Orange County NC Website
Browse       Search
DocuSign Envelope ID: FCD9FE56-CF01-4E96-B983-B8E8DFE6811C <br /> 23 <br /> PAYMENT SCHEDULE <br /> COMMENCEMENT BILLING BILLING BASIS <br /> DATE FREQUENCY <br /> Deductible Plan <br /> Plan Losses 07/01/2022 DB-Monthly Paid <br /> Issued <br /> Claim Handling Charges <br /> Workers Compensation 07/01/2022 DB-Monthly Paid <br /> Issued <br /> Administrative Expense Reimbursement Adjustment <br /> Administrative Expense Reimbursement 01/01/2024 Once As per Expenses Section of <br /> Adjustment the Program Exhibit <br /> Non-Loss Responsive Premium(s) <br /> Non-Loss Responsive Premium(s)Adjustment 01/01/2024 Once As per Non-Loss <br /> Responsive Section of the <br /> Program Exhibit <br /> • Paid Basis means the amount of each loss actually paid within your plan layer. <br /> POLICY NUMBER TYPE OF COVERAGE STATES PLAN TYPE COMPANY <br /> UB-5T768836-22-PB-D Workers Compensation NC Deductible Farmington Casualty <br /> and Employers Liability Company <br /> The Company(ies)listed above have an address of One Tower Square,Hartford, CT 06183-7312. The omission of,or failure to include, <br /> any Policy in this Program Exhibit shall not relieve you of any of your duties or Obligations under this Agreement or under the Policies. <br /> Orange County THE TRAVELERS INDEMNITY COMPANY <br /> 208 SOUTH CAMERON STREET Travelers,385 Washington Street <br /> HILLSBOROUGH,NC 27278 St.Paul,MN 55102 <br /> Attention: Bonnie Hammersly,County Manager Attention:Stephanie Gardner <br /> BHAMMERSLEY@ORANGECOUNTYNC.GOV Email:SGARDNE2@travelers.com <br /> TRAVELERS J~ <br /> Version 02.01.22 2022 Program Exhibit Orange County Page 16 <br /> CA Form-W04M8F19 <br /> ©(2019)The Travelers Indemnity Company.All rights reserved <br />