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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 07 E <br /> (Ed. 01-22) <br /> <br />WC 99 06 07 E Page 2 of 2 <br />(Ed. 01-22) <br /> <br /> <br />Short Rate Table <br />Extended <br />Number of <br />Days <br /> Percent of <br />Full Policy <br />Premium <br />Extended <br />Number of <br />Days <br /> Percent of <br />Full Policy <br />Premium <br />Extended <br />Number of <br />Days <br /> Percent of <br />Full Policy <br />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% 215-218 . . . . . . 68% 361-365 (12 mos.) 100% <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br /> <br /> (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br /> <br />Endorsement Effective: Policy No.: Endorsement No.: <br /> <br />Insured: Premium $ <br /> <br />Insurance Company: <br /> <br /> <br /> <br /> <br /> Countersigned by ______________________________ <br />Berkshire Hathaway Homestate Ins Co <br />04/01/2026 FOWC726350 <br />Docusign Envelope ID: 9624BEFC-E18C-8094-83D4-B6529DE9F703