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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />Short Rate Cancellation Table (Cont'd) <br />WC 04 04 22 <br />(Ed.01-12) <br />nayan Paioy <br />Period <br />Short late <br />Perc-t ges <br />Fadorlo Appyto <br />EanedAwrkmf r <br />Period Poky in <br />wed <br />n Poky <br />Period <br />Strait Rae <br />Peraer "@- <br />Fadarto AppVto <br />EanedPreniin7f& <br />PeriodPoigr n <br />Fred <br />Oayn nftiry <br />Period <br />Shart Rate <br />P <br />Faarxto Applyto <br />Earted Pr emiirn <br />fix PeriodAAW In <br />BfeR <br />2; 1 <br />b <br />1. <br />1 <br />1 <br />1. 111 <br />272 <br />80 <br />1-0735 <br />317 <br />90 <br />1.0363 <br />362 <br />100 <br />1.0083 <br />27: <br />80 <br />1.0695 <br />318 <br />90 <br />1.0330 <br />363 <br />1Q0 <br />1.0055 <br />274 <br />81 <br />1_0790 <br />319 <br />90 <br />1.0298 <br />364 <br />100 <br />1.0027 <br />27" <br />81 <br />1 0761 <br />320 <br />91 <br />1A380 <br />366 <br />nn <br />1,0000 <br />276 <br />81 <br />1.0712 <br />321 <br />91 <br />1.0347 <br />277 <br />81 <br />1.0673 <br />322 <br />91 <br />10315 <br />278 <br />81 <br />1.0635 <br />323 <br />91 <br />1.0283 <br />279 <br />82 <br />1.0728 <br />324 <br />92 <br />1,6364 <br />28u <br />82 <br />1-0889 <br />325 <br />92 <br />1.0332 <br />281 <br />82 <br />1.0651 <br />326 <br />92 <br />1.0301 <br />262 <br />82 <br />1.0614 <br />327 <br />92 <br />1 0269 <br />283 <br />83 <br />1.0705 <br />328 <br />92 <br />1.0238 <br />28.1 <br />83 <br />10667 <br />320 <br />93 <br />10318 <br />286 <br />83 <br />1.0630 <br />330 <br />93 <br />1.0286 <br />28F <br />83 <br />1.0593 <br />331 <br />93 <br />1.0255 <br />28i <br />83 <br />1-0556 <br />332 <br />93 <br />1.0224 <br />288 <br />84 <br />1.0646 <br />333 <br />94 <br />1.0303 <br />28!_1 <br />84 <br />1.0609 <br />334 <br />94 <br />1.0272 <br />290 <br />84 <br />1.0572 <br />335 <br />94 <br />1.0242 <br />291 <br />84 <br />1.0526 <br />336 <br />94 <br />1.0211 <br />292 <br />85 <br />1.0625 <br />337 <br />94 <br />1.0181 <br />2V <br />.-;5 <br />10589 <br />338 <br />95 <br />1:0259 <br />294 <br />85 <br />1.0553 <br />339 <br />95 <br />1.0229 <br />295 <br />85 <br />1.0517 <br />340 <br />95 <br />1.U198 <br />296 <br />85 <br />1.0481 <br />341 <br />95 <br />1.0169 <br />297 <br />86 <br />1.0569 <br />342 <br />95 <br />1.0139 <br />298 <br />85 <br />1-0534 <br />343 <br />Be <br />1.0216 <br />299 <br />86 <br />1.0498 <br />344 <br />96 <br />1.0186 <br />300 <br />86 <br />10463 <br />345 <br />96 <br />1,0156 <br />301 <br />86 <br />1.0429 <br />346 <br />96 <br />1.0127 <br />302 <br />87 <br />1.0515 <br />347 <br />97 <br />1.0203 <br />303 <br />87 <br />1.0400 <br />348 <br />97 <br />1.0174 <br />304 <br />87 <br />1.0445 <br />349 <br />97 <br />1.0145 <br />3.05 <br />87 <br />1.0411 <br />350 <br />97 <br />1.0116 <br />306 <br />88 <br />1_0497 <br />351 <br />97 <br />1.0087 <br />307 <br />88 <br />1.0462 <br />362 <br />98 <br />1.01 V <br />308 <br />88 <br />1.0429 <br />353 <br />98 <br />1.0133 <br />309 <br />88 <br />1,0395 <br />354 <br />96 <br />1.0106 <br />310 <br />88 <br />1.0361 <br />355 <br />9B <br />1.0076 <br />311 <br />89 <br />1.0445 <br />356 <br />99 <br />1.0150 <br />312 <br />89 <br />1.0412 <br />357 <br />99 <br />1.0122 <br />313 <br />89 <br />1-0379 <br />358 <br />99 <br />1.0094 <br />314 <br />89 <br />1.0345 <br />359 <br />99 <br />1.0005 <br />315 <br />90 <br />1_0429 <br />360 <br />99 <br />1.0030 <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 09-07-21 Policy No. WC80946 <br />Insured BACKHAUS DANCE <br />Insurance Company Sirius America Ins Co <br />Countersigned By <br />Endorsement No. <br />Premium $ Incl . <br />Risk Managawnl DlAsian <br />REVIEWED & APPROVED BY. <br />Z Maud <br />Risk Management Analyst <br />