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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 10 A <br /> (Ed.01-18) <br /> ESTIMATED ANNUAL PREMIUM ENDORSEMENT—CALIFORNIA <br /> The premium with respect to the insurance provided by this policy by reason of the designation of California in item 3 of the <br /> Information Page is subject to experience modification. Your experience modification, when issued, will be effective on <br /> 03/14/2026 , your rating effective date determined by the Workers' Compensation Insurance Rating Bureau of <br /> California(WCIRB) in accordance with California law. Pending the issuance of your experience modification by the WCIRB, the <br /> estimated annual premium shown below is based on an estimated experience modification. The estimated annual premium will <br /> be revised when the WCIRB issues your applicable experience modification. <br /> ESTIMATED ANNUAL PREMIUM $ $1,430.00 <br /> NOTE: THE ESTIMATED ANNUAL PREMIUM MAYBE INCREASED WHEN THE WCIRB ISSUES THE EXPERIENCE <br /> MODIFICATION APPLICABLE TO THIS POLICY. <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 Insurance Company <br /> Countersigned By <br /> WC040410A <br /> (Ed. 01-18) <br />