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WC 99 03 65 (03/11) <br />Page 1 of 1 <br />OLD REPUBLIC INSURANCE COMPANY <br />WORKERS’ COMPENSATION AND EMPLOYERS’ LIABILITY POLICY <br />DESIGNATED ENTITY - NOTICE OF CANCELATION PROVIDED BY US <br />ENDORSEMENT <br />SCHEDULE <br />Number of Days Notice of Cancellation:30 <br />Person or Organization: <br />Orange County <br />300 West Tryon Street <br />Hillsborough, NC 27278 <br />Address: <br />THE ADDRESSES AS SPECIFIED IN THE CONTRACTS OR AGREEMENTS. <br />If we cancel this policy for any statutorily permitted reason other than nonpayment of premium, and a <br />number of days is shown for cancelation in the schedule above, we will mail notice of cancelation to the <br />person or organization shown in the schedule above. We will mail such notice to the address shown in the <br />schedule above at least the number of days shown for cancelation in the schedule above before the <br />effective date of cancelation. <br />Docusign Envelope ID: 08EB7AB9-4CA5-42DD-AE56-28706889019F