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Version 02.01.22 2022 Program Exhibit Orange County Page 16 <br />CA Form - W04M8F19 <br />© (2019) The Travelers Indemnity Company. All rights reserved <br />PAYMENT SCHEDULE <br />PAYMENT AND VALUATION KEY DATES <br />COMMENCEMENT <br />DATE <br />BILLING <br />FREQUENCY <br />BILLING BASIS <br />Deductible Plan <br />Plan Losses 07/01/2022 DB-Monthly <br />Issued <br />Paid <br />Claim Handling Charges <br />Workers Compensation 07/01/2022 DB-Monthly <br />Issued <br />Paid <br />Administrative Expense Reimbursement Adjustment <br />Administrative Expense Reimbursement <br />Adjustment <br />01/01/2024 Once As per Expenses Section of <br />the Program Exhibit <br />Non-Loss Responsive Premium(s) <br />Non-Loss Responsive Premium(s) Adjustment 01/01/2024 Once As per Non-Loss <br />Responsive Section of the <br />Program Exhibit <br />ď‚·Paid Basis means the amount of each loss actually paid within your plan layer. <br />INSURANCE POLICIES <br />POLICY NUMBER TYPE OF COVERAGE STATES PLAN TYPE COMPANY <br />UB-5T768836-22-PB-D Workers Compensation <br />and Employers Liability <br />NC Deductible Farmington Casualty <br />Company <br />The Company(ies) listed above have an address of One Tower Square, Hartford, CT 06183-7312. The omission of, or failure to include, <br />any Policy in this Program Exhibit shall not relieve you of any of your duties or Obligations under this Agreement or under the Policies. <br />NOTICES <br />Orange County <br />208 SOUTH CAMERON STREET <br />HILLSBOROUGH, NC 27278 <br />Attention: Bonnie Hammersly, County Manager <br />BHAMMERSLEY@ORANGECOUNTYNC.GOV <br />THE TRAVELERS INDEMNITY COMPANY <br />Travelers,385 Washington Street <br />St. Paul, MN 55102 <br />Attention: Stephanie Gardner <br />Email: SGARDNE2@travelers.com <br />DocuSign Envelope ID: FCD9FE56-CF01-4E96-B983-B8E8DFE6811C