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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />EXPERIENCE RATING MODIFICATION FACTOR 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 />The premium for the policy will be adjusted by an experience rating modification factor. The factor was not available when <br />the policy was issued. The factor, if any, shown on the Information Page is an estimate. We will issue an endorsement to <br />show the proper factor, if different from the factor shown, when it is calculated. <br />Countersigned by <br />Form WC 00 04 03 Printed in U.S.A. <br />Process Date: 05/25/20 Policy <br />cF RAMmVmentDMsian <br />REVIEWED & APPROVED BY.- <br />V"° <br />--� Risk janagement Analyst <br />