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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />PREMIUM DISCOUNT 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 this policy and the policies, if any, listed in Item 3 of the Schedule may be eligible for a discount. This <br />endorsement shows your estimated discount in Item 1 or 2 of the Schedule. The final calculation of premium discount will <br />be determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective rating <br />is not subject to premium discount. <br />SCHEDULE <br />1. State Estimated Eligible Premium <br />First Next Next <br />$5,000 $95,000 $400,000 Balance <br />North Carolina 3.5% 5.0% 7.0% <br />or any other State that has approved the premium discount plan applicable to the total policy premium on an <br />interstate basis at the effective date of the policy. <br />2. Average percentage discount: 3.30 % <br />3. Other policies: <br />4. If there are no entries in Items 1, 2 and 3 of the Schedule, see the Premium Discount Endorsement attached to your <br />policy number: <br />Countersigned by <br />Form WC 00 04 06 A Printed in U.S.A. <br />Process Date: 05/25/20 <br />J�N <br />RAMmWmentDMsian <br />REVIEWED & APPROVEDSY: <br />--� Risk Pjanagement Analyst <br />