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INFORMATION PAGE (Continued) Policy Number: 76 WEG BX3ZPJ <br /> 3.A.Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states <br /> listed here: TX SEE ENDORSEMENT-WC 99 03 67 <br /> B. Employers Liability Insurance: Park Two of the policy applies to work in each state listed in Item 3.A. <br /> The limits of our liability under Part Two are: <br /> Bodily injury by Accident $1,000,000 each accident <br /> Bodily injury by Disease $1,000,000 policy limit <br /> Bodily injury by Disease $1,000,000 each employee <br /> C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here: <br /> ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES <br /> DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. <br /> D. This policy includes these endorsements and schedule: <br /> SEE ENDORSEMENT-WC 99 03 68 <br /> 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating <br /> Plans. All information required below is subject to verification and change by audit. _ <br /> Premium Basis <br /> Classifications Total Estimated Rates Per Estimated <br /> Code Number and Annual $100 of Annual <br /> Description Remuneration Remuneration Premium <br /> Total Standard Premium $5,084 <br /> Premium Discount _$4 <br /> Expense Constant $200 <br /> Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement $68 <br /> Catastrophe (Other Than Certified Acts Of Terrorism) $31 <br /> Estimated Annual Premium (before Surcharges) $5,379 <br /> Total Estimated Surcharges $204 <br /> *See the attached Schedule(s) of Operations for Location and State Level Premium Information <br /> Total Estimated Annual Premium: $5,583 <br /> Deposit Premium: <br /> Policy Minimum Premium: $600 CA(Includes Increased Limit Min. Prem.) <br /> Interstatellntrastate Identification Number: Refer to Schedule of Operations <br /> NAICS: 713940 <br /> Labor Contractors Policy Number: SIC: 7991 <br /> Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 <br /> Process Date: 11/04/25 Policy Expiration Date: 11/04/26 <br />