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Page 3 <br />Named Insured BACKHAUS DANCE <br />Customer ID <br />Policy Number WC80946 <br />Transaction Type New Business Effective <br />PREMIUM RECAP BY RATING GROUP <br />9/7/2021 <br />State: CA Rating Group: 0001-01 <br />Term <br />Class Code <br />Exposure <br />Rate <br />Premium <br />9156 <br />86,005 <br />5.72 <br />4,919.00 <br />Total Class Premium <br />4,919.00 <br />Territory Modification (2) <br />(SP: 4,919.00) <br />984.00 <br />Increase Limits (.011) <br />(SP: 5,903.00) <br />65.00 <br />Empl Minimum Difference <br />55.00 <br />Total Subject Premium <br />6,023.00 <br />Total Modified Premium <br />6,023.00 <br />Schedule Modification (-.09) <br />(SP: 6,023.00) <br />-542.00 <br />Standard Total <br />5,481.00 <br />Premium Discount (.01) <br />(SP: 5,481.00) <br />-55.00 <br />Expense Constant <br />160.00 <br />Terrorism Risk Ins Act 2002 (.04) <br />(SP: 86,005.00) <br />34.00 <br />**Terrorism Premium Is Per $100 Of Payroll** <br />Catastrophe (O/T Acts of Terr) (.02) <br />(SP: 86,005.00) <br />17.00 <br />**Catastrophe Premium Is Per $100 Of Payroll** <br />Total Estimated Premium <br />5,637.00 <br />CA Admin Revolving Fund Assess (.022646) <br />(SP: 5,637.00) <br />128.00 <br />CA Occ Safety & Health Fund (.002584) <br />(SP: 5,637.00) <br />15.00 <br />CA Fraud Assessment (.004734) <br />(SP: 5,637.00) <br />27.00 <br />CA Unins Empl Benefits Assess (.000775) <br />(SP: 5,637.00) <br />4.00 <br />CA Subs Inj Benefits Assess (.006579) <br />(SP: 5,637.00) <br />37.00 <br />CA LECF Assessment (.002272) <br />(SP: 5,637.00) <br />13.00 <br />Final Total <br />5,861.00 <br />�oRaN <br />RAMmagementDMsian <br />REVIEWED & APPROVED BY. - <br />Risk Management Analyst <br />