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DocuSign Envelope ID:07A4359F-6D47-4987-B1F1-BF667ACBB3BA WORKERS COMPENSATION $ EMPLOYERS LIABILITY <br /> L Raleigh, North Carolina 27624-0005 Insurance Policy <br /> MUTUAL (800)809-4859 <br /> Policy Number From <br /> Period To <br /> ® Builders Premier Insurance Company <br /> ❑ Builders Mutual Insurance Company PWC 1017090 01 03/10/2024 03/10/2025 <br /> 12:01 A.M.Standard Time at the described location <br /> RENEWAL DECLARATION Customer#: <br /> 1. Named Insured and Address Agent <br /> MOFFAT PIPE INC JONES INSURANCE AGENCY INC <br /> 701 FINGER LAKES DR 820 BENSON RD <br /> WAKE FOREST NC 27587 GARNER, NC 27529 <br /> Tele hone: 919-772-0233 0000250 <br /> NCCI Carrier# FEIN# Risk ID# Entity of Insured <br /> 63792 562183333 6120783 CORPORATION <br /> Other workplaces not shown above: See Site Location Schedule <br /> 2.The Policy Period is from 03/10/2024 to 03/10/2025 12:01 a.m. Standard Time at the Insured's mailing address. <br /> 3.A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states <br /> listed here:North Carolina <br /> B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A. <br /> The limits of our liability under Part Two are: <br /> Bodily Injury by Accident $ 1, 000, 000 each accident <br /> Bodily Injury by Disease $ 1, 000, 000 policy limit <br /> Bodily Injury by Disease $ 1, 000, 000 each employee <br /> C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: <br /> SC, VA, TN, MD, MS, DC except state(s) listed in Item 3.A. above. <br /> D. This policy includes these endorsements and schedules: See attached schedule. <br /> 4.The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. <br /> All information required below is subject to verification and change by audit. <br /> SEE CLASSIFICATIONS OF OPERATIONS EXTENSION OF INFORMATION PAGE <br /> FAILURE TO PAY ANY PAST OR CURRENT PREMIUMS DUE WILL RESULT <br /> IN THE RESCISSION OF THIS OFFER OF COVERAGE . <br /> Minimum Premium $ 872 Total Estimated Annual Premium $ 65,259 <br /> Expense Constant $ 210 <br /> Premium Discount $ - 7,220 <br /> Premium Adjustment Period: ® Annual; ❑ Semiannual; ❑ Quarterly; ❑ Monthly <br /> Countersigned this Day of <br /> Issued Date: 02/08/2024 Authorized Representative <br /> Issuing Office BUILDERS PREMIER INSURANCE CO. <br /> WC 00 00 01 A 07 21 INSURED COPY Page 1 of <br />