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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 22 <br />(Ed.01-12) <br />CALIFORNIA SHORT -RATE CANCELLATION ENDORSEMENT <br />It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by <br />reason of the designation of 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 <br />Code, final premium will be based on the time this policy was in force and increased by the short -rate cancelation table <br />below: <br />Short Rate Cancellation Table <br />flays n Poky <br />pa <br />Shot PAe <br />Ps'osrtw- <br />FaclortoAppllylo <br />EariodPranii_mfd <br />Period Poky in <br />EF&d <br />Dgjw nPoigr <br />P"dad <br />Shot Fa& <br />P-111 sus <br />Fadtorin Appiytn <br />Earned fterimfor <br />Pianod Pofyrn <br />nrs m Pb r <br />Phliod <br />Sihot lisle <br />P-t> <br />Fat4+xtbap"lo <br />Earned Prelim <br />firfood PCkviti <br />Ldfer4 <br />2 <br />6 <br />1 V-1 f' <br />47 <br />23 <br />1,7861 <br />9? <br />36 <br />1.4203 <br />3 <br />7 <br />8e5 , ' <br />48 <br />24 <br />1.8250 <br />93 <br />36 <br />1.4129 <br />4 <br />7 <br />6.3G'LJ <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 />1.4216 <br />6 <br />8 <br />4.8662 <br />51 <br />24 <br />1,7176 <br />96 <br />37 <br />1.4060 <br />7 <br />9 <br />46924 <br />52 <br />25 <br />1.7540 <br />97 <br />37 <br />1.3923 <br />8 <br />9 <br />4 10 5r, <br />53 <br />25 <br />1.721 Fi <br />92 <br />37 <br />1.3781 <br />9 <br />10 <br />4 u-': _ <br />54 <br />25 <br />1.6399 <br />99 <br />38 <br />1.4010 <br />10 <br />10 <br />J 0��r) <br />55 <br />25 <br />1.7255 <br />100 <br />38 <br />1.3670 <br />11 <br />11 <br />36496 <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 />1.6660 <br />102 <br />R <br />1 2590 <br />13 <br />12 <br />3.36G9 <br />58 <br />26 <br />1.6362 <br />103 <br />=.9 <br />1.3820 <br />14 <br />1 ' <br />3.1 2t 1 <br />59 <br />27 <br />1.6704 <br />104 <br />39 <br />1.3688 <br />15 <br />I J <br />3.1 � .: J <br />60 <br />27 <br />1.6425 <br />105 <br />39 <br />1.3557 <br />16 <br />13 <br />2 9')F i <br />61 <br />27 <br />1.6156 <br />106 <br />40 <br />1.3774 <br />17 <br />14 <br />3 0:ir., <br />62 <br />27 <br />1,5895 <br />107 <br />40 <br />1.3646 <br />18 <br />14 <br />2e83t.3 <br />63 <br />29 <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 />23 <br />1.5723 <br />110 <br />41 <br />1.3605 <br />21 <br />16 <br />27012 <br />66 <br />29 <br />1.6038 <br />ill <br />41 <br />1.3492 <br />22 <br />16 <br />26547 <br />67 <br />29 <br />1.5799 <br />112 <br />Al <br />1.3362 <br />23 <br />17 <br />2-69' 3 <br />68 <br />29 <br />1.45565 <br />113 <br />Al <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 />2.4621 <br />70 <br />30 <br />1.5543 <br />115 <br />42 <br />1.3330 <br />26 <br />113 <br />25271 <br />71 <br />30 <br />1.5423 <br />116 <br />42 <br />1.3215 <br />27 <br />18 <br />2 42` 1 <br />72 <br />30 <br />1.53013 <br />117 <br />43 <br />1.3414 <br />0 <br />18 <br />2.3465 <br />73 <br />30 <br />1.5000 <br />118 <br />43 <br />1.3301 <br />±9 <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 />1.5367 <br />120 <br />43 <br />1.3079 <br />31 <br />19 <br />22371 <br />76 <br />31 <br />1.4388 <br />121 <br />44 <br />1.3273 <br />2 <br />10 <br />" 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 />2D <br />2.1471 <br />79 <br />32 <br />1.4785 <br />124 <br />44 <br />1.2951 <br />35 <br />20 <br />2.0657 <br />80 <br />32 <br />1.4500 <br />125 <br />=5 <br />1.3140 <br />36 <br />20 <br />2.0278 <br />81 <br />33 <br />1.4370 <br />126 <br />-5 <br />1.3036 <br />37 <br />21 <br />20716 <br />82 <br />33 <br />1.4689 <br />127 <br />45 <br />1.2933 <br />38 <br />21 <br />2.0171 <br />93 <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_0162 <br />85 <br />34 <br />1.4500 <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 />.2 <br />22 <br />19119 <br />87 <br />34 <br />1.4264 <br />132 <br />47 <br />1.2996 <br />Y3 <br />22 <br />1.8674 <br />98 <br />35 <br />1.4517 <br />123 <br />47 <br />1.2899 <br />44 <br />23 <br />1.9079 <br />99 <br />35 <br />1.4354 <br />134 <br />47 <br />1.2802 <br />45 <br />23 <br />1.8655 <br />g0 <br />35 <br />1.4194 <br />135 <br />47 <br />1.2708 <br />Risk Management D'I%islan <br />REVIEWED & APPROVED BY. <br />Risk Management Analyst <br />