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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 /> Policy Totals <br /> Total Estimated Premium for California <br /> Expense Constant <br /> Total Estimated Annual Premium <br /> CA CA Workers Compensation Administration Revolving Fund 10/01/2019-10/0112020 1.4479% <br /> CA CA Workers Compensation Fraud Account Assessment 10/01/2019-10101/2020 0.2878% <br /> CA CIGA Surcharge <br /> CA CA Subsequent Injuries Benefits Trust Fund Assessment 10101/2019-10/01/2020 0.2737% <br /> CA CA Uninsured Employers Benefits Trust Fund Assessment 10101/2019-10/01/2020 0.0831% <br /> CA CA Occupational Safety and Health Fund Assessment 10/0112019-10101/2020 0.3765% <br /> CA CA Labor Enforcement and Compliance Fund 10/01/2019-10/0112020 0.3431% <br /> Total Estimated Cost for FOWC012986 <br /> WC 99 03 13 <br /> (Ed.9-14) <br />