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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />CERTIFIED RISK MANAGEMENT PROGRAMS ENDORSEMENT <br />Policy Number: 59 WEC AC9055 Endorsement Number: <br />Effective Date: 07/03/20 Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address: BAY SPROUTS LLC <br />655 S MAIN ST STE 200-317 <br />ORANGE CA 92868 <br />This endorsement applies to Part One (Workers Compensation Insurance) because Colorado is listed in Item 3.A of the <br />Information Page. <br />The Colorado Workers Compensation Cost Containment Board has determined that a premium differential shall be <br />provided on all policies when you have selected a designed medical provider. <br />If you qualify for experience and/or schedule rating and you have implemented a certified workers compensation risk <br />management program or service, we must allow a 5% premium credit if your loss experience has improved since your last <br />renewal date. The Schedule below will indicate if you qualify for this credit. <br />If you do not qualify for experience and/or schedule rating on your workers compensation insurance and you have <br />implemented a certified workers compensation risk management program or service, we must offer premium credits as <br />follows: <br />Premium Credit Credit Criteria <br />10% If you have been loss free for at least the last year immediately preceding the effective date <br />of the premium credit. <br />8% If you have had one medical loss exceeding $250 in the last year immediately preceding <br />the effective date of the premium credit. <br />6% If you have had two medical losses, each exceeding $250 within the last year immediately <br />preceding the effective date of the premium credit. <br />4% If you have had three medical losses, each exceeding $250 within the last year <br />immediately preceding the effective date of the premium credit. <br />2% If you have had three medical losses, each exceeding $250, and one claim for loss of time <br />in the last year immediately preceding the effective date of the premium credit. <br />0% If you have had more than three medical losses and one claim for loss time in the last year <br />immediately preceding the effective date of the premium credit. <br />Countersigned by <br />ew cF RAMwagementDMsian <br />°RE�AED&APPROVED SY: <br />Form WC 05 04 03 Printed in U.S.A. x <br />.v <br />Process Date: 05/25/20 Policy E �__ _� R.Wjanagementftalpt <br />