INVOICE
North Carolina Self-Insurance Security Association
Post Office Box 12442
Raleigh, North Carolina 27605-2442
NORTH CAROLINA SELF-INSURANCE SECURITY
ASSOCIATION AGGREGATE SYSTEM
(N.C. Gen. Stat. § 97-133)
**COMPANY NAME:
FEDERAL TAX I.D. NO. 56-1916436
Invoice No.
Invoice Date: October 31, 2007
Due Date: November 30, 2007
COVERAGE PERIOD: DECEMBER 1, 2007 TO NOVEMBER 30, 2008
Member Workers’ Compensation Liability Assessment Assessment Assessment
Index Rate Amount
TOTAL ASSESSEMENT DUE
PAYMENT OPTIONS:
MAKE CHECK PAYABLE AND REMIT TO:
N.C. SELF-INSURANCE SECURITY ASSOCIATION
P.O. BOX 12442
RALEIGH, NC 27605
OR
WIRE TRANSFER:
WACHOVIA BANK
CHARLOTTE, NC
BANK ROUTING NUMBER 053000219
BANK ACCOUNT NUMBER
FAILURE TO PAY YOUR ASSESSMENT BY NOVEMBER 30, 2007 IS GROUNDS FOR
REVOCATION OF YOUR LICENSE TO SELF-INSURE.
INQUIRIES:
Franklin Roberts: (919) 787-8212 ext.106
James Stuart: (919) 787-6050
IF YOUR COMPANY LICENSE TO SELF-INSURE IS TERMINATED DURING THE
DECEMBER 1, 2007 TO NOVEMBER 30, 2008 COVERAGE PERIOD YOUR COMPANY IS
REQUIRED TO POST INDIVIDUAL SECURITY WITH THE NORTH CAROLINA
DEPARTMENT OF INSURANCE PURSUANT TO N.C. GEN. STAT. §§ 97-180 AND 97-185 (h).