ALPHABETICAL INDEX Forms are listed alphabetically by form title. The forms included in this section, which WOLTERS KLUWER FINANCIAL SERVICES makes available as stock items, are as follows: 1. Standard and Advisory General Use and State Endorsements based on National Council on Compensation Insurance (NCCI) text. 2. Endorsements containing Tables of Rating Values (used in conjunction with Retrospective Premium Endorsements ). Based on NCCI text. 3. Specific state endorsements in text provided by local Workers Compensation Boards or Bureaus with corresponding Identification Numbers when designated. Monopolistic Jurisdiction:None of the forms listed herein are for use in the following jurisdictions having a "monopolistic" Workers' Compensation program, except where specifically listed: Ohio, North Dakota, Washington, and Wyoming. Certain Employers Liability forms may, of course, be used even though Workers' Compensation is not used. PAGE WC 1 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
-------------------------------------------------------- GENERAL USE/STATE SPECIFIC -------------------------------------------------------- Alabama WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC598 11/96 WC010402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000415 B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC000417 B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 PAGE WC 2 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
JOINT VENTURE AS INSURED WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC463 11/92 WC010401 MERIT RATING WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES PAGE WC 3 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Alaska WC331 05/86 WC000401A AIRCRAFT PREMIUM WC540601 01/13 WC5406010113 ALASKA NOTICE OF INSTALLMENT OPTION FORM542 03/13 FORM 54-2 ALASKA POLICYHOLDER NOTICE - ACCESS TO MANUAL INFORMATION WC540403 01/99 WC5404030199 ALASKA RESIDUAL MARKET SAFE WORKPLACE INCENTIVE WC540501 A 01/15 WC540501A ALASKA RETROSPECTIVE RATING PLAN PREMIUM ONE-YEAR PLAN WC540504 A 01/15 WC540504A ALASKA RETROSPECTIVE RATING PLAN PREMIUM ONE-YEAR PLAN MULTIPLE LINES WC540502 A 01/15 WC540502A ALASKA RETROSPECTIVE RATING PLAN PREMIUM THREE-YEAR PLAN WC540505 01/15 WC540505A ALASKA RETROSPECTIVE RATING PLAN PREMIUM THREE-YEAR PLAN MULTIPLE LINES WC540503 08/10 WC 54 05 03 ALASKA RETROSPECTIVE RATING PLAN PREMIUM WRAP-UP CONSTRUCTION PROJECT WC540503 A 01/15 WC540503A ALASKA RETROSPECTIVE RATING PLAN PREMIUM WRAP-UP CONSTRUCTION PROJECT WC540506 A 01/15 WC540506A ALASKA RETROSPECTIVE RATING PLAN PREMIUM WRAP-UP CONSTRUCTION PROJECT MULTIPLE LINES WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC465 09/92 WC540401 ASSIGNED RISK PREMIUM SURCHARGE WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE PAGE WC 4 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC573 05/95 WC540602 CANCELLATION AND NONRENEWAL ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC584 01/96 WC540402 CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT WC646 12/03 FORM541CCPAP CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC572 05/95 WC540301 LIMIT OF LIABILITY WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A PAGE WC 5 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC424 08/91 WC540601 NOTICE OF INSTALLMENT OPTION WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Arizona WC331 05/86 WC000401A AIRCRAFT PREMIUM WC020401 C 02/10 WC020401C ALCOHOL/DRUG-FREE WORKPLACE PREMIUM CREDIT WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE PAGE WC 6 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC020602 08/02 WC0206020802 ARIZONA BENEFITS DEDUCTIBLE WC020601 A 09/15 WC020601A ARIZONA CANCELLATION AND NONRENEWAL WC020301 A 05/17 WC020301A ARIZONA EMPLOYEE LEASING WC020501 03/02 WC020501 ARIZONA RETROSPECTIVE PREMIUM LARGE RISK ALTERNATIVE RATING OPTIOIN WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC330 05/86 WC020601 CANCELLATION ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC604 01/97 WC0203020197 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC603 01/97 WC0203010197 EMPLOYEE LEASING WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC605 01/97 WC0203030197 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 PAGE WC 7 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE PAGE WC 8 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Arkansas WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC262 A 04/92 WC030601A AMENDATORY WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC030603 A 07/11 WC030603A ARKANSAS CONTRACT HAULING WARRANTY WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC552 01/94 WC030301 ASSIGNED RISK ASSOCIATED OR SPONSORED POLICY COVERAGE WC553 01/94 WC030302 ASSIGNED RISK MULTIPLE COORDINATED POLICY COVERAGE WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC556 A 10/96 WC030602A1096 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE PAGE WC 9 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC617 10/97 WC0304041097 MANAGED CARE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC117 04/84 WC000306 MEDICAL BENEFITS EXCLUSION WC118 04/84 WC000307 MEDICAL BENEFITS REIMBURSEMENT WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PAGE WC 10 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS WC540 03/94 WC030401 WORKERS COMPENSATION INSURANCE PLAN ALTERNATE PREFERRED PLAN PREMIUM WC538 03/94 WC030402 WORKERS COMPENSATION INSURANCE PLAN ASSIGNED RISK TABULAR ADJUSTMENT PROGRAM PREMIUM WC539 03/94 WC030403 WORKERS COMPENSATION INSURANCE PLAN MERIT RATING California WC040412 11/02 WC0404121102 1999 PREMIUM INCREASE ENDORSMENT - CALIFORNIA WC040413 11/02 WC0404131102 2000 PREMIUM INCREASE ENDORSMENT - CALIFORNIA WC040414 11/02 WC0404141102 2001 PREMIUM INCREASE ENDORSMENT - CALIFORNIA WC040415 11/02 WC0404151102 2002 PREMIUM INCREASE ENDORSMENT - CALIFORNIA WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC256 04/84 WC040401 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE PAGE WC 11 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC040422 01/12 WC040422 CALIFORNIA SHORT-RATE CANCELATION WC535 12/93 WC040601A CANCELLATION ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC565 01/95 WC0403100195 DUTY TO DEFEND WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC387 A 10/98 WC040307A1098 EMPLOYEE LEASING WC626 A 10/98 WC040312A1098 EMPLOYEE LEASING (FOR LEASING ARRANGEMENTS THAT DO NOT FALL WITHIN THE SCOPE OF THE EMPLOYEE) WC388 A 10/98 WC040308A1098 EMPLOYEE LEASING SHORT FORM WC625 A 10/98 WC040311A1098 EMPLOYEE LEASING SHORT FORM (FOR LEASING ARRANGEMENTS THAT DO NOT FALL WITHIN THE SCOPE OF THE EMPLOYEE LEASING RULE) WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC040360 B 01/15 WC040360B EMPLOYERS LIABILITY COVERAGE AMENDATORY - CALIFORNIA WC253 04/84 WC040331 AGREEMENT [CA] WC7815 04/93 NO14 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE (LIABILITY NOT INSURED) WC7805 04/93 NO13 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE (LIABILITY NOT INSURED) WC7956 F 08/99 FORM 11 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE WC7606 K 08/99 FORM 10 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE WC7802 04/93 FORM 4 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE (RELATIVES NOT INSURED) WC7967 H 01/84 FORM 7 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE - MEDICAL BENEFITS NOT INSURED WC040317 06/06 WC0403170606 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE (EMPLOYEE INSURED BY GENERAL EMPLOYER EXCLUDED) WC040313 09/05 WC0403130905 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE PAGE WC 12 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
(LABOR CONTRACTOR AS NAMED INSURED - EXCLUSION OF LEASED EMPLOYEES) WC040315 09/05 WC0403150905 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE (LABOR CONTRACTOR AS NAMED INSURED WITH LCF DESIGNATION RESTRICTION OF COVERAGE TO CLIENT WORKERS) WC040316 09/05 WC0403160905 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE (LABOR CONTRACTOR AS NAMED INSURED EXCLUSION OF CLIENT'S EMPLOYEES) WC040314 09/05 WC0403140905 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE (LABOR CONTRACTOR AS NAMED INSURED RESTRICTION OF COVERAGE TO CLIENT WORKERS) WC7765 05/94 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE/ WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY AMENDATORY WC255 04/84 WC040337 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE- JOINT VENTURE WC354 01/88 WC040410 ESTIMATED ANNUAL PREMIUM WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC040005 07/98 WC0400050798 EXTENSION OF INFORMATION PAGE CLASSIFICATIONS WC040004 07/98 WC0400040798 EXTENSION OF INFORMATION PAGE SCHEDULE OF FORMS WC040003 07/98 WC0400030798 EXTENSION OF INFORMATION PAGE SCHEDULE OF LOCATIONS WC040002 07/98 WC0400020798 EXTENSION OF INFORMATION PAGE SCHEDULE OF NAMED INSURED WC040406 C 01/09 WC 04 04 06 C FARM SCHED ENDORSE-CALIFORNIA WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC040001 B 10/14 WC040001B INFORMATION PAGE WC040411 01/04 WC0404110104(CA) INSOLVENT RATING ADJUSTMENT PLAN WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED PN049907 A 07/15 PN049907A JANUARY 1, 2014 AUDIT REQUIREMENTS FOR POLICIES WITH FINAL PREMIUM OF LESS THAN $10,000 THAT DEVELOP PAYROLL IN HIGH WAGE DUAL WAGE CONSTRUCTION OR ERECTION CLASSIFICATIONS WC116 04/84 WC000305 JOINT VENTURE AS INSURED PAGE WC 13 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC040603 B 01/15 WC040603B LARGE RISK DEDUCTIBLE WC040318 07/13 WC 04 03 18 LIMITED LIABILITY COMPANY COVERAGE / EXCLUSION -CALIFORNIA WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC247 A 04/92 WC040101A0492 LONGSHOREMEN S AND HARBOR WORKERS COMPENSATION ACT COVERAGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE PN049903 11/99 PN0499031199 NOTICE REQUIRED BY LAW WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC249 A 01/85 WC040303 OFFICER & DIRECTOR (CA) WC040421 01/08 WC0404210108 OPTIONAL PREMIUM INCREASE - CA WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC248 B 10/86 WC040302A PARTNERSHIP COVERAGE/EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC166 B 03/98 WC040301A0398 POLICY AMENDATORY END WC040301 C 10/14 WC040301C POLICY AMENDATORY - CALIFORNIA PN049904 12/01 PN0499041201 POLICY HOLDER NOTICE - CALIFORNIA INSURANCE GUARANTEE ASSOCIAITON (CIGA) SURCHARGE PN049905 03/03 PN0499050303 POLICY HOLDER NOTICE - DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE NEW AND RENEWAL POLICIES WC130 04/84 WC000405 POLICY PERIOD PN049906 C 07/15 PN049906C POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE PN049902 B 05/02 PN049902B0502 POLICYHOLDER NOTICE (INSURANCE RATING LAWS) PN049901 F 03/15 PN049901F POLICYHOLDER NOTICE (YOUR RIGHT TO RATING AND DIVIDEND INFORMATION) WC040407 10/99 WC0404071099 PREMIUM ADJUSTMENT WC040409 06/05 WC0404090605 PREMIUM CHANGE EFFECTIVE JULY 1, 2005 WC266 07/91 WC000409 PAGE WC 14 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC561 01/95 WC0405110195 RETRO PREMIUM SHORT FORM WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC040501 E 01/15 WC040501E RETROSPECTIVE PREM END [CA] WC040602 B 12/06 WC040602B1206 SMALL DEDUCTIBLE WC250 A 01/85 WC040304 SOLE PROPRIETOR COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC251 A 01/85 WC040305 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC252 04/84 WC040306 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Colorado WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC385 11/90 WC0504021190 CLASSIFICATION WC050404 A 01/12 WC050404 COLORADO NON-COOPERATION WITH PREMIUM AUDIT SURCHARGE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A PAGE WC 15 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP PAGE WC 16 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC567 03/93 WC050403 PREMIUM CREDIT FOR CERTIFIED RISK MANAGEMENT PROGRAMS WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Connecticut WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC199 04/84 WC060301 APPLICATION OF WORKERS COMPENSATION INSURANCE PAGE WC 17 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000415 B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC000417 B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC060402 01/14 WC060402 CONNECTICUT FOREIGN VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC060601 01/03 WC0606010103 CONNECTICUT WORKERS' COMPENSATION FUNDS WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC588 07/96 WC060401 CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT NC5000 A 07/11 FORM NC-5000A CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 PAGE WC 18 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
JOINT VENTURE AS INSURED WC392 04/91 WC000320 LABOR CONTRACTOR WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC060602 07/08 WC060602 MANDATORY ARBITRATION WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC146 04/84 WC060501 RETRO PREM SUPP (CT) WC142 04/84 WC000508 RETRO PREMIUM AVIATION PAGE WC 19 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Delaware FORM07-1 10/04 FORM0711004 AGREEMENT BY EXCECUTIVE OFFICE NOTICE FORMDCRB- EX 12/09 DCRB-EXCL AGREEMENT BY EXECUTIVE OFFICER(S)/ LLC MEMBER(S) NOT TO BE SUBJECT TO THE DELAWARE WORKERS' COMPENSATION LAW WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC184 04/84 WC070303 AMENDATORY FARMING OPERATIONS WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC375 07/90 WC070402 CONSTRUCTION CLASSIFICATION PREMIUM ADJUSTMENT WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC181 04/84 WC070401 DEDUCTIBLE WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC651 D 06/14 DCCPAP DELAWARE WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 PAGE WC 20 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC117 04/84 WC000306 MEDICAL BENEFITS EXCLUSION WC118 04/84 WC000307 MEDICAL BENEFITS REIMBURSEMENT WC070408 07/99 WC070408 MERIT RATING PLAN WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC358 07/88 WC070601 NONRENEW WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC271 04.08 WC890600 POLICY INFORMATION PAGE PAGE WC 21 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC481 10/93 WC0005151093 RETROSPECTIVE PREMIUM - FLEXIBILITY OPTIONS WC414 12/91 WC000505A1291 RETROSPECTIVE PREMIUM - LONG TERM CONSTRUCTION PROJECT WC417 12/91 WC000514A1291 RETROSPECTIVE PREMIUM - LONG-TERM CONSTRUCTION PROJECT - MULTIPLE LINES WC144 04/84 WC0005100484 RETROSPECTIVE PREMIUM - NON RATABLE CATASTROPHE ELEMENT OR SURCHARGE WC412 12/91 WC000503A1291 RETROSPECTIVE PREMIUM - ONE YEAR PLAN WC415 12/91 WC000512A1291 RETROSPECTIVE PREMIUM - ONE YEAR PLAN - MULTIPLE LINES WC413 12/91 WC000504A1291 RETROSPECTIVE PREMIUM - THREE YEAR PLAN WC416 12/91 WC000513A1291 RETROSPECTIVE PREMIUM - THREE YEAR PLAN - MULTIPLE LINES WC650 04/84 WC000509 RETROSPECTIVE PREMIUM CHANGES WC120 04/84 WC000309 RURAL ELECTRIFICATION ADMINISTRATION WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS District of Columbia PAGE WC 22 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000415 B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC000417 B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC263 04/84 WC080601 CANCELLATION ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC392 04/91 WC000320 LABOR CONTRACTOR WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE PAGE WC 23 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC117 04/84 WC000306 MEDICAL BENEFITS EXCLUSION WC118 04/84 WC000307 MEDICAL BENEFITS REIMBURSEMENT WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) PAGE WC 24 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC080401 A 09/01 WC080401A0901 SAFE WORKPLACE PRGR ENDT (DC) WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Florida WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC8093 C 07/04 FORM09010704 APPLICATION FOR DRUG-FREE WORKPLACE PREMIUM CREDIT PROGRAM WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC401 07/90 WC0906050790 BENEFITS DEDUCTIBLE NC3011 07/06 FORMSAFETY93 CERTIFICATION EMPLOYER WORKPLACE SAFETY PROGRAM PREMIUM CREDIT FORM09-3 07/06 FORM0930706 CERTIFICATION OF EMPLOYER WORKPLACE SAFETY PROGRAM PREMIUM CREDIT WC399 07/90 WC0906030790 COINSURANCE AND DEDUCTIBLE WC400 07/90 WC0906040790 COINSURANCE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR FORM094 C 01/10 CONTRACTING CLASS PREM ADJ(FL) WC483 06/87 WC0904010687 CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC090303 08/05 WC090303 PAGE WC 25 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
EMPLOYERS LIABILITY COVERAGE WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC359 10/88 WC090402 EXPER RAT MOD END (FL) WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC090314 07/07 WC0903140707 FLORIDA EMPLOYEE LEASING COMPANY CLIENT COMPANY DIRECT WORKERS INCLUSION WC090311 07/07 WC0903110707 FLORIDA EMPLOYEE LEASING COMPANY CLIENT COMPANY EXCLUSION WC090312 07/07 WC0903120707 FLORIDA EMPLOYEE LEASING COMPANY EXCLUSION WC090310 07/07 WC0903100707 FLORIDA EMPLOYEE LEASING COMPANY EXTENSION WC090606 10/98 WC0906061098 FLORIDA EMPLOYMENT AND WAGE INFORMATION RELEASE WC090406 A 07/14 WC090406 FLORIDA FOREIGN VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC090201 01/15 WC090201 FLORIDA MARITIME COVERAGE WC090313 07/07 WC0903130707 FLORIDA MULTIPLE COORDINATED POLICY WC090407 07/13 WC090407 FLORIDA NON-COOPERATION WITH PREMIUM AUDIT FORM09 A 01/14 FORM 09-NOTICE FLORIDA NOTICE OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC090505 07/15 WC 09 05 05 FLORIDA RETROSPECTIVE RATING PLAN PREMIUM - LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC090503 A 01/15 WC090503A FLORIDA RETROSPECTIVE RATING PLAN PREMIUM ONE-YEAR PLAN WC090504 A 01/15 WC090504A FLORIDA RETROSPECTIVE RATING PLAN PREMIUM ONE-YEAR PLAN - MULTIPLE LINES WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC392 04/91 WC000320 LABOR CONTRACTOR WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A PAGE WC 26 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC589 05/95 WC090501 RETRO PREMIUM END (FL) WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC414 12/91 WC000505A1291 RETROSPECTIVE PREMIUM - LONG TERM CONSTRUCTION PROJECT WC417 12/91 WC000514A1291 RETROSPECTIVE PREMIUM - LONG-TERM CONSTRUCTION PROJECT - MULTIPLE LINES WC144 04/84 WC0005100484 RETROSPECTIVE PREMIUM - NON RATABLE CATASTROPHE ELEMENT OR SURCHARGE PAGE WC 27 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC412 12/91 WC000503A1291 RETROSPECTIVE PREMIUM - ONE YEAR PLAN WC415 12/91 WC000512A1291 RETROSPECTIVE PREMIUM - ONE YEAR PLAN - MULTIPLE LINES WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC090502 A 01/08 WC090502A0108 RETROSPECTIVE PREMIUM FOR NON-RATABLE CATASTROPHE ELEMENT OR SURCHARGE WC090309 01/06 WC0903090106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC090403 B 01/15 WC090403B TERRORISM RISK INSURANCE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Georgia WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC000417 B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC370 07/90 WC100602 BENEFITS DED END [GA] WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC379 A 04/93 WC100601A CANCLTN/NONR/CHG [GA] ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC7729 03/94 FORMGID63 DISCLOSURE STATEMENT (FOR USE WITH EXPERIENCE RATED INSUREDS) WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT PAGE WC 28 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC100601 B 07/14 WC100601B GEORGIA CANCELLATION, NONRENEWAL, AND CHANGE WC100301 11/99 WC100301 GEORGIA EMPLOYEE LEASING WC100402 01/13 WC1004020113 GEORGIA NON-COOPERATION WITH PREMIUM AUDIT WC100501 A 01/15 WC100501A GEORGIA RETROSPECTIVE RATING PLAN PREMIUM ONE- YEAR PLAN WC100504 A 01/15 WC100504A GEORGIA RETROSPECTIVE RATING PLAN PREMIUM ONE- YEAR PLAN MULTIPLE LINES WC100502 A 01/15 WC100502A GEORGIA RETROSPECTIVE RATING PLAN PREMIUM THREE- YEAR PLAN WC100505 A 01/15 WC100505A GEORGIA RETROSPECTIVE RATING PLAN PREMIUM THREE- YEAR PLAN MULTIPLE LINES WC100503 A 01/15 WC100503A GEORGIA RETROSPECTIVE RATING PLAN PREMIUM WRAP- UP CONSTRUCTION PROJECT WC100506 A 01/15 WC100506A GEORGIA RETROSPECTIVE RATING PLAN PREMIUM WRAP UP CONSTRUCTION PROJECT MULTIPLE LINES WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC536 01/94 WC100401 MERIT RATING END [GA] WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE PAGE WC 29 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 PAGE WC 30 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WAIVER OF RIGHT TO RECOVER FROM OTHERS Hawaii WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC112 04/84 WC0003010484 ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC583 01/96 WC520403 CONT CLSFCTN PREM WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR NC5000 A 07/11 FORM NC-5000A CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC520101 01/08 WC5201010108 HAWAII TERRORISM RISK INSURANCE PROGRAM REQUATHORIZATION ACT ENDORSMENET WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 PAGE WC 31 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC329 A 10/89 WC520601A MED BEN DED END (HI) WC341 03/87 WC520402 MERIT RATING (HI) WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC587 01/96 WC520602 NOTIFICATION END (HI) WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC597 02/97 WC000326 RESIDUAL MARKET LIMITED OTHER STATES INSURANCE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 PAGE WC 32 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC570 04.08 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC140 04/84 WC520401 VOLUNTR WRKRS END (HI) WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Idaho WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC458 09/92 WC110401 ASSGN RISK PREM END [ID] WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000415 B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC000417 B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE PAGE WC 33 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC110402 A 07/11 WC110402A IDAHO ALCOHOL-AND DRUG-FREE WORKPLACE PREMIUM CREDIT WC110601 07/99 WC1106010799 IDAHO COMPENSATION REIMBURSEMENT OPTION WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PAGE WC 34 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Illinois WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC120601 E 01/15 WC120601E AMENDATORY END (IL) WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000415 B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC000417 B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC464 09/92 WC120402 CONTRACTING CLASS PREM ADJ [IL WC644 12/03 FORM121CCPAP CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM PAGE WC 35 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
(ILCCPAP) CONFIDENTIAL WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC120303 A 06/03 WC120303A0603 EMPLOYEE LEASING ENDT (IL) WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC120304 06/99 WC120304 IL EMPLOYEE LEASING CLIENT EXCLUSION WC120305 06/99 WC120305 IL LABOR CONTRACTOR EXCLUSION WC120307 06/15 WC120307 ILLINOIS SOLE PROPRIETORS, PARTNERS, OFFICERS, MEMBERS OF LIMITED LIABILITY COMPANIES, AND OTHER EXCLUDED EMPLOYEES AND EMPLOYMENTS EXCLUSION WC120306 A 07/11 WC120306A ILLINOIS WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY EXCLUSION WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC150 A 08/92 WC120602A0892 MED DEDUCT END [IL] WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A PAGE WC 36 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
MULTIPLE COORDINATED POLICY FORM635 L 11/11 635L NEW YORK WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Indiana PAGE WC 37 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC000417 B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC430 01/92 WC130604 BENE DED END [IN] WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC432 01/92 WC130603 COINSURANCE END (IN) WC431 01/92 WC130602 COINSURANCE/DED END(IN) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 PAGE WC 38 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE PAGE WC 39 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Iowa WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000415 B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC140602 07/02 WC1406020702 IOWA EXECUTIVE OFFICERS, SOLE PROPRIETORS, PARTNERS, MEMBERS AND MANAGERS OF LIMITED LIABILITY COMPANIES AND OTHERS, BENEFIT LEVEL SELECTION WC140603 01/11 WC140603 PAGE WC 40 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
IOWA MEDICAL DEDUCTIBLE PROGRAM CARRIER REIMBURSED DEDUCTIBLE WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC597 02/97 WC000326 RESIDUAL MARKET LIMITED OTHER STATES INSURANCE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION PAGE WC 41 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC141 04/84 WC000505 RETROSPECTIVE PREMIUM - RATING OPTIONS V - LONG TERM CONSTRUCTION PROJECT WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Kansas WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000415 B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC000417 B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC150403 F 01/15 WC150403F ASSIGNED RISK RESTRO (KS) WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC152 A 01/87 WC150601A CANC NONRENEW END ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC312 03/85 WC1503010385 DOMESTIC/AG WRKS [KS] WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT PAGE WC 42 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC622 01/98 WC1504080198 KANSAS ASSIGNED RISK WC621 03/98 WC150407A0198 KANSAS ASSIGNED RISK WC150302 01/05 WC1503020105 KANSAS HOME AND COMMUNITY BASED SERVICES WAIVER PROGRAM WC150603 07/06 WC1506030706 KANSAS PER CLAIMANT BENEFITS DEDUCTIBLE WC150602 07/06 WC1506020706 KANSAS PER OCCURRENCE BENEFITS DEDUCTIBLE WC150303 A 09/14 WC150303A KANSAS PROFESSIONAL EMPLOYER ORGANIZATION (PEO) MULTIPLE COORDINATED POLICY FOR POLICY COVERING THE PEO WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC586 03/96 WC150405 LOSS COST CHG END (KS) WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO PAGE WC 43 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC585 03/96 WC150404 PENDING LOSS COST (KS) WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC597 02/97 WC000326 RESIDUAL MARKET LIMITED OTHER STATES INSURANCE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Kentucky WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER PAGE WC 44 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC610 05/97 WC1603030597 EMPLOYEE LEASING (KY) WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC160302 A 12/99 WC160302A1299 EMPLOYEE LEASING END'T (KY) WC160302 B 05/17 WC160302B EMPLOYEE LEASING END'T (KY) WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC618 12/97 WC1606011297 KENTUCKY CANC/NONREN END WC160602 10/99 WC160602 KENTUCKY NOTICE OF APPEAL RIGHTS WC160305 06/07 WC1603050607 KENTUCKY PART ONE WORKERS COMPENSATION INSURANCE WC611 05/97 WC1603040597 LABOR CONT EXCL END(KY) WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE PAGE WC 45 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC117 04/84 WC000306 MEDICAL BENEFITS EXCLUSION WC118 04/84 WC000307 MEDICAL BENEFITS REIMBURSEMENT WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC292 10/84 NOTICE TO INSUREDS TAX AND ASSESSMENT CHARGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC549 05/97 WC1603010597 REJ OF COV END (KY) WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C PAGE WC 46 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE Louisiana WC126 04/84 WC000401 AIRCRAFT PREMIUM WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC537 A 02/96 WC170602A COST CONT ACT END (LA) WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE PAGE WC 47 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC170601 F 08/15 WC170601F LOUISIANA AMENDATORY WC170401 11/04 WC1704011104 LOUISIANA ANNIVERSARY RATING DATE WC170303 12/00 WC170303 LOUISIANA DUTY TO DEFEND WC170304 02/03 WC1703040203 LOUISIANA PROFESSIONAL EMPLOYER ORGANIZATION WC170305 02/03 WC1703050203 LOUISIANA PROFESSIONAL EMPLOYER ORGANIZATION EXCLUSION ENDOREMENT WC170501 B 01/15 WC170501B LOUISIANA RETROSPECTIVE RATING PLAN PREMIUM ONE- YEAR PLAN WC170504 B 01/15 WC170504B LOUISIANA RETROSPECTIVE RATING PLAN PREMIUM ONE- YEAR PLAN MULTIPLE LINES WC170502 B 01/15 WC170502B LOUISIANA RETROSPECTIVE RATING PLAN PREMIUM THREE- YEAR PLAN WC170505 B 01/15 WC170505B LOUISIANA RETROSPECTIVE RATING PLAN PREMIUM THREE- YEAR PLAN - MULTIPLE LINES WC170503 B 01/15 WC170503B LOUISIANA RETROSPECTIVE RATING PLAN PREMIUM WRAP- UP CONSTRUCTION PROJECT WC170506 B 01/15 WC170506B LOUISIANA RETROSPECTIVE RATING PLAN PREMIUM WRAP- UP CONSTRUCTION PROJECT - MULTIPLE LINES WC000201 B 01/15 WC000201B MARITIME COVERAGE WC117 04/84 WC000306 MEDICAL BENEFITS EXCLUSION WC118 04/84 WC000307 MEDICAL BENEFITS REIMBURSEMENT WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A PAGE WC 48 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 PAGE WC 49 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WAIVER OF RIGHT TO RECOVER FROM OTHERS Maine WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC599 09/96 WC1804070996 ANNIV MODIFICATION (ME) WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC360 A 06/95 WC180603A CANC & NONREN END (ME) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC395 05/88 WC1806040588 FINAL PREM AUD END (ME) WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC153 04/84 WC180601 INSPEC IMUNTY END [ME] WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 LIMITED MARITIME COVERAGE PAGE WC 50 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC357 D 12/97 WC180602D1297 MAINE BENEFITS DED END WC180606 08/99 WC180606 MAINE NOTICE OF FILING OF FIRST REPORTS OF INJURY WC180607 A 07/11 WC180607A MAINE SUPPLEMENTAL BENEFITS FUND WC000201 B 01/15 WC000201B MARITIME COVERAGE WC356 11/87 WC180402A MERIT RAT ENDT [ME] WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C PAGE WC 51 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Maryland WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC190601 F 01/16 WC 19 06 01 F CANCELLATION (MD) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC476 07/93 WC1904010793 CONST CLASS PREM [MD] WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE PAGE WC 52 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC190602 01/14 WC190602 MARYLAND NOTIFICATION OF 45-DAY UNDERWRITING PERIOD WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PAGE WC 53 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE SOLEPROP 01/10 WCC FORM IC-02 SOLE PROPRIETOR'S STATUS AS A COVERED EMPLOYEE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Massachusetts WC126 04/84 WC000401 AIRCRAFT PREMIUM WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC474 01/93 WC200602 BENEFITS DET END [MA] ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC386 01/91 WC200403 CONSTRUCTION CLASSIFICTN (MA) WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION PAGE WC 54 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC443 03/92 WC200305 EXC OF COV LSD [MA] WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC200306 B 06/13 WC200306B LIMITED OTHER STATES BENEFIT WC242 04/84 WC200301 LMTS OF LIAB END (MA) WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC444 B 12/97 WC200304B1297 MASS EMPLY LEASING END WC200307 11/02 WC2003071102 MASSACHUSETTS ASSIGNED RISK POOL ELIGIBILITY WC200603 A 04/15 WC200603A MASSACHUSETTS BENEFITS CLAIM AND AGGREGATE DEDUCTIBLE WC200601 07/08 WC200601A MASSACHUSETTS CANCELATION WC652 B 11/11 MASSACHUSETTS CONSTRUCTION CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC200102 01/14 WC200102 MASSACHUSETTS NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC200604 11/02 WC2006041102 MASSACHUSETTS POLICY DEFINITION WC200405 06/01 WC200405 MASSACHUSETTS PREMIUM DUE DATE WC200101 01/08 WC20010101/08 MASSACHUSETTS TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT WC200302 A 09/08 WC200302A MASSACHUSETTS-ASSESSMENT CHARGE WC448 07/92 WC000111 PAGE WC 55 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC200303 D 08/10 WC200303D NOTICE TO POLICYHOLDER WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC380 11/90 WC200401 PNDNG REM CHG END (MA) WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC418 B 01/94 WC200402 QUAL LOSS MGMT [MA] WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC571 04/95 WC200501 RETRO PREM END [MA] WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 PAGE WC 56 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Michigan WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC112 04/84 WC0003010484 ALTERNATE EMPLOYER WC169 04.08 WC210603 AMENDMENT TO MICHIGAN LAW - EXCLUSION OF DESIGNATED CONSTRUCTION SITE WC168 04/84 WC210602 AMENDMENT TO MICHIGAN LAW (COVERAGE LIMITED TO DESIGNATED CONSTRUCTION SITE) WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC509 04/84 WC210301 DESGNTD CONST SITE [MI] WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC510 04/84 WC210302 DESIGNTD CONST SIT [MI] WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC170 04/84 WC210604 DUAL OR JOINT EMPLY END WC516 04/84 WC210601 DUAL/JOINT EMP END [MI] WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC103 04/84 WC000104 FEDERAL EMPLOYERS' LIABILITY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC491 04/84 WC210304 LAW ENDORSMNT [MI] WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A PAGE WC 57 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC117 04/84 WC000306 MEDICAL BENEFITS EXCLUSION WC118 04/84 WC000307 MEDICAL BENEFITS REIMBURSEMENT WC210503 A 06/97 WC210503A0697 MICHIGAN RETRO PREM END WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC171 A 01/87 WC 21 05 01A NON-RATABLE SPECIFIC DISEASE ELEMENT (SUPPLEMENT TO RETROSPECTIVE PREMIUM ) WC210303 A 06/97 WC210303A0697 NOTICE TO POLCHLDR ENDT (MI) WC210102 01/14 WC210102 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC271 04.08 WC890600 POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC514 04/84 WC210401 PREM DETERMNT END [MI] WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC172 04/84 WC210502 RETRO PREM END [MI] WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A PAGE WC 58 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC144 04/84 WC0005100484 RETROSPECTIVE PREMIUM - NON RATABLE CATASTROPHE ELEMENT OR SURCHARGE WC141 04/84 WC000505 RETROSPECTIVE PREMIUM - RATING OPTIONS V - LONG TERM CONSTRUCTION PROJECT WC137 04/84 WC000503 RETROSPECTIVE PREMIUM - RATING OPTIONS V - ONE YEAR PLAN WC650 04/84 WC000509 RETROSPECTIVE PREMIUM CHANGES WC000501 04/84 WC0005010484 RETROSPECTIVE-1 YR PLAN-OPTION I,II,III & IV WC000502 04/84 WC0005020484 RETROSPECTIVE-3YR PLAN-OPTION I,II,III & IV WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC210402 B 01/15 WC210402B TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE WC530 04/84 WC210101 VOL COMP FED EMP [MI] WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS WC320 10/85 WC2106051085 WAIVER/COORD BEN [MI] WC511 04/84 WC210305 WC PLAMNT FAC END [MI] WC512 01/85 WC210306 WC PLANT FAC (MI) Minnesota WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC220000 A 11/03 WC220000A1103 AMENDATORY (MN) WC580 09/95 WC220402 ANNIV RATING DATE ENDT (MN) WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC220601 D 08/06 WC220601D0806 CANCELL & NONREN ENDT (MN) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC438 10/92 WC2204011092 CONTRACT PREM ADJ [MN] WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION PAGE WC 59 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC220306 08/09 WC220306 MINNESOTA ALTERNATE EMPLOYER [EXCLUDING EMPLOYERS LIABILITY COVERAGE] WC220301 01/05 WC2203010105 MINNESOTA COMPLIANCE WITH APPLICABLE TRADE SANCTION LAWS WC220304 01/06 WC2203040106 MINNESOTA EMPLOYEE LEASING WC220620 01/05 WC2206200105 MINNESOTA ENTITY ADDRESS SCHEDULE WC220305 01/06 WC2203050106 MINNESOTA EXCLUSION OF COVERAGE FOR LEASED EMPLOYEES WC220001 09/02 WC2200010902 MINNESOTA INFORMATION PAGE AND NOTES WC220303 01/06 WC2203030106 MINNESOTA THIRD DEGREE OF KINDRED FAMILY MEMBER EXCLUSION WC220302 01/05 WC2203020105 MINNESTOA INDEPENDENT CONTRACTORS COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO PAGE WC 60 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC220600 01/02 WC220600 POLICY CHANGE WC220616 A 10/07 WC220616A POLICY CHANGE WC220611 01/02 WC220611 POLICY INFORMATION PAGE - ADD STATES WC220619 01/02 WC220619 POLICY INFORMATION PAGE - CARRIER NUMBER WC220617 01/02 WC220617 POLICY INFORMATION PAGE - CARRIER SERVICING OFFICE WC220613 01/02 WC220613 POLICY INFORMATION PAGE - CHANGE IN STATE WC220609 01/02 WC220609 POLICY INFORMATION PAGE - CHANGE IN WORKPLACE OF INSURED WC220615 A 10/07 WC220615A POLICY INFORMATION PAGE - CLASS, RATE, OTHER CHANGE WC220604 01/02 WC220604 POLICY INFORMATION PAGE - EFFECTIVE DATE WC220612 01/02 WC220612 POLICY INFORMATION PAGE - EMPLOYER LIMITS WC220614 01/02 WC220614 POLICY INFORMATION PAGE - NUMBERS WC220607 01/02 WC220607 POLICY INFORMATION PAGE - EXPERIENCE MODIFICATION WC220605 01/02 WC220605 POLICY INFORMATION PAGE - EXPIRATION DATE WC220610 01/02 WC220610 POLICY INFORMATION PAGE - INSURED'S LEGAL STATUS WC220606 01/02 WC220606 POLICY INFORMATION PAGE - INSURED'S MAILING ADDRESS WC220602 01/02 WC220602 POLICY INFORMATION PAGE - INSURED'S NAME WC220618 01/02 WC220618 POLICY INFORMATION PAGE - INTERSTATE / INTRASTATE RISK I.D. NUMBER WC220603 01/02 WC220603 POLICY INFORMATION PAGE - POLICY NUMBER WC220608 01/02 WC220608 POLICY INFORMATION PAGE - PRODUCER'S NAME WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 PAGE WC 61 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC547 02/94 WC000309A RURAL ELECTRIFICATION ADMINISTRATION WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Mississippi WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC000417 B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR PAGE WC 62 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC230401 01/99 WC2304010199 MISSISSIPPI-SMALL EMPLOYER LOSS- FREE POLICY PREM C WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 PAGE WC 63 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Missouri WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC112 04/84 WC0003010484 ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC439 09/91 WC2404020991 ASSGND RISK PREM [MO] WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM PAGE WC 64 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC579 10/95 WC2406031095 BENEFITS DED END (MO) WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC158 B 01/96 WC240601B CANC & NONREN END (MO) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC368 01/90 WC240401 CONT CLASS PREM AS [MO] WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR NC5000 A 07/11 FORM NC-5000A CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC240406 C 08/05 WC240406C0805 EMPLOYER PAID MEDICAL END (MO) WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 PAGE WC 65 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC240604 B 01/17 WC240604B MISSOURI AMENDATORY FORM24-1 A 01/14 FORM2410301 MISSOURI CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM WORKERS COMPENSATION - PREMIUM CREDIT APPLICATION WC240303 A 01/14 WC 24 03 03 MISSOURI EXCLUSION OF ADDITIONAL MESOTHELIOMA BENEFITS WC240302 A 01/14 WC 24 03 02 MISSOURI NOTIFICATION OF ADDITIONAL MESOTHELIOMA BENEFITS WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC240602 B 07/06 WC240602B0706 P&C GUAR ASSOC NOTIFIC END(MO) WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC157 A 12/91 WC240501A1291 RETROSP PREM SUP [MO] WC000504 C 01/15 WC000504C PAGE WC 66 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Montana WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC250601 A 10/03 WC250601A1003 CANCEL & NONRENEWAL ENDT (MT) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR NC5000 A 07/11 FORM NC-5000A CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A PAGE WC 67 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC117 04/84 WC000306 MEDICAL BENEFITS EXCLUSION WC118 04/84 WC000307 MEDICAL BENEFITS REIMBURSEMENT WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC250302 10/99 WC250302 MONTANA EMPLOYEE LEASING/ PROFESSIONAL EMPLOYER CLIENT EXCLUSION WC250301 10/99 WC250301 MONTANA EMPLOYEE LEASING/ PROFESSIONAL EMPLOYER WC250305 07/02 WC2503050702 MONTANA INTENTIONAL INJURY EXCLUSION WC250303 10/99 WC250303 MONTANA LABOR CONTRACTOR/ PROFESSIONAL EMPLOYER ORGANIZATION EXCLUSION WC250401 10/12 WC250401 MONTANA NON-COOPERATION WITH PREMIUM AUDIT SURCHARGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE PAGE WC 68 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC542 01/94 WC250602 SAFETY END (MT) WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Nebraska WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC337 C 07/96 WC260601C CANC & NONREN END(NE) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION PAGE WC 69 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR NC5000 A 07/11 FORM NC-5000A CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC304 01/95 WC260402 CONTRACTION CLASS [NE] WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC381 05/89 WC2604010589 EXP RATY MOD END [NE] WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC393 07/90 WC260602 MED BENEFITS END [NE] WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY (New) WC260401 A 05/17 WC260401A NEBRASKA EXPERIENCE RATING MODIFICATION WC260303 05/13 WC260303 NEBRASKA PROFESSIONAL EMPLOYER ORGANIZATION (PEO) CLIENT EXCLUSION ENDORSMENT WC260304 05/13 WC260304 PAGE WC 70 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
NEBRASKA PROFESSIONAL EMPLOYER WC260302 05/13 WC260302 NEBRASKA PROFESSIONAL EMPLOYER ORGANIZATION (PEO) MULTIPLE COORDINATED POLICY FOR POLICY COVERING THE CLIENT (New) WC260302 A 05/17 WC260302A NEBRASKA PROFESSIONAL EMPLOYER ORGANIZATION (PEO) MULTIPLE COORDINATED POLICY FOR POLICY COVERING THE CLIENT WC260301 05/13 WC260301 NEBRASKA PROFESSIONAL EMPLOYER ORGANIZATION (PEO) MULTIPLE COORDINATED POLICY FOR POLICY COVERING THE PEO WC260301 A 05/17 WC260301A NEBRASKA PROFESSIONAL EMPLOYER ORGANIZATION (PEO) MULTIPLE COORDINATED POLICY FOR POLICY COVERING THE PEO WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN PAGE WC 71 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Nevada WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000415 B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC000417 B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE PAGE WC 72 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC270601 C 10/08 WC270601C NEVADA CANCEL/NONRENEWAL ENDT WC270302 A 06/12 WC270302A NEVADA EMPLOYEE LEASING CLIENT EXCLUSION WC270303 A 06/12 WC270303A NEVADA EMPLOYEE LEASING EXCLUSION WC270304 06/12 WC270304 NEVADA EMPLOYEE LEASING MASTER POLICY BASIS WC270301 A 06/12 WC270301A NEVADA EMPLOYEE LEASING MULTIPLE COORDINATED POLICIES BASIS WC270301 B 05/17 WC270301B NEVADA EMPLOYEE LEASING MULTIPLE COORDINATED POLICIES BASIS WC270501 10/15 WC270501 NEVADA RETROSPECTIVE RATING PLAN PREMIUM WRAP-UP CONSTRUCTION PROJECT WC270502 10/15 WC270502 NEVADA RETROSPECTIVE RATING PLAN PREMIUM WRAP-UP CONSTRUCTION PROJECT MULTIPLE LINES WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE PAGE WC 73 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS New Hampshire WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC447 04/92 WC2806040492 AMENDAROTY END (NH) WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC477 12/92 WC2804011292 ASSIGN RISK SUR [NH] WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000415 B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC000417 B 01/11 WC000417A PAGE WC 74 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC280402 A 07/03 WC280402A0703 CERTIFIED MANAGED CARE (NH) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 PAGE WC 75 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC280404 01/08 WC2804040108 PENDING RATE CHANGE WC446 03/92 WC2806030392 PER ACCID PER DIS (NH) WC445 03/92 WC2806020392 PER CLAIM BENE END (NH) WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC365 A 01/96 WC280403A SAFETY INC PROG (NH) WC200 04/84 WC280601 SDE REPRESENTV [NH] PAGE WC 76 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS WC280301 B 01/09 WC280301B WC/EMPLYRS LIAB COV RES [NH] New Jersey WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC531 A 01/96 WC290409A APP MNGD CARE PGRM (NJ) WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC577 04/96 WC290410 CONSTRUCTION CLASIF(NJ) WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC470 01/93 WC2903040193 EMP LEAS CL EX END [NJ] WC471 01/93 WC2903050193 EMP LEAS CONT END [NJ] WC469 01/93 WC2903030193 EMP LEAS CONT EQ [NJ] WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED NJLRLD 07/06 FORMNJLRLD LARGE RISK - LARGE DEDUCTIBLE PROGRAM NOTICE OF ELECTION WC497 A 01/94 WC290601A LG RISK DED END [NJ] WC290309 A 07/05 WC290309A0705 LIMIT OTHER STATE INS ENDT(NJ) PAGE WC 77 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC290605 01/05 WC2906050105 NEW JERSEY LARGE RISK - LARGE DEDUCTIBLE PER PERSON BASIS WC290412 01/13 WC290412 NEW JERSEY PREMIUM DISCOUNT SCHEDULE X WC290307 04/00 WC290307 NEW JERSEY SOLE PROPRIETORS AND PARTNERS COVERAGE WC203 A 01/99 WC290302A NEW JERSEY WC EMP LIAB RESID. WC290310 07/04 WC2903100704 NEW JERSEY WORKERS' COMPENSATION INSURANCE PLAN ELIGIBILITY WC290604 01/03 WC2906040103 NJ LARGE RISK - LARGE DEDUCTIBLE AGGREGATE LIMIT ENDORSMENT WC614 01/98 WC290603 NJ PARTICIPATING PROV END WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC106 01/89 NOTICE FORMPP1 B 07/07 FORMPP1B NOTICE OF ELECTION - PROPRIETORS AND PARTNERS WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE NJRR2 01/14 NJRR-2 (1/14) NOTICE OF ELECTION OF RETROSPECTIVE RATING (MUST BE FILED WITH NJCRIB) WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC290306 B 07/07 WC290306B0707 PART 2 EMPLYRS LIAB ENDT (NJ) WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC205 A 01/86 WC290407 PREM DIXC END SCHD (NJ) WC267 07/91 WC000410 PAGE WC 78 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC290411 B 01/15 WC290411B PREMIUM DISCOUNT - SCHEDULE Y WC290406 Y 01/12 WC290406Y PREMIUM DISCOUNT SCHEDULE Y WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC290509 C 07/00 WC290509C RETRO PREM ENDT PRT2 EXC (NJ) WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC290602 B 01/05 WC290602B0105 RETROSPECTIVE ADJMNT ENDT (NJ) WC290513 C 01/05 WC290513C0105 RETROSPECTIVE PREM 1 YEAR (NJ) WC144 04/84 WC0005100484 RETROSPECTIVE PREMIUM - NON RATABLE CATASTROPHE ELEMENT OR SURCHARGE WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC137 04/84 WC000503 RETROSPECTIVE PREMIUM - RATING OPTIONS V - ONE YEAR PLAN WC650 04/84 WC000509 RETROSPECTIVE PREMIUM CHANGES WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC290514 C 01/05 WC290514C0105 RETROSPECTOVE PREM 3 YR (NJ) WC290515 C 01/05 WC290515C0105 RETROSPECTOVE PREM ENDT (NJ) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC201 04/84 WC290101 VOL COMP FED [NJ] WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS New Mexico WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000415 B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 PAGE WC 79 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC300305 09/07 WC300305 CONSUMER DIRECTED PROGRAM WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR NC5001 01/11 FORM NC-5001 CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM APPLICATION FOR NON-ARD STATES NC5000 A 07/11 FORM NC-5000A CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE PAGE WC 80 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC300402 01/05 WC3004020105 NEW MEXICO ASSIGNED RISK SURCHARGE WC300601 A 03/15 WC300601A NEW MEXICO CANCELLATION AND NONRENEWAL WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 PAGE WC 81 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC159 04/84 WC300301 SAFETY DEVICE CURG (NM) WC160 04/84 WC300302 SFTY DEVICE EX [NM] WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC161 04/84 WC300303 VOLUNTEER WRKR END (NM) WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS WC459 A 07/93 WC300401A WC PREM ADJ PROG [NM] New York WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC485 01/89 WC3106090189 AMBULANCE DIST LB [NY] WC488 01/89 WC3106120189 AMBULANCE/FIRE D [NY] WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC402 A 04/94 WC310315A BENEFITS DED END (NY) WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC473 04/93 WC310401 CONS CLASS PREM AD [NY] WC310319 G 10/13 WC310319G CONSTRUCTION CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM EXPLANATORY WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC218 04/84 WC310301 COV FOR ELECTED (NY) WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC219 04/84 WC310302 DESIGNATED WORKPLCE(NY) WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC220 04/84 WC310601 DOMESTIC WORKERS (NY) WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC423 04/92 WC000303B EMPLOYERS LIABILITY COVERAGE WC487 01/89 WC3106110189 EXC FOR DESGNTD [NY] PAGE WC 82 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC221 04/84 WC310303 EXCESS MEDICAL [NY] WC223 B 01/94 WC310305B EXCL OF EXEC OFF (NY) WC222 04/84 WC310602 EXCLUSION DES [NY] WC224 01/86 WC310304 EXEC OFF EXCL [NY] WC225 04/84 WC310603 EXECUTIVE OFFCRS [NY] WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC226 A 01/89 WC3106040189 FIRE DIST LIAB EC [NY] WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC310314 A 08/00 WC310314A INCLUSION OF AUXILIARY POLICY WC227 A 01/87 WC310306A0187 INCLUSION OF EXEC (NY) WC000001 A 05/98 WC000001A INFORMATION PAGE WC310003 A 10/08 WC310003A INFORMATION PAGE NEW YORK VOLUNTEER AMBULANCE WORKERS BENEFIT POLICY WC9941 03/15 WC000001C INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC479 07/93 WC310317 LABOR CONT END [NY] WC480 07/93 WC310318 LABOR CONT EXC END [NY] WC228 04/84 WC310307 LIAB OF MUNIC (NY) WC230 04/84 WC310309 LIMIT OF LIAB END [NY] WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC231 04/84 WC310310 MED BEN REIMBURS (NY) WC554 10/94 WC310402 MERIT RATNG END [NY] WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC310617 A 10/08 WC310617A NEW YORK FOREIGN VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC310308 01/00 WC3103080100 NEW YORK LIMIT OF LIABILITY WC310404 10/99 WC310404 NEW YORK PEND PAYROLL LIMIT & PREM DIFFERERENTIAL WC310316 B 02/15 WC310316B NEW YORK SOLE PROPRIETORS, PARTNERS AND MEMBERS OF LLC S, PSLC S, RLLP S, ETC. EXCLUSION WC310001 A 10/08 WC310001A NEW YORK VOLUNTEER FIREFIGHTERS BENEFIT FORM PAGE WC 83 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC232 04/84 WC310311 NON/SUBJ EMP END [NY] WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC233 04/84 WC310312 NON-SUBJECT EXEC [NY] RR50 10/10 RR-50 NOTICE OF ELECTION OF RETROSPECTIVE RATING PLAN NYLR1 10/10 NYLR-1 NOTICE OF ELECTION OF RETROSPECTIVE RATING PLAN - NEW YORK LARGE RISK RATING OPTION WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP RR1 10/10 RR-1 NOTIFICATION OF COVERAGE - MULTI- STATE RETROSPECTIVE RATING PLAN WC633 01/99 WC310322 NY OPT CLIENT EXCL ENDT WC631 01/99 WC310320 NY OPT LABOR CONTRACTR ENDT WC632 01/99 WC310321 NY OPT LABOR CONTRCTR EXCL END WC615 A 01/99 WC310616A NY PREF PROV ORG END WC616 A 01/99 WC310403A NY PREF PROV ORG PREM END WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC271 04.08 WC890600 POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC310618 03/15 WC310618 POLICYHOLDER NOTICE OF RIGHT TO APPEAL WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC481 10/93 WC0005151093 RETROSPECTIVE PREMIUM - FLEXIBILITY OPTIONS WC414 12/91 WC000505A1291 RETROSPECTIVE PREMIUM - LONG TERM CONSTRUCTION PROJECT WC417 12/91 WC000514A1291 RETROSPECTIVE PREMIUM - LONG-TERM PAGE WC 84 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
CONSTRUCTION PROJECT - MULTIPLE LINES WC144 04/84 WC0005100484 RETROSPECTIVE PREMIUM - NON RATABLE CATASTROPHE ELEMENT OR SURCHARGE WC412 12/91 WC000503A1291 RETROSPECTIVE PREMIUM - ONE YEAR PLAN WC415 12/91 WC000512A1291 RETROSPECTIVE PREMIUM - ONE YEAR PLAN - MULTIPLE LINES WC413 12/91 WC000504A1291 RETROSPECTIVE PREMIUM - THREE YEAR PLAN WC416 12/91 WC000513A1291 RETROSPECTIVE PREMIUM - THREE YEAR PLAN - MULTIPLE LINES WC650 04/84 WC000509 RETROSPECTIVE PREMIUM CHANGES WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC120 04/84 WC000309 RURAL ELECTRIFICATION ADMINISTRATION WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC466 10/92 WC310316 SOLE PROPRIETORS [NY] WC000420 12/02 WC0004201202 TERRORISM RISK INSURANCE ACT WC407 04/91 WC310613 VOL AMB BEND [NY] WC319 11/85 WC3106071185 VOL FIREFT (NY) WC234 04/84 WC310605 VOL FIREMENS [NY] WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC486 01/89 WC3106100189 VOLUNTEER AMB W [NY] WC484 01/89 WC3106080189 VOLUNTEER AMB W PR [NY] WC139 01/93 WC310002A0193 VOLUNTEER AMB WK [NY] WC235 04/84 WC310606 VOLUNTEER FIREMEN'S(NY WC114 01/93 WC310000A0193 VOLUNTEER FIRFT [NY] WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS North Carolina WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC320304 01/09 WC320304 ALTERNATE EMPLOYER (EXCLUDING EMPLOYERS LIABILITY COVERAGE) WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000415 B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC000417 B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC000411 PAGE WC 85 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC320601 A 07/10 WC320601A CANCELLATION/NON-RENEWAL ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC320302 2 11/08 WC 32 03 02 CONTROL INS PROG W/LARGE DEDUCTIBLE WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC103 04/84 WC000104 FEDERAL EMPLOYERS' LIABILITY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC117 04/84 WC000306 MEDICAL BENEFITS EXCLUSION WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE PAGE WC 86 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC270501 10/15 WC270501 NEVADA RETROSPECTIVE RATING PLAN PREMIUM WRAP-UP CONSTRUCTION PROJECT WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC320301 C 01/14 WC320301C NORTH CAROLINA AMENDED COVERAGE WC320303 11/08 WC320303 NORTH CAROLINA CONTROLLED INSURANCE PROGRAM - AMENDATORY WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC130 04/84 WC000405 POLICY PERIOD NCDISC2 02/15 DISCLOSURE NO.2 POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE NCDISC1 02/15 DISCLOSURE NO.1 POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC320602 01/10 WC 32 06 02 PRO-RATA CANCELLATION WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC414 12/91 WC000505A1291 RETROSPECTIVE PREMIUM - LONG TERM CONSTRUCTION PROJECT WC000504 C 01/15 WC000504C PAGE WC 87 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS North Dakota WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 PAGE WC 88 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC137 04/84 WC000503 RETROSPECTIVE PREMIUM - RATING OPTIONS V - ONE YEAR PLAN WC000501 04/84 WC0005010484 RETROSPECTIVE-1 YR PLAN-OPTION I,II,III & IV WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Ohio WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE PAGE WC 89 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 PAGE WC 90 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
RETRO PREMIUM AVIATION WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Oklahoma WC112 04/84 WC0003010484 ALTERNATE EMPLOYER WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC350602 C 07/06 WC350602C0706 BENEFITS DED ENDT (OK) WC350601 F 02/14 WC350601F CANCELTN/NONREN/CHANGE (OK) WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC590 07/96 WC350404 CONTR CLSFCTN PREM (OK) NC5000 A 07/11 FORM NC-5000A CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC336 01/87 WC350302 EMPLOYERS LIAB AM [OK] WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC534 12/93 WC350603 FRAUD WARNING END [OK] WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC350403 B 11/01 WC350403B1101 MERIT RATING END (OK) WC525 11/85 FORM351 NOTICE TO POLICYHOLDERS WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC350604 08/99 WC350604 OKLAHOMA ELECTION OF COV NOTIFICATION WC350303 03/11 WC350303 OKLAHOMA EMPLOYERS LIABILITY INTENTIONAL TORT EXCLUSION WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC350402 A 01/01 WC350402A0101 PREM REDCT PROG(WCPR)ENDT (OK) WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC142 04/84 WC000508 RETRO PREMIUM AVIATION PAGE WC 91 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE FORM35-4 A 07/06 FORM354A0706 WORKERS COMPENSATION DEDUCTIBLE ACCEPTANCE/REJECTION FORM FORM35-3 B 04/97 FORM353B0497 WORKERS COMPENSATION MEDICAL DEDUCTIBLE ACCEPTANCE/REJECTION FORM WC526 11/85 FORM352 WORKERS COMPENSATION PREMIUM CHANGE NOTICE Oregon WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC478 01/93 WC3604030193 ASSIGNED RISK ADJUSTMENT PROGRAM WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000415 B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC000417 B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC360601 E 01/08 WC360601E0108 CANCELATION END (OR) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC405 01/91 WC3604020191 CONT CLASS PRE ADJ (OR) WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR NC5000 A 07/11 FORM NC-5000A CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 PAGE WC 92 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC532 10/93 WC3604041093 GROUP SUPPL EXP [OR] WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC353 01/88 WC360401 MERIT RATING ENDT (OR) WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC360602 01/11 WC360602 OREGON CONFIDENTIALITY WC360603 01/11 WC360603 OREGON EMPLOYER PAID MEDICAL CLAIMS (New) WC360404 A 05/17 WC360404A OREGON GROUP SUPPLEMENTAL EXPERIENCE RATING PLAN WC360306 01/02 WC3603060102 OREGON LIMITS OF LIABILITY WC360406 10/01 WC3604061001 OREGON PREMIUM DUE DATE WC421 04/92 WC000109A PAGE WC 93 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC541 01/94 WC360302 PILOT PROG MED BEN (OR) WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC162 04/84 WC360301 UNSAFE EQUIP EXCL [OR] WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Pennsylvania WC190 04/84 WC370301 (PA)CHURCH END WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL PAGE WC 94 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC370404 B 12/02 WC370404B1202 CERT SAFETY COM END(PA) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC279 01/91 WC370402 CONST CLASS PREM (PA) WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC498 08/93 WC370403 DEDUCTIBLE ENDT [PA] WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC192 04/84 WC370303 EXCLUSION OF EMP (PA) WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC595 08/96 WC370405 MERIT RATING PLAN(PA) WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC346 A 08/95 WC370603A NOT OF INC OF PREM (PA) WC434 04/84 WC370602 NOTICE (PA) WC000114 01/14 WC000114 PAGE WC 95 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC193 04/84 WC370304 PARINCIPALS AS ADD (PA) WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC370109 01/05 WC3701090105 PENNSYLVANIA - NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE ACT OF 2002 WC370406 01/05 WC3704060105 PENNSYLVANIA - TERRORISM RISK INSURANCE ACT WC370604 10/99 WC370604 PENNSYLVANIA EMPLOYER ASSISSMENT WC370311 01/13 WC370311 PENNSYLVANIA MULTIPLE COORDINATED POLICY WC649 E 06/15 PA CCPAP (PA) PENNSYLVANIA WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC191 04/84 WC370302 POLICE/FIRE EN [PA] WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC194 04/84 WC370305 PROF ASSOC ACT EN [PA] WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC195 04/84 WC370306 REAL ESTATE MGMT END (PA) WC196 04/84 WC370307 RELIGIOUS INS [PA] WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC414 12/91 WC000505A1291 RETROSPECTIVE PREMIUM - LONG TERM CONSTRUCTION PROJECT WC417 12/91 WC000514A1291 RETROSPECTIVE PREMIUM - LONG-TERM CONSTRUCTION PROJECT - MULTIPLE LINES PAGE WC 96 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC144 04/84 WC0005100484 RETROSPECTIVE PREMIUM - NON RATABLE CATASTROPHE ELEMENT OR SURCHARGE WC412 12/91 WC000503A1291 RETROSPECTIVE PREMIUM - ONE YEAR PLAN WC415 12/91 WC000512A1291 RETROSPECTIVE PREMIUM - ONE YEAR PLAN - MULTIPLE LINES WC413 12/91 WC000504A1291 RETROSPECTIVE PREMIUM - THREE YEAR PLAN WC416 12/91 WC000513A1291 RETROSPECTIVE PREMIUM - THREE YEAR PLAN - MULTIPLE LINES WC650 04/84 WC000509 RETROSPECTIVE PREMIUM CHANGES WC120 04/84 WC000309 RURAL ELECTRIFICATION ADMINISTRATION WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC189 04/84 WC370601 SPECIAL END (PA) WC197 04/84 WC370308 SPOUSE OF INS END (PA) WC198 B 03/86 WC370309 STATUTORY EMPLOYER (PA) WC000420 12/02 WC0004201202 TERRORISM RISK INSURANCE ACT WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Rhode Island WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC163 04/84 WC380601 DIRECT LIAB ST [RI] WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM PAGE WC 97 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC117 04/84 WC000306 MEDICAL BENEFITS EXCLUSION WC118 04/84 WC000307 MEDICAL BENEFITS REIMBURSEMENT WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE PAGE WC 98 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC496 06/93 WC380602 SAFETY INSP END [RI] WC380401 B 01/15 WC380401B SHORT RATE CANCELLATION WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS South Carolina WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE FORM39-1 A 09/14 FORM39-1A APPLICATION FOR DRUG - AND ALCOHOL-FREE WORKPLACE PREMIUM CREDIT PROGRAM WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000415 B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM PAGE WC 99 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC000417 B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC117 04/84 WC000306 PAGE WC 100 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
MEDICAL BENEFITS EXCLUSION WC118 04/84 WC000307 MEDICAL BENEFITS REIMBURSEMENT WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE PAGE WC 101 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS South Dakota WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000415 B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC000417 B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC400602 07/90 WC400602 BENEFITS DEDUCTIBLE WC400605 B 04/06 WC400605B0406 CANCELLATION AND NONRENEWAL ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A PAGE WC 102 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC568 01/94 WC400603 MANAGED CARE END [SD] WC000201 B 01/15 WC000201B MARITIME COVERAGE WC600 09/96 WC4006040996 MED BEN DED END (SD) WC117 04/84 WC000306 MEDICAL BENEFITS EXCLUSION WC118 04/84 WC000307 MEDICAL BENEFITS REIMBURSEMENT WC457 A 01/96 WC400401A MERIT RATING END (SD) WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC266 07/91 WC000409 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC267 07/91 WC000410 PAGE WC 103 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Tennessee WC410403 07/12 WC410403 (TWCIP) LARGE ACCOUNT INCURRED LOSS PREMIUM ADJUSTMENT PLAN (TAIL PLAN) - AND NOTICE WC410404 07/12 WC410404 (TWCIP) LARGE ACCOUNT INCURRED LOSS PREMIUM ADJUSTMENT PLAN (TAIL PLAN) - RATING WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC410401 A 01/08 ASSIGND RISK PREM SURCHRG [TN] WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE PAGE WC 104 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC410301 01/09 WC 41 03 01 LIMITED OTHER STATES WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO PAGE WC 105 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC410402 08/03 WC4104020803 TENNESSEE PENDING LOSS COST AND ASSIGNED RISK RATE WC410405 07/15 WC410405 TENNESSEE SMALL EMPLOYER PLAN WC410406 07/15 WC410406 TENNESSEE SPECIAL RISK PLAN WC410407 07/15 WC410407 TENNESSEE TABULAR SURCHARGE WC410601 A 09/12 WC410601A TENNESSEE WORKERS COMPENSATION INSURANCE PLAN (TWCIP) REHABILITATION AND TABULAR SURCHARGE REDUCTION INCENTIVE PROGRAM PREMIUM PAGE WC 106 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS FORM41-3 01/07 FORM4130107 WORKERS' COMPENSATION INSURANCE PLAN - COST REDUCTION SEMINAR INCENTIVE PLAN PREMIUM CREDIT FORM FORM41-1 01/07 FORM4110107 WORKERS COMPENSATION INSURANCE PLAN - SMALL EMPLOYER PLAN FORM FORM41-2 01/07 FORM4120107 WORKERS' COMPENSATION INSURANCE PLAN - SPECIAL RISK PLAN FORM Texas WC420604 B 01/00 WC420604B0100 ACC/AGGREG DED ENDT (TX) WC548 A 01/02 ERM411 ACCIDENTS INVOLVING TWO OR MORE PERSONS WC420603 B 01/00 WC420603B0100 AGGREGATE DED END (TX) WC126 04/84 WC000401 AIRCRAFT PREMIUM WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC112 04/84 WC0003010484 ALTERNATE EMPLOYER WC420301 G 06/14 WC420301G AMENDATORY END (TX) WC564 A 03/97 WC420402A0397 ANNIV RATING DATE (TX) WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC527 04/90 FORM421 ASSIGNED RISK RATING PROGRAM REPORT WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR DNE1 A 06/14 DNE-1A DEDUCTIBLE NOTICE OF ELECTION WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC420406 D 06/14 WC420406D EMPL PROV CLIENT CO END (TX) WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC420305 A 01/00 WC420305A0100 EXEMPT EMPL COV END(TX) WC275 A 03/97 WC420403A0397 EXPERIENCE RATING (TX) WC551 05/94 ERM12 EXPERIENCE RATING FORM WC128 04/84 WC000403 PAGE WC 107 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC103 04/84 WC000104 FEDERAL EMPLOYERS' LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC528 04/90 FORM4220490 NOTICE TO WORKERS COMPENSATION ASSIGNED RISK POLICYHOLDERS WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC601 01/97 WC4203080197 PRTNRS,OFFCRS & OTHER WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC000516 01/10 WC 00 05 16 PAGE WC 108 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC120 04/84 WC000309 RURAL ELECTRIFICATION ADMINISTRATION WC602 01/97 WC4203100197 SOLE PROPRIETORS WC420407 03/02 WC4204070302 TEXAS - AUDIT PREMIUM AND RETROSPECTIVE PREMIUM WC420602 A 06/14 WC420602A TEXAS ACCIDENT DEDUCTIBLE WC420315 07/15 WC420315 TEXAS ADVANCE NOTICE OF CANCELLATION TO THE PROFESSIONAL EMPLOYER ORGANIZATION (PEO) WC420605 06/14 WC420605 TEXAS CLAIM DEDUCTIBLE WC420312 07/15 WC420312 TEXAS COVERED EMPLOYEE EXCLUSION FOR POLICY COVERING DIRECT EMPLOYEES OF A CLIENT WC420404 A 06/14 WC420404A TEXAS GROUP PURCHASE OF WORKERS COMPENSATION INSURANCE WC420408 A 06/14 WC420408A TEXAS HEALTH CARE NETWORK WC420606 06/14 WC420606 TEXAS MEDICAL BENEFITS DEDUCTIBLE WC420601 01/94 WC4206010194 TEXAS NOTICE OF MATERIAL CHANGE WC420316 07/15 WC420316 TEXAS PROFESSIONAL EMPLOYER ORGANIZATION (PEO) CLIENT WC420311 07/15 WC420311 TEXAS PROFESSIONAL EMPLOYER ORGANIZATION (PEO) WC420314 07/15 WC420314 TEXAS PROFESSIONAL EMPLOYER ORGANIZATION (PEO) EXECUTIVE EMPLOYEE EXCLUSION WC420313 07/15 WC420313 TEXAS PROFESSIONAL EMPLOYER ORGANIZATION (PEO) EXECUTIVE EMPLOYEE INCLUSION WC420511 06/11 WC420511 TEXAS RETROSPECTIVE PREMIUM SHORT FORM WC420505 B 01/15 WC420505B TEXAS RETROSPECTIVE RATING PLAN PREMIUM LONG-TERM CONSTRUCTION PROJECT WC420514 B 01/15 WC420514B TEXAS RETROSPECTIVE RATING PLAN PREMIUM LONG-TERM CONSTRUCTION PROJECT - MULTIPLE LINES WC420510 B 01/15 WC420510B TEXAS RETROSPECTIVE RATING PLAN PREMIUM NONRATABLE CATASTROPHE ELEMENT OR SURCHARGE WC420303 B 01/00 WC420303B0100 VOL WORKERS COV ENDT (TX) WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC570 04.08 WC000311 PAGE WC 109 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS WC420304 B 06/14 WC420304B WAIVER OF RIGHT TO RECOVR [TX] Utah WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A PAGE WC 110 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 PAGE WC 111 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC430602 07/02 WC4306020702 UTAH CANCELLATION WC430303 01/00 WC4303030100 UTAH EMPLOYEE LEASING CLIENT EXCLUSION WC430304 01/00 WC4303040100 UTAH EMPLOYEE LEASING COMPANY EXCLUSION WC430302 01/00 WC4303020100 UTAH EMPLOYEE LEASING WC430302 A 05/17 WC430302A UTAH EMPLOYEE LEASING WC430305 07/00 WC4303050700 UTAH WAIVER OF SUBROGATION WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS WC490 01/93 WC430601 WKPLACE SFTY PROG [UT] Vermont WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC000415 B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC000417 B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC440603 07/08 WC440603 BENEFITS DEDUCT WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC436 02/92 WC000322 EMPLOYEE LEASING CLIENT EXCLUSION WC000322 A 01/06 WC000322A PAGE WC 112 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC435 02/92 WC000321 LABOR CONTRACTOR EXCLUSION WC165 04/84 WC440601 LAW END [VT] WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC117 04/84 WC000306 MEDICAL BENEFITS EXCLUSION WC118 04/84 WC000307 MEDICAL BENEFITS REIMBURSEMENT WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC000323 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE PAGE WC 113 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC440602 B 07/14 WC440602B VERMONT CANCELLATION AND NONRENEWAL WC440401 04/03 WC4404010403 VERMONT WORKERS COMPENSATION INSURANCE PLAN MERIT RATING WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Virginia WC173 A 10/85 WC450601 ADDTL BENE [VA] WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC489 07/93 WC450602 AMENDTRY END [VA] WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000415 B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL PAGE WC 114 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC593 05/96 WC450603 BENEFITS DED END (VA) WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC450604 01/97 WC450604 CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC117 04/84 WC000306 MEDICAL BENEFITS EXCLUSION WC118 04/84 WC000307 MEDICAL BENEFITS REIMBURSEMENT WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A PAGE WC 115 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE FORM45-1 11/89 FORM45-1 NOTICE TO VIRGINIA POLICYHOLDERS WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC000406 PREMIUM DISCOUNT WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC450303 01/01 WC450303 VIRGINIA CLIENT COMPANY WC450304 01/01 WC450304 VIRGINIA CLIENT COMPANY EXCLUSION WC450301 01/01 WC450301 VIRGINIA PEO PAGE WC 116 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC450302 01/01 WC450302 VIRGINIA PEO EXCLUSION FORM45-2 11/89 FORM45-2 VIRGINIA WORKERS COMPENSATION RATE CHANGE NOTICE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS Washington WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE PAGE WC 117 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS West Virginia WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC000415 B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC000418 F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC000417 B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC000424 01/17 WC000424 AUDIT NONCOMPLIANCE CHARGE WC470601 01/06 WC470601 CANCELLATION ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION PAGE WC 118 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC236 09/85 WC000315 DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 A 05/98 WC000001A INFORMATION PAGE WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC470306 08/09 WC470306 MULTIPLE COORDINATED POLICY WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC000114 01/14 WC000114 NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE PAGE WC 119 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC470304 08/09 WC470304 PROFESSIONAL EMPLOYER ORGANIZATION CLIENT COMPANY EXCLUSION WC470305 08/09 WC470305 PROFESSIONAL EMPLOYER ORGANIZATION EXCLUSION WC470303 08/09 WC470303 PROFESSIONAL EMPLOYER ORGANIZATION EXTENSION WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS WC470301 A 07/08 WC470301A WEST VIRGINIA EMPLOYERS LIABILITY INSURANCE DELIBERATE INTENTION EXCLUSION WC470314 B 07/11 WC470314B WEST VIRGINIA WORKERS COMPENSATION AND EMPLOYERS LIABILITY COVERAGE FOR DOMESTIC SERVICE EMPLOYEES WC470302 07/06 WC4703020706 WEST VIRGINIA WORKERS COMPENSATION INSURANCE RECOVERY FROM OTHERS Wisconsin PAGE WC 120 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE WC480606 B 01/02 WC480606B0102 CANCELL/NONRENEWL ENDT (WI) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC607 07/97 WC4804010797 CONTRA PREM ADJ PRG(WI) WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC000102 B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC000104 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC480603 B 01/01 WC480603B0101 FOREIGN COVERAGE END [WI] WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM WC000001 B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC480601 C 04/01 WC480601C0401 LAW (WI) WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC480301 C 12/07 WC480301C LIMITED OTHER STATES INSURANCE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE PAGE WC 121 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC000000 C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC271 04.08 WC890600 POLICY INFORMATION PAGE WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC000406 A 07/95 WC000406A PREMIUM DISCOUNT WC000419 01/01 WC000419 PREMIUM DUE DATE WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC000504 C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC480507 A 01/15 WC480507A RETROSPECTIVE PREMIUM LARGE RISK ALTERNATIVE RATING OPTION WC480506 09/11 WC480506 RETROSPECTIVE RATING PLAN PREMIUM - LARGE RISK ALTERNATIVE RATING OPTION WC480502 02/12 WC480502 RETROSPECTIVE RATING PLAN PREMIUM - LARGE RISK ALTERNATIVE RATING OPTION - PLAN TYPE WC480503 02/12 WC480503 RETROSPECTIVE RATING PLAN PREMIUM - LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC480508 07/11 WC480508 RETROSPECTIVE RATING PLAN PREMIUM - LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC480512 07/11 WC480512 PAGE WC 122 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
RETROSPECTIVE RATING PLAN PREMIUM - LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC480510 09/11 WC480510 RETROSPECTIVE RATING PLAN PREMIUM - WISCONSIN LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC178 04/84 WC480602 RURAL ELECT COOP (WI) WC000309 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC653 05/11 WC480501 SCHEDULE OF VARIABILITY TO WC 48 05 01 WC654 09/11 WC480506 SCHEDULE OF VARIABILITY TO WC 48 05 06 WC655 07/11 WC480512 SCHEDULE OF VARIABILITY TO WC 48 05 12 WC121 04/84 WC000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC000203 04/84 WC0002030484 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS WC480605 06/01 WC480605 WISCONSIN CHANGE OF INSURANCE CARRIER NAME WC480316 04/08 WC480316 WISCONSIN EMPLOYEE LEASING COMPANY CLIENT TERMINATION MASTER POLICY WC480314 04/08 WC480314 WISCONSIN EMPLOYEE LEASING COMPANY MASTER POLICY WC480315 04/08 WC480315 WISCONSIN EMPLOYEE LEASING COMPANY MULTIPLE COORDINATED POLICY (MCP) WC480514 02/12 WC480514 WISCONSIN RETROSPECTIVE RATING PLAN PREMIUM - LARGE RISK ALTERNATIVE RATING OPTION WC623 11/96 WC4806041196 WISCONSIN WAIVER OF SOVEREIGN WC480302 A 01/13 WC480302A WISCONSIN WORK-STUDY COVERAGE WC606 03/97 WC4803020397 WORKSTUDY COV END (WI) Wyoming WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC467 07/92 WC4903010792 AMENDATORY END [WY] WC127 04/84 WC000402 ANNIVERSARY RATING DATE WC505 07/90 WC000415 ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC000411 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC000413 ASSIGNED RISK PREMIUM SURCHARGE WC403 02/91 WC000603 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC000412 PAGE WC 123 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC000302 DESIGNATED WORKPLACE EXCLUSION WC391 04/91 WC000319 EMPLOYEE LEASING CLIENT WC000322 A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC000303 C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC000403 EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC115 04/84 WC000304 INSURANCE COMPANY AS INSURED WC116 04/84 WC000305 JOINT VENTURE AS INSURED WC449 06/92 WC000204 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC000408 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC000201 B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC000111 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC000323 A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC369 07/90 WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC119 04/84 WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC000404 PENDING RATE CHANGE WC130 04/84 WC000405 POLICY PERIOD WC267 07/91 WC000410 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC000321 A 01/06 WC000321A PROFESSIONAL EMPLOYER WC000320 B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC000407 RATE CHANGE WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC000508 RETRO PREMIUM AVIATION WC340 04/87 WC000509A PAGE WC 124 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424
RETRO PREMIUM CHANGES WC145 04/84 WC000511 RETRO PREMIUM SHORT FORM WC636 01/84 WC000311 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC124 04/84 WC000313 WAIVER OF RIGHT TO RECOVER FROM OTHERS PAGE WC 125 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: 800-382-2424