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AMINDIANA FARM <br />BUREAU INSURANCE' <br />WORKERS COMP & EMPLOYERS LIABIUTY <br />Policy No, <br />WC 83416646 02 <br />Policy Period <br />From 0 8 / 21 / 2 0 24 to 0 8 / 21 / 2 0 2 5 at 12:01 a.m. Standard Time at the described location <br />EXTENSION OF INFORMATION PAGE <br />CLASSIFICATION OF OPERATIONS <br />Premium Basis <br />Rate Per <br />Estimated <br />Cade <br />Total Est. Annual <br />$100 of <br />Annual <br />No. Classification Description <br />Remuneration <br />Remuneration <br />Premium <br />Indiana <br />Rating Period 08/21 /2024 through 08/21 /2025 <br />Site 00001 <br />5183 PLUMBING NOC & DRIVERS <br />8810 CLERICAL OFFICE EMPLOYEES - NOC <br />933,825 <br />1.36000p <br />12,700.00 <br />Site 00001 Total <br />233,160 <br />0.100000 <br />233.00 <br />$ <br />12,933.00 <br />Total of Sites for Rating Period <br />$ <br />12, 933.00 <br />Rating Period Total <br />$ <br />12, 933.00 <br />Rating Period 08/21 /2024 through 08/21 /2025 <br />9812 EMPLOYER'S LIABILITY INCREASED LIMITS <br />9898 EXPERIENCE MODIFICATION 0.86 <br />12,933 <br />0.028000 <br />362.00 <br />9887 SCHEDULE RATING CREDIT <br />13,295 <br />-0.140000 <br />-1,861.00 <br />0900 EXPENSE CONSTANT <br />11,434 <br />-C.200000 <br />-2,287.00 <br />0935 STATE ASSESSMENT/SECOND INJURY FUND <br />9,541 <br />0.p07500 <br />160.04 <br />72.00 <br />9740 TERRORISM <br />9741 CATASTROPHE -OTHER THAN CERTIFIED ACTS <br />1,167,005 <br />OF TERRORISM 1,167,OCS <br />0.010000 <br />0.010000 <br />117.00 <br />Rating Period Total <br />117.00 <br />$ <br />-3,320.00 <br />Total of all NON -SPLIT Classes <br />Total of all SPLIT Classes <br />$ <br />320 <br />, 320.00 <br />-3-3.00 <br />$ <br />, <br />State Total <br />$ <br />91613.00 <br />Policy Total <br />$ <br />9,613.00 <br />Issued Date; 06/1-3/2024 <br />WCPDEC 0101 INSURED 00121-00004 Page 2 of 3 <br />