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1001700 2008 137728 208 09-18-2015Page 1 of 4EA 2504.2 Rev. 07-2015 <br />State Farm Fire and Casualty Company <br />Home Office, Bloomington, IL <br />Workers Compensation Application <br />Agent's Name <br />Donny Dingess Jr <br />Agent's Code <br />33-6492 <br />Policy Number <br />93-GB-C886-2 F <br />New Rew.of Policy Number Effective Date <br />05-17-2022 <br />Expiration Date <br />05-17-2023 <br />Term <br />12 Months <br />Underwriting <br />NAME <br />Please print <br />Last Name <br />SCHWARTZ <br />First Name <br />VALARIE <br />Middle Name or Initial <br />DBA <br />Attention, In care of, <br />subdivision, or other <br />Mailing <br />address <br />Number and Street <br />77 DOGWOOD ACRES DR <br />City or Town <br />CHAPEL HILL <br />State <br />NC <br />ZIP Code <br />27516-3111 <br />County Telephone Number <br />H B <br />Location address of all work places <br />Give a detailed description of the applicant's business (i.e. work performed, processes, services, products produced, etc.) <br />insured will be visiting various restaurants and hotels to document the provided provisions for disabled and <br />handicapped people to compile research for a article she is writing <br />Estimated annual revenue Number of years as an employer in this business 5 <br />The named applicant is Individual <br />Does the insured do work in more than one state? <br />Yes No <br />If yes, attach separate sheet showing separate states and payroll applicable to each. <br />Is the applicant engaged in any other type of business? <br />Yes No <br />Please explain: <br />Is the applicant currently covered through an assigned risk pool, fund, or plan? <br />Yes No <br />If yes, explain. <br />Name of person who has payroll and other financial records for the policy premium period Telephone Number <br />Address <br />Name of person to contact for inspection Telephone Number <br />Federal Employer's <br />I.D. number 455040737 <br />Unemployment <br />I.D. number <br />NCCI Risk <br />I.D. number <br />In the past 3 years, has Workers Compensation insurance been declined, canceled, <br />or non-renewed? <br />Yes No If yes, provide name of previous insurance company, policy <br />number, and other details. <br />Other State Farm®Fire policy numbers <br />Policy Number <br />Has the applicant had any Workers Compensation accidents, injuries, or incidents, insured or not, within the last 3 years? <br />Yes No If yes, complete loss <br />section below. <br />Workers Compensation Losses (Insured or not) In last three years. Attach loss history documentation from prior carrier. <br />Date of accident Type of loss or injury Amount paid <br />or reserved <br />Insurer <br />(Policy number, if available) <br />DocuSign Envelope ID: C91CBC16-495D-4832-812B-E650985A3B1B