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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 99 06 07 D <br />Short Rate Table <br />(Ed 10-17) <br />Extended <br />Number of <br />Days <br />Percent of <br />Full Policy <br />Pcamiun <br />Extended <br />Number of <br />Days <br />Percent of <br />Full Policy <br />Ptemiun <br />Extended <br />Number of <br />Days <br />Percent of <br />Full Policy <br />Premion <br />1 <br />.. .... 5% <br />95-98 <br />.. .... 37% <br />219-223 <br />...... 69% <br />2 <br />.... 6% <br />99-102 <br />...... 38% <br />224-228 <br />.. _ .. 70% <br />3-4 <br />...... 7% <br />103-105 <br />...... 39% <br />229-232 <br />...... 71% <br />5-6 <br />...... 8% <br />106-109 <br />...... 40% <br />233-237 <br />...... 72% <br />7-8 <br />...... 9% <br />110-113 <br />...... 41% <br />238-241 <br />...... 73% <br />9-10 <br />...... 10% <br />I14-116 <br />...... 42% <br />242-246 <br />(8 mos.) 74% <br />11-12 <br />...... 11% <br />117-120 <br />...... 43% <br />247-250 <br />...... 75% <br />13-14 <br />.,,... 12% <br />121-124 <br />(4 mos.) 44% <br />251-255 <br />...... 76% <br />15-16 <br />...., 13 % <br />125-127 <br />...... 45% <br />256-260 <br />...... 77% <br />17-18 <br />...... 14% <br />128-131 <br />...... 46% <br />261-264 <br />...... 78% <br />19-20 <br />... 15% <br />132-135 <br />...... 47% <br />265-269 <br />...... 79% <br />21-22 <br />...... 16 % <br />136-138 <br />...... 48% <br />270-273 <br />(9 mos.) 80% <br />23-25 <br />...... 17% <br />139-142 <br />...... 49% <br />274-278 <br />...... 81% <br />26-29 <br />...... 18% <br />143-146 <br />...... 50% <br />279-282 <br />...... 82% <br />30-32 <br />(1 mo.) 19 % <br />147-149 <br />...... 51% <br />283-287 <br />...... 83 % <br />33-36 <br />..,,.. 20% <br />I50-153 <br />(5 mos.) 52% <br />288-291 <br />...... 84% <br />3740 <br />...... 21% <br />154-156 <br />...... 53% <br />292-296 <br />...... 85% <br />4143 <br />,.... , 22% <br />157-160 <br />...... 54% <br />297-301 <br />...... 86% <br />4447 <br />...... 23% <br />161-164 <br />...... 55% <br />302-305 <br />(10 mos.) 87% <br />48-51 <br />...... 24% <br />165-167 <br />...... 56% <br />306-310 <br />.... 88% <br />52-54 <br />...... 25% <br />168-171 <br />...... 57% <br />311-314 <br />...... 89% <br />55-58 <br />...... 26% <br />172-175 <br />...... 58% <br />315-319 <br />...... 90% <br />59-62 <br />(2 mos.) 27% <br />176-178 <br />...... 59% <br />321-323 <br />...... 91% <br />63-65 <br />...... 28% <br />179-182 <br />(6 mos.) 60% <br />324-328 <br />...... 92% <br />66-69 <br />...... 29% <br />183-187 <br />...... 61% <br />329-332 <br />...... 93% <br />70-73 <br />...... 30% <br />188-191 <br />...... 62% <br />333-337 <br />(11 mos.) 94% <br />74-76 <br />...... 31% <br />192-196 <br />...... 63% <br />338-342 <br />...... 95% <br />77-90 <br />.... 32% <br />197-200 <br />...... 64% <br />343-346 <br />...... 96% <br />81-83 <br />...... 33% <br />201-205 <br />...... 65% <br />347-351 <br />...... 97% <br />84-87 <br />...... 34% <br />206-209 <br />...... 66% <br />352-355 <br />...... 98% <br />88-91 <br />(3 mos.) 35% <br />210-214 <br />(7 mos.) 67% <br />356-360 <br />...... 99% <br />92-94 <br />....., 36% <br />215-218 <br />...... 68% <br />361-365(12 mos.)100% <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The Information below is required only when this endorsement is Issued subsequent to preparation of the policy.) - <br />Endorsement Effective: 10/01/2021 Policy No.: QUWC202153 Endorsement No.: <br />Insured: <br />Insurance Company: Cypress Insurance Company ate. R1JelNougebd0biion <br />Countersigned by w� ReAeNED&APPRov 11y: s. <br />� _. �r , <br />WC 99 06 07D - Page 2 of 2 868 Management Analyst <br />(Ed 10-17) <br />