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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 03 <br /> (Ed. 4-84) <br /> EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT <br /> The premium for the policy will be adjusted by an experience rating modification factor. The factor was not available <br /> when the policy was issued. The factor, if any, shown on the Information Page is an estimate. We will issue an <br /> endorsement to show the proper factor, if different from the factor shown, when it is calculated. <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 Policy No. Endorsement No. <br /> Insured Premium$ <br /> Insurance Company Countersigned by <br /> WC 00 04 03 <br /> (Ed.4-84) <br /> ©1983,1994 National Council on Compensation Insurance,Inc. <br />