ITEM 3.D. <br /> State Form Nbr. Ed. Date Description <br /> US WCOOOOOOC (1/15) POLICY PAGE ENDORSEMENT <br /> US WC000414A (1/19) NOTE OF CHG IN OWNERSHIP END <br /> US WC000419 (1/01) PREMIUM DUE DATE ENDORSEMENT <br /> NC WC000302 (4/84) DESIGNATED WORKPLACES EXCL END <br /> NC WC000310 (4/84) SPROP/PARTNER/OTH CVG END <br /> NC WC000313 (4/84) WAIVER OF SUBROGATION <br /> NC WC000403 (4/84) EXP RATING MOD FACTOR END <br /> NC WC000404 (4/84) PENDING RATE CHG ENDORSEMENT <br /> NC WC000406A (7/95) PREMIUM DISCOUNT ENDORSEMENT <br /> NC WC000421 E (1/21) DOM TERR, EQUAKE, IND ACC END <br /> NC WC000422C (1/21) TRIPRA DISCLOSURE ENDT <br /> NC WC000424 (1/17) AUDIT NON-COMPLIANCE CHARGE EN <br /> NC WC000425 (1/17) EXP RATING MOD FACTOR END <br /> NC WC320301 D (7/18) NC AMENDED COVERAGE ENDORSE <br /> NC WC320601B (11/19) CANCELLATION AND NONRENEWAL <br /> NC WC320603 (7/18) INC NON-INS GOODS OR SRV ENDORS <br /> Issued Date: 1 1/29/2021 <br /> WC000001 A072I INSURED COPY Page 5 of 5 <br />