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Version 02.01.22 2022 Program Exhibit Orange County Page 14 <br />CA Form - W04M8F19 <br />© (2019) The Travelers Indemnity Company. All rights reserved <br />Workers Compensation and Employers Liability Losses including Allocated Loss Adjustment Expenses (ALAE) arising out of a single <br />accident shall be limited to the amount indicated above. For Occupational Disease Claims, this limitation shall apply to each employee. <br />ESTIMATED MAXIMUM AND MINIMUM BILLED AMOUNTS <br />Your Loss Responsive Rating Plan is subject to this section. All other rating plans are NOT subject to the <br />Maximum or the Minimum Billed Amount. <br />CHARGE TYPE RATE AMOUNT <br />Estimated Maximum Billed Losses $2.1444 Per $100 of <br />Audited Total WC <br />Payroll Excluding <br />Monopolistic States <br />Payroll <br />$1,182,500 <br />Your Maximum Billed Losses will not be less than $1,182,500 <br />Rating Plan Components Subject to Maximum Billed Losses: <br />WC Deductible Plan Losses <br />Minimum Billed Amount $0.4122 Per $100 of <br />Audited Total WC <br />Payroll Excluding <br />Monopolistic States <br />Payroll, but in no <br />event less than the <br />sum of the minimum <br />amounts shown in <br />other parts of the <br />Program Summary <br />$227,358 <br />Rating Plan Components Subject to Minimum Billed Amount: <br />Administrative Expense Reimbursement <br />Workers Compensation Deductible Premium <br />ESTIMATED EXPOSURES APPLICABLE TO OTHER THAN GUARANTEED COST POLICIES <br />RATING PLAN EXPOSURE LOCATION ESTIMATED EXPOSURE AMOUNT <br />WC Payroll Deductible Plan States NC $55,143,903 <br />TOTAL WC PAYROLL EXCLUDING MONOPOLISTIC STATES $55,143,903 <br />YOU HAVE AGREED TO PROVIDE COLLATERAL AND LOSS FUNDS IN THE <br />AMOUNT AND OF THE TYPE DESCRIBED BELOW, AS FURTHER SET FORTH <br />IN THE COLLATERAL AND REMEDIES SECTION AND THE COLLATERAL <br />EXHIBIT OF THE INSURANCE PROGRAM AGREEMENT. <br />DocuSign Envelope ID: FCD9FE56-CF01-4E96-B983-B8E8DFE6811C