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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 07 E <br /> (Ed. 01-22) <br /> Short Rate Table <br /> Extended Percent of Extended Percent of Extended Percent of <br /> Number of Full Policy Number of Full Policy Number of Full Policy <br /> Days Premium Days Premium Days Premium <br /> 1 . .... . 5% 95-98 ..... . 37% 219-223 . .... . 69% <br /> 2 . .... . 6% 99-102 ..... . 38% 224-228 . .... . 70% <br /> 3-4 ..... . 7% 103-105 . .... . 39% 229-232 ..... . 71% <br /> 5-6 . .... . 8% 106-109 . ..... 40% 233-237 . ... . . 72% <br /> 7-8 . .... . 9% 110-113 . ..... 41% 238-241 . ... . . 73% <br /> 9-10 . .... . 10% 114-116 . ..... 42% 242-246 (8 mos.) 74% <br /> 11-12 ..... . 11% 117-120 . .... . 43% 247-250 ..... . 75% <br /> 13-14 . .... . 12% 121-124 (4 mos.) 44% 251-255 . .... . 76% <br /> 15-16 . .... . 13% 125-127 ..... . 45% 256-260 . .... . 77% <br /> 17-18 ...... 14% 128-131 .. ... . 46% 261-264 ...... 78% <br /> 19-20 ...... 15% 132-135 .. ... . 47% 265-269 ...... 79% <br /> 21-22 . .... . 16% 136-138 ..... . 48% 270-273 (9 mos.) 80% <br /> 23-25 . .... . 17% 139-142 ..... . 49% 274-278 . .... . 81% <br /> 26-29 ...... 18% 143-146 . .... . 50% 279-282 ..... . 82% <br /> 30-32 (1 mo.) 19% 147-149 . .... . 51% 283-287 . .... . 83% <br /> 33-36 . .... . 20% 150-153 (5 mos.) 52% 288-291 . .... . 84% <br /> 37-40 . .... . 21% 154-156 . .... . 53% 292-296 . .... . 85% <br /> 41-43 ..... . 22% 157-160 . .... . 54% 297-301 ...... 86% <br /> 44-47 . .... . 23% 161-164 ..... . 55% 302-305 (10 mos.) 87% <br /> 48-51 . .... . 24% 165-167 ..... . 56% 306-310 . .... . 88% <br /> 52-54 ...... 25% 168-171 .. ... . 57% 311-314 ...... 89% <br /> 55-58 ...... 26% 172-175 .. ... . 58% 315-319 ...... 90% <br /> 59-62 (2 mos.) 27% 176-178 ..... . 59% 321-323 . .... . 91% <br /> 63-65 . .... . 28% 179-182 (6 mos.) 60% 324-328 . .... . 92% <br /> 66-69 ...... 29% 183-187 . .... . 61% 329-332 ...... 93% <br /> 70-73 . .... . 30% 188-191 . ..... 62% 333-337 (11 mos.) 94% <br /> 74-76 . .... . 31% 192-196 . ..... 63% 338-342 . .... . 95% <br /> 77-80 . .... . 32% 197-200 . ..... 64% 343-346 . ... . . 96% <br /> 81-83 ...... 33% 201-205 . .... . 65% 347-351 ...... 97% <br /> 84-87 ..... . 34% 206-209 ..... . 66% 352-355 . .... . 98% <br /> 88-91 (3 mos.) 35% 210-214 (7 mos.) 67% 356-360 . .... . 99% <br /> 92-94 ...... 36% 1 215-218 .. ... . 68% 1 361-365 12 mos. 100% <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 Effective: 04/01/2026 Policy No.: FOWC726350 Endorsement No.: <br /> Insured: Premium$ <br /> Insurance Company: Berkshire Hathaway Homestate Ins Co <br /> Countersigned by <br /> WC 99 06 07 E Page 2 of 2 <br /> (Ed. 01-22) <br />