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TRAVELERSJ�' <br />ONE TOWER SQUARE <br />HARTFORD CT 06183 <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />WC 04 04 22 (00) <br />POLICYNUMBER: UB-OR34080A-20-42-G <br />CALIFORNIA SHORT -RATE CANCELATION ENDORSEMENT <br />It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of <br />California in Item 3 of the Information Page is subject to the following provisions: <br />If you cancel the policy and a disclosure was provided in accordance with Section 481(c) of the California Insurance Code, final premium will be <br />based on the time this policy was in force and increased by the short -rate cancelation table below: <br />Short Rate Cancelation Table <br />Days In <br />Policy <br />Period <br />Short Rate <br />Percentages <br />Factors to Apply to <br />Earned Premium for <br />Period Policy in Effect <br />Days In <br />Policy <br />Period <br />Short Rate <br />Percentages <br />Factors to Apply to <br />Earned Premium for <br />Period Policy In Effect <br />Days In <br />Policy <br />Period <br />Short Rate <br />Percentages <br />Factors to Apply to <br />Earned Premium for <br />Period Policy In Effect <br />1 <br />5% <br />18.2482 <br />46 <br />23% <br />1,8250 <br />91 <br />35% <br />1_,4038 <br />2 <br />6 <br />10.9489 <br />47 <br />23 <br />1.7861 <br />92 <br />36 <br />1.4283 <br />3 <br />7 <br />8.5158 <br />48 <br />24 <br />1.8250 <br />93 <br />36 <br />1.4129 <br />4 <br />7 <br />6.3869 <br />49 <br />24 <br />1.7877 <br />94 <br />36 <br />1.3979 <br />5 <br />8 <br />5.8394 <br />50 <br />24 <br />1.7520 <br />95 <br />37 <br />1A216 <br />6 <br />8 <br />4.8662 <br />51 <br />24 <br />1.7176 <br />96 <br />37 <br />1.4068 <br />7 <br />9 <br />4.6924 <br />52 <br />25 <br />1.7548 <br />97 <br />37 <br />1.3923 <br />8 <br />9 <br />4.1058 <br />53 <br />25 <br />1.7216 <br />98 <br />37 <br />1,3781 <br />9 <br />10 <br />4.0552 <br />54 <br />25 <br />1,6899 <br />99 <br />38 <br />1.4010 <br />10 <br />10 <br />3.6496 <br />55 <br />26 <br />1.7255 <br />100 <br />38 <br />1.3870 <br />11 <br />11 <br />3.6496 <br />56 <br />26 <br />1.6947 <br />101 <br />38 <br />1.3733 <br />12 <br />11 <br />3.3455 <br />57 <br />26 <br />1.6650 <br />102 <br />38 <br />1.3598 <br />13 <br />12 <br />3.3689 <br />58 <br />26 <br />1.6362 <br />103 <br />39 <br />1.3820 <br />14 <br />12 <br />3.1283 <br />59 <br />27 <br />1.6704 <br />104 <br />39 <br />1.3688 <br />15 <br />13 <br />3.1630 <br />60 <br />27 <br />1.6425 <br />105 <br />39 <br />1.3557 <br />16 <br />13 <br />2.9653 <br />61 <br />27 <br />1.6156 <br />106 <br />40 <br />1.3774 <br />17 <br />14 <br />3.0056 <br />62 <br />27 <br />1.5895 <br />107 <br />40 <br />1.3645 <br />18 <br />14 <br />2.8386 <br />63 <br />28 <br />1.6222 <br />108 <br />40 <br />1.3519 <br />19 <br />15 <br />2.8818 <br />64 <br />28 <br />1.5969 <br />109 <br />40 <br />1.3395 <br />20 <br />15 <br />2.7377 <br />65 <br />28 <br />1.5723 <br />110 <br />41 <br />1.3605 <br />21 <br />16 <br />2.7812 <br />66 <br />29 <br />1.6038 <br />111 <br />41 <br />1.3482 <br />22 <br />16 <br />2.6547 <br />67 <br />29 <br />1.5799 <br />112 <br />41 <br />1.3362 <br />23 <br />17 <br />2.6980 <br />68 <br />29 <br />1.5566 <br />113 <br />41 <br />1.3243 <br />24 <br />17 <br />2.5856 <br />69 <br />29 <br />1.5341 <br />114 <br />42 <br />1.3447 <br />25 <br />17 <br />2.4821 <br />70 <br />30 <br />1.5643 <br />115 <br />42 <br />1.3330 <br />26 <br />18 <br />2,5270 <br />71 <br />30 <br />1.5423 <br />116 <br />42 <br />1.3215 <br />27 <br />18 <br />2.4334 <br />72 <br />30 <br />1.5208 <br />117 <br />43 <br />1.3414 <br />28 <br />18 <br />2.3465 <br />73 <br />30 <br />1.5000 <br />118 <br />43 <br />1.3301 <br />29 <br />18 <br />2.2656 <br />74 <br />31 <br />1.5291 <br />119 <br />43 <br />1.3189 <br />30 <br />19 <br />2.3117 <br />75 <br />31 <br />1.5087 <br />120 <br />43 <br />1.3079 <br />31 <br />19 <br />2.2371 <br />76 <br />31 <br />1.4888 <br />121 <br />44 <br />1.3273 <br />32 <br />19 <br />2.1672 <br />77 <br />32 <br />1.5169 <br />122 <br />44 <br />1.3164 <br />33 <br />20 <br />2.2121 <br />78 <br />32 <br />1.4974 <br />123 <br />44 <br />1.3057 <br />34 <br />20 <br />2.1471 <br />79 <br />32 <br />1.4785 <br />124 <br />44 <br />1.2951 <br />35 <br />20 <br />2.0857 <br />80 <br />32 <br />1.4600 <br />125 <br />45 <br />1.3140 <br />36 <br />20 <br />2.0278 <br />81 <br />33 <br />1.4870 <br />126 <br />45 <br />1.3036 <br />37 <br />21 <br />2.0716 <br />82 <br />33 <br />1.4689 <br />127 <br />45 <br />1.2933 <br />38 <br />21 <br />2.0171 <br />83 <br />33 <br />1.4512 <br />128 <br />46 <br />1.3117 <br />39 <br />21 <br />1.9654 <br />84 <br />34 <br />1,4774 <br />129 <br />46 <br />1.3016 <br />40 <br />21 <br />1.9162 <br />85 <br />34 <br />1.4600 <br />130 <br />46 <br />1.2916 <br />41 <br />22 <br />1.9585 <br />86 <br />34 <br />1,4430 <br />131 <br />46 <br />1.2817 <br />42 <br />22 <br />1.9119 <br />87 <br />34 <br />1.4264 <br />132 <br />47 <br />1.2996 <br />43 <br />22 <br />1.8674 <br />88 <br />35 <br />1.4517 <br />133 <br />47 <br />1.2899 <br />44 <br />23 <br />1.9079 <br />89 <br />35 <br />1.4354 <br />134 <br />47 <br />1.2802 <br />45 <br />23 <br />1.8655 <br />90 <br />35 <br />1.4194 <br />135 <br />47 <br />1.2708 <br />© 2011 Workers' Compensation Insurance Rating Bureau of California. All rights reserved <br />DATE OF ISSUE: 05-11-20 ST ASSIGN: <br />,, �` r Riele ManagetnentDhtielan <br />�rRitviEwED&pAP,P`Rov®Br. <br />; I ahkf vNe h. Y�idv14F,Q <br />Risk Mana9exten[Analyst ' <br />