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DocuSign Envelope ID:418ADAA3-2F7B-4243-AF32-4541C164B6FA
<br /> WORKERS COMPENSATION EXPERIENCE RATING
<br /> Risk Name: D H GRIFFIN INFRASTRUCTURE LLC Risk ID: 913665694
<br /> Rating Effective Date: 12/31/2015 Production Date: 09/09/2015 State: INTERSTATE
<br /> State Ego Esc, Expected Exp Prim Act Ex c Losses Belfast Act Inc Losses Act Prim
<br /> 1111
<br /> Los, , Louse Legge: Leases
<br /> KY 15 0 0 0 0 31,200 0
<br /> . .
<br /> NG .12 97,201 123,257 28,058 281,530 41,650 297,030 15,531
<br /> sc 12 91 118 27 0 44,450 0 0
<br /> VA mial 1,46 1,924 461 0 33,250 0 Is
<br /> IZEINIE11111111111M 2,874 1,038 0 30,600 0
<br /> 0
<br /> (C)Exp Excess (0)Expected (E)"Exp,Prim (F)Act Exc (0)Ballast (H)Act Inc (I)Act Petri
<br /> Losses(D-E) Losses Losses Loses*(H-I) L• es Losses
<br /> IEE 100,593 126,17 27,580 281,530
<br /> ...___ . 41,2791 297,0301 15,500
<br /> Prima/Losses StabllizInp Value • ., 'ble Excess Totals
<br /> (I) C*CI -A)+G (A)*(F) (J)
<br /> Actual 15,500 129,801 33,784 179,085
<br /> (6) C (1-A)+G (A)"(C) (K) _
<br /> Expected 27,580 129,801 12,071 169,452
<br /> AMP FLARAP SARAP ' . ,RAP Exp Mod
<br /> *-- —
<br /> (J)1(k)
<br /> Factors 1.18 1.06
<br /> _ __
<br /> . .
<br /> THE ARAP FACTOR SHOWN IS FOR THOSE STATES CONTAINED ON THIS
<br /> RATING THAT HAVE APPROVED THE ARAP PROGRAM AND IS CALCULATED
<br /> BASED ON THE STATE WITH THE HIGHEST APPROVED MAXIMUM ARAP I
<br /> SURCHARGE.THE ' IMUM ARAP SURCHARGE MAY VARY BY STATE.
<br /> PLEASE REFER TO EACH STATES APPROVED RULES FOR THE
<br /> APPLICABLE MAXIMUM ARAP SURCHARGE.
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