PART THREE - LOSS COSTS (NOT RATES)

NEW YORK WORKERS COMPENSATION Page 1 Original Printing Effective October 1, 2015 PART THREE - LOSS COSTS (NOT RATES) (a) Loss Cost, etc., for each individual risk shall be obtained from the Rating Board. e Refer to Page 7 for Loss Costs. c Refer to Page 5 for Loss Costs. F Loss Cost provides coverage under the United States Longshore & Harbor Workers' Compensation Act. D This classification may only be used upon the specific assignment of r Refer to Page 3 for Loss Costs. the Board. Code Code Code Code Code Number Loss Cost Number Loss Cost Number Loss Cost Number Loss Cost Number Loss Cost 0005 2.92. 1924 7.00. 2402 2.87. 2818 D 4.96. 3146 2.92. 0006 5.09. 1925 6.73. 2413 5.71. 2835 4.09. 3169 3.26. 0007 4.48. 2001 9.45. 2416 2.24. 2841 5.95. 3179 2.98. 0031 4.17. 2002 8.06. 2417 5.76. 2881 4.83. 3188 5.31. 0034 4.86. 2003 6.56. 2501 1.06. 2883 5.13. 3190 3.44. 0035 3.22. 2014 7.82. 2503 1.16. 2913 3.02. 3191 3.63. 0042 7.00. 2021 5.99. 2534 4.93. 2916 5.57. 3200 3.94. 0050 5.27. 2039 6.60. 2553 2.84. 2923 2.15. 3220 4.49. 0106 11.08. 2041 5.13. 2570 6.47. 2942 TT 2.79. 3227 45.21. 0251 9.40. 2065 7.20. 2571 4.56. 3004 7.43. 3241 6.81. 0767 h, T 3.34. 2070 7.76. 2576 6.30. 3018 12.48. 3255 T 4.54. 0771 i 4.90. 2081 18.01. 2578 4.13. 3022 12.31. 3257 4.47. 0908 r. 2089 11.34. 2590 3.22. 3027 1.83. 3270 2.76. 0909 r. 2095 11.70. 2591 5.79. 3028 10.42. 3300 T 4.45. 0912 r. 2101 6.30. 2593 6.65. 3030 9.81. 3303 T 6.09. 0913 r. 2105 8.51. 2594 7.22. 3040 10.74. 3307 6.17. 0917 6.03. 2111 6.62. 2600 6.61. 3041 D 6.44. 3315 5.79. 1170 6.26. 2112 9.16. 2623 6.21. 3042 7.96. 3336 2.72. 1320 9.26. 2114 7.42. 2640 15.92. 3060 22.66. 3365 10.20. 1430 7.30. 2121 7.15. 2660 4.41. 3064 9.70. 3372 5.24. 1438 5.20. 2143 6.16. 2670 4.80. 3066 D 4.55. 3381 3.66. 1439 7.58. 2150 12.19. 2683 5.19. 3067 D 6.28. 3383 1.08. 1452 6.40. 2157 14.77. 2688 2.05. 3076 4.16. 3384 0.41. 1463 8.24. 2172 2.39. 2689 0.98. 3081 14.16. 3385 1.47. 1470 15.11. 2211 T 7.35. 2702 40.39. 3085 9.90. 3400 8.06. 1624 4.88. 2286 T 5.31. 2710 8.26. 3110 13.23. 3507 4.33. 1701 6.15. 2288 12.59. 2714 13.28. 3111 7.57. 3515 4.23. 1710 7.09. 2302 5.54. 2731 6.68. 3113 3.05. 3548 3.85. 1741 8.60. 2303 T 6.46. 2735 T 4.57. 3114 2.48. 3559 2.79. 1747 21.86. 2305 T 7.71. 2737 8.89. 3118 3.55. 3561 2.68. 1748 8.74. 2362 2.53. 2759 13.95. 3122 6.70. 3574 1.33. 1809 11.82. 2380 12.03. 2790 3.98. 3126 15.58. 3581 2.36. 1810 11.84. 2383 T 4.16. 2802 7.39. 3129 5.69. 3612 3.57. 1853 5.00. 2387 4.09. 2816 D 5.89. 3132 3.74. 3620 7.09. 1860 12.60. 2388 4.28. 2817 D 4.55. 3145 3.13. 3629 2.31. h Non-Ratable Code and Loss Cost (not Rate) to be used with: 4767 i Non-Ratable Code and Loss Cost (not Rate) to be used with: 4771 T Code is scheduled to be discontinued, effective October 1, 2017. TT Code is scheduled to be discontinued, effective October 1, 2022.

Page 2 Effective October 1, 2015 NEW YORK WORKERS COMPENSATION Original Printing Code Code Code Code Code Number Loss Cost Number Loss Cost Number Loss Cost Number Loss Cost Number Loss Cost 3632 3.73. 4250 3.64. 4710 4.91. 5507 10.26. 6874 F 59.93. 3634 2.65. 4251 4.90. 4712 5.24. 5508 7.34. 6875 F 80.08. 3635 3.46. 4263 4.31. 4720 4.91. 5536 7.65. 6882 5.08. 3638 3.33. 4273 3.50. 4751 4.11. 5538 10.02. 6884 45.07. 3642 2.55. 4279 4.33. 4767 g, T 6.88. 5545 25.79. 6885 63.41. 3643 4.32. 4282 0.77. 4771 m 7.32. 5547 16.16. 7016 6.65. 3647 6.33. 4298 2.46. 4825 1.29. 5606 3.63. 7024 7.39. 3648 3.78. 4299 3.53. 4828 1.70. 5610 8.92. 7038 2.93. 3681 1.95. 4301 6.05. 4829 3.22. 5645 11.89. 7046 4.57. 3685 1.45. 4304 7.46. 4902 4.36. 5648 18.69. 7047 11.09. 3686 2.03. 4307 3.65. 4923 2.39. 5651 8.61. 7050 4.91. 3724 5.73. 4310 4.11. 5000 33.24. 5701 18.12. 7090 3.26. 3726 16.39. 4312 2.85. 5022 17.63. 5703 19.35. 7098 5.08. 3737 5.06. 4351 2.31. 5037 29.66. 5709 16.87. 7099 7.59. 3807 5.47. 4352 0.93. 5040 28.99. 5951 1.35. 7133 5.64. 3808 4.60. 4360 0.37. 5057 17.47. 5954 4.50. 7197 7.41. 3821 12.47. 4361 1.11. 5059 35.51. 6003 16.16. 7201 6.57. 3823 12.00. 4362 0.63. 5069 53.21. 6005 6.59. 7207 4.54. 3824 4.96. 4410 6.95. 5102 14.63. 6017 3.03. 7219 12.54. 3826 2.84. 4420 12.65. 5160 5.49. 6018 18.34. 7231 11.60. 3827 8.52. 4431 5.52. 5183 7.60. 6045 4.68. 7242 25.96. 3830 3.88. 4432 2.22. 5184 9.29. 6204 10.69. 7309 F 8.91. 3832 3.86. 4439 TT 2.03. 5188 6.39. 6216 9.94. 7313 F 2.15. 3865 2.97. 4452 4.47. 5190 5.74. 6217 7.87. 7317 FD 23.52. 3881 (a). 4459 5.25. 5191 1.74. 6229 7.50. 7327 F 24.13. 4000 6.02. 4470 4.09. 5192 6.06. 6233 6.71. 7333 8.68. 4024 6.67. 4475 3.84. 5193 12.63. 6235 9.63. 7335 9.64. 4034 13.68. 4476 3.08. 5213 16.80. 6251 13.44. 7337 14.48. 4038 5.24. 4479 3.42. 5221 12.02. 6252 4.14. 7364 5.60. 4053 10.66. 4491 T 6.70. 5222 12.75. 6260 (a). 7366 F 14.43. 4061 8.85. 4493 6.80. 5223 10.94. 6306 12.95. 7367 10.56. 4062 7.34. 4511 0.75. 5348 7.71. 6319 8.98. 7368 9.17. 4101 4.04. 4557 3.20. 5402 12.68. 6325 8.70. 7370 (c). 4111 4.46. 4558 3.87. 5403 13.96. 6400 10.26. 7377 9.61. 4112 3.49. 4561 T 4.72. 5428 11.22. 6504 6.01. 7380 * 10.11. 4114 3.90. 4568 3.82. 5429 8.27. 6701 15.03. 7390 10.88. 4130 8.30. 4583 13.26. 5443 10.87. 6801 FD 31.12. 7394 4.35. 4131 4.72. 4597 3.96. 5445 9.35. 6811 D 8.56. 7395 4.82. 4133 2.04. 4611 2.82. 5462 11.36. 6824 F 13.85. 7398 7.16. 4150 2.22. 4628 2.07. 5473 25.17. 6826 F 3.39. 7403 6.38. 4207 1.81. 4635 5.85. 5474 10.75. 6834 4.54. 7405 h 2.05. 4239 5.30. 4653 3.53. 5479 7.19. 6836 4.56. 7421 1.70. 4240 5.91. 4665 13.18. 5480 7.07. 6843 FD 4.87. 7422 2.84. 4243 4.72. 4692 0.92. 5491 4.27. 6854 D 3.11. 7431 i 1.35. 4244 3.65. 4693 3.71. 5506 17.34. 6872 F 28.63. 7445 j 0.45. * 7380 - Ex-Medical Loss Cost (not Rate) for this classification is 6.92 g For Non-Ratable portion of Loss Cost (not Rate), refer to: 0767 m For Non-Ratable portion of Loss Cost (not Rate), refer to: 0771 h For Non-Ratable portion of Loss Cost (not Rate), refer to: 7445 i For Non-Ratable portion of Loss Cost (not Rate), refer to: 7453 J Non-Ratable Code and Loss Cost (not Rate) to be used with: 7405 T Code is scheduled to be discontinued, effective October 1, 2017. TT Code is scheduled to be discontinued, effective October 1, 2022.

NEW YORK WORKERS COMPENSATION Page 3 Original Printing Effective October 1, 2015 Code Code Code Code Code Number Loss Cost Number Loss Cost Number Loss Cost Number Loss Cost Number Loss Cost 7453 k 0.43. 8034 7.93. 8382 2.73. 8868 0.59. 9157 5.38. 7502 1.89. 8039 3.17. 8385 9.37. 8869 0.88. 9158 2.09. 7515 1.57. 8043 1.44. 8391 4.39. 8871 0.56. 9159 1.38. 7520 6.48. 8044 3.93. 8392 2.81. 8901 0.28. 9160 1.80. 7536 10.10. 8046 4.43. 8394 6.21. 9014 6.30. 9178 2.95. 7538 9.62. 8047 2.44. 8500 9.09. 9015 2.96. 9179 6.81. 7539 1.77. 8048 7.03. 8601 D 0.60. 9016 9.24. 9180 2.93. 7542 6.08. 8068 0.77. 8709 F 20.77. 9019 2.64. 9182 2.30. 7570 T 1.74. 8069 1.26. 8719 2.67. 9025 26.63. 9186 13.82. 7580 5.32. 8072 1.30. 8720 2.86. 9026 4.56. 9220 8.34. 7590 4.83. 8090 1.56. 8726 F 3.67. 9027 r. 9402 7.24. 7600 6.82. 8102 7.94. 8731 2.97. 9028 3.53. 9403 13.97. 7601 8.96. 8103 5.44. 8742 0.35. 9029 5.68. 9410 5.73. 7610 0.36. 8105 4.11. 8745 8.94. 9030 5.49. 9501 2.77. 7710 5.25. 8106 8.39. 8747 0.31. 9040 # 5.76. 9505 3.70. 7711 (e). 8107 4.74. 8748 1.46. 9044 5.73. 9519 4.97. 7716 (e). 8111 5.81. 8751 4.56. 9048 3.70. 9521 4.84. 7720 1.70. 8116 3.76. 8755 0.75. 9051 5.18. 9522 3.02. 7723 2.20. 8199 4.88. 8800 2.35. 9052 4.11. 9526 20.96. 7855 6.29. 8209 9.98. 8802 1.39. 9055 1.29. 9527 31.67. 7998 3.58. 8215 13.26. 8803 0.08. 9058 2.65. 9534 18.07. 7999 2.26. 8227 D 11.80. 8809 0.19. 9059 7.99. 9539 13.10. 8001 2.93. 8232 7.76. 8810 & 0.17. 9060 1.93. 9545 11.71. 8006 2.03. 8235 7.39. 8820 0.17. 9061 1.85. 9549 3.66. 8008 1.11. 8263 9.81. 8829 4.30. 9063 1.20. 9552 14.73. 8012 1.78. 8264 9.09. 8831 1.68. 9065 1.02. 9553 10.41. 8013 0.49. 8265 11.82. 8832 0.57. 9071 2.10. 9585 1.29. 8016 0.41. 8280 16.47. 8833 @ 1.90. 9072 2.33. 9586 0.75. 8017 1.54. 8288 4.67. 8838 0.56. 9074 1.57. 9600 1.72. 8018 4.40. 8291 10.00. 8840 0.55. 9088 11.54. 9610 0.91. 8021 5.97. 8292 7.63. 8854 4.69. 9089 0.62. 9620 1.67. 8025 3.28. 8293 14.46. 8857 2.34. 9093 2.37. 8031 3.64. 8350 10.34. 8864 3.90. 9101 4.29. 8032 1.23. 8353 7.30. 8865 4.02. 9102 3.37. 8033 4.13. 8381 3.69. 8866 4.38. 9149 2.34. k Non-Ratable Code and Loss Cost (not Rate) to be used with: 7431 i 8068 - Class established effective October 1, 2011 8069 - Class established effective October 1, 2011 & 8810 - Ex-Medical Loss Cost (not Rate) for this classification i 0.12 @ 8833 - Ex-Medical Loss Cost (not Rate) for this classification i 1.42 # 9040 - Ex-Medical Loss Cost (not Rate) for this classification is 4.05 9048 - Camps: Any adjustment in tuition fee made in consideration of services rendered shall not be considered as remuneration. T Code is scheduled to be discontinued, effective October 1, 2017. DOMESTIC WORKERS - RESIDENCES CLASSIFICATIONS Code No. Per Capita Loss Cost Domestic Workers - Inside... 0913 397.37 Domestic Workers - Inside - Occasional... 0908 109.89 Domestic Workers - Outside - including private chauffeurs... 0912 993.52 Domestic Workers - Outside - Occasional - including occasional private chauffeurs... 0909 223.01. BUILDINGS Code No. Per Location Loss Cost 9027 21.67

Page 4 Effective October 1, 2015 NEW YORK WORKERS COMPENSATION Original Printing RESERVED FOR FUTURE USE

NEW YORK WORKERS COMPENSATION Page 5 1st Reprint Effective October 1, 2015 MISCELLANEOUS VALUES Ambulance-Volunteer Service Company - Code 7370 Applicable in accordance with Manual Rule II-G3 Ambulance - Loss Cost (NOT Rate) $7,060 Each additional Ambulance - Loss Cost (NOT Rate) $3,530 For a group policy subject to the provisions of Section 32.2 of the Volunteer Ambulance Workers Benefit Law, premium is determined based on a charge for the first ambulance plus the additional ambulance charge for each additional ambulance covered by the group policy. See Manual rule regarding the application of this charge to antique ambulances. Construction Employment Geographic Territories and Differentials # Territory 1 - Counties of The Bronx, Kings, New York, Queens, and Richmond 0.0 % Territory 2 - Counties of Dutchess, Nassau, Orange, Putnam, Rockland, Suffolk, and Westchester 0.0 % Territory 3 - All Other Counties 0.0 % # Location of work actually performed determines the territory for premium determination purposes. Territory Differentials are to be applied to each portion of an affected classification s manual premium corresponding to the payroll related to work performed in each territory. Refer to Rule VI.I. Deductible Program - Deductible applies on a per occurrence basis. Percentage Loss Elimination Ratios (NOT Premium Credits) by Hazard Group Deductible A B C D E F G $100 0.2% 0.2% 0.1% 0.1% 0.1% 0.1% 0.1% $200 0.4% 0.3% 0.3% 0.2% 0.2% 0.2% 0.2% $300 0.6% 0.5% 0.4% 0.4% 0.3% 0.3% 0.2% $400 0.7% 0.7% 0.5% 0.5% 0.4% 0.3% 0.3% $500 0.9% 0.8% 0.6% 0.6% 0.5% 0.4% 0.4% $1,000 1.7% 1.5% 1.2% 1.1% 1.0% 0.8% 0.7% $1,500 2.5% 2.2% 1.7% 1.6% 1.4% 1.1% 1.0% $2,000 3.2% 2.8% 2.2% 2.0% 1.8% 1.4% 1.2% $2,500 3.8% 3.4% 2.7% 2.4% 2.2% 1.7% 1.5% $5,000 6.8% 6.1% 4.9% 4.4% 4.0% 3.1% 2.8% Expense Constant - an expense constant shall be charged for each policy, regardless of premium size, except for those policies that insure Per Capita classification operations only. Refer to Rule XIV-F for special instructions concerning policies insuring only Per Capita classifications. Expense constants are carrier specific. Maximum Weekly Remuneration Executive Officers Non - Construction Employments - applicable in accordance with Manual Rule IX-A-6-a2...$2,000.00 Construction Employments - refer to Manual Rule IX-A-6-a7...$1,296.48 * Non - Executive Officers - applicable in accordance with Manual Rule V-F for classifications with footnotes limiting the maximum remuneration...$5,350.00 Construction Employments refer to Manual Rule V-G...$1,296.48 * Sole Proprietors and Partners Non - Construction Employments - applicable in accordance with Manual Rule IX-B-4a...$2,000.00 Construction Employments - refer to Manual Rule IX-B-4b...$1,296.48 * * effective July 1, 2016 Minimum Weekly Remuneration Executive Officers - applicable in accordance with Manual Rule IX-A-6-a1... $ 675.00 Executive Officers of not-for-profit unincorporated associations - applicable with Manual Rule IX-A-6-b... $ 325.00 Sole Proprietors and Partners - applicable in accordance with Manual Rule IX-B-4a and 4b... $ 675.00

Page 6 Effective January 1, 2016 NEW YORK WORKERS COMPENSATION 1 st Reprint MISCELLANEOUS VALUES (continued) New York State Assessment Charges General Instructions and Information Refer to Rule IX-L., Sections 1. and 2. Applicable Standard Premium Assessment Rate... 12.9% Premium Base Refer to Rule IX-L., Section 3. Standard premium is the only premium base to be used in calculating the New York State Assessment policyholder charge. For policyholder assessment purposes, standard premium is defined as the premium determined on the basis of the insurer s approved rates, as modified by any experience modification or merit rating factor, any applicable territory differential premium, the minimum premium, any Construction Classification Premium Adjustment Program credits, any credit from return to work and/or drug and alcohol prevention programs, including credits under the Workplace Safety Loss Prevention Incentive Program (WSLPIP), any surcharge or credit from a workplace safety program, including credits under the Workplace Safety Loss Prevention Incentive Program (WSLPIP), any credit from independently-filed insurer specialty programs (for example, alternative dispute resolution, drug-free workplace, managed care or preferred provider organization programs), any charge for the waiver of subrogation, any charge for foreign voluntary coverage and the additional charge for terrorism, and the charge for natural disasters and catastrophic industrial accidents. For purposes of determining standard premium, the insurer s expense constant, including the expense constant in the minimum premium, the insurer s premium discount and premium credits for participation in any deductible program, as well as any premiums providing federal coverage, and coverage under the volunteer firefighter benefit law and volunteer ambulance workers benefit law, shall be excluded from the premium base. Terrorism and Catastrophe Loss Cost Charges Terrorism Applicable only in conjunction with Rule IX-N.1 of the Manual Terrorism loss cost (NOT RATE) charge per $100 of total policy payroll... $.045 For non-payroll based classes, charge is % of non-payroll class manual premium... 3.4% Natural Disasters and Catastrophic Industrial Accidents Applicable only in conjunction with Rule IX-N.2 of the Manual Catastrophe loss cost (NOT RATE) charge per $100 of total policy payroll... $.008 For non-payroll based classes, charge is % of non-payroll class manual premium... 0.7% Workers Compensation Security Fund Surcharge Applicable only in accordance with Rule IX - M of the Manual Charge is % of total policy premium.... 0.0% United States Longshore and Harbor Workers Compensation Coverage Percentage Applicable only in connection with Rule XII-D of the Manual... 50.2% (Multiply a Non-F classification rate by a factor of 1.502 to adjust for differences in state and federal benefits and assessments)

NEW YORK WORKERS COMPENSATION Page 7 Original Printing Effective October 1, 2015 MISCELLANEOUS VALUES (continued) LOSS COSTS (NOT RATES) FOR VOLUNTEER FIREFIGHTERS - Code 7711 Population Annual Loss Costs Population Annual Loss Costs Population Annual Loss Costs Up to 300 $5,247 3,501 to 4,000 $27,686 8,001 to 8,500 $56,486 301 to 500 6,043 4,001 to 4,500 31,675 8,501 to 9,000 60,048 501 to 700 7,981 4,501 to 5,000 34,081 9,001 to 9,500 63,729 701 to 1,000 10,028 5,001 to 5,500 36,478 9,501 to 10,000 67,261 1,001 to 1,500 13,281 5,501 to 6,000 39,714 10,001 to 15,000 79,763 1,501 to 2,000 14,818 6,001 to 6,500 42,947 15,001 to 20,000 92,148 2,001 to 2,500 18,443 6,501 to 7,000 46,882 20,001 to 25,000 104,107 2,501 to 3,000 20,019 7,001 to 7,500 50,095 25,001 to 35,000 122,593 3,001 to 3,500 24,035 7,501 to 8,000 53,302 35,001 to 50,000 153,531 For populations over 50,000, the annual loss cost shall be $153,531 plus $24,089 for each 10,000 people or major part thereof. For All Population Groups: Minimum loss cost (NOT premium)... $5,247 A. The premium charge for the home area shall be the sum of: 1. The premium charge corresponding to the population of the home area, and 2. A loss cost (NOT premium) charge of $115 per fire protection contract where the home area has obligated itself to provide protection to another home area pursuant to a fire protection contract, and 3. The separate premium charges for each outside area corresponding to the population of each such outside area that is serviced by the home area under a fire protection contract. However, when a outside area has more than one contract for fire protection, the additional premium charge for each home area providing fire protection to such outside area shall be a proportionate share of the total premium corresponding to the population of the outside area, provided that the books and records of the home area are maintained so as to show separately its contract price as well as the total cost of all contracts being paid by the outside area. The proportionate share shall be determined on the basis of the ratio that the contract price paid to the home area bears to the total contract price for all fire protection for such outside area. B. The premium charge where a fire company or fire department operates in, or is maintained jointly by, two or more villages, towns, or fire districts, shall be the sum of the separate premium charges for each village, town, or fire district, corresponding to the population of each such village, town, or fire districts. C. Section 30 of the Volunteer Firefighters Benefit Law makes a county, city, town, village, or fire district responsible for such benefits to volunteer firefighters of fire departments or companies in their area. Employers Liability coverage is not automatically afforded under these circumstances to the fire departments or companies whose firefighters are covered by the municipality s policy. However, the municipality may elect to extend Employers Liability coverage for an additional 10% of that premium which is developed for the volunteer firefighters of these fire departments or companies. Use endorsement WC 31 06 07. This additional premium shall be assigned to Code 9850 Premium for the Extension of Employers Liability Coverage to Additional Interests under a VBFL policy. D. The premium charge for a group policy subject to the provisions of Section 32.2 of the Volunteer Firefighters Benefit Law is determined on the basis of the aggregate population of all entities insured under the group policy. Refer to Rule II.F.2 of the Manual. The terms home area and outside area used in Rule A above are defined as follows: Home Area a. Any city, village, or fire districts, having its own fire department, or protected pursuant to a fire protection contract with an incorporated fire company, located within the city, village, or district. b. Any town fire protection district or town fire alarm district protected pursuant to a fire protection contract with an incorporated fire company located within the town fire protection district or town fire alarm district. c. The territory of a town located outside of a city, village, fire district, town fire protection of town fire alarm district, included within the area of operating set forth in the certificate of incorporation of an incorporated fire company located in such territory. Outside Area Any city, village or fire district, town fire protection district or town fire alarm district which either does not have its own fire department or an incorporated fire company located within its boundaries, and is protected pursuant to a fire protection contract. Firefighters - Volunteer, Including drivers - Elective Coverage for Assistance from individual Volunteer Firefighters... 7716 Loss Cost (NOT Premium) Charge - $50 per policy