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DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED <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: MWC0106102-01 <br /> Issued to: Senior Care of Orange County Inc <br /> Effective Date: 02/08/2017- 02/08/2018 <br /> Coverage Provided By: Markel Insurance Company <br /> Carrier Code: 22616 <br /> Period of Operation: 02/08/2017- 02/08/2018 <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 /> 8868 College Professional $267,123.00 0.560 $1,496.00 <br /> Employees&Clerical <br /> Manual Premium $1,496.00 <br /> Total Manual Premium $1,496.00 <br /> 9807 Employers Liability 0.800 $12.00 <br /> 9848 ELL Minimum 63.000 $63.00 <br /> Subject Premium $1,571.00 <br /> Total Subject Premium $1,571.00 <br /> Modified Premium $1,571.00 <br /> 9887 Schedule Rating -0.050 ($79.00) <br /> Standard Premium $1,492.00 <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 $1,782.00 <br /> Total Amount Due $1,782.00 <br /> 2of24 <br /> ©1991 National Council on Compensation Insurance. <br />