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g Workers' Compensation and Employer's Liability Policy <br />t GUARD Am GUARD Insurance Company - A Stock Company <br />INSURANCEPolicy Number ORWC311495 <br />"* �y Renewal of ORWC208613 <br />G` R U ('� NCCI No.[21873] <br />Policy Information Page <br />Policy Payment 'terms <br />Payment Optlon: Payroll Bill <br />You have requested payment via payroll deduction, so your premium will be deducted from <br />your account by your payroll service and remitted to us in accordance with the timetable you <br />have established with that provider. Since you have agreed to pay via this methodology, we <br />have waived our usual down payment requirement and authorized you to pay in smaller <br />increments over a longer period of time than would otherwise be the case, If payroll <br />deduction is terminated or suspended for any reason or If you fail to maintain sufficient funds <br />in your account to meet your obligations to us, the entire remaining unpaid balance shall <br />then become immediately due and payable. <br />* If we provided you with coverage in a prior policy terrn and any unpaid premium <br />is owed for that year, you must pay the amount due in full by the date specified in <br />our billing notice. <br />INTERNAL USE xx <br />MGA :ORWC311495 <br />Date :09/08/2012 <br />Page - 5 - <br />16 South River Street • P.O. Box A-H • Wilkes-Barre, PA 18703-0020 • www,guard.corn <br />