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Named Insured <br />Special Notes: <br />Policy Number: <br />Client Number: <br />System Assign: <br />System Release: <br />Business Type: <br />Insurance Co: <br />Line Of Business: <br />Effective Date: <br />Anniversary Date: <br />Policy Term: <br />Predominant State: <br />Transaction Type: <br />POLICY DECISIONS <br />Pie Insurance Holdings Inc. <br />101515th Street NW, Suite 600 <br />Washington, DC 20005-2605 <br />RATING WORKSHEETS <br />BACKHAUS DANCE Date: <br />DANCE EDUCATION THROUGH A <br />WC80946 <br />08209400000000 <br />21.04 <br />Non -Profit <br />Sirius America Ins Co <br />Workers Comp (Voluntary) <br />09/07/2021 <br />1 Year <br />CA <br />NEW BUSINESS <br />POLICY PREMIUM TOTALS <br />Coverages <br />Class Premium <br />Employer's Liab Premium <br />Empl Liab Min Diff Premium <br />Schedule Mod Premium <br />Territory Factor <br />Standard Premium <br />Premium Discount <br />Expense Constant <br />Terrorism <br />Catastrophe <br />Estimated Premium <br />Taxes and Assessments <br />Estimated Total <br />Agy/Prod Number: <br />Agy/Prod Name: <br />Operator <br />Expiration Date: <br />Audit Frequency: <br />09/02/2021 <br />1850 <br />Automatic Data Processing Insurance Agency, Inc. <br />JSPIVEY <br />09/07/2022 <br />Annual <br />Transaction Sequence: 001 <br />Term Premium <br />4,919.00 <br />65.00 <br />55.00 <br />-542.00 <br />984.00 <br />5,481.00 <br />-55.00 <br />160.00 <br />34.00 <br />17.00 <br />5,63 7.00 <br />224.00 <br />5,861.00 <br />�oRaN <br />Ii:AMwag mentDMsian <br />REVIEWED & APPROVED BY. - <br />Risk Management Analyst <br />