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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 21 <br />(Ed. 1-08) <br />OPTIONAL PREMIUM INCREASE ENDORSEMENT— CALIFORNIA <br />You must provide us, or our authorized representative, access to records necessary to perform a payroll verification <br />audit. If you fail to provide access within 90 days after expiration of the policy, you are liable to pay a total premium <br />equal to 3 times our current estimate of the annual premium for your policy. In addition, if you fail to provide access <br />after our third request within a 90 day or longer period, you are also liable for our costs in attempting to perform the <br />audit unless you provide a compelling business reason for your failure. <br />We will contact you to schedule appointments during normal business hours. <br />We will notify you of your failure to provide access by mailing a certified, return -receipt document stating the increased <br />premium and the total amount of our costs incurred in our attempt(s) to perform an audit. In addition to any other <br />obligations under this contract, 30 days after you receive the notification, you will be obligated to pay the total premium <br />and costs referenced above. If, thereafter, you provide access to your records within three years after the policy <br />expires, or within another mutually agreed upon time, and we succeed in performing the audit to our satisfaction, we <br />will revise your total premium and the costs due to reflect the results of the audit. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement Effective 0 9 — 0 7 — 2 1 Policy No. WC 80946 00 Endorsement No. <br />Insured BACKHAUS DANCE <br />Insurance Company Sirius America Ins Co <br />Countersigned By <br />C 2007 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />Premium $ Incl . <br />�oRaN <br />} z <br />Risk ManaganadDMsfan <br />REVIEWED & APPROVED BY.- <br />f R. V;&wd <br />Risk Management Analyst <br />