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[4] Premium (coat.) <br />Workers' Compensation and Emnlover's Liabilitv Polic <br />AmGUARD Insurance Company A Stock Company <br />Policy Number ORWC311495 <br />Renewal of ORWC208613 <br />NCCI No,[21873] <br />Policy Information Page <br />California <br />— — ^ Classification <br />Code <br />Premium Basis: <br />Total Estimated <br />Annual <br />Remuneration <br />Rate per <br />$100 <br />Remuneration <br />Estimated <br />Annual <br />Premium <br />Effective: 10/08/2012-10/08/2013 <br />CLERICAL OFFICE EMPLOYEES NOC <br />8810 <br />82,066,00 <br />_. .72 <br />591 <br />TerrlCorlal Rating, Los Angeles Region_ <br />CATR <br />1,000 <br />0 <br />Tot Est Premium 10/08/2012-10/08/2013� <br />Minimum Premium $'270 <br />� - <br />_ <br />»�-- 591 <br />Tot Est Standard Premium for Californla _.._____— <br />591 <br />Policv Totals <br />Total Estimated Standard Premium for California <br />Expense ConstantW �A � _ <br />160 <br />Terlrorism CA 97,10 0,03 82,066 _ <br />25 <br />Catastrophe — 9741 0.02 82,066 s — <br />16 <br />Minimum Premium CA $270 <br />—_ <br />Total Estimated Annual Premium <br />792 <br />CA WCARF Assessment 10/08/2012-10/08/2013 0.9669% <br />8 <br />CA Fraud Surcharge 10/08/2012-10/08/2013 0.2648% <br />2 <br />CA CIGA Surcharge 10/08/2012-10/08/2013 2.2850% <br />18 <br />.._._. _ <br />CA SIBTF Assessment 10/08/2012-1.0/08/2013 0,12550/. <br />1 <br />CA UEBTF Assessment 10/08/2012-10/08/2013 1 1362% <br />1 <br />CA OSHF Assessment 10/08/2012-10/08/2013 0,2350% <br />2 <br />CA LFCF Assessment 10/08/2012-10/08/2013 0.2380% <br />_ 2 <br />Total Estimated Cost for ORWC311495 <br />826 <br />i NTERNFlL USE. XX Page - 4 - Information Page <br />MGA :ORWC311495 WC 000001A <br />Dale,oe/on/zolz <br />.1.6 South River Street• P.O. Box A-H • Wilkes -Bane, PA 18703-0020• WWW.guard.com <br />