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►EMPLOYER O America's smaO bueness insurance spvecWsO Government under a formula established by the Terrorism Risk Insurance Act, as amended. However, your policy may contain other exclusions which might affect your coverage, such as an exclusion for nuclear events. Under the formula, the United States Government generally reimburses 85% through 2015; 84% beginning on January 1, 2016; 83% beginning on January 1, 2017; 82% beginning on January 1, 2018; 81% beginning on January 1, 2019 and 80% beginning on January 1, 2020, of covered terrorism losses exceeding the statutorily established deductible paid by the insurance company providing the coverage. The Terrorism Risk Insurance Act, as amended, contains a $100 billion cap that limits U.S. Government reimbursement as well as insurers' liability for losses resulting from certified acts of terrorism when the amount of such losses exceeds $100 billion in any one calendar year. If the aggregate Insured losses for all insurers exceed $100 billion, your coverage may be reduced. The portion of your annual premium that is attributable to coverage for acts of terrorism is: $14, and does not include any charges for the portion of losses covered by the United States government under the Act. Earthquake, Catastrophic Industrial Accidents and Noncertified Acts of Terrorism Coverage for earthquake, catastrophic industrial accidents and noncertified acts of terrorism is included in your quote. This coverage applies to any single event resulting from an earthquake, catastrophic industrial accident, or noncertified act of terrorism which results in aggregate workers' compensation losses in excess of $50 million. The portion of your quoted premium that is attributable to this coverage is: $19. Employers Preferred Insurance Company charges a fee if the insured cancels the policy before the end of the policy term. This means that the final premium may be increased by a short -rate or penalty cancellation fee, which varies depending on how early the policy is cancelled or whether your policy is subject to an annual minimum premium. The range of penalty is 5% to 100% of the full policy premium. This quote includes coverage for the following additional scheduled Named Insureds: DBA: ALBI Named Insured: N/A Officers, Sole Proprietors, Members and/or Partners (or others) Coverage Exclusion: We will accommodate requests for exclusion (rejection of coverage) of employees to the extent permitted by the applicable workers' compensation laws of the states shown in Item 3.A of the information page, but only upon receipt of the following documentation: California CA Waiver of Workers Compensation Coverage - Corporate Officers or Members of a Board of Directors (attached) - UW_General (10/2016) CA Waiver of Workers Compensation Coverage - Partners and LLC Managing Members (attached) - UW_PH_0025_CA (10/2016) In California, effective 1/1/2017, each individual requesting waiver of his or her rights to workers' compensation benefits must provide to the insurer an executed written waiver stating under penalty of perjury that he or she qualifies for the waiver. Exclusions will be effective only upon receipt and acceptance of the waiver form(s) by the insurer. See attached forms for instructions. Any policy issued will include all state mandated endorsements. This quote includes the following optional endorsements: Conditions of binding: Quotation for Workers' Compensation and Employers Liability Insurance Page 4