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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 89 06 00 B <br />(Ed. 7-01) <br />POLICY INFORMATION PAGE ENDORSEMENT <br />ELI Increased Limits Charge <br />Safety Factor <br />Drug -Free Workplace Factor <br />Experience Rating Premium <br />Waiver of Subrogation <br />Premium Deductible Premium <br />Total State Surcharges <br />Total Estimated Annual Premium $ 12,392.00 Total Amount Due 12,392.00 <br />Minimum Premium $ 1,057.00 Deposit Premium $ 0.00 <br />All other terms and conditions of this policy remain unchanged. <br />$665.00 <br />$594.00 <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement Effective08/30/2025 Policy No. NXTRWKKV3Q-01-WC 01 <br />Endorsement No. <br />Insured WORKING WARDROBES FOR A NEW ST Premium $ 12,392.00 <br />Insurance Company National Specialty Insurance <br />Company Countersigned by <br />WC 89 06 OOB <br />(Ed. 7-01) <br />C 1987 National Council on Compensation Insurance, Inc. <br />