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Page 3 <br />Named InsuredBACKHAUS DANCE <br />Customer ID <br />Policy NumberWC80946 <br />Transaction TypeNew BusinessEffective9/7/2021 <br /> <br />QSFNJVN!SFDBQ!CZ!SBUJOH!HSPVQ <br />Tubuf;DBSbujoh!Hspvq;!1112.12 <br />Term <br />Class CodeExposureRatePremium <br />915686,0055.724,919.00 <br />Upubm!Dmbtt!Qsfnjvn5-:2:/11 <br />Territory Modification (.2)(SP: 4,919.00)984.00 <br />Increase Limits (.011)(SP: 5,903.00)65.00 <br />Empl Minimum Difference55.00 <br />Upubm!Tvckfdu!Qsfnjvn7-134/11 <br />Upubm!Npejgjfe!Qsfnjvn7-134/11 <br />Schedule Modification (-.09)(SP: 6,023.00)-542.00 <br />Tuboebse!Upubm6-592/11 <br />Premium Discount (-.01)(SP: 5,481.00)-55.00 <br />Expense Constant160.00 <br />Terrorism Risk Ins Act 2002 (.04)(SP: 86,005.00)34.00 <br />**Terrorism Premium Is Per $100 Of Payroll** <br />Catastrophe (O/T Acts of Terr) (.02)(SP: 86,005.00)17.00 <br />**Catastrophe Premium Is Per $100 Of Payroll** <br />Upubm!Ftujnbufe!Qsfnjvn6-748/11 <br />CA Admin Revolving Fund Assess (.022646)(SP: 5,637.00)128.00 <br />CA Occ Safety & Health Fund (.002584)(SP: 5,637.00)15.00 <br />CA Fraud Assessment (.004734)(SP: 5,637.00)27.00 <br />CA Unins Empl Benefits Assess (.000775)(SP: 5,637.00)4.00 <br />CA Subs Inj Benefits Assess (.006579)(SP: 5,637.00)37.00 <br />CA LECF Assessment (.002272)(SP: 5,637.00)13.00 <br />Gjobm!Upubm6-972/11 <br /> <br />