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NCACC Risk Management Pools <br />Workers’ Compensation <br />7/1/2021 to 7/1/2022 <br />ESTIMATED PAYROLL $55,795,803 <br />MANUAL CONTRIBUTION $1,611,319 <br />MODIFIED CONTRIBUTION $1,160,079 <br />ESTIMATED CONTRIBUTION $1,160,079 <br />Deductible Option $300,000 <br />Deductible Factor (No Aggregate)0.32308 <br />Deductible Contribution (No Aggregate)$374,798 <br />(Member Contribution multiplied by Deductible Factor) <br />Expected Losses $852,658 <br />Expected Losses Limited to Deductible $579,807 <br />Expected Total Cost for $300,000 Deductible (No Aggregate)$954,605 <br />(Deductible Contribution plus Expected Losses within the Deductible) <br />Aggregate Retention <br />Aggregate Percentage of Expected Losses 0% <br />Aggregate Retention $0 <br />Aggregate Contribution Factor 0 <br />Additional Contribution for Aggregate $0 <br />Expected Total Cost for $300,000 Deductible with Aggregate $374,798 <br />(Expected Total Cost for Deductible plus Additional Contribution for Aggregate) <br />Estimated Total Contribution for Deductible and Aggregate $374,798 <br />Please bind the $300,000 Deductible Option for the 7/1/2021 to 7/1/2022 Fund Year. <br />Signed: _______________________________________________________________ <br />Title: _____________________________________________ Date: ______________ <br />Financial Officer ____________________________________ Date _______________ <br />(In addition to excess insurance, which provides coverage for a single claim in excess of <br />your retention, we limit the total amount you will pay for claims in any one fund year. This <br />represents your maximum claims cost for the Fund Year.) <br />This instrument has been preaudited in the manner required by the Local Government Budget and Fiscal <br />Control Act. <br />We appreciate your participation. To insure effective, efficient operation of your Pool we must <br />receive payment in full no later than August 1st. A two percent late payment fee will be <br />assessed on all amounts received after that date. <br />Orange County <br />PROPOSAL FOR $300,000 DEDUCTIBLE OPTION <br />6/17/21County Manager <br />DocuSign Envelope ID: 4BC4D079-09BF-4F15-BDA0-A24B1EDE73EF