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TRAVELERS, WORKERS COMPENSATION <br />AND <br />ONE TOWER SQUARE HARTFORD CT 06183 EMPLOYERS LIABILITY POLICY <br />EXTENSION OF INFO PAGE -SCHEDULE WC 00 00 01 ( A) <br />POLICY NUMBER: UB-OR34080A-20-42-G <br />CA MANUAL PREMIUM $ 3759 <br />TOTAL PREMIUM SUBJECT TO EXPERIENCE MOD. $ <br />3759 <br />EXPERIENCE MODIFICATION:NONE MODIFIED PREMIUM <br />NONE <br />TOTAL ESTIMATED ANNUAL STANDARD PREMIUM <br />3759 <br />EXPENSE CONSTANT(0900) <br />160 <br />TERRORISM(9740) <br />40 <br />TOTAL ESTIMATED PREMIUM <br />3959 <br />1.704% WC ADMIN REVOLVING FUND ASSESSMENT <br />67 <br />0.335% STATE FRAUD SURCHARGE <br />13 <br />0.127% UNINSURED EMPLOYERS BENEFIT TRUST FUND ASST <br />5 <br />0.482% SUBSEQUENT INJURY BENEFIT TRUST FUND ASST <br />19 <br />0.391% OCCUPATIONAL SAFETY & HEALTH FUND ASSESSMENT <br />15 <br />0.381% LABOR ENFORCEMENT & COMPLIANCE FUND ASSESSMENT <br />15 <br />TOTAL PREMIUM <br />4093 <br />DEPOSIT AMOUNT DUE <br />4093 <br />DATE OF ISSUE: 05-11-20 JW SCHEDULE N <br />WdeManagementDMs(an <br />' REVIEWED&{ PPR�O/VVMBY. <br />F'L4WSN.E R. V' <br />�. <br />'-® Risk Management Analyst �- <br />se <br />