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Page 5 <br />Named InsuredBACKHAUS DANCE <br />Customer ID <br />Policy NumberWC80946 <br />Transaction TypeNew BusinessEffective9/7/2021 <br /> <br />XPSLFST!DPNQ!TUBUF!JOGPSNBUJPO!SFDBQ <br />Tubuf;CA Rate Change PendingInsurance Co.: <br />Split Period: <br />Rate Mode:GTier Level: <br />Retro Plan:NoTerritory Zip Code: <br />Deductible:Deductible Factor: <br />Coinsurance: <br />Deductible:Deductible Factor: <br />Aggregate Limit:Hazard Group: <br />Large Deductible:Large Aggregate Limit: <br />Intermediate Deductible:Aggregate Deductible: <br />Jousb!Fyqfs!Npe!JE; <br />Effective Date:09/07/2021 <br />Exper Mod:1.00 (Tentative) <br />Rate Revision Date:09/01/2021Dev Revision Date: <br />Qsfnjvn!Ejtdpvou <br />First:NIL (5,000) <br />Next:.109 (95,000) <br />Next:.126 (400,000) <br />Balance:.144 (Balance) <br />Commission (Norm):.Prem Subj to Comm:5,637 <br />____________________________________________________________ <br />Safety Group Program <br />Rating TierOriginal Rating Tier <br />Rating Tier Override <br /> <br />