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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT <br />Policy Number: 59 WEC AC9055 Endorsement Number: <br />Effective Date: 07/03/20 Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address: BAY SPROUTS LLC <br />655 S MAIN ST STE 200-317 <br />ORANGE CA 92868 <br />Part Five - Premium, Section G. (Audit) of the Workers Compensation and Employers Liability Insurance Policy is revised <br />by adding the following: <br />If you do not allow us to examine and audit all of your records that relate to this policy, and/or do not provide audit <br />information as requested, we may apply an Audit Noncompliance Charge. The method for determining the Audit <br />Noncompliance Charge by state, where applicable, is shown in the Schedule below. <br />If you allow us to examine and audit all of your records after we have applied an Audit Noncompliance Charge, we will <br />revise your premium in accordance with our manuals and Part 5 - Premium, E. (Final Premium) of this policy. <br />Failure to cooperate with this policy provision may result in the cancellation of your insurance coverage, as specified <br />under the policy. <br />Schedule <br />State(s) <br />Basis of Audit Noncompliance <br />Maximum Audit Noncompliance <br />Charge <br />Charge Multiplier <br />AL, AR, CO, CT, DC, DE, GA, IA, ID, <br />Estimated Annual Premium <br />Up to two times <br />IL, KY, MD, ME, MI, MN, MS, NE, <br />NH, NJ, NM, OR, RI, SC, SD, TN, UT, <br />VA, VT, WV <br />AZ, HI, KS, OK <br />Estimated Annual Premium <br />Two times <br />NC <br />Estimated Annual Premium <br />Up to three times <br />NV <br />Estimated Annual Premium <br />Up to one times <br />WI <br />Estimated Annual Premium <br />One time <br />Form WC 00 04 24 Printed in U.S.A. <br />Process Date: 05/25/20 <br />ew cF RAMwagementDMsian <br />Jy/\'x REVIEWED & APPROVED BY.- <br />,v <br />POlic) R.Wjanagementftalpt <br />