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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B POLICY INFORMATION PAGE ENDORSEMENT The following item(s) X Insured's Name (WC 89 06 01) ❑ Policy Number (WC 89 06 02) ❑ Effective Date (WC 89 06 03) ❑ Expiration Date (WC 89 06 04) ❑ Insured's Mailing Address PC.890605) ❑ Experience Modification (WC 89 04 06) ❑ Producer's Name (WC 89 06 07) ❑ Change In Workplace of Insured (WC 89 06 08) ❑ Insured's Legal Status (WC 89 06 10) ❑ Item 3,A.States MC890611) (Ed. 7-01) ;❑ Item 3:13. Limits (WC 89 06 12) ❑ Item 3.C. States (WC 89 06 13) ❑ Item 3.D. Endorsement Numbers (WC 89 06 14) ❑ Item 4.* Class, Rate, Other (WC 89 0415) ❑ Interim Adjustment of Premium (WC 8904 16) ❑ Carrier Servicing Office (WC 89 08 17) ❑ Interstate/Intrastate Risk ID Number (WC 89 06 18) ❑ Carrier Number (WC 89 00 19) ❑ Issuing Agency/Producer Office Address (WC 89 06 25) is changed to read: Effective 8/16114 amend the first named insured to read Miller & Pidskalny Custom Woodwork *Item 4. Change To: Total Estimated Annual Premium :$ 42,527 Minimum Premium $ All other terms and conditions of this poloyremain unchanged. Deposit Premium $ This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 08-16-2014 Policy No, Premium Basis Rate Per $100 ATW 005341-00 Classifications Code Total Estimated. of Estimated 08-16-2014 No. Annual Annual Premium Countersigned by Remuneration Remuneration 3 (Ed. 7-01) Exhibit C ® 2001 National Council on Compensation Insurance, Inc. Total Estimated Annual Premium :$ 42,527 Minimum Premium $ All other terms and conditions of this poloyremain unchanged. Deposit Premium $ This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 08-16-2014 Policy No, Endorsement No..1 Insured ATW 005341-00 Premium Included Miller & Pidskalny Custom Woodwork (A Corp Policy Effective Insurance Company 08-16-2014 Republic Underwriters Insurance Company Countersigned by WC 89 06 00 B 3 (Ed. 7-01) Exhibit C ® 2001 National Council on Compensation Insurance, Inc.