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1111:IRI4kiIBiel :4.14114ki III 1[s]:/_1kiM4:19:I:11e7lill[WMJIIIIA-l"ANA-1117111IDEA N 4111111MA <br />AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT <br />Policy Number: ❑6 WEG B❑3❑P❑ Endorsement Number: <br />Effective Date: 11/04/211 Effectie Eolir is t❑e same as stated on t❑e Information Page of t❑e policy. <br />Named Insured and Address: Beginners Edge Sports Training <br />432 E TIERRA B❑E❑A L❑ <br />SCOTTSDALE All 8E260 <br />Part Fi e - Premi-n, Section G. [A❑dit❑of t❑e Wor❑ers Compensation and Employers LiaJlity Ins-rance Policy is reused <br />❑y adding t❑e following❑ <br />If yo❑ do not allow e to eemine and a❑dit all of yob records t-at relate to tEJs policy, and/or do not pro:jde a❑dit <br />information as re❑❑ested, we may apply an A❑dit ❑oncompliance C❑arge. T❑e met❑od for determining tie A❑dit <br />❑oncompliance Cerge y state, were applicade, is sEown in t❑e Scedde ❑elow. <br />If yo❑ allow ❑s to eemine and aF-dit all of yoj records after we ❑ae applied an A❑dit ❑oncompliance Cerge, we will <br />redse yo-r premi❑m in accordance wit❑off manels and Part ❑- Premi-n, E. final PremiE]n❑of tEis policy. <br />Fail -re to cooperate wit[] tEJs policy prodsion may rest in t❑e cancellation of yo-r instance co erage, as specified <br />eder tie policy. <br />Schedule <br />Basis of Audit Noncompliance <br />Maximum Audit Noncompliance <br />State(s) <br />Charge <br />Charge Multiplier <br />AL, AR, CO, CT, DC, DE, GA, IA, ID, <br />Estimated Anne] Premi-m <br />❑p to two times <br />IL, ❑Y, MD, ME, MI, M❑, MS, ❑E, ❑q <br />❑M, OR, RI, SC, SD, T❑, ❑T, ❑A, ❑T, <br />W❑ <br />All, ❑I, ❑S, O❑ <br />Estimated Ann -al Premi-n <br />Two times <br />❑C <br />Estimated Ann -al Premi-m <br />❑p to tree times <br />❑❑ <br />Estimated Ann❑al PremiErn <br />❑p to one times <br />WI <br />Estimated Annel Premi::n <br />One time <br />Form WC 00 04 24 Printed in ❑.S.A. <br />Process Date: 11/04/2❑ Policy Expiration Date: 11/04/26 <br />