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DocuSign Envelope ID: FCD9FE56-CF01-4E96-B983-B8E8DFE6811C <br /> 20 <br /> The Medical Cost Containment Components are charged pursuant to the Allocated Loss Adjustment Expense Exhibit to the <br /> Insurance Program Agreement. Allocated Loss Adjustment Expense has the same meaning as Allocated Loss Adjustment <br /> Expense', ALAE"or "claim expense"in any applicable Policy, or, if the Policy has no such definition, it shall have the <br /> same meaning as set forth in the Allocated Loss Adjustment Exhibit. <br /> Savings Expense Fee Percentage of 27% <br /> Savings Achieved <br /> Non-Loss Responsive Premium Formula <br /> 7N!onLossResponsive Rate(s)x Corresponding Exposure Base(s),but in no event <br /> (other than Guaranteed Cost Policies) ny stated Minimum Non-Loss Responsive Premium shown in the Non- <br /> ponsive Premium section of this Program Exhibit(below). <br /> NON-LOSS RESPONSIVE PREMIUM <br /> TYPE OF COVERAGE RATE MINIMUM ESTIMATED <br /> AMOUNT AMOUNT <br /> Workers Compensation Deductible $0.2767 Per$100 of Audited Total WC Payroll $152,583 $152,583 <br /> Premium Excluding Monopolistic States Payroll <br /> TOTAL ESTIMATED NON-LOSS RESPONSIVE PREMIUM $152,583 <br /> Your premium amounts referenced above will include any residual market charges which may be assessed by the various states. <br /> You will pay Surcharges and Assessments pursuant to individual state law or regulation. Surcharges and <br /> Assessments are exclusive of, and in addition to,your Rating Plans <br /> CHARGE TYPE RATE DEPOSIT/ESTIMATED <br /> AMOUNT <br /> TOTAL CHARGE INCLUDED IN THE INSTALLMENT SCHEDULE $0 <br /> THE FOLLOWING APPLY TO YOUR PROGRAM: AMOUNTS RETAINED BY <br /> YOU, ESTIMATED MAXIMUM AND MINIMUM BILLED AMOUNTS AND <br /> ESTIMATED EXPOSURES <br /> Workers Compensation and Employers Liability Loss including ALAE $300,000 <br /> TRAVELERS <br /> Version 02.01.22 2022 Program Exhibit Orange County Page 13 <br /> CA Form-W04M81`19 <br /> ©(2019)The Travelers Indemnity Company.All rights reserved <br />