25-84131500-ITN DFS BOR Attachment N OOS WC Policy_Redacted.pdf

Technology Insurance Company, Inc. is required to provide its policyholders with certain accident prevention services at no cost as required by Ark. Code Ann. Sec. 11-9-409(d) and

AWCC Rule 32. If you would like more information, call Technology Insurance Company, Inc.

Loss Control Department at 888-486-7466. If you have any questions about this requirement, call the Health and Safety Division, Arkansas Workers' Compensation Commission at 1-800-622-

4472.

Arkansas

Workers' Compensation

Notice to Policyholder

Technology Insurance Company, Inc. is required by law (KSA 44.5, 104 Part C) to provide its policyholders with certain accident prevention services at no additional cost.

If you would Like additional information, contact Technology Insurance Company, Inc.

Loss Control Department at 888-486-7466.

English And Spanish versions Of the Workers' Compensation Information Booklets (K- WC25 And K-WC250) and "Important Information For Injured Employees"(K - WC 27 And K-WC 270) are included With this Notice As required by Kansas Law 44-5, 101 And 102.

Kansas

Workers' Compensation and Employers Liability

Missouri

Notice to Policyholders

1. We will make available Safety Engineering and Management consultation services to each Missouri policyholder requesting these services in writing. For further information or to request a consultation, please contact:

Loss Control Department Technology Insurance Company, Inc.

800 Superior Avenue East, 21st Floor

Cleveland, OH 44114 888-486-7466

2. The Missouri Division of Workers’ Compensation offers free safety services to Missouri employers through its Missouri Workers' Safety Program (MWSP). MWSP’s main goal is to help employers control workers’ compensation costs. The Division also certifies Missouri insurance carriers’ safety engineering and management programs that are available to insured’s upon request. Employers may contact MWSP at 573-526-5757, email MWSP@labor.mo.gov for more information about workplace safety or for a registry of safety consultants and safety engineers who are certified by the Division.

Phone: 573-526-5757 Email: MWSP@labor.mo.gov

Website: www.labor.mo.gov/MWSP Mailing Address:

421 E. Dunklin St

P.O. Box 58 Jefferson City, MO 65102-0058

Oklahoma

Notice to Policyholders

Technology Insurance Company, Inc. is required by law to provide its policyholders with certain workplace safety services including, but not limited to surveys, recommendations, training programs, consultations, analysis of accident causes, industrial hygiene and industrial health services.

If you would like information, please call or contact:

Loss Control Department

Technology Insurance Company, Inc.

800 Superior Avenue East, 21st Floor

Cleveland, OH 44114 888-486-7466

Technology Insurance Company, Inc. is required by law to provide its policyholders with certain workplace safety services. Such services shall be adequate to implement workplace safety plans as required by the nature of its policyholders' operations and shall include but not be limited to surveys, recommendations, training programs, consultations, analyses of accident causes, industrial hygiene, and industrial health services in accordance with policy holder's operations.

Oklahoma Notification of Workplace Safety Services

Pennsylvania

Notice to Policyholder

Pursuant to Pennsylvania Workers Compensation Act (77 P.S. Sec. 1038.1 and 1038.2), and in accordance with Title 34, Part VIII, Sec. 129.102, Technology Insurance Company, Inc. has available to its policyholders certain accident and illness prevention services. These services include surveys, recommendations, training programs, consultations, analysis of accident and illness causes, and industrial hygiene and industrial health services.

Technology Insurance Company, Inc. may grant a premium discount of 5% to a Policyholder whose Workplace Safety Committee is certified by the Department of Labor and Industry of the Commonwealth (See 77 P.S. Sec. 1038.2).

If you would like more information about accident and illness prevention services or certification of Safety Committees, call the Loss Control Department of Technology Insurance Company, Inc. at 888-486-7466, or write to Technology Insurance Company, Inc., 800 Superior Avenue East, 21st Floor, Cleveland, OH 44114.

Pursuant to Texas Labor Code §411.066, Technology Insurance Company, Inc. is required to notify its policyholders that accident prevention services are available from Technology

Insurance Company, Inc. at no additional charge. These services may include surveys, recommendations, training programs, consultations, analyses of accident causes, industrial hygiene, and industrial health services. Technology Insurance Company, Inc. is also required to provide return-to-work coordination services as required by Texas Labor Code §413.021 and to notify you of the availability of the return-to-work reimbursement program for employers under

Texas Labor Code §413.022. If you would like more information, contact Technology Insurance

Company, Inc. at 888-486-7466 and AskLC@amtrustgroup.com for accident prevention services or 888-486-7466 and AskLC@amtrustgroup.com for return-to-work coordination services. For information about these requirements call the Texas Department of Insurance, Division of

Workers' Compensation (TDI-DWC) at 1- 800-687- 7080 or for information about the return-to-work reimbursement program for employers call the TDI-DWC at (512) 804-5000. If Technology

Insurance Company, Inc. fails to respond to your request for accident prevention services or return-to-work coordination services, you may file a complaint with the TDI-DWC in writing at http://www.tdi.texas.gov or by mail to Texas Department of Insurance, Division of Workers'

Compensation, MS-8, at 7551 Metro Center Drive, Austin, Texas 78744-1645.

Texas

ARKANSAS

30-0819 0907

Your Workers Compensation and Employers Liability Insurance Policy contains rates and classifications that apply to your business for the purpose of determining the premium you must pay.

NOTICE TO POLICYHOLDER

CLARIFICATION TO CERTIFICATE OF NONCOVERAGE LAW

THIS NOTICE CONTAINS A BRIEF SYNOPSIS OF THE SIGNIFICANT CHANGES THAT MAY

OCCUR TO YOUR PREMIUM CHARGED.

PLEASE READ YOUR POLICY AND ALL FORMS ATTACHED TO YOUR POLICY CAREFULLY. NO COVERAGE

IS PROVIDED BY THIS POLICYHOLDERS NOTICE NOR CAN IT BE CONSTRUED TO REPLACE OR PROVIDE

ANY PROVISIONS IN YOUR POLICY.

Pursuant to House Bill 1700 of 2007 amending § 11-9-402, an uninsured intermediate contractor cannot present Certificate of Noncoverage (CnCs) for workers of the subcontractor(s) to the prime contractor to satisfy the requirement for workers compensation insurance coverage. If the intermediate contractor does not have workers compensation coverage insurance for its workers, additional premium for the workers of the subcontractor(s) must be charged on the prime contractor's workers compensation policy in accordance with NCCI's Basic Manual for Workers Compensation and Employers Liability Insurance Rule 2-H.

If the intermediate contractor does have workers compensation coverage, all employees are reported under this policy, and additional premium for the workers of the subcontractor(s) must be charged on the intermediate contractor's workers compensation policy in accordance with NCCI's Basic Manual for Workers Compensation and Employers Liability Insurance Rule 2-H. The policyholder may select to be excluded from the policy.

If the intermediate contractor does not have workers compensation coverage and does not have any employees, a CnC may be presented to the prime contractor to satisfy the requirement for workers compensation insurance coverage for the intermediate contractor.

Effective July 31, 2007, on new and renewal policies, House Bill 1700 has the potential to affect how much workers compensation insurance may cost as a result of presenting Certificates of Noncoverage.

TECHNOLOGY INSURANCE COMPANY, INC.

59 Maiden Lane, 43rd Floor New York, NY 10038

WORKERS' COMPENSATION

and

EMPLOYERS’ LIABILITY INSURANCE POLICY

In Witness Whereof, we have caused this policy to be executed and attested, and, if required by state law, this policy shall not be valid unless countersigned by our authorized representative.

Stephen Ungar, Secretary Christopher H. Foy, President

To obtain information, please contact your agent or Technology Insurance Company, Inc.

at 877-528-7878. You may also write Technology Insurance Company, Inc. Consumer Relations at:

800 Superior Avenue East, 21st Floor Cleveland, OH 44114

WC 99 00 00 A

[ 59 Maiden Lane, 43rd Floor New York, NY 10038 ]

WORKERS' COMPENSATION

and

EMPLOYERS’ LIABILITY INSURANCE POLICY

In Witness Whereof, we have caused this policy to be executed and attested.

[ Stephen Ungar, Secretary ] [ Christopher H. Foy, President ]

To obtain information, please contact your agent or Technology Insurance Company, Inc.

at 877-528-7878. You may also write Technology Insurance Company, Inc. Consumer Relations at:

800 Superior Avenue East, 21st Floor Cleveland, OH 44114

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective 8/1/2024 Policy No. TWC4473846 Endorsement No. 0

Insured State of Florida (A Corp) Premium $ 173650

Insurance Company Technology Insurance Company, Inc.

WC 99 00 00 B

KEEP THIS NOTICE WITH YOUR INSURANCE

PAPERS

PROBLEMS WITH YOUR INSURANCE? - If you are having problems with your insurance company or agent, do not hesitate to contact the insurance company or agent to resolve your problem.

Technology Insurance Company, Inc.

800 Superior Avenue East, 21st Floor

Cleveland, OH 44114 877-528-7878

You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency, which enforces Wisconsin’s insurance laws, and file a complaint. You can contact the OFFICE OF THE COMMISSIONER OF INSURANCE by contacting:

OFFICE OF THE COMMISSIONER OF INSURANCE

Complaint Department

P.O. Box 783 Madison, WI 53707-7873

800-236-8517 608-266-0103

ILLINOIS INDUSTRIAL COMMISSION

OPERATIONS FUND SURCHARGE

POLICYHOLDER DISCLOSURE

Your policy has been surcharged as a result of the Illinois Industrial Commission Operations Fund Surcharge effective July 1, 2004. The establishment of this Fund provides that every insurance company, authorized or licensed by the Illinois Insurance Department and insuring employer’s liabilities arising under the Workers’ Compensation Act or the Workers’ Occupational Disease Act, must remit a surcharge equal to 1.01% of the direct written premium for insuring employers’ liability under the Workers’ Compensation Act or Workers’ Occupational Disease Act.

The portion of your annual premium that is attributable to this surcharge is shown on your declaration page.

34-1910 07 04 Page 1 of 1

NOTICE OF RIGHTS TO FILE A COMPLAINT

KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS

This notice is to advise you that should any complaints arise regarding this insurance, you may contact the following:

Technology Insurance Company, Inc.

800 Superior Avenue East, 21st Floor Cleveland, OH 44114 877-528-7878

You can also contact the Illinois Division of Insurance, a state agency, which enforces Illinois’ insurance laws, and file a complaint. You can contact the Illinois Division of Insurance by contacting:

Illinois Division of Insurance Consumer Division 320 W. Washington Street Springfield, Illinois 62767 866-445-5364

25-0002 06 08 Page 1 of 1

NOTICE CONCERNING POLICYHOLDER RIGHTS IN AN INSOLVENCY UNDER

32-1368 (11/02)

The financial strength of your insurer is one of the most important things for you to consider when determining from whom to purchase a property or liability insurance policy. It is your best assurance that you will receive the protection for which you purchased the policy. If your insurer becomes insolvent, you may have protection from the Minnesota Insurance Guaranty Association as described below but to the extent that your policy is not protected by the Minnesota Insurance Guaranty Association or if it exceeds the Guaranty Association’s limits, you will only have the assets, if any, of the insolvent insurer to satisfy your claim.

Residents of Minnesota who purchase property and casualty or liability insurance from insurance companies licensed to do business in Minnesota are protected, SUBJECT TO LIMITS AND EXCLUSIONS, in the event the insurer becomes insolvent. This protection is provided by the Minnesota Insurance Guaranty Association.

THE MINNESOTA INSURANCE GUARANTY ASSOCIATION LAW:

Minnesota Insurance Guaranty Association 4640 West 77th Street, Suite 342

Edina, Minnesota 55435

(952) 831-1908

The maximum amount that the Minnesota Insurance Guaranty Association will pay in regard to a claim under all policies issued by the same insurer is limited to $300,000.� This limit does not apply to workers’ compensation insurance.

Protection by the Guaranty Association is subject to other substantial limitations and exclusions. If your claim exceeds the Guaranty Association’s limits, you may still recover a part or all of that amount from the proceeds from the liquidation of the insolvent insurer, if any exist. Funds to pay claims may not be immediately available. The Guaranty Association assesses insurers licensed to sell property and casualty or liability insurance in Minnesota after the insolvency occurs. Claims are paid from the assessment.

THE PROTECTION PROVIDED BY THE GUARANTY ASSOCIATION IS NOT SUBSTITUTE FOR USING CARE IN SELECTING INSURANCE COMPANIES THAT ARE WELL MANAGED AND FINANCIALLY STABLE. IN SELECTING

AN INSURANCE COMPANY OR POLICY, YOU SHOUL NOT RELY ON PROTECTION BY THE GUARANTY

ASSOCIATION.

THIS NOTICE IS REQUIRED BY MINNESOTA STATE LAW TO ADVISE POLICYHOLDER OF PROPERTY AND CASUALTY INSURANCE POLICIES OF THEIR RIGHTS IN THE EVENT THEIR INSURANCE CARRRIER BECOMES INSOLVENT. THIS NOTICE IN NO WAY IMPLIES THAT THE COMPANY CURRENTLY HAS ANY TYPE OF FINANCIAL PROBLEMS. ALL PROPERTY AND CASUALTY INSURANCE POLICIES ARE REQUIRED TO PROVIDE

THIS NOTICE.

PN049902B

POLICYHOLDER NOTICE

(Ed. 05-02)

Pursuant to Section 11752.8 of the California Insurance Code, we are providing you with an explanation of the California workers’ compensation rating laws.

CALIFORNIA WORKERS’ COMPENSATION

INSURANCE RATING LAWS

1. We establish our own rates for workers’ compensation. Our rates, rating plans, and related information are filed with the insurance commissioner and are open for public inspection.

2. The insurance commissioner can disapprove our rates, rating plans, or classifications only if he or she has determined after public hearing that our rates might jeopardize our ability to pay claims or might create a monopoly in the market. A monopoly is defined by law as a market where one insurer writes 20% or more of that part of the California workers’ compensation insurance that is not written by the State Compensation Insurance Fund. If the insurance commissioner disapproves our rates, rating plans, or classifications, he or she may order an increase in the rates applicable to outstanding policies.

3. Rating organizations may develop pure premium rates that are subject to the insurance commissioner’s approval. A pure premium rate reflects the anticipated cost and expenses of claims per $100 of payroll for a given classification.

Pure premium rates are advisory only, as we are not required to use the pure premium rates developed by any rating organization in establishing our own rates.

4. We must adhere to a single, uniform experience rating plan. If you are eligible for experience rating under the plan, we will be required to adjust your premium to reflect your claim history. A better claim history generally results in a lower experience rating modification; more claims, or more expensive claims, generally result in a higher experience rating modification. The uniform experience rating plan, which is developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner.

5. A standard classification system, developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. The standard classification system is a method of recognizing and separating policyholders into industry or occupational groups according to their similarities and/or differences. We can adopt and apply the standard classification system or develop and apply our own classification system, provided we can report the payroll, expenses, and other costs of claims in a way that is consistent with the uniform statistical plan or the standard classification system.

6. Our rates and classifications may not violate the Unruh Civil Rights Act or be unfairly discriminatory.

7. We will provide an appeal process for you to appeal the way we rate your insurance policy. The process requires us to respond to your written appeal within 30 days. If you are not satisfied with the result of your appeal, you may appeal our decision to the insurance commissioner.

California Workers’ Compensation Insurance

Notice of Nonrenewal

Section 11664 of the California Insurance Code requires us, in most instances, to provide you with a notice of nonrenewal. Except as specified in paragraphs 1 through 6 below, if we elect to nonrenew your policy, we are required to deliver or mail to you a written notice stating the reason or reasons for the nonrenewal of the policy. The notice is required to be sent to you no earlier than 120 days before the end of the policy period and no later than 30 days before the end of the policy period. If we fail to provide you the required notice, we are required to continue the coverage under the policy with no change in the premium rate until 60 days after we provide you with the required notice.

PN049902B

(Ed. 05-02)

We are not required to provide you with a notice of nonrenewal in any of the following situations:

1. Your policy was transferred or renewed without a change in its terms or conditions or the rate on which the premium is based to another insurer or other insurers who are members of the same insurance group as us.

2. The policy was extended for 90 days or less and the required notice was given prior to the extension.

3. You obtained replacement coverage or agreed, in writing, within 60 days of the termination of the policy, to obtain that coverage.

4. The policy is for a period of no more than 60 days and you were notified at the time of issuance that it may not be renewed.

5. You requested a change in the terms or conditions or risks covered by the policy within 60 days prior to the end of the policy period.

6. We made a written offer to you to renew the policy at a premium rate increase of less than 25 percent.

(A) If the premium rate in your governing classification is to be increased 25 percent or greater and we intend to renew the policy, we shall provide a written notice of a renewal offer not less than 30 days prior to the policy renewal date. The governing classification shall be determined by the rules and regulations established in accordance with California Insurance Code Section 11750.3(c).

(B) For purposes of this Notice, “premium rate” means the cost of insurance per unit of exposure prior to the application of individual risk variations based on loss or expense considerations such as scheduled rating and experience rating.

This notice does not change the policy to which it is attached.

PN049904

POLICYHOLDER NOTICE

(Ed. 12-04)

Companies writing property and casualty insurance business in California are required to participate in the California Insurance Guarantee Association. If a company becomes insolvent, the California Insurance Guarantee Association settles unpaid claims and assesses each insurance company for its fair share.

CALIFORNIA INSURANCE GUARANTEE ASSOCIATION (CIGA) SURCHARGE

California law requires all companies to surcharge policies to recover these assessments. If your policy is surcharged, “CA Surcharge” or “CA Surcharge (CIGA Surcharge)” with an amount will be displayed on your premium notice.

This notice does not change the policy to which it is attached.

IMPORTANT NOTICE

Employer Option for Reimbursement of Medical Expenses On Non-Disabling Claims

POLICY NUMBER: TWC4473846 POLICY PERIOD

FROM: 8/1/2024 TO: 8/1/2025

INSURED: State of Florida (A Corp)

Oregon Regulation 436-060-0055 offers you the option of electing to reimburse us for medical expenses up to $2,400 on non-disabling workers compensation claims. This option allows you to eliminate this claim cost from consideration when determining future experience modifications.

A non-disabling claim is a claim in which the injured employee does not receive any payment from us for time lost from work.

REIMBURSABLE AMOUNT EACH CLAIM

$2,400

You are not required to reimburse us for the claim payment. Any claim not reimbursed will be used in experience modification calculations.

Please check the option you have elected and return this form to us as soon as possible.

No, I do not choose to participate in the reimbursement option described in this Notice.

Yes, I chose to participate. I understand that the Company shall pay the claim and invoice the employer shown above for reimbursement.

If you fail to respond promptly to the Company, it will be construed to mean you have not elected the reimbursement option.

If you have any questions, please contact your agent or broker.

INSURED’S SIGNATURE AND TITLE DATE

Policyholder Notice OR – Medical Reimbursement

AmTrust North America, Inc.

800 Superior Avenue • Cleveland, OH 44114 • (877) 528-7878

Re:

Rate Change Notification Policy No.:

Policy Expiration Date:

Dear

This letter is to notify you that your Workers’ Compensation policy written through an AmTrust North America company coming up for renewal on contains a change in rate for the state of New York.

The New York State Department of Financial Services approved updated loss costs with an average overall decrease of 3.1% for policies effective 10/1/2023 and later. Your policy may or may not contain a decrease in rate(s) with this change. To check the impact to your specific operations, please go to the following link to view the individual classification code percentage changes. https://amtrustfinancial.com/small-business-insurance/policyholders-policy-notices

The following is a description of the various components of the approved change:

Loss Experience – The latest two policy years of experience produced a decrease of 2.2% in the overall loss cost level.

Legislative Changes – This revision includes an estimate of the cost impact of the latest increases in the maximum weekly benefits that were set forth in the 2007 workers’ compensation reform legislation. This component contributed an increase of 0.4% to the overall change.

Loss Adjustment Expenses – A review of the latest data available resulted in an increase of 1.1% in the Loss Adjustment Expense provision.

Future Trends – The latest analysis of New York claim severity and claim frequency indicates a slight increase in claim frequency, an upward trend in indemnity claim costs and a mild upward trend in medical claim costs. Combined with a projected wage trend, the final selected net trend factor is -1.7%.

7/26/2024

State of Florida (A Corp) P.O. Box 8020 Tallahassee, FL 32314

TWC4285026

8/1/2024

8/1/2024

State of Florida (A Corp)

IMPORTANT NOTICE

To obtain information or make a complaint:

You may contact your Agent.

You may call AmTrust Financial’s toll-free telephone number for information or to make a complaint at:

1-877-528-7878

You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at:

1-800-252-3439

You may write the Texas Department of Insurance at:

P.O. Box 149104 Austin, TX 78714-9104

Fax: 512-475-1771

Web: www.tdi.state.tx.us

E-mail: ConsumerProtection@tdi.state.tx.us

PREMIUM OR CLAIM DISPUTES:

Should you have a dispute concerning your premium or about a claim, you should contact the agent or the company first. If the dispute is not resolved, you may contact the Texas Department of Insurance.

ATTACH THIS NOTICE TO YOUR POLICY:

This notice is for information only and does not become a part or condition of the attached document.

AVISO IMPORTANTE

Para obtener informacion o para someter una queja:

Puede comunicarse con su Agente.

Usted puede llamar al numero de telefono gratis de AmTrust Financial's para informacion o para someter una queja al:

1-877-528-7878

Puede comunicarse con el Departamento de Seguros de Texas para obtener informacion acerca de companias, coberturas, derechos o quejas al:

1-800-252-3439

Puede escribir ai Departamento de Seguros de Texas:

P.O. Box 149104 Austin, TX 78714-9104

Fax: 512-475-1771

Web: www.tdi.state.tx.us

E-mail: ConsumerProtection@tdi.state.tx.us

DISPUTAS SOBRE PRIMAS O RECLAMOS:

Si tiene una disputa concerniente a su prima o a un reclamo, debe comunicarse con el agente primero. Si no se resuelve la disputa, puede entonces comunicarse con el departamento (TDI).

UNA ESTE AVISO A SU POLIZA:

Este aviso es solo para proposito de informacion y no se convierte en parte o condicion del documento adjunto.

30-0599 05 21

PN 04 99 01 I

(Ed. 02-22)

POLICYHOLDER NOTICE

YOUR RIGHT TO RATING AND DIVIDEND INFORMATION

I. Information Available to You A. Information Available from Us-

(1) General questions regarding your policy should be directed to:

800 Superior Ave. E., 21st Floor Cleveland, OH 44114

(877) 528-7878 www.amtrustfinancial.com

(2) Dividend Calculation. If this is a participating policy (a policy on which a dividend may be paid), upon payment or non¬ payment of a dividend, we shall provide a written explanation to you that sets forth the basis of the dividend calculation. The explanation will be in clear, understandable language and will express the dividend as a dollar amount and as a percentage of the earned premium for the policy year on which the dividend is calculated.

(3) Claims Information. Pursuant to Sections 3761 and 3762 of the California Labor Code, you are entitled to receive information in our claim files that affects your premium. Copies of documents will be supplied at your expense during reasonable business hours.

For claims covered under this policy, we will estimate the ultimate cost of unsettled claims for statistical purposes eighteen months after the policy becomes effective and will report those estimates to the Workers’ Compensation Insurance Rating Bureau of California (WCIRB) no later than twenty months after the policy becomes effective. The cost of any settled claims will also be reported at that time. At twelve-month intervals thereafter, we will update and report to the WCIRB the estimated cost of any unsettled claims and the actual final cost of any claims settled in the interim. The amounts we report will be used by the WCIRB to compute your experience modification if you are eligible for experience rating.

B. Information Available from the Workers’ Compensation Insurance Rating Bureau of California

(1) The WCIRB is a licensed rating organization and the California Insurance Commissioner’s designated statistical agent. As such, the WCIRB is responsible for administering the California Workers’ Compensation Uniform Statistical Reporting Plan— 7995 (USRP) and the California Workers’ Compensation Experience Rating Plan—7995 (ERP). WCIRB contact information is:

WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612, Attn: Customer Service; 888.229.2472 (phone); 415.778.7272 (fax); and customerservice@wcirb.com (email). The regulations contained in the USRP and ERP are available for public viewing through the WCIRB's website at wcirb.com.

(2) Policyholder Information. Pursuant to California Insurance Code (CIC) Section 11752.6, upon written request, you are entitled to information relating to loss experience, claims, classification assignments, and policy contracts as well as rating plans, rating systems, manual rules, or other information impacting your premium that is maintained in the records of the WCIRB. Complaints and Requests for Action requesting policyholder information should be forwarded to: WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612, Attn: Custodian of Records. The Custodian of Records can be reached at

415.777.0777 (phone) and 415.778.7272 (fax).

(3) Experience Rating Form. Each experience rated risk may receive a single copy of its current Experience Rating Form/Worksheet free of charge by completing a Policyholder Experience Rating Worksheet Request Form on the WCIRB's website at wcirb.com/ratesheet. The Experience Rating Form/Worksheet will include a Loss-Free Rating, which is the experience modification that would have been calculated if $0 (zero) actual losses were incurred during the experience period.

This hypothetical rating calculation is provided for informational purposes only.

II. Dispute Process You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1.

A. Our Dispute Resolution Process.

If you are aggrieved by our decision adopting a change in a classification assignment that results in increased premium, or by the application of our rating system to your workers’ compensation insurance, you may dispute these matters with us. If you are dissatisfied with the outcome of the initial dispute with us, you may send us a written Complaint and Request for Action as outlined below.

You may send us a written Complaint and Request for Action requesting that we reconsider a change in a classification assignment that results in an increased premium and/or requesting that we review the manner in which our rating system has been applied in connection with the insurance afforded or offered you. Written Complaints and Requests for Action should be forwarded to:

After you send your Complaint and Request for Action, we have 30 days to send you a written notice indicating whether your written request will be reviewed. If we agree to review your request, we must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If we decline to review your

PN 04 99 01 I 1 of 2 (Ed. 02-22)

Technology Insurance Company, Inc.

Technology Insurance Company, Inc.

AmTrust North America, Inc., 1 Park Plaza, Suite 800, Irvine, CA 92614, or Telephone: (877) 528-7878 or by email at: amtrustcomplaints@amtrustgroup.com

COLORADO

WORKERS' COMPENSATION DISCLOSURE NOTICE

IMPORTANT NOTICE TO POLICYHOLDERS

1. Notice Of Change in Rate by Classification

If you desire information whenever there is a change in your worker's compensation insurance rate by classification, you must request such information from your insurer. This request for information must be in writing.

2. Notice Of Policyholder's Right To Appeal Classification

Your insurer can charge and collect any additional amount of money not included in the initial premium charged as a result of job misclassification.

If you have any questions regarding the employee classification assigned to calculate your workers' compensation insurance premium, you need to direct your questions to your insurer, or the insurer's authorized representative within either thirty (30) days after the anniversary date of the policy or the date of receipt by you of notice of a change in job classification. Within thirty

(30) days after receipt of your request for information, your insurer or the insurer's authorized representative must explain to you why a particular employee classification was used.

If you disagree with your insurer or the insurer's authorized representative on the employee classification assignment, you may appeal to the Workers' Compensation Classification Appeal Board by filing written notice with said board within thirty (30) days after you have exhausted all appeal review procedures provided by the insurer. Your request should be sent to the:

Secretary of the Colorado Worker's Compensation Classification Appeals Board, Michael Craddock c/o National Council on Compensation Insurance

901 Peninsula Corporate Circle Boca Raton, FL 33487

Written instructions for your appearance before the Colorado Worker's Compensation Classification Appeals Board, will be furnished by the Secretary of the Board. The board will render a decision as to whether a misclassification has occurred.

A decision by the board is final and not subject to appeal unless you, the insurer or Pinnacol Assurance provides written notice of appeal within thirty (30) days after the board's decision to the office of the Commissioner of Insurance, 1560 Broadway, Suite 850, Denver, CO 80202. The Commissioner shall review any decision of the board properly appealed.

3. Notice Of Availability of Medical Case Management Services

The Medical Case Management Services to be contacted is:

Coventry Healthcare P. 0. Box 30055

Tampa, Florida 33630

34-1897A 0317

California Short-Rate Cancellation Disclosure Notice

IMPORTANT INFORMATION REGARDING YOUR POLICY

The policy for which you have applied contains a cancellation provision that permits us to refund premium on a basis other than pro rata when you cancel the policy. Under the policy for which you have applied, if you cancel the policy, your final premium will be calculated based on the time your policy was in force with us, using the percentage specified in the short-rate cancellation table listed below.

SHORT RATE CANCELLATION TABLE FOR A TERM OF ONE YEAR

800 Superior Avenue E • 21st Floor • Cleveland, OH 44114

(p) 866.203.3037 • (f) 800.487.9654 • www.amtrustnorthamerica.com

Dear Policyholder, In an effort to continue to provide AmTrust customers with a variety of billing options, we have updated our fee structure to help customers meet payment due dates, ensure that valid and properly funded payments are submitted, and provide an incentive for paid-in-full options.

Our updated fee structure is as follows:

Fee Title Fee Amount Description

Returned Payment Fee $25 A returned payment fee applied to any returned payment.

Late Fee $20 Late fee applied if payment not received on or before payment due date.

Installment Fee $15 A “paper” billing fee that is assessed for each mailed installment invoice. Excludes down payment and annual payment plans. Fee is billed at the account level.

Reinstatement Fee $50 Fee applied upon reinstatement of a non-payment cancellation.

EFT Fee $3 An “electronic” billing fee that is assessed for each ACH Direct Debit transaction. Fee is billed at the account level.

*Fee amount may vary by state and program of business

For policyholders who choose to pay their annual premium on installments, we plan to implement an installment fee, which will be displayed on your renewal invoice.

Thank you for your attention to this fee structure change. If you have any questions, feel free to contact our Customer Service Department at 877.528.7878.

We value you as a policyholder and appreciate the opportunity to serve you.

Sincerely, AmTrust North America Customer Service Department

July 26, 2024

Technology Insurance Company, Inc.

A Stock Insurance Company

WORKERS COMPENSATION WC 99 00 01 E

AND EMPLOYERS LIABILITY 1 of 5

INSURANCE POLICY INFORMATION PAGE

Ncci Code: 39071 MN Un. #: 051312030001, ME Un. #: 0000000002, RI Un. #: 0000000001, HI Un. #:

9318574080

1. Insured:

State of Florida (A Corp) c/o Division of Risk Management, P.O. Box 8020 Tallahassee, FL 32314

Other workplaces not shown above:

See Extension of Information Page

Producer:

Brown & Brown Insurance Services Inc.

P.O. Box 2412 Daytona Beach, FL 32115

Policy Number: TWC4473846

Individual Partnership

X Corporation or

Federal Tax ID: 596001874 Risk Id:

Renewal of: TWC4285026

2. The policy period is from 8/1/2024 to 8/1/2025 12:01 a.m. at the insured's mailing address.

3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: Alaska, Alabama, Arkansas, Arizona, California, Colorado, Connecticut, District of Columbia, Delaware, Georgia, Hawaii, Iowa, Idaho, Illinois, Indiana, Kansas, Kentucky, Louisiana, Massachusetts, Maryland, Maine, Michigan, Minnesota, Missouri, Mississippi, Montana, North Carolina, Nebraska, New Hampshire, New Jersey, New Mexico, Nevada, New York, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Virginia, Vermont, Wisconsin, West Virginia

B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.

The limits of our liability under Part Two are:

State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease

$1,000,000 each accident $1,000,000 policy limit $1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:

All states except ND, OH, WA, WY and State(s) Designated in Item 3.A D. This policy includes these endorsements and schedules: See Extension of Information Page

4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit.

See Extension of Information Page

TOTAL ESTIMATED ANNUAL PREMIUM 173,650

STATE ASSESSMENT 5,032

TOTAL ESTIMATED COST 178,682

Minimum Premium 750 Deposit Premium 178,682 Issue Date: 7/26/2024 Countersigned by:

Authorized Representative

Kentucky Premium Surcharge - Total Estimated Cost includes a surcharge as required by KRS 136.392

Technology Insurance Company, Inc. WC 99 00 01 E

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE

POLICY INFORMATION PAGE

Insured: State of Florida (A Corp) Policy Number: TWC4473846

EXTENSION OF INFORMATION PAGE FOR ITEM #3.D

ITEM 3.D: ENDORSEMENT SCHEDULE

State Form Number Description

WC990001E DECLARATIONS PAGE

CA 34-2005 1008 CA Important Notice

TN LB-1111 DRUG FREE WORKPLACE PROGRAM APPLICATION

WC000000C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

WC000303C EMPLOYERS LIABILITY COVERAGE ENDORSEMENT

WC000404 PENDING RATE CHANGE ENDORSEMENT

WC000406 PREMIUM DISCOUNT ENDORSEMENT

WC000406A PREMIUM DISCOUNT ENDORSEMENT

WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT

WC000414A NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT

WC000419 PREMIUM DUE DATE ENDORSEMENT

WC000419A PREMIUM DUE DATE ENDORSEMENT

WC000421E Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement

WC000421F CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM

ENDORSEMENT

WC000422C TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT

DISCLOSURE ENDORSEMENT

WC000424 AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT

WC000425 EXPERIENCE RATING MODIFICATION FACTOR REVISION ENDORSEMENT

AZ WC020601C AZ Cancellation and Nonrenewal Endorsement AZ WC020603A Arizona Amendatory Endorsement

AR WC030601B ARKANSAS AMENDATORY ENDORSEMENT

CA WC040301D POLICY AMENDATORY ENDORSEMENT CALIFORNIA

CA WC040310 CA DUTY TO DEFEND

CA WC040360B EMPLOYERS’ LIABILITY COVERAGE AMENDATORY ENDORSEMENT -

CALIFORNIA

CA WC040421 CA OPTIONAL PREMIUM INCREASE ENDORSEMENT

CA WC040601B CALIFORNIA CANCELATION ENDORSEMENT

CA WC040604A Covid-19 Reporting Requirement Endorsement-California

CO WC050402 COLORADO CLASSIFICATION ENDORSEMENT

CO WC050403 COLORADO PREMIUM CREDIT FOR CERTIFIED RISK MANAGEMENT

PROGRAMS ENDORSEMENT

CT WC060301 CONNECTICUT APPLICATION OF WORKERS COMPENSATION INSURANCE

ENDORSEMENT

CT WC060303C CONNECTICUT WORKERS COMPENSATION FUNDS ENDORSEMENT

CT WC060601A CONNECTICUT NONRENEWAL AND RENEWAL ENDORSEMENT

DE WC070408 DELAWARE MERIT RATING PLAN ENDORSEMENT

DE WC070601 DELAWARE NONRENEWAL ENDORSEMENT

DC WC080601 DISTRICT OF COLUMBIA CANCELATION ENDORSEMENT

GA WC100601C GEORGIA CANCELLATION, NONRENEWAL, AND CHANGE ENDORSEMENT

ID WC110402A IDAHO ALCOHOL AND DRUG-FREE WORKPLACE PREMIUM CREDIT

ENDORSEMENT

IL WC120601F ILLINOIS AMENDATORY ENDORSEMENT

IL WC120603 Illinois Renewal Endorsement

KS WC150401A KANSAS FINAL PREMIUM ENDORSEMENT

KS WC150404 KANSAS PENDING LOSS COST ENDORSEMENT

KS WC150601A KANSAS CANCELATION AND NONRENEWAL ENDORSEMENT

KY WC160305 KENTUCKY PART ONE WORKERS COMPENSATION INSURANCE

ENDORSEMENT

KY WC160601 KENTUCKY CANCELATION AND NONRENEWAL ENDORSEMENT

KY WC160602 KENTUCKY NOTICE OF APPEAL RIGHTS ENDORSEMENT

LA WC170303 LOUISIANA DUTY TO DEFEND ENDORSEMENT

LA WC170601J LOUISIANA AMENDATORY ENDORSEMENT

LA WC170602A LOUISIANA COST CONTAINMENT ACT ENDORSEMENT

ME WC180601 MAINE INSPECTION IMMUNITY ENDORSEMENT

ME WC180603A MAINE CANCELATION AND NONRENEWAL ENDORSEMENT

ME WC180604 MAINE FINAL PREMIUM AUDIT ENDORSEMENT

ME WC180606 MAINE NOTICE OF FILING OF FIRST REPORTS OF INJURY

ME WC180607A MAINE SUPPLEMENTAL BENEFITS FUND ENDORSEMENT

MD WC190601G MARYLAND CANCELLATION AND NONRENEWAL ENDORSEMENT

MD WC190602 MARYLAND NOTIFICATION OF 45-DAY UNDERWRITING PERIOD

ENDORSEMENT

MA WC200301 MASSACHUSETTS LIMITS OF LIABILITY ENDORSEMENT

MA WC200302 MASSACHUSETTS - ASSESSMENT CHARGE

MA WC200303C MASSACHUSETTS NOTICE TO POLICYHOLDER ENDORSEMENT

MA WC200401 MASSACHUSETTS PENDING PREMIUM CHANGE ENDORSEMENT

MA WC200405 MASSACHUSETTS PREMIUM DUE DATE ENDORSEMENT

MA WC200601A MASSACHUSETTS CANCELLATION ENDORSEMENT

MA WC200604 MASSACHUSETTS POLICY DEFINITION ENDORSEMENT

MI WC210303A MICHIGAN NOTICE TO POLICYHOLDER ENDORSEMENT

MI WC210304 MICHIGAN LAW ENDORSEMENT

MN WC220000A MINNESOTA AMENDATORY ENDORSEMENT

MN WC220601D MINNESOTA CANCELLATION AND NONRENEWAL ENDORSEMENT

MS WC230601 MISSISSIPPI CANCELLATION, NONRENEWAL, AND RENEWAL ENDORSEMENT

MO WC240302 MISSOURI NOTIFICATION OF ADDITIONAL MESOTHELIOMA BENEFITS

ENDORSEMENT

MO WC240406D MISSOURI EMPLOYER-PAID MEDICAL ENDORSEMENT

MO WC240601B MISSOURI CANCELATION AND NONRENEWAL ENDORSEMENT

MO WC240602B Missouri Property and Casualty Guaranty Association Notification Endorsement

MO WC240604C MISSOURI AMENDATORY ENDORSEMENT

MT WC250305 MONTANA INTENTIONAL INJURY EXCLUSION ENDORSEMENT

MT WC250401A MONTANA AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT

MT WC250601B MONTANA AMENDATORY ENDORSEMENT

MT WC250602 MONTANA SAFETY ENDORSEMENT

NE WC260401B NEBRASKA EXPERIENCE RATING MODIFICATION ENDORSEMENT

NE WC260403 NEBRASKA EXPERIENCE RATING MODIFICATION FACTOR REVISION

ENDORSEMENT

NE WC260601C NEBRASKA CANCELATION AND NONRENEWAL ENDORSEMENT

NV WC270601C NEVADA CANCELLATION AND NONRENEWAL ENDORSEMENT

NH WC280404 NEW HAMPSHIRE PENDING RATE CHANGE ENDORSEMENT

NH WC280405 New Hampshire Audit Noncompliance Charge Endorsement

NH WC280601 NEW HAMPSHIRE SOLE REPRESENTATIVE ENDORSEMENT

NH WC280604 NEW HAMPSHIRE AMENDATORY ENDORSEMENT

NJ WC290306B NEW JERSEY PART TWO LIMIT OF LIABILITY ENDORSEMENT

NJ WC290603 NJ PARTICIPATING PROVISION ENDORSEMENT

NM WC300601A NEW MEXICO CANCELLATION AND NONRENEWAL ENDORSEMENT

NY WC310308 NEW YORK LIMIT OF LIABILITY ENDORSEMENT

NY WC310319M NEW YORK CONSTRUCTION CLASSIFICATION PREMIUM ADJUSTMENT

PROGRAM EXPLANATORY ENDORSEMENT

NY WC310407 New York Merit Rating Revision Endorsement

NY WC310618A NEW YORK WORKERS COMPENSATION POLICYHOLDER NOTICE OF RIGHT

TO APPEAL

NC WC320301D NORTH CAROLINA AMENDED COVERAGE ENDORSEMENT

OK WC350302 OKLAHOMA EMPLOYERS LIABILITY AMENDED COVERAGE ENDORSEMENT

OK WC350303 OKLAHOMA EMPLOYERS LIABILITY INTENTIONAL TORT EXCLUSION

ENDORSEMENT

OK WC350601F OKLAHOMA CANCELLATION, NONRENEWAL AND CHANGE ENDORSEMENT

OK WC350603 OKLAHOMA FRAUD WARNING ENDORSEMENT

OR WC360306 OREGON LIMITS OF LIABILITY ENDORSEMENT

OR WC360601E OREGON CANCELLATION ENDORSEMENT

OR WC360603 OREGON EMPLOYER PAID MEDICAL CLAIMS ENDORSEMENT

OR WC360604 OREGON AMENDATORY ENDORSEMENT

PA WC370401 PENNSYLVANIA AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT

PA WC370601 PA – INSPECTION OF MANUALS

PA WC370602 PENNSYLVANIA NOTICE

PA WC370603A PENNSYLVANIA ACT 86-1986 ENDORSEMENT

PA WC370604 PA - EMPLOYER ASSESSMENT ENDORSEMENT

RI WC380401B RHODE ISLAND SHORT RATE CANCELLATION ENDORSEMENT

RI WC380601 RHODE ISLAND DIRECT LIABILITY STATUTE ENDORSEMENT

RI WC380602 RHODE ISLAND SAFETY INSPECTION ENDORSEMENT

SC WC390601 South Carolina Cancellation and Nonrenewal Endorsement

TN WC410402 TENNESSEE PENDING LOST COST AND ASSIGNED RISK RATE

ENDORSEMENT

TX WC420301L TEXAS AMENDATORY ENDORSEMENT

UT WC430602 UTAH CANCELLATION ENDORSEMENT

VT WC440601 VERMONT LAW ENDORSEMENT

VT WC440602C Vermont Cancellation and Nonrenewal Endorsement

VA WC450602 VIRGINIA AMENDATORY ENDORSEMENT

WV WC470302 WEST VIRGINIA WORKERS COMPENSATION INSURANCE RECOVERY FROM

OTHERS ENDORSEMENT

WV WC470601 WEST VIRGINIA CANCELLATION ENDORSEMENT

WI WC480301C WISCONSIN LIMITED OTHER STATES INSURANCE ENDORSEMENT

WI WC480601C WISCONSIN LAW ENDORSEMENT

WI WC480604 WISCONSIN WAIVER OF SOVEREIGN IMMUNITY ENDORSEMENT

WI WC480606B WISCONSIN CANCELLATION AND NONRENEWAL ENDORSEMENT

WC490301 WYOMING AMENDATORY ENDORSEMENT

HI WC520402 HAWAII MERIT RATING ENDORSEMENT

HI WC520602 HAWAII NOTIFICATION ENDORSEMENT

AK WC540301 ALASKA LIMIT OF LIABILITY ENDORSEMENT

AK WC540601A ALASKA NOTICE OF INSTALLMENT OPTION ENDORSEMENT

AK WC540602 ALASKA CANCELLATION AND NONRENEWAL ENDORSEMENT

KS WcKsLc1 KS - LOSS CONTROL NOTICE TO POLICYHOLDERS MO WcMoLc3 MO - LOSS CONTROL NOTICE TO POLICYHOLDERS OK WcOkLc1 OK - LOSS CONTROL NOTICE TO POLICYHOLDERS

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE

POLICY INFORMATION PAGE

Insured: State of Florida (A Corp) Policy Number: TWC4473846

EXTENSION OF INFORMATION PAGE FOR ITEM #4

ITEM 4: SCHEDULE OF PREMIUMS

Classifications # of

Emps Code No.

Premium Basis Total Estimated

Annual Remuneration

Rate Per $100 of Remun.

Estimated Annual

Premium

Alaska College—Professional Employees & Clerical 0 8868 11,829 0.58 69 Manual Premium 69

Total Manual Premium 69 Premium for Increased Limits Part Two: 1.1% (1000/1000/1000) 9812 1 Total Premium Subject To Experience Modification 70 Experience Modification 57% 40 Premium Discount 8.5% 0063 -3 Terrorism 0.9% 9740 1 Catastrophe (other than Terrorism) 2% 9741 2 Expense Constant 0900 0 Total AK Premium 40 Total AK Cost 40

Alabama Analytical Chemist 0 4511 0.39 Salespersons, Collectors or Messengers—Outside 0 8742 0.19 Attorney—All Employees & Clerical, Messengers, Drivers 0 8820 46,796 0.08 37 College—Professional Employees & Clerical 0 8868 1,253,056 0.27 3,383 Manual Premium 3,420

Total Manual Premium 3,420 Premium for Increased Limits Part Two: 1.4% (1000/1000/1000) 9812 48 Total Premium Subject To Experience Modification 3,468 Experience Modification 57% 1,977 Premium Discount 11.2% 0063 -221 Terrorism 0.6% 9740 78 Catastrophe (other than Terrorism) 1% 9741 130 Expense Constant 0900 0 Total AL Premium 1,964 Total AL Cost 1,964

Arkansas Clerical Office Employees NOC 0 8810 0.06 Manual Premium

Total Manual Premium Premium for Increased Limits Part Two: 1.1% (1000/1000/1000) 9812 0 Total Premium Subject To Experience Modification 0 Experience Modification 57% 0 Premium Discount 11.2% 0063 0 Terrorism 0.6% 9740 0 Catastrophe (other than Terrorism) 1% 9741 0 Expense Constant 0900 0 Total AR Premium 0 Total AR Cost 0

Arizona College—Professional Employees & Clerical 0 8868 869,951 0.22 1,914 Manual Premium 1,914

Total Manual Premium 1,914 Premium for Increased Limits Part Two: 1.1% (1000/1000/1000) 9812 21 Total Premium Subject To Experience Modification 1,935 Experience Modification 57% 1,103 Premium Discount 8.5% 0063 -94 Terrorism 1% 9740 87 Catastrophe (other than Terrorism) 1% 9741 87 Expense Constant 0900 0 Total AZ Premium 1,183 Total AZ Cost 1,183

California Analytical or Testing Laboratories 0 4511 1.30 Salespersons — Outside 0 8742 1.14 Auditors or Accountants 0 8803 1,238,070 0.23 2,848

CLERICAL OFFICE EMPLOYEES — N.O.C

— Non–Governing Class 0 8810 0.79 Colleges or Schools — private — academic professionals 0 8868 3,733,605 1.37 51,150 Manual Premium 53,998

Total Manual Premium 53,998 Total Premium Subject To Experience Modification 53,998 Experience Modification 76% 41,038 Premium Discount 4% 0063 -1,642 Terrorism 3% 9740 1,492 Catastrophe (other than Terrorism) 1% 9741 497 Expense Constant 0900 0 Total CA Premium 41,385

WCARF 2.4604% 9999 1,018

UEBTF 0.1505% 9999 62

SIBTF 1.5891% 9999 658

OSHAF 0.7266% 9999 301

LECF 0.7109% 9999 294

FRAUD 0.4122% 9999 171

Total CA Cost 43,889

Colorado Analytical Laboratories or Assaying - Including Laboratory, Outside Employees, Collectors of Samples & Drivers 0 4511 0.33 Clerical Office Employees NOC 0 8810 0.09 College—Professional Employees & Clerical 0 8868 1,357,657 0.39 5,295 Manual Premium 5,295

Total Manual Premium 5,295 Premium for Increased Limits Part Two: 1.1% (1000/1000/1000) 9812 58 Total Premium Subject To Experience Modification 5,353 Experience Modification 57% 3,051 Premium Discount 11.2% 0063 -342 Terrorism 0.7% 9740 95 Catastrophe (other than Terrorism) 1% 9741 136 Expense Constant 0900 0 Total CO Premium 2,940 Total CO Cost 2,940

Connecticut

Laboratory, Outside Employees, Collectors of Samples & Drivers 0 4511 0.48 College—Professional Employees & Clerical 0 8868 788,920 0.38 2,998 Manual Premium 2,998

Total Manual Premium 2,998 Premium for Increased Limits Part Two: 1.1% (1000/1000/1000) 9812 33 Total Premium Subject To Experience Modification 3,031 Experience Modification 57% 1,728 Premium Discount 11.2% 0063 -194 Terrorism 3.8% 9740 300 Catastrophe (other than Terrorism) 2% 9741 158 Expense Constant 0900 0 Total CT Premium 1,992 Second Injury Fund Assessment 2.25% 9999 49 WC Admin Funds Assessment - Industrial Classes 2.3% 9999 40 Total CT Cost 2,081

District of Columbia Analytical Chemist 0 4511 0.31 Salespersons, Collectors or Messengers—Outside 0 8742 410,404 0.11 451 Clerical Office Employees NOC 0 8810 150,962 0.06 91 College—Professional Employees & Clerical 0 8868 1,224,202 0.20 2,448 Manual Premium 2,990

Total Manual Premium 2,990 Premium for Increased Limits Part Two: 1.1% (1000/1000/1000) 9812 33 Total Premium Subject To Experience Modification 3,023 Experience Modification 57% 1,723 Premium Discount 11.2% 0063 -193 Terrorism 11% 9740 1,964 Catastrophe (other than Terrorism) 2% 9741 357 Expense Constant 0900 0 Total DC Premium 3,851 Total DC Cost 3,851

Delaware College or School, NOC 0 965 24,973 0.31 77 Manual Premium 77

Total Manual Premium 77 Premium for Increased Limits Part Two: 1.1% (1000/1000/1000) 9812 1 Total Premium Subject To Experience Modification 78 Experience Modification N/A 78 Merit Rating Credit -5% 9885 -4 Premium Discount 11.2% 0063 -8 Terrorism 1% 9740 2 Catastrophe (other than Terrorism) 1% 9741 2 Expense Constant 0900 0 Total DE Premium 70 Total DE Cost 70

Georgia Analytical Chemist 0…