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DocuSign Envelope ID:418ADAA3-2F7B-4243-AF32-4541C164B6FA <br /> WORKERS COMPENSATION EXPERIENCE RATING <br /> 7- <br /> im Cri. Risk Name:D H GRIFFIN INFRASTRUCTURE LLC Risk ID: 913665894 <br /> Rating Effective Date: 12/31/2015 Production Date: 09/09/2015 State: INTERSTATE <br /> 32-NORTH CAROLINA Firm ID: Firm Name: D H GRIFFIN INFRASTRUCTURE LLC <br /> Carrier: 15172 Poi Icy No. WC015656220 Eff Date: 12/31/2013 Exp Date: 12/31/2014 <br /> Code ELR D- Payroll Expected Exp Prim Claim Date 14 OF Act Inc Act Prim <br /> Ratio . ses , Losses Losses Losses <br /> 0930 ADDITIONAL PREMIUM 0 0 <br /> 5606 .74 .21 423,939 3,137 659 <br /> 6308 2.58 21 1,288,511 33,244 6,981 <br /> 8810 .09 .29 805,226 725 210 <br /> 9812 ADDITIONAL PREMIUM —0 0 <br /> Subject Total Act Inc <br /> Policy Total: 2,517,676 Premium: 176,454 Losses: 0 j <br /> 39-SOUTH CAROUNA Firm ID: Firm Name: 0 11 GRIFFIN INFRASTRUCTURE LLC <br /> Carrier: 13889 Policy No. WCO21417612 Eff Date: 12/31/2011 Exp Date; 12/31/2012 <br /> _ ,_....._ <br /> Code ELR D. Payroll Expected Exp Prim Claim Data U OF Act Inc Act Prim <br /> Ratio Lasses Losses Loess' L. as <br /> 111 I NO EXPOSURE UNIT R 0 0 <br /> .. -- <br /> Subject Total Act Inc <br /> Policy Total:_ 0 Premium: 0, Losses: 0 <br /> 39-SOUTH CAROUNA Firm ID: Firm Name: D H GRIFFIN INFRASTRUCTURE LLC <br /> Carrier; 15172 Policy No. WC0358!.743 Eff Date: 12131/2012 Exp Date: 12/31/2013 <br /> Code ELR 0- Payroll Expected Exp Prim Claim Data IJ Act Inc Act Prim- <br /> 1 'Ratio Leases Losses • Losses Losses <br /> 0:'0 DDITIONAL PREMIUM 0 0 =MN <br /> 5606 .89 .23 3,914 35 8 J 1.1 <br /> 6306 3.37 .23 2 474 83 19 <br /> 9812 •DDITIONAL PREMIUM 0 0 <br /> -° - <br /> Subject Total Act Inc <br /> Policy Total; 6,38 Premium: 404 Losses: 0 <br /> _. <br /> 39-SOUTH CAROLINA Firm ID: Firm Name: D H GRIFFIN INFRASTRUCTURE LLC <br /> Carrier: 15172 Policy No. WC015656220 Eft Date: 12/31/2013 Exp Date: 12/31/2014 <br /> ---1 <br /> Code ELR 03- Payroll Expected Exp Prim Claim Data U OF Act Inc Act Prim <br /> ,Ratio_ Losses 1 Loa . Lasses L. es .1 <br /> - <br /> 1111 NO EXPOSURE UNIT R 0 0 I ., <br /> Subject Total Act Inc —1 <br /> Policy Total: - 0 Losses: 0 <br /> _ --14 <br /> 0(klpyriahl t 9934015,All tights reserved. Pas product is compose of compilahons and itifrantairen viiiitia;-ilieiiroprolary and oxclusee property OP aro Rational Council on —1 <br /> Corapencolion'amitotic°,Inc iNcGD Na WOW(DK dIsserninelico,solo,transier,assonant is disposition of lids imoduct,In vrtu. or in pad,may Isis re •without Ina plcir volt len <br /> cunserd d NW' This product Is!wished AS IV'As available''WC all defects'end ineltslasinfrarnation available at lien Woof puhhcation only NCCI makes Ira rearrasenintiune or <br /> warns Atm La any land ruining to the product and burley ogifessly deroferos any ano all arvess,statutory,or ropier!warranties,'WWI.*the',option wooarsty co merchontabitity,illness <br /> for 9 pentlarlar purpose,estputety,cempteleness,edreninesc,or al' 'she of any ittarrnatton or landed furnished Iluieurator API sesptnstbility For the use of end for any end ail results <br /> derived Of obtained Ibrougt i amuse al Ow pfdluct ere the and user's olio NCCI shell riot have any liability thereat <br /> _ — — <br /> Tot^1 by Policy Year of encases$a r r or loss 0 Disease Loss X ExAledical Coverage U USLSHW <br /> C Caleetraphic Loss E Emperors Llebility Lass a Limed Loss Page 3 of 4 <br />