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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04 00 OS (Ed. 7-98) <br />EXTENSION OF INFORMATION PAGE <br />Classifications <br />ITEM 4 <br />Policy No. MW00017162-01 <br /> Premium Basis Total Rate Per Estimated <br /> <br />Code <br />Classification Estimated Annual $100 of Annual <br /> Remuneration Remuneration <br />Premium <br />8742 Salespersons- Outside (CA <br /> only) $129,000.00 0.940 $1213.00 <br />8810 Clerical Office Employees Noc <br /> (CA only) $115,000.00 0.790 $909.00 <br /> Manual Premium <br /> <br />Subject Premium $2,122.00 <br /> $2,122.00 <br /> Total Subject Premium <br /> <br />Modified Premium $2,122.00 <br /> <br />9887 <br />Schedule Rating $2,122.00 <br /> -0.070 <br />($149.00) <br /> Standard Premium <br /> <br />0900 <br />Expense Constant $1,973.00 <br />9740 <br />Terrorism $250.00 <br /> <br />Estimated Annual Premium 0.040 $98.00 <br /> <br />WC Admin Revolving $2,321.00 <br /> Assessment 1.472 $34.00 <br /> Fraud Surcharge <br /> 0.434 $10.00 <br /> UEBTFA <br /> 0.410 $10.00 <br /> Subsequent Injury Fund <br /> 0.177 $4.00 <br /> CA SURCHARGE <br /> 2.559 $59.00 <br /> Occupation Safety and Health <br /> Fund Surcharge 0.246 $6.00 <br /> Labor Enforcement and <br /> Compliance Fund Surcharge 0.231 $5.00 <br /> Total Amount Due <br /> $2,449.00 <br />If you elect a payment plan, then you will be subject to installment fees for each payment ranging from $3-$10 depending on the <br />state. If you elect electronic funds transfer, these fees will not apply. <br />© 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />From the WCIRB's California Workers' Compensation Insurance Forms Manual ©2001. <br />5of28 <br />