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POLICY NO:9048876-15 <br />DATE: June 26, 2015 <br />PAGE 3 OF 4 <br />Any policy that was cancelled during the 2014 policy year did not <br />receive a dividend. <br />Policies for which the final audit had not been completed by 18 <br />months after the policy inception date did not receive a dividend. <br />Only policyholders with no overdue premium for the 2014 policy at <br />the time of scheduled dividend.disbursement were eligible to receive <br />a dividend. <br />No other factors, considerations or practices were used, other than those described above. <br />PART II: PROPOSAL DISCLOSURE <br />The provisions, factors, and arrangements which are expected to be used in your Dividend <br />Plan are identical to those contained in the prior POLICYHOLDER DIVIDEND DISCLOSURE <br />STATEMENT, PART I: HISTORICAL DISCLOSURE displaying our actual performance as <br />paid except as identified in the following proposal: <br />The dividend formula remains: <br />Dividend= Estimated Annual Premium X the percentage factor. <br />I€ a future dividend is authorized by the Board of Directors, the <br />percent amount (the percentage % factor) will be set by the Board <br />of Directors. <br />As of the date printed on this Dividend Disclosure Statement, the <br />Board of Directors has not'declav ed any dividend for the 2015 <br />policy year. <br />Under California law it is unlawful for an insurer to promise the future payment of dividends <br />under an unexpired workers' compensation policy or to misrepresent the conditions for <br />dividend payment. Dividends are payable only pursuant to conditions determined by the <br />Board of Directors of the State Compensation Insurance Fund following policy expiration. <br />PREMIUM <br />Changes, if any: <br />NONE <br />Changes, if any: <br />NONE <br />In accordance with California Administrative Code, Title 10, Section 2504, no workers' <br />compensation insurer or officer or agent thereof or insurance broker or solicitor shall <br />represent, either orally or in writing as an inducement either to insure or to continue or <br />to renew insurance, that the insurer has agreed or will agree (a) to pay a specified polic��p dhy <br />holder's dividend or (b) upon a formula, criteria or factors which set forth or can be�Ml`��� <br />to determine the amount of dividend, or percentage of premium to be paid asa�l�didend <br />, or <br />amount or percentage of premium to be retained by the insurer after payment of dividend. Gue��� <br />15302 104.20101 <br />