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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> EXTENSION OF INFORMATION PAGE <br /> Policy Information Page Schedule <br /> Item 4 <br /> Insured Name: Fox Loomis, Inc. <br /> Effective Date: 10/01/2019 <br /> Expiration Date: 10/01/2020 Policy Number: FOWC012986 <br /> Premium Basis Total Rate Per Estimated <br /> Code Estimated Annual $100 Annual <br /> Classification No. Remuneration Remuneration Premium <br /> State California <br /> Effective: 10/01/2019-10/0112020 <br /> Millwright Work-N.O.C. 3724 6.59 <br /> Drilling-N.O.C. 6204 14.76 <br /> Construction/Erection Yards 8227 8.25 <br /> Salespersons-outside 8742 62 <br /> Clerical Office Employees N.O.C. 8810 .46 <br /> Blanket Waiver of Subrogation 0930 1.020 <br /> Experience Modification 9898 960 <br /> Risk Adjustment <br /> Tot Est Standard Premium 10/01/2019-10/0112020 <br /> Premium Discount 0063 .707 <br /> Minimum Premium $3,000 <br /> Tot Est Standard Premium for California <br /> WC 99 03 13 <br /> (Ed. 9-14) <br />