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Version 02.01.22 2022 Program Exhibit Orange County Page 12 <br />CA Form - W04M8F19 <br />© (2019) The Travelers Indemnity Company. All rights reserved. <br />Your Insurance Program is comprised of your Insurance Policies and any services charged <br />separately. This Program Exhibit outlines how your Obligations to us are calculated and paid. <br />INSURED: Orange County <br />PROGRAM TERM: 07/01/2022 TO 07/01/2023 <br />RATING PLAN(S) <br />Your Rating Plan Obligation(s) is a combination of all of the below plans and amounts: <br />(1) LOSS RESPONSIVE RATING PLAN(S) (INCLUDING EXPENSES, CLAIM HANDLING <br />CHARGES, PREMIUM TAXES) + (2) NON-LOSS RESPONSIVE RATING PLAN(S) + (3) SURCHARGES AND <br />ASSESSMENTS + (4) SERVICES CHARGED SEPARATELY (IF ANY). <br />(1) LOSS RESPONSIVE RATING PLAN(S) <br />Deductible Plan Computation Formula Deductible Plan Paid Losses + Deductible Plan Claim Handling Charges + <br />Administrative Expense Reimbursement = Deductible Plan Charges <br />EXPENSES <br />EXPENSE TYPE RATE (IF APPLICABLE)MINIMUM <br />AMOUNT <br />ESTIMATED <br />AMOUNT <br />Administrative Expense Reimbursement1 $0.1356 Per $100 of Audited Total WC Payroll <br />Excluding Monopolistic States Payroll <br />$74,775 $74,775 <br />TOTAL EXPENSES INCLUDED IN THE INSTALLMENT SCHEDULE $74,775 <br />1 Administrative Expense Reimbursement is the amount we charge for our annual, non-risk bearing expenses for certain policies, and is in addition to <br />the Claim Handling Charges outlined below. Administrative Expense Reimbursement includes Risk Management Information System (RMIS) Charges, if <br />purchased. If this program is non-renewed, and the parties agree that continued RMIS services will be provided to you, such continued services will be <br />charged on an annual basis at a rate to be negotiated by the parties. <br />CLAIM HANDLING CHARGES <br />Workers Compensation and Employers Liability Claim Handling Charges Basis Rate <br />Loss Conversion Factor (LCF)LCF .080 <br />The LCF will be multiplied by the first $250,000 of each Workers Compensation and Employers Liability Loss and Allocated <br />Loss Adjustment Expense associated therewith. The LCF will be applied beginning on the first day of the Program Term for <br />this Program Exhibit and according to the billing basis and billing frequency noted in the Payment Schedule section of this <br />Program Exhibit. <br />Medical Cost Containment Component of Allocated Loss Adjustment Expense <br />DocuSign Envelope ID: FCD9FE56-CF01-4E96-B983-B8E8DFE6811C