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In the state of VA, the premium charge is 5% of the total manual premium, <br />subject to a minimum premium of $250 per policy. <br />In the state of WI, the premium charge is 2% of the total manual premium, <br />subject to a minimum premium of $50 per policy. <br />Issued by LM Insurance Corporation27243 <br />For attachment to Policy No. WC5-Z51-290099-011 Effective Date 10/1 /2021 <br />Issued to Opex Corporation <br />WC 00 03 13 ® 1983 National Council on Compensation Insurance. <br />Ed. 04/01/1984 <br />s. RbkMvngemerdONda� <br />gl � 1 a. <br />f SK Peeve. <br />Hek AMria9�m[ �aial Aide <br />C: <br />