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CHANGE IN INFORMATION PAGE (Continued) <br /> Policy Number: 21 WB DU9567 <br /> i <br /> SCHEDULE <br /> IT IS AGREED THAT THE POLICY IS AMENDED AS FOLLOWS : <br /> CLASS CODE NUMBER ESTIMATED RATES ESTIMATED <br /> AND DESCRIPTION TOTAL ANNUAL PER 100 OF ANNUAL <br /> REMUNERATION REMUNERATION PREMIUMS <br /> c° ( A ) <br /> � 8861 999 , 739 <br /> CD C> 999 , 739 OR WELFARE ORGANIZATION - 1 . 52 15 , 196 <br /> PROFESSIONAL EMPLOYEES & CLERICAL <br /> Ln ALL OTHER STATE CLASS PREMIUM <br /> N 2 , 336 <br /> O <br /> r� TOTAL CLASSPREMIUM 17 , 532 <br /> L INCREASED LIMITS PART TWO ( 9807 ) . 80 PERCENT 85 <br /> °` TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 17 , 617 <br /> A FL - INTRA EXPERIENCE MODIFICATION 091190907 1 . 020 <br /> 'N <br /> N PREMIUM ADJUSTED BY APPLICATION OF EXPERIENCE MODIFICATION 17 , 969 <br /> N TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 17 , 969 <br /> C) PREMIUM DISCOUNT 2 . 5 PERCENT - 449 <br /> C> EXPENSE CONSTANT ( 0900 ) <br /> * TERRORISM RISK INS ACT OF 2002 9740 1 , 376 , 439 200 <br /> TOTAL ESTIMATED ANNUAL PREMIUM - FL . 030 413 <br /> 18 , 133 <br /> INCREASED LIMITS PART TWO ( 9807 ) . 80 PERCENT 85 <br /> TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 17 , 617 <br /> FL - INTRA EXPERIENCE MODIFICATION 091190907 <br /> _= 1 . 02 0 _ <br /> PREMIUM ADJUSTED BY APPLICATION OF EXPERIENCE MODIFICATION 17 , 969 <br /> TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 17 , 969 <br /> PREMIUM DISCOUNT 2 . 5 PERCENT - 449 <br /> EXPENSE CONSTANT 0900 200 <br /> =- TERRORISM RISK INS ACT OF 2002 , ( 9740 ) 413 <br /> TOTAL ESTIMATED ANNUAL PREMIUM 18 , 133 <br /> ESTIMATED ANNUAL ADDITIONAL ENDORSEMENT PREMIUM 61948 <br /> 0 <br /> Form WC 99 00 06 A (1 ) Printed in U.S.A. Page 2 <br /> Process Date : 01 / 26 / 05 Policy Expiration Date : 12 / 01 / 05 <br />