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CHANGE IN INFORMATION PAGE (Continued) <br />Policy Number: 72 WEC AMOKNA <br />SCHEDULE <br />IT IS AGREED THAT THE POLICY IS AMENDED AS FOLLOWS: <br />CLASS CODE NUMBER AND DESCRIPTION <br />CA <br />Total State Summary <br />ESTIMATED RATES PER 100 ESTIMATED <br />TOTALANNUAL OF ANNUAL <br />REMUNERATION REMUNERATION PREMIUMS <br />Waiver charge <br />0.00 <br />0.020000 <br />1,600 <br />Experience modifier 5657962 <br />0.00 <br />0.630000 <br />-592 <br />Schedule Rating Factor <br />0.00 <br />0.550000 <br />-453 <br />Premium discount <br />0.00 <br />0.028000 <br />-658 <br />Premium discount <br />0.00 <br />0.027000 <br />620 <br />CA User Fund <br />0.00 <br />2.460400 <br />13 <br />CA Fraud <br />0.00 <br />0.412200 <br />2 <br />CA Subsequent Injuries Benefit Trust Fund Assessments <br />0.00 <br />1.589100 <br />8 <br />CA Occupational Safety & Health Fund <br />0.00 <br />0.726600 <br />4 <br />CA Labor Enforcement & Compliance Fund <br />0.00 <br />0.710900 <br />3 <br />California Total Cost <br />547 <br />Form WC 99 00 06 A (1) Printed in U.S.A. <br />Process Date: 07/22/24 <br />ATTY/AGR.2024.136Nesta (2022 Broadway) (Page 27 of 31) <br />Page 2 <br />Policy Expiration Date: 06/07/25 <br />