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Sect By: Teen Challenge; 951682357; May-24-05 9:17AM; 05.'25,2305 15:5'/ STIdTE LUMP INS FIND � 919516823754 Paqe 415 NGISCQT ANNUA: FA71NG ENDOR$FM ENT STATE "DIME OFFICE SAN FRA COMPENSATIONINSURANCE IT IS AGREED THAT THE CLASSIFICATIONS AND RATES PER $100 OF REMUNFRATION APNEA.HING Ct 'Nn IN THE CONTINUOUS POLICY ISSUED TO THIS EMPLOYER ARE AM FNDFO AS SHOWN 130 OVl HERE ARE YOUR NCW RATES FOR THE PERIOD INDICATED, IF YOUR NAME OR ADDRESS SHOULD RE CORFECTEO OR IF INSURANCE IS NOT NEEDED FOR NEXT YEAR, PLEASE TELL US. IMPORTANT THIS=NOTA CONTINUOUS POLICY 489-04 SEND NO HONEY UNLESS STATENE THE RATING PERIOD BEGINS AND ENDS AT 12:01AM RATING k'ERIOD 2-U1-0cJ TO 2-UT-OG: PACIFIC STANDARD TIFE UNIT 626 * INTERIM BILLING RATES WILI. BE USED ON PAYROLL REPORTS. THEY -TAKE INTO ACCOUNT RATING PLAN CREDITS (OR DEBITS) WHICH WILL APPLY AT FINAL BILLING AND AN ESTIMATE OF YOUR PREMIUM DISCOUNT" AS DETAILED BELOW. RATING PLAN CREDITS (DFBTTSI EFFECTIVE FROM 0zQI-051`0 02-01-n6 RATING PLAN MODIFIER 0-911Hn ESTIMATED PREMIUM DISCOUNT MODIFIER H-Hsi11 COMPOSITE FACTOR APPLIED TO BASE PATES TO DERIVE INTERIM BILLING RATES 0.70152 aiasaiiiarra..ir........ *........... Y = PREMIUM DISCOUNT SCHEDULE FFFECTTVE FROM 02--01-05 TO 02-01-06 _ ESTIMATFD MODIFIED PREMIUM IS DISCOUNTED ACCORDING TO THE FOLLOWING; SCHEDULE: _ FIRST ABOVE _ $5,000 $5,000 = = 0.0% 15.0%L = s a fiiii=fiiii=iiiiaiiiiYiiiaaiiiiaaaaalaiiaiirraraiiaa.A.Rii............. ki!=iFt# SHE ESTIMATED PRFATUM DISCOUNT IS BASED ON AN ESTIMATE OF YOUR PAYROLL- ACTUAL PREMIUM DISCOUNT APPLIED AT FINAL BILLING WILL BE BASED ON THE ACTUAL PAYROLL REPORTED ON YOUR POLICY AND SUBJECT TO AUDIT. APPROVED AS Iv I Lauri >IIu .,Wordy �- l�SSISI.illi COUNTERSIGNED AND ISSUED AT SAN FRANCISCO FE.ARUARY 11, 2005 POLICY L P_J E, 2 OF 3 SUP Fown 1050(Rtvs 3) (OVER PLEASE)