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Version 02.01.22 2022 Program Exhibit Orange County Page 15 <br />CA Form - W04M8F19 <br />© (2019) The Travelers Indemnity Company. All rights reserved <br />LOSS FUND REQUIREMENTS <br />LOSS FUND TYPE <br />AMOUNT REQUIRED FOR <br />ALL YEARS (HISTORICAL <br />AND CURRENT) <br />AMOUNT CURRENTLY <br />HOLDING (HISTORICAL <br />POLICIES) <br />ADDITIONAL (RETURN) <br />AMOUNT DUE <br />Deductible Plan Deposit $25,000 $0 $25,000 <br />TOTAL LOSS FUND DUE (OR RETURN)$25,000 <br />COLLATERAL REQUIREMENTS <br />COLLATERAL TYPE AMOUNT REQUIRED FOR <br />ALL YEARS (HISTORIC AND <br />CURRENT) <br />AMOUNT CURRENTLY <br />HOLDING <br />ADDITIONAL (RETURN) <br />AMOUNT DUE <br />Letter Of Credit $300,000 $0 $300,000 <br />TOTAL $300,000 $0 $300,000 <br />TOTAL COLLATERAL DUE PER COLLATERAL SCHEDULE $300,000 <br />COLLATERAL SCHEDULE <br />COLLATERAL TYPE AMOUNT DUE DATE <br />Letter Of Credit <br />$300,000 07/01/2022 <br />TOTAL COLLATERAL DUE $300,000 <br />INSTALLMENT SCHEDULE <br />PAYMENT TYPE DUE DATE AMOUNT DUE <br />Rating Plan Obligations Payable in 4 equal installments, beginning July 01, 2022 and <br />the 1st day of each succeeding quarter thereafter. <br />$227,358 <br />Loss Fund Due with First installment $25,000 <br />Installment Payments: Remit to Agent/Broker <br />Plan Loss Payments: Pay Direct to Travelers <br />Plan Adjustment Payments: Pay Direct to Travelers <br />It is the agent’s or broker’s responsibility to comply with any applicable laws regarding disclosure to the policyholder of commission or <br />other compensation We pay, if any, in connection with any Policy or program. <br />DocuSign Envelope ID: FCD9FE56-CF01-4E96-B983-B8E8DFE6811C