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DocuSign Envelope ID:07A4359F-6D47-4987-B1F1-BF667ACBB3BA WORKERS COMPENSATION&EMPLOYERS LIABILITY <br /> BUILDERS PREMIER INSURANCE CO. <br /> Post Office Box 150005 Policy Number: PWC 1017090 01 <br /> Raleigh, North Carolina 27624-0005 Named Insured: MOFFAT PIPE INC <br /> Agent: JONES INSURANCE AGENCY INC 0000250 <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 /> NC WC000302 (4/84) DESIGNATED WORKPLACES EXCL END <br /> NC WC000308 (4/84) PARTNER/OFFICER/OTH EXC 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 WC000419 (1/01) PREMIUM DUE DATE ENDORSEMENT <br /> NC WC000421 F (8/22) 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) NC NON-INS GOODS OR SRV ENDORS <br /> Issued Date: 02/08/2024 <br /> WC 00 00 01 A 07 21 INSURED COPY Page 4 of 4 <br />