Laserfiche WebLink
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 00 05 <br />(Ed. 7-98) <br />EXTENSION OF INFORMATION PAGE <br />Classifications <br />ITEM 4 <br />POLICY NO. WC 80946 00 <br />Premium Basis Rate Per $100 Estimated <br />Code Estimated Annual of Annual <br />No. Classifications Remuneration Remuneration Premium <br />Total Class Premium <br />$ <br />4,919.00 <br />9036 <br />Territory Modification 1.20 <br />$ <br />984.00 <br />9812 <br />Increase Limits 1.011 <br />$ <br />65.00 <br />9848 <br />Empl Minimum Difference <br />$ <br />55.00 <br />Total Subject Premium <br />$ <br />6,023.00 <br />9897 <br />Experience Premium 1.00 <br />$ <br />0.00 <br />Total Modified Premium <br />$ <br />6,023.00 <br />9887 <br />Schedule Modification .91 <br />$ <br />-542.00 <br />Standard Total <br />$ <br />5,481.00 <br />0063 <br />Premium Discount .99 <br />$ <br />-55.00 <br />0900 <br />Expense Constant <br />$ <br />160.00 <br />Terrorism Risk Ins Act <br />9740 <br />2002 .04 <br />$ <br />34.00 <br />Catastrophe (Other Than <br />Certified Acts of <br />9741 <br />Terrorism) .02 <br />$ <br />17.00 <br />Total Estimated Premium <br />$ <br />5,637.00 <br />CA Admin Revolving Fund <br />0987 <br />Assess 1.022646 <br />$ <br />128.00 <br />CA Occ Safety & Health <br />0000 <br />Fund 1.002584 <br />$ <br />15.00 <br />0988 <br />CA Fraud Assessment 1.004734 <br />$ <br />27.00 <br />CA Unins Empl Benefits <br />0000 <br />Assess 1.000775 <br />$ <br />4.00 <br />CA Subs Inj Benefits <br />0000 <br />Assess 1.006579 <br />$ <br />37.00 <br />California Labor Enforcement <br />& Compliance (LECF) <br />0000 <br />Assessment 1.002272 <br />$ <br />13.00 <br />Final Total <br />$ <br />5,861.00 <br />Policy Total Estimated Cost <br />$ <br />5,861.00 <br />Copyright 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 2001. <br />�oRaN <br />r <br />Risk MwagzmedDivisiun <br />REVIEWED & APPROVED BY.- <br />p P. vj&wd <br />Risk Management Analyst <br />