Agenda - 08-01-2022; 2 - Ratification of County Manager's Execution of an Insurance Coverage Agreement with Travelers Insurance and Approval of a Letter of Credit Agreement

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DocuSign Envelope ID: FCD9FE56-CF01-4E96-B983-B8E8DFE6811C 14 PROGRAM EXHIBIT 4? Your Insurance Program is comprised of your Insurance Policies and any services charged separately. This Program Exhibit outlines how your Obligations to us are calculated and paid. INSURED: Orange County PROGRAM TERM: 07/01/2022 TO 07/01/2023 RATING PLAN(S) Your Rating Plan Obligation(s) is a combination of all of the below plans and amounts: (1) LOSS RESPONSIVE RATING PLAN(S) (INCLUDING EXPENSES, CLAIM HANDLING CHARGES, PREMIUM TAXES) +(2) NON-LOSS RESPONSIVE RATING PLAN(S)+ (3) SURCHARGES AND ASSESSMENTS+(4) SERVICES CHARGED SEPARATELY(IF ANY). Deductible Plan Computation Formula Deductible Plan Paid Losses+Deductible Plan Claim Handling Charges+ Administrative Expense Reimbursement=Deductible Plan Charges EXPENSES EXPENSE TYPE RATE(IF APPLICABLE) MINIMUM ESTIMATED AMOUNT AMOUNT Administrative Expense Reimbursement' $0.1356 Per$100 of Audited Total WC Payroll $74,775 $74,775 Excluding Monopolistic States Payroll TOTAL EXPENSES INCLUDED IN THE INSTALLMENT SCHEDULE $74,775 Administrative Expense Reimbursement is the amount we charge for our annual,non-risk bearing expenses for certain policies,and is in addition to the Claim Handling Charges outlined below. Administrative Expense Reimbursement includes Risk Management Information System(RMIS)Charges,if 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 charged on an annual basis at a rate to be negotiated by the parties. CLAIM HANDLING CHARGES Workers Compensation and Employers Liability Claim Handling Charges Basis Rate Loss Conversion Factor(LCF) LCF .080 The LCF will be multiplied by the first$250,000 of each Workers Compensation and Employers Liability Loss and Allocated Loss Adjustment Expense associated therewith. The LCF will be applied beginning on the first day of the Program Term for this Program Exhibit and according to the billing basis and billing frequency noted in the Payment Schedule section of this Program Exhibit. Medical Cost Containment Component of Allocated Loss Adjustment Expense Version 02.01.22 2022 Program Exhibit Orange County Page 12 CA Form-W04M8F19 ©(2019)The Travelers Indemnity Company.All rights reserved.