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DocuSign Envelope ID:418ADAA3-2F7B-4243-AF32-4541C164B6FA
<br /> WORKERS COMPENSATION EXPERIENCE RATING
<br /> Ara, Risk Name:0 H GRIFFIN INFRASTRUCTURE LLC Risk ID: 913665694
<br /> Rating Effective Date: 12/31/2015 Production Date: 09/09/2015 State: INTERSTATE
<br /> 18-KENTUCKY Finn ID: Firm Name: 0 H GRIFFIN INFRASTRUCTURE LLC _
<br /> Carrier: 15172 Policy No. WC015656220 Elf Date: 12/31/2013 Exp Date: 12/31/2014
<br /> Code ELR D. Payroll Expo . Exp Prim Claim Data 1 IJ I OF Act Inc Act Prim _
<br /> Ratio . 501 LOOMIS Losses
<br /> 1111 NO EXPOSURE UNIT R 0 0
<br /> Subject Total Act Inc
<br /> Policy Total: ■ Premium: 0, Losses: 0 ..
<br /> 32-NORTH CAROLINA Firm ID: Firm Name: D H GRIFFIN INFRASTRUCTURE LLC
<br /> Carrier: 13889 Policy No, WCO21417612 Elf Date: 12/31/2011 Exp Date: 12/31/2012
<br /> Coda ELR 0- Payroll I
<br /> Expected Exp Prim Claim Data LI OF Act Inc 1 Act Prim
<br /> Reno Lows Les Leases 1 L
<br /> 0930 ADDITIONAL PREMIUM 0 0 555020548 09 CI 297 030 15, 411
<br /> . --- .
<br /> 1710 2„67 83,609' 2232 513 I
<br /> =MI 11111111 ______.
<br /> 5606 .74 258,297 1,911 1.
<br /> 401
<br /> MIMI 1111
<br /> 8300 2.58 110 1,; 1,846 43,392 9,112 ,
<br /> =MO 1
<br /> : 10 09 29 515,938 464 135 M 1
<br /> IMI
<br /> _
<br /> i 9812 ADDITIONAL PREMIUM 0 0
<br /> Subject Total Act inc
<br /> Policy Total: 2,639,688 Premium: 209,690 Losses:
<br /> , 297,030 _
<br /> 32-NORTH CAROLINA Firm ID: Firm Name: D H GRIFFIN INFRASTRUCTURE LLC
<br /> Carrier: 15172 Policy No. WC035898743 Elf Date: 12/31/2012 Exp Date: 12/31/2013
<br /> Coda 0- Payroll Expected Exp Prim Claim Data IJ OF Act Inc Act Prim
<br /> El
<br /> .
<br /> Ratio Losses Losses Losses Loss..
<br /> 0930 L1ITIONAL PREMIUM 0 0
<br /> 5606 .74 NEI 235,914 1,746 367
<br /> ' —
<br /> 6306 2.58 1E0 1.395,034 35.992 7,558 ill
<br /> 8810 ,09 ,29 460,501 414 120
<br /> 9812 'DOITIONAL PREMIUM 0 0
<br /> ---
<br /> Subject Total Act Inc
<br /> Policy Total: 2,1.1,449 Premium: 193,938 Losses:
<br /> , 0
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<br /> u Total by Polluoy yew or ell cam$X11 or W14.3 0 ONoeso kola X Fx Muticat Corarago U USL6t101
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