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DocuSign Envelope ID: FCD9FE56-CF01-4E96-B983-B8E8DFE6811C <br /> 21 <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 /> 7YourLOSMSResponsive Rating Plan is subject to this section. All other rating plans are NOTsubject to the <br /> r the Minimum Billed Amount. <br /> CHARGE TYPE RATE AMOUNT <br /> Estimated Maximum Billed Losses $2.1444 Per$100 of $1,182,500 <br /> Audited Total WC <br /> Payroll Excluding <br /> Monopolistic States <br /> Payroll <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 $227,358 <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 /> Rating Plan Components Subject to Minimum Billed Amount: <br /> Administrative Expense Reimbursement <br /> Workers Compensation Deductible Premium <br /> EXPOSURES APPLICABLE TO OTHER THAN GUARANTEED COST • <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 /> TRAVELERS <br /> 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 />