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DocuSign Envelope ID:418ADAA3-2F7B-4243-AF32-4541C164B6FA <br /> WORKERS COMPENSATION EXPERIENCE RATING <br /> 111Q Risk Name: 0 H GRIFFIN INFRASTRUCTURE LLC Risk ID: 913865694 <br /> , <br /> Rating Effective Date:12/31/2015 Production Date: 09109/2015 State: INTERSTATE <br /> _ - <br /> 45-VIRGINIA Firm ID: Firm Name; 0 H GRIFFIN INFRASTRUCTURE LLC <br /> Carrier: 13889 Policy No. WCO21417612 Eft Date: 12131/2011 Exp Date: 12/31/2012 <br /> Code ELR D- Payroll Expected Exp Prim Claim Data IJ OF Act Inc Act Prim <br /> 1- <br /> o Losses Losses Losses L. es <br /> !30 ADDrTIONAL PREMIUM 0 0 <br /> — _1 <br /> 5606 .63 .24 19901 126 30 <br /> --"" <br /> 63s; 176 .24 67,344 1,185 284 <br /> ::12 ADDITIONAL PREMIUM 0 0 <br /> Subject Total Act Inc <br /> Policy Total. 87,245 Premium: 3,699 Losses: 0 <br /> 45-VIRGINIA Firm ID: Firm Name: D H GRIFFIN INFRASTRUCTURE LLC <br /> Carrier: 15172 Policy No. WC035898743 Eff Date: 12/3112012 Exp Date: 12/31/2013 <br /> Code ELR D- Psywii7 Expected Exp Prim Claim Data IJ OF. Act Inc Act Prim <br /> o • wee L. es Losses • <br /> 0930 ADDITIONAL PREMIUM 0 0 <br /> _ . <br /> 1 <br /> 5606 .63 .24 9,871 62 15 <br /> 6306 1 76 .24 6,960 122 29 <br /> 9812 ADDITIONAL PREMIUM 0 0 _ <br /> _ - -__ <br /> Subject Total Act Inc <br /> Policy Total: 16,831 Premium: 734 Losses: 0 <br /> 45-VIRGINIA 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 /> Code ELR O- Payroll Expected Exp Prim Claim Data IJ • Act Inc Act Prim <br /> - o Los . Losses Losses • us <br /> 0930 ADDITIONAL PREMIUM 0 0 EMIIIIIIIIII <br /> 1 .. <br /> 416 .63 24 17,296 109 26 <br /> 6306 1.76 .24 18,263 321 77 =I <br /> I <br /> II <br /> 9812 ADDITIONAL PREMIUM 0 0 <br /> — , ., <br /> Subject Total Act Inc <br /> Policy Total: 35,5 . Premium: 1,698 Losses: 0 <br /> 47-WEST VIRGINIA Finn ID; Firm Name: 0 H GRIFFIN INFRASTRUCTURE LLC <br /> Carrier: 13889 Policy No. WCO21417612 Eff Date: 12/3112011 Exp Date: 12/31/2012 <br /> 1 <br /> Code D- Payroll Expected _ .. . <br /> Exp Prim Claim Dela LI OF Act Inc Act Prim <br /> Ratio Losses Losses _ Losses Lo <br /> 6308 1 38 .36 210,771 2,866 1.032 <br /> 8810 _ 09 Mal 8,654 8 4 <br /> 9812 ADDITIONAL PREMIUM 0 0 <br /> _ . <br /> Subject Total Act Inc <br /> Policy Total: 219,42'Premium: 14,477 Losses: 0 <br /> o CopTira-ilua I 41 i 2015,Allraitea imayadal Rao produti ile abunpferaral oli., Mauna ond%Noel-Patron OM aro ley 1.ma:taw and raincirarairara pooperally ell Ilea kraollinnoli Col on <br /> ICaareanorallioniraxieranera,frac IlillCC,11111 No furalleas uao,adysenfionifor4 orate 0. alkali fimmerairafrat of di:uptake%of raffia p000llef,linver.■ D4O imuu,may iaQ old*wavoza arta Razor ra011aa <br /> ;a Wag edi ivnna null,rofiLaat al tuairauattaffl'mid°'lie Jana/AV Ilehth ni%dolier.ire and anctidaa ilratorreoll. i affable fall tee boor%■ ; Atalvaf 11 My, NCCI IIP UM imply semi,limo or <br /> your mhos of arty ked rellelloca Imam rode.%nref Natal*eaproo,IV drachma Gov rand eill ovum,.allfoldfoiy,dr%foraged wry-make,1%,. rairig flea gap rra Hi rof courteeeeseedy,IlaaaLa <br /> fan a paulalka-poouratio,moo/racy,rmarilalaaaas COrreiciln04 it,al CM nnfirma of 4fery informarar%Of PfOCkle oi kanisiied haratuaara 41,111 4 Vslp(110100 kV III*URI 00 a.agi dor aura(am;Aar Ilmmingo <br /> don it 1 co obi raii mad dutione Oa 140 af Ma paraalICII ore fee end MORI,ulna Nr;01 SNIP)W• Wee any fiabiatii emelt% <br /> 'roue by PoIllicy fif i.r an woe If 200,0 or[loot 0 Clsease IL X V::n-Medical'Coverirap Q.)lraSL.ailiff <br /> C Caioallna, GUM IE Earrefirryero 1 gabillRy Leas V t wand Less Pane 4 of 4 <br />