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Total Payroll : $11,976,641 Total Premium : $180,507 <br />Premium Information <br />Description Period Adjustment Amount <br />Ratable Manual Premium 01/01/2013 - 01/01/2014 $180,507 <br />Deductible Discount ($1000 Ded) 01/01/2013 - 01/01/2014 .942 $10,469- <br />Experience Modification 01/01/2013 - 01/01/2014 .860 $23,805 - <br />Schedule Rating & Designated Provider 01/01/2013 - 01/01/2014 .925 $10,967 - <br />Cost Containment Credit 01/01/2013 - 01/01/2014 .950 $6,763 - <br />Loss Control Surcharge 01/01/2013 - 01/01/2014 1.050 $6,42.5 <br />Premium Discount 01/01/2013 - 01/01/2014 .916 $11,334 - <br />Annual Policy Fee 01/01/2013 - 01/01/2014 $195 <br />Terrorism Insurance Coverage 01/01/2013 - 01/01/2014 $1,198 <br />Catastrophe Insurance Coverage 01/01/2013 - 01/01/2014 $1,198 <br />Net Estimated Annual Premium 01/01/2013 - 01/01/2014 $126,185 <br />Pinnacol Assurance ' 7501E Lowry OIvd ' Denver, CO 50230 <br />Page 2 015 GATEW00,1- Underviiler 12:1512012 00:04:10 205 LCFGU <br />13 <br />