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DocuSign Envelope ID: 313DA256 -1EDE- 4396- A716- 4C53B809027E <br />=sis for HM Korn Corporation <br />(D) - (E) <br />(H) - (n <br />0.0.9 <br />41,319 <br />53,389 <br />12,070 <br />0 <br />30,250 <br />0 <br />0 <br />EXPECTED <br />TOTAL <br />EXP <br />ACTUAL <br />"B" <br />TOTAL TOTAL <br />VALUE <br />EXCESS <br />EXPECTED <br />ITOTAL <br />PRIM. <br />JEXCESS <br />VALUE <br />ACTUAL ACT. PRIM. <br />(A) x (F) <br />ACTUAL <br />0 <br />67,850 <br />0 <br />67,850 <br /># Limited loss. <br />s Subrogation <br />or other special loss. <br />ARAP <br />1.00 <br />if applicable <br />EXP <br />MOD <br />(J� � �K� <br />0.81 <br />" Rating reflects a decrease of 70 percent medical -only primary and excess loss dollars where ERA is applied, reflected <br />only in totals (F), (H), and (1). <br />The ARAP surcharge shown is for those states in the rating that have approved the ARAP program. It was calculated based <br />on the general interstate formula and maximum, however, the maximum surcharge may vary by state. <br />MotIlvliilI, -i NfixIAnaly,rv. wj!W IoyoII by SIALaro rrp(Jachsonville) P011.0 I' <br />I IM Xern Corpm itian NCRiI <br />Mod rffectivr. hate! 7/7,12o17 <br />Experience <br />1 <br />1111 <br />Modification <br />PRIMARY <br />STABILIZING <br />RATABLE <br />ADJUSTED <br />Calculation <br />LOSSES <br />VALUE <br />EXCESS <br />TOTALS <br />(1) <br />(C) X (? -A) + (G) <br />(A) x (F) <br />ACTUAL <br />0 <br />67,850 <br />0 <br />67,850 <br />(E) <br />(C) X (! -A) + (G) <br />(A) X (C) <br />EXPECTED <br />12,070 <br />67,850 <br />3,719 <br />83,639 <br />EXP <br />MOD <br />(J� � �K� <br />0.81 <br />" Rating reflects a decrease of 70 percent medical -only primary and excess loss dollars where ERA is applied, reflected <br />only in totals (F), (H), and (1). <br />The ARAP surcharge shown is for those states in the rating that have approved the ARAP program. It was calculated based <br />on the general interstate formula and maximum, however, the maximum surcharge may vary by state. <br />MotIlvliilI, -i NfixIAnaly,rv. wj!W IoyoII by SIALaro rrp(Jachsonville) P011.0 I' <br />I IM Xern Corpm itian NCRiI <br />Mod rffectivr. hate! 7/7,12o17 <br />