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ENDORSEMENT SCHEDULE - ITEM 3.D. <br />State Form Nbr.Ed. Date Description <br />Named Insured: <br />Agent: <br />EXTENSION OF INFORMATION PAGE <br />WORKERS COMPENSATION & EMPLOYERS LIABILITY <br />BUILDERS MUTUAL INSURANCE CO. <br />Post Office Box 150005 <br />Raleigh, North Carolina 27624-0005 <br />WCP 0044355 13 <br />BROWN BROTHERS PLUMBING <br />& HEATING CO INC <br />DIVERSIFIED INSURANCE SOLUTION 0000443 <br />Policy Number: <br />US WC000000C (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 WC000421E (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 WC320301D (7/18)NC AMENDED COVERAGE ENDORSE <br />NC WC320601B (11/19)CANCELLATION AND NONRENEWAL <br />NC WC320603 (7/18)NC NON-INS GOODS OR SRV ENDORS <br />Issued Date: <br />WC 00 00 01 A 07 21 <br />11/29/2021 <br />INSURED COPY Page 5 of 5 <br />DocuSign Envelope ID: F0A3B2EE-E33F-4F23-BBF0-3EFDC539D263