2022-252-E-County Mgr-Travelers Insurance-Work comp coverage

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Version 02.01.22 2022 Program Exhibit Orange County Page 13 CA Form - W04M8F19 © (2019) The Travelers Indemnity Company. All rights reserved The Medical Cost Containment Components are charged pursuant to the Allocated Loss Adjustment Expense Exhibit to the Insurance Program Agreement. Allocated Loss Adjustment Expense has the same meaning as “Allocated Loss Adjustment Expense”, “ALAE” or “claim expense” in any applicable Policy, or, if the Policy has no such definition, it shall have the same meaning as set forth in the Allocated Loss Adjustment Exhibit. Savings Expense Fee Percentage of Savings Achieved 27% (2) NON-LOSS RESPONSIVE RATING PLAN Non-Loss Responsive Premium Formula (other than Guaranteed Cost Policies) Non-Loss Responsive Rate(s) x Corresponding Exposure Base(s), but in no event less than any stated Minimum Non-Loss Responsive Premium shown in the Non- Loss Responsive Premium section of this Program Exhibit (below). NON-LOSS RESPONSIVE PREMIUM TYPE OF COVERAGE RATE MINIMUM AMOUNT ESTIMATED AMOUNT Workers Compensation Deductible Premium $0.2767 Per $100 of Audited Total WC Payroll Excluding Monopolistic States Payroll $152,583 $152,583 TOTAL ESTIMATED NON-LOSS RESPONSIVE PREMIUM $152,583 Your premium amounts referenced above will include any residual market charges which may be assessed by the various states. (3) SURCHARGES AND ASSESSMENTS You will pay Surcharges and Assessments pursuant to individual state law or regulation. Surcharges and Assessments are exclusive of, and in addition to, your Rating Plans CHARGE TYPE RATE DEPOSIT/ESTIMATED AMOUNT TOTAL CHARGE INCLUDED IN THE INSTALLMENT SCHEDULE $0 THE FOLLOWING APPLY TO YOUR PROGRAM: AMOUNTS RETAINED BY YOU, ESTIMATED MAXIMUM AND MINIMUM BILLED AMOUNTS AND ESTIMATED EXPOSURES AMOUNTS RETAINED BY YOU Workers Compensation and Employers Liability Loss including ALAE a$300,000 DocuSign Envelope ID: FCD9FE56-CF01-4E96-B983-B8E8DFE6811C