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EXPERIENCE MODIFICATION ENDORSEMENT <br />HOME OFFICE <br />SAN FRANCISCO EFFECTIVE JULY 1, 2021 AT 12.01 A.M. <br />ALL EFFECTIVE DATES ARE <br />AT 12:01 AM PACIFIC <br />STANDARD TIME OR THE <br />TIME INDICATED AT <br />PACIFIC STANDARD TIME <br />FRIENDS OF SANTA ANA ZOO <br />1801 E CHESTNUT AVE <br />SANTA ANA, CA 92701 <br />REP D1 <br />9048876-21 <br />RENEWAL <br />SP <br />3-68-03-58 <br />PAGE 1 OF <br />ANY CONTRADICTION BETWEEN THE POLICY AND THIS ENDORSEMENT <br />WILL BE CONTROLLED BY THIS ENDORSEMENT. <br />IT IS AGREED THAT THE POLICY CONTRACT PREMIUM EARNED <br />AT THE BASE RATE SHALL BE MODIFIED BY 174 % IN <br />ACCORDANCE WITH THE CALIFORNIA WORKERS' COMPENSATION <br />EXPERIENCE RATING PLAN. <br />NOTHING IN THIS ENDORSEMENT SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND <br />ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY <br />OTHER THAN AS ABOVE STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE <br />HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR <br />LIMITATIONS IN THIS ENDORSEMENT. <br />1 <br />COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: JUNE 25, 2021 <br />4 <br />Risk ManagemA..ent DMsian <br />2 512Ar/1i idEVIEWED & APPROVED BY: <br />AUTHORIZED REPRESENT IVE PRESIDENT AND <br />SCIF FORM 10217 (REV.4-2018) <br />-�_r- Risk Management Specialist <br />