INVOICE
North Carolina Self-Insurance Security Association Post Office Box 12442 Raleigh, North Carolina 27605-2442
**COMPANY NAME: FEDERAL TAX I.D. NO. 56-1916436
NORTH CAROLINA SELF-INSURANCE SECURITY ASSOCIATION AGGREGATE SYSTEM (N.C. Gen. Stat. § 97-133) 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 Index Assessment Rate Assessment 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).