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<br /> DocuSign Envelope ID: B94F2D40-3B3C-47A7-86C2-6F1 B4F92C62C
<br /> I
<br /> WORKERS COMPENSATION EXPERIENCE RATING
<br /> CC/.. Risk Name: SASSER CO INC Risk ID: 914011531
<br /> Rating Effective Date:02/01/2019 Production Date: 11/13/2018 State: INTERSTATE
<br /> 09-FLORIDA Firm ID: Firm Name: SASSER CO INC
<br /> Carrier: 90468 Policy No. WCV6139124 Eff Date: 02/0112017 Exp Date: 02/01/2018
<br /> ti a t ^�. M� s .
<br /> rE e x R Clad to �.i O jnc
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<br /> x..�,tom,txst
<br /> 8810 08 .43 17,210 14 fi
<br /> 8810 .08 .43 12,155 10 4
<br /> 9812 EMPLOYERS LIABILIT 0 0
<br /> Subject Total Act Inc
<br /> Policy Total: 29,36 Premium: 78 Losses: 0
<br /> 32-NORTH CAROLINA Firm ID: Firm Name: SASSER CO INC
<br /> Carrier: 22438 Policy No. ACPWCK2234904984 Eff Date: 0210112W5 Exp pate: 02/01/2016
<br /> Oil
<br /> 0930 WAIVER OF SUBROGAT 0 6 32A62290 05 F 56,082: 16,500
<br /> 5190 1,57 .25 60,878 956 239 32A65088 06 F 2,428 2,428
<br /> [5437 2.07 .25 249,480 5,164 1,291
<br /> .45 .22 519,070 2,336 514
<br /> .71 .35 88,438 628 220
<br /> .06 .31 571,817 343 106
<br /> 9044 1.31 .31 1,787,970' 23,422 7,261 -
<br /> 9812 EMPLOYERS LIABILIT 0 0
<br /> Subject Total Act Inc
<br /> Policy Total: 3,277,64 Premium: 114,524 Losses: 58,510
<br /> 32-NORTH CAROLINA Firm III Firm Name: SASSER CO INC
<br /> Carrier: 22438 Policy No. ACPWCK2244904984 Eff Date: 02/0112016 Exp Date: 02/01/2017
<br /> y. -y� ewc,>: r x- ,v e;� �. yrs x. a„yy
<br /> C L grab 47 IF
<br /> � E ctetl r � � m �IaE D
<br /> ; cr,z4;. a rr o PQ ' r' £ e
<br /> . i 11,11 ����� ��
<br /> k., ..
<br /> 0930 WAIVER OF SUBROGAT 0 0 .32A69363 06 F 1,039 1,039
<br /> 5190 1.57 .25 71,574 1,124 281
<br /> 5437 2.0.7 .25 107,411 2,223 556
<br /> 5606 .45 .22 548,026 2,466 543
<br /> 8017 .71 .35 120,328 854 299
<br /> 8810 .06 .31 698,601 419 130
<br /> 9014 1.31 .31 1,140,918 14,946 4,633
<br /> 9812 EMPLOYERS LIABILIT 0 0
<br /> Subject Total Act Inc
<br /> Policy Total: 2,686,85 Premlum: 75,494 Losses: 1,039
<br /> J Copyright 1993-2018.All fights reserved.This product Is comprised of compilations and Information which are the proprietary and exclusive property of the National Council on Gompensation Insurance,
<br /> Igo,(Neel).No further use,dissemfna$on,sale,transfer,assignment or dlsposhton of this product,In whole or In part,may be made without the priorwritten consent of NCCI,This product is fum[shed'As
<br /> Is''As availahle""With all defects'and Includes infonmahon available at he time of publloation only.NCCI makes no representations or warranties of any kind relating to the ptaduct and hereby expressly
<br /> disclaims any and all express,statutory,or Implied warranties,Including the implied warranty of merchantability,fltness for a particular purpose,accuracy,completeness,currentness,or correclrress of the
<br /> product or Information contained therein.This product and the Information contained therein are to be used exclusively for undenvdfing,premium calcufaflon and other Insurance purposes and may net be
<br /> used for any other purpose Including but not limited to safety scoring for project bidding purposes.All responsibility for the use of and for any and all results delved erobtalned through the use of the product
<br /> and Information are the end user's and NCCI snail not have any liability thereto.
<br /> "Total by Policy Year of al[cases$2000 or less. D Disease Loss X Px-Medlcal Coverage U DSL&HW
<br /> 0 Catastrophic Loss E Employers Liability Loss #1 Limited Loss Page 2 of 4
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