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INDIANA FARM <br />r&Z BUREAU INSURANCE) <br />WORKERS COMP & EMPLOYERS LIA61UTY <br />Policy No. <br />WC 8341646 01 <br />Policy Period <br />From 0 8 / 21 / 2 0 2 3 to 0 8 / 21 / 2 0 2 4 at 12:01 a.m. Standard Time at the described location <br />EXTENSION OF INFORMATION PAGE <br />CLASSIFICATION OF OPERATIONS <br />Code <br />No. Classification Description <br />Premium Basis <br />Total Est. Annual <br />Remuneration <br />Rate Per <br />$100 of <br />Remuneration <br />Estimated <br />Annual <br />Premium <br />Indiana <br />Rating Period 08/21 /2023 through 08/21 /2024 <br />Site 00001 <br />5183 PLUMBING NOC Sc DRIVERS <br />933,825 <br />1.540000 <br />14,381.00 <br />8610 CLERICAL OFFICE EMPLOYEES - NOC <br />233,160 <br />0.100000 <br />233.00 <br />Site 00001 Total <br />$ <br />14,614.00 <br />Total of Sites for Rating Period <br />$ <br />14,614.00 <br />Rating Period Total <br />$ <br />14,614.00 <br />Rating Period 08/21 /2023 through 08/21/2024 <br />9812 EMPLOYER'S LIABILITY INCREASED LIMITS <br />14,614 <br />0.028000 <br />409.00 <br />9898 EXPERIENCE MODIFICATION 0.86 <br />15,023 <br />-0.140000 <br />-2,103.00 <br />9887 SCHEDULE RATING CREDIT <br />12,920 <br />-0.200000 <br />-2,584.00 <br />0064 PREMIUM DISCOUNT <br />10,336 <br />-0.003000 <br />-31.00 <br />0900 EXPENSE CONSTANT <br />160.00 <br />0935 STATE ASSESSMENT/SECOND INJURY FUND <br />10,699 <br />0.007500 <br />80.00 <br />9740 TERRORISM <br />1,167,005 <br />0.010000 <br />117.00 <br />9741 CATASTROPHE -OTHER THAN CERTIFIED ACTS OF <br />TERRORISM 1,167,005 <br />0.010000 <br />117.00 <br />Rating Period Total <br />$ <br />-3,835.00 <br />Total of all NON -SPLIT Classes <br />$ <br />-3, 835.00 <br />Total of all SPLIT Classes <br />$ <br />14, 614.00 <br />State Total <br />$ <br />10, 779.00 <br />Policy Total <br />$ <br />10, 779.00 <br />Issued Date: 11/14/2023 <br />WCPDEC 0101 INSURED 00267-00004 Page 2 of 4 <br />