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Technology Insurance Company, Inc. <br />WC 99 00 01 E <br />4 of 5 <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE <br />POLICY <br />INFORMATION PAGE <br />Insured: A Pa Pe, Inc. <br />Policy Number: TES4516027 <br />EXTENSION OF INFORMATION <br />PAGE FOR ITEM #4 <br />ITEM 4: SCHEDULE OF PREMIUMS <br />Premium Basis <br />Total Estimated <br />Rate Per Estimated <br /># of <br />Code Annual <br />$100 of Annual <br />Classifications Emps <br />No. Remuneration <br />Remun. Premium <br />California <br />Restaurants -full service 19 <br />9080 249,085 <br />2.86 7,124 <br />Manual Premium <br />7,124 <br />Total Manual Premium <br />7,124 <br />Waiver of Subrogation: <br />The City of Redwood City <br />0930 <br />250 <br />Total Premium Subject To Experience Modification <br />7,374 <br />Experience Modification 79% <br />5,825 <br />Schedule Modifier 5% <br />9889 <br />291 <br />Premium Discount 0.6% <br />0063 <br />-37 <br />Terrorism 3% <br />9740 <br />75 <br />Catastrophe (other than Terrorism) 1 % <br />9741 <br />25 <br />Expense Constant <br />0900 <br />100 <br />Total CA Premium <br />6,279 <br />WCARF 2.4604% <br />9999 <br />154 <br />UEBTF 0.1505% <br />9999 <br />9 <br />SIBTF 1.5891% <br />9999 <br />100 <br />OSHAF 0.7266% <br />9999 <br />46 <br />LECF 0.7109% <br />9999 <br />45 <br />FRAUD 0.4122% <br />9999 <br />26 <br />Total CA Cost <br />6,659 <br />TOTAL ESTIMATED ANNUAL PREMIUM 6,279 <br />STATE ASSESSMENT 380 <br />TOTAL COST 6,659 <br />POLICY COST BEFORE ENDORSEMENT 6,447 <br />TOTAL ENDORSEMENT PREMIUM CHANGE 212 <br />ATTY/AGR.2025.207/A Pa Pe, Inc. (2616 Broadway) (Page 41 of 55) <br />