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DocuSign Envelope ID: 313DA256 -1EDE- 4396- A716- 4C53B809027E
<br />Workers' Compensation Experience Rating Worksheet
<br />Effective [date: 7/112017
<br />Risk ID:
<br />State: NC
<br />* * ** *North Carolina
<br />Policy Period:
<br />7/1/2013 to
<br />7/1/2014
<br />Policy #:
<br />0042
<br />2.24
<br />0.28
<br />28,625
<br />641
<br />180
<br />5022
<br />125
<br />0.21
<br />72,135
<br />2,344
<br />492
<br />5221
<br />1.90
<br />0.25
<br />129,454
<br />2,460
<br />615
<br />5403
<br />2.64
<br />0,21
<br />341,565
<br />9,017
<br />1,894
<br />5606
<br />0,54
<br />0.21
<br />211,260
<br />1,141
<br />240
<br />8810
<br />0.06
<br />0.31
<br />511,494
<br />307
<br />95
<br />9014
<br />1.36
<br />0.31
<br />70,279
<br />956
<br />296
<br />Policy Period Totals
<br />1,364,812
<br />16,866
<br />3,811-
<br />Policy Period;
<br />711/2014 to 7!112015
<br />Policy #:
<br />0042
<br />2.24
<br />0.28
<br />29,791
<br />667
<br />187
<br />5022
<br />3.25
<br />0.21
<br />74,798
<br />2,431
<br />511
<br />5221
<br />1.90
<br />0.25
<br />135,687
<br />2,578
<br />645
<br />5403
<br />2.64
<br />0.21
<br />331,326
<br />8,747
<br />1,837
<br />5606
<br />0.54
<br />0.21
<br />218,932
<br />1,182
<br />248
<br />8810
<br />0.06
<br />0.31
<br />504,970
<br />303
<br />94
<br />9014
<br />1.36
<br />0.31
<br />75,304
<br />1,024
<br />317
<br />Policy Period Totals
<br />1,370,808
<br />16,933
<br />3,833
<br />Policy Period:
<br />7/1/2015
<br />to 7/1/2016
<br />Policy
<br />M
<br />0042
<br />2.24
<br />0.28
<br />32,314
<br />724
<br />203
<br />5022
<br />3.25
<br />0.21
<br />84,396
<br />2,743
<br />576
<br />5221
<br />1.90
<br />0.25
<br />149,895
<br />2,848
<br />712
<br />5403
<br />2.64
<br />0.21
<br />397,167
<br />10,485
<br />2,202
<br />5606
<br />0.54
<br />0.21
<br />256,216
<br />1,384
<br />291
<br />8810
<br />0.06
<br />0.31
<br />533,570
<br />320
<br />99
<br />9014
<br />1.36
<br />0.31
<br />79,930
<br />1,087
<br />337
<br />Policy Period Totals
<br />1,533,488
<br />19,591
<br />4,410
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<br />Moil E'fiective Date: Y /1 /21117
<br />
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