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Technology Insurance Company, Inc. WC 99 00 01 E <br /> 4 of 5 <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE <br /> POLICY INFORMATION PAGE <br /> Insured: Orange County Gold Aquatics Policy Number:TSP4812276 <br /> EXTENSION OF INFORMATION PAGE FOR ITEM#4 <br /> ITEM 4:SCHEDULE OF PREMIUMS <br /> Premium Basis <br /> Total Estimated Rate Per Estimated <br /> #of Code Annual $100 of Annual <br /> Classifications Emps No. Remuneration Remun. Premium <br /> California <br /> Swimming Pools or Swimming Clubs 3 9053 45,000 3.15 1.418 <br /> Manual Premium 1,418 <br /> Total Manual Premium 1,418 <br /> Blanket Waiver 2% ($250 Minimum) 0930 250 <br /> Total Premium Subject To Experience Modification 1,668 <br /> Experience Modification N/A 1,668 <br /> Schedule Modifier-15% 9887 -250 <br /> Terrorism 3% 9740 14 <br /> Catastrophe(other than Terrorism) 1% 9741 4 <br /> Expense Constant 0900 100 <br /> Total CA Premium 1,536 <br /> WCARF 1.4958% 9999 23 <br /> UEBTF 0.0956% 9999 1 <br /> SIBTF 2.0428% 9999 31 <br /> OSHAF 0.5678% 9999 9 <br /> LECF 0.5301% 9999 8 <br /> FRAUD 0.459% 9999 7 <br /> Total CA Cost 1,615 <br /> TOTAL ESTIMATED ANNUAL PREMIUM 1,536 <br /> STATE ASSESSMENT 79 <br /> TOTAL COST 1,615 <br /> POLICY COST BEFORE ENDORSEMENT 1,392 <br /> TOTAL ENDORSEMENT PREMIUM CHANGE 223 <br />