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Page 5 <br />Named Insured BACKHAUS DANCE <br />Customer ID <br />Policy Number WC80946 <br />Transaction Type New Business Effective <br />WORKERS COMP STATE INFORMATION RECAP <br />State: <br />CA Rate Change Pending <br />Insurance Co.: <br />Split Period: <br />Rate Mode: <br />G <br />Tier Level: <br />Retro Plan: <br />No <br />Territory Zip Code: <br />Deductible: <br />Deductible Factor: <br />Coinsurance: <br />Deductible: <br />Deductible Factor: <br />Aggregate Limit: <br />Hazard Group: <br />Large Deductible: <br />Large Aggregate Limit: <br />Intermediate Deductible: <br />Aggregate Deductible: <br />Intra Exper Mod ID: <br />Effective Date: <br />09/07/2021 <br />Exper Mod: <br />1.00 (Tentative) <br />Rate Revision Date: <br />09/01/2021 <br />Dev Revision Date: <br />Premium Discount <br />First: <br />NIL (5,000) <br />Next: <br />.109 (95,000) <br />Next: <br />.126 (400,000) <br />Balance: <br />.144 (Balance) <br />Commission (Norm): <br />Prem Subj to Comm: 5,637 <br />Safety Group Program <br />Rating Tier <br />Original Rating Tier <br />Rating Tier Override <br />9/7/2021 <br />oRaN <br />RiskMmWmentDMsian <br />REVIEWED & APPROVED BY. - <br />Risk Management Analyst <br />