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DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 <br /> WC 99 06 01 <br /> EXTENSION OF INFORMATION PAGE <br /> Worker's Compensation and <br /> Employer's Liability Policy <br /> Schedule Of Premium Information <br /> Policy Number: MWC0071930-02 <br /> Issued to: Family Centered Healthcare INC <br /> Effective Date: 11/17/2015 - 11/17/2016 <br /> Coverage Provided By: Markel Insurance Company <br /> Carrier Code: 22616 <br /> Period of Operation: 11/17/2015 - 11/17/2016 <br /> State of Operation: NC <br /> Premium Basis <br /> Total Rate Per Estimated <br /> Estimated Annual $100 of Annual <br /> Code Classification Remuneration Remuneration Premium <br /> Class code Description <br /> 8832 Physician $268,000.00 0.510 $1,367.00 <br /> Manual Premium $1,367.00 <br /> Total Manual Premium $1,367.00 <br /> Subject Premium $1,367.00 <br /> Total Subject Premium $1,367.00 <br /> Modified Premium $1,367.00 <br /> 9887 Schedule Rating -0.270 ($369.00) <br /> Standard Premium $998.00 <br /> 0900 Expense Constant $210.00 <br /> 9740 Terrorism 0.015 $40.00 <br /> 9741 Catastrophe(other than 0.015 $40.00 <br /> Certified Acts of Terrorism) <br /> Estimated Annual Premium $1,288.00 <br /> Total Amount Due $1,288.00 <br /> ©1991 National Council on Compensation Insurance. 3 of 6 <br />