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EMPLOYERS WORKERSCOMPENSATION AND EMPLOYERS <br />EMPLOYERS LIABILITY INSURANCE POLICY <br />EMPLOYERS PREFERRED INS. CO. Policy Number: EIG 1571658 10 <br />A Stock Company Named Insured: NATIONAL POLYTECHNIC COLLEGE <br />P.O. BOX 539003 <br />HENDERSON, NV 89053-9003 Agent: UNITEDAGENCIES (BURBANK) 1377002 <br />EXTENSION OF INFORMATION PAGE <br />CLASSIFICATION OF OPERATIONS <br />Code <br />No. <br />Classification Description <br />Premium Basis <br />Total Est. Annual <br />Remuneration <br />Rate Per <br />$100 of <br />Remuneration <br />Estimated <br />Annual <br />Premium <br />California <br />Rating <br />Period: 12/01/2022 through 12/01/2023 <br />Site <br />00001 <br />B810 <br />CLERICAL OFFICE EMPLOYEES-N.O.C. <br />655, 629 <br />0.450000 <br />2,950.00 <br />8868 <br />COLLEGES OR SCHOOLS -PRIVATE -NOT VOCATIONAL <br />366,408 <br />1.270000 <br />4,653.00 <br />SCHOOLS -PROFESSORS, TEACHERS OR ACADEMIC <br />PROFESSIONALS - INCLUDING CLERICAL OFFICE <br />EMPLOYEES AND OUTSIDE SALESPERSONS <br />9101 <br />COLLEGES OR SCHOOLS -PRIVATE -NOT VOCATIONAL <br />0 <br />7.750000 <br />0.00 <br />SCHOOLS -ALL EMPLOYEES OTHER THAN PROFESSORS, <br />TEACHERS, OR ACADEMIC PROFESSIONALS <br />9101 <br />COLLEGES/SCHOOLS - PRIVATE <br />0 <br />7.750000 <br />0.00 <br />Site <br />00001 Total <br />$ <br />7,603.00 <br />Total <br />of Sites for Rating Period <br />$ <br />7,603.00 <br />Rating <br />Period Total <br />$ <br />7,603.00 <br />Rating <br />Period: 12/01/2022 through 12/01/2023 <br />9898 <br />EXPERIENCE MODIFICATION <br />7,603 <br />1.000000 <br />9887 <br />SCHEDULE CREDIT <br />7,603 <br />0,130000 <br />-988.00 <br />9707 <br />YEARS IN BUSINESS, YEARS IN INDUSTRY RATING <br />6,615 <br />0.120000 <br />-794.00 <br />MODIFICATION <br />0063 <br />PREMIUM DISCOUNT <br />5,821 <br />0.015000 <br />-87.00 <br />0900 <br />EXPENSE CONSTANT <br />160.00 <br />0936 <br />STATE W.C. FRAUD ASSESSMENT <br />6,405 <br />0.004856 <br />31.00 <br />0935 <br />STATE W.C. ADMINISTRATIVE ASSESSMENT <br />6,405 <br />0.019277 <br />123.00 <br />0937 <br />CA INSURANCE GUARANTY <br />6,405 <br />0938 <br />CA UNINSURED EMPLOYERS FUND <br />6,405 <br />0.001455 <br />9.00 <br />0939 <br />CA SUBSEQUENT INJURY FUND <br />6,405 <br />0.017451 <br />112.00 <br />0940 <br />OSHF ASSESSMENT <br />6, 405 <br />0.009177 <br />59.00 <br />0943 <br />LABOR ENFORCEMENT & COMPLIANCE <br />6,405 <br />0.007102 <br />45.00 <br />9741 <br />CATASTROPHE PREMIUM <br />1,022,037 <br />0.020000 <br />204.00 <br />9740 <br />TERRORISM PREMIUM <br />1,022,037 <br />0,030000 <br />307.00 <br />Rating <br />Period Total <br />$ <br />819. 00— <br />StateTotal <br />$ <br />6,784.00 <br />Policy Total <br />$ <br />6,784.00 <br />Issued Date 10127/2022 <br />WC990630 (5198 Ed.) <br />INSURED COPY <br />Page 2 of 4 <br />