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DocuSign Envelope ID: 11 591086-0989-4E2D-8A03-5E4CDBBE1 178 <br />ADDITIONAL COVERAGES <br />Ref # <br />Description <br />WC & Employer's liability <br />Coverage Code <br />WCEL <br />Form No. <br />Edition Date <br />Limit 1 <br />1,000,000 <br />Limit 2 <br />1,000,000 <br />Limit 3 <br />1,000,000 <br />Deductible Amount <br />Deductible Type <br />Premium <br />Ref # <br />Description <br />Adjst. to reconcile -exp mod. premium <br />Coverage Code <br />AREM <br />Form No. <br />Edition Date <br />Limit 1 <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />-$1,588.00 <br />Ref # <br />Description <br />Increased employer's liability <br />Coverage Code <br />INEL <br />Form No. <br />Edition Date <br />Limit 1 <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />$100.00 <br />Ref # <br />Description <br />Increased employer's liability <br />Coverage Code <br />INEL <br />Form No. <br />Edition Date <br />Limit 1 <br />--j <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />$154.00 <br />Ref # <br />Description <br />Waiver of Subrogation <br />Coverage Code <br />WVSUB <br />Form No. <br />Edition Date <br />Limit 1 <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />$250.00 <br />Ref # <br />Description <br />Expense constant <br />Coverage Code <br />EXCNT <br />Form No. <br />Edition Date <br />Limit 1 <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />$230.00 <br />Ref # <br />Description <br />Coverage Code <br />Form No. <br />Edition Date <br />Limit 1 <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />Ref # <br />Description <br />Coverage Code <br />Form No. <br />Edition Date <br />Limit 1 <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />Ref # <br />Description <br />Coverage Code <br />Form No. <br />Edition Date <br />Limit 1 <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />Ref # <br />Description <br />Coverage Code <br />Form No. <br />Edition Date <br />Limit 1 <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />Ref # <br />Description <br />Coverage Code <br />Form No. <br />Edition Date <br />Limit 1 <br />Limit 2 <br />Limit 3 <br />Deductible Amount <br />Deductible Type <br />Premium <br />rFADTLCv Copyright 2001, AMS Services, Inc. <br />