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<br />GJ Risk Name: CITY OF SUNNY ISLES BEACH <br /> <br />WORKERS COMPENSATION EXPERIENCE RATING <br /> <br />Risk 10: 091103249 <br /> <br />Rating Effective Date: 10/0112011 <br /> <br />Product/on Date: 06/15/2011 <br /> <br />State: FLORIDA <br /> <br />09.FLORIDA <br /> <br />Firm 10: <br /> <br />Firm Name: CITY OF SUNNY ISLES BEACH <br /> <br />Carrier; 31860 <br /> <br />Polley No. FMIT0820 <br /> <br />EN Date: <br /> <br />10/01/2009 <br /> <br />Exp Date: 10/0112010 <br /> <br />i Code I ElR D- Payroll I Expected Exp Prim /. Claim Oall I'J OF Actlnc Acip~ <br />Ratio Losses Losses Losses Losses ; <br />7382 2.16 .22 241'247t 5,211 1,146 WC201011535 5 0 6,500 5.000 <br />7720 1.35 .18 47.890 8,620 WC201011457 5 0 200,000 # 5.000 <br />3.547,432 <br />8810 .10 .22 2.815.793 2,816 620 INO. 3 /6 . 1,504 1.504 <br />8820 .07 .20 312,351 219 44 WC200911372 6 F 2,244 2.244 <br /> .-- -- <br />9015 1.63 .22 978,113 15.943 3,507 WC201011497 6 0 2,500 2,500 <br />9102 1.36 .22 1,250.140L 17.002 3,740 WC200911337 6 F 2.884 2,884 <br />- -- r---- . 37,080f <br />9402 2.35 .18 871 157 WC200911334 6 F 3.650 3.650 <br />9410 ~L-~~_ I ~79,219L_ 8'0/.61 1,7661 I <br />~ <br />9765 WORKPLACE SAFETY C -2,105 -421 <br />9841 DRUG FREE CREDIT .5,158 -1.032 ~ <br />9944 P~EMIUM CREDIT FOR 0 0 <br /> SUbject Total Act Inc <br />Policy Total: 9,961,375 Premium: 252,005 Losses: 219,282 <br /> <br />F'~~ <br />~ <br /> <br />Copyright 1993.2011, All rights ,eserved n.~ e)l!~rJence mod'ltlcahon fiKtor ts corr.priSf-d of compllallons and inlofm~fiol"l wntcll are the plopr~ary and t'lldusive pio~rtyof .tle National <br />Council on COmp'lOsabon Insurilnce.lnc. (NCCQ. No turUle, uso. di$semt~tjon, sate, t/;ln5ter. assignm.nt ordlspo~tio'" of thls elCpen!'nr:;:e raring modiflcahon ractor or any part thereof <br />may bl! used withovt the written COI'Iaer'lt or Heel Nee! makes no rePfesentation or warunty, e)(ptes~cd or Impled, as to arlY matt.erwttat5Oever Iflcluchng but lIot limited 10 the accuracy 01 <br />any inforrniltlon, producl or service ftrnrs,hed ~reUf1der and, as to Neer, reClp1ent ollfus experience fating modi' ~al,on factor :s.vbsaibe-s tQ and lllil,ZeoS (he fntorm3hon seoMce -IS is", <br /> <br />. ToIal by Policy Year 0' all cas.es. $2OJO or ress 0 Disease Loss <br />C CatastrophIC lo.s E Employer. lIability Loss <br /> <br />X Ex.Medical COv'''ge <br />" limited Loss <br /> <br />UUSl&HW <br /> <br />Page 3 of 3 <br /> <br />000115/000366 CX1435 T <br />