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Page 4 of 4 <br />POLICY NUMBER:1000013056 <br />LA <br />12/23/2022 07:39:33 <br />REQUIREMENTS <br />Supplemental Schedules <br />WC 00 03 13 (04 84) Waiver of Our Right to Recover from Others Endorsement <br />Specific Waiver: NC <br />Name of Person or Organization: <br />ANY PERSON WITH WHOM OR AN ORGANIZATION WITH WHICH YOU <br />HAVE AGREED IN WRITING TO WAIVER YOUR RIGHTS TO RECOVER <br />Premium:$100 <br />WC 00 04 06 (08 84) Premium Discount Endorsement <br />State: SC <br />Estimated Eligible Premium <br />First <br />$5,000 <br />0.0% <br />Next <br />$95,000 <br />10.90% <br />Next <br />$400,000 <br />12.60% <br />Over <br />$500,000 <br />14.40% <br />WC 00 04 06 A (08 95) Premium Discount Endorsement <br />State: NC <br />Estimated Eligible Premium <br />First <br />$5,000 <br />0.0% <br />Next <br />$95,000 <br />10.90% <br />Next <br />$400,000 <br />12.60% <br />Over <br />$500,000 <br />14.40% <br />WC 00 04 24 (01 17) Audit Noncompliance Charge Endorsement <br />State Basis of Audit <br />Noncompliance Charge <br />Maximum Audit <br />Noncompliance Charge Multiplier <br />Any State listed in Item 3.A. <br />of the information page <br />Estimated Annual Premium Up to two times <br />WCD 90 02 (05 12) Notice of Cancellation to Third Party <br />Name of Person or Organization and Mailing Address: <br />CHOATE CONSTRUCTION COMPANY <br />8200 ROBERTS DR STE 600, ATLANTA, GA 30350 <br />Number of Days Advanced Notice for cancellation for any reason other than non-payment of premium or for <br />non-renewal: 30 <br />Docusign Envelope ID: 55889BA8-C67F-4754-881E-630DCDB08991