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TRAVELERSJ� <br />ONE TOWER SQUARE <br />HARTFORD CT 06183 <br />CHANGE EFFECTIVE DATE: 07-27-20 <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />CHANGE DOCUMENT WC 99 99 98 ( A) <br />POLICY NUMBER: UB-5J743745-20-47-G <br />NCCI CO CODE: 13579 <br />INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA <br />INSURED'S NAME: SAGECREST PLANNING AND <br />ENVIRONMENTAL, <br />This change is issued by the Company or Companies that issued the policy and forms a part of the policy. It is <br />agreed that the policy is amended as follows: <br />An absence of an entry in the premium spaces below means that the premium adjustment, if any, will be made at <br />time of audit. <br />ADDITIONAL PREMIUM $ NIL <br />RETURN <br />PREMIUM <br />$ NIL <br />ADDITIONAL <br />NON -PREMIUM $ NIL <br />RETURN <br />NON -PREMIUM $ NIL <br />Tax and Assessment charges are changed as <br />follows: <br />STATE <br />DESCRIPTION <br />STAT CODE PERCENTAGE <br />CA <br />LABOR ENFORCEMENT AND <br />COMPLIANCE FUND ASSESSMENT <br />0069 <br />0.381 <br />% <br />CA <br />OCCUPATIONAL SAFETY AND <br />HEALTH FUND ASSESSMENT <br />9714 <br />0.391 <br />% <br />CA <br />SUBSEQUENT INJURY BENEFIT <br />TRUST FUND ASST <br />9716 <br />0.482 <br />% <br />CA <br />UNINSURED EMPLOYERS BENEFIT <br />TRUST FUND ASST <br />9715 <br />0.127 <br />% <br />CA <br />STATE FRAUD SURCHARGE <br />9713 <br />0.335 <br />% <br />CA <br />WC ADMIN REVOLVING FUND <br />ASSESSMENT <br />9712 <br />1.704 <br />% <br />Item 3.D Form Number is added: <br />WC 99 06 R3 00 - 004 NOTICE OF CAN TO DESIGN PERSONS OR ORGAN <br />DATE OF ISSUE: 07-27-20 AS CHANGE NO: 1 PAGE 1 OF 1 <br />POL. EFF. DATE: 06-01-20 POL. EXP. DATE: 06-01-21 <br />OFFICE: SPECIALIST A&E 21X <br />PRODUCER: HALL & COMPANY CGX28 <br />COUNTERSI <br />Rime Management DMsinn <br />rrREMEWED&{{A�P'PIRIovEDBY. <br />�� Risk Management Analyst <br />