Workers Compensation And Employers Liability Insurance

Premium Audit Adjustment Statement

Final Audit

POLICY NUMBER POLICY PERIOD UNDERWRITING COMPANY PRODUCER PROCESSING CODE

WC 7 12740877 04/15/2021 - Valley Forge Insurance Company 030-081945
04/15/2022

FIRST NAMED INSURED AND ADDRESS PRODUCER INFORMATION

ESPANATE LLC THE CODY GROUP INC
MICHELLE RUIZ 150 W 28TH ST STE 301
7332 S HAVANA ST APT 3056 NEW YORK, NY 10001-6181
CENTENNIAL, CO 80112-4922

Audit Processing Date: 05/24/2022

AUDIT BASED ON AUDITOR'S REPORT

WORKERS COMPENSATION AUDIT SUMMARY

TOTAL EARNED PREMIUM (SEE ATTACHED SCHEDULE) $408.00
TOTAL PREVIOUSLY CHARGED $289.00
BALANCE DUE COMPANY $119.00

THIS IS NOT A BILL. THIS STATEMENT IS A REVIEW OF THE PREMIUM AUDIT THAT WAS PERFORMED ON
THE POLICY INDICATED AND IS FOR INFORMATIONAL PURPOSES. THE AMOUNT SHOWN ON THIS
STATEMENT WILL BE APPLIED TO YOUR POLICY/ACCOUNT BALANCE AND WILL BE REFLECTED IN YOUR
NEXT BILL.
THIS AUDIT STATEMENT IS VALID ONLY IF THE AMOUNT INDICATED AS PREVIOUSLY CHARGED, HAS, IN
FACT, BEEN RECEIVED BY CNA.
Policy Issuing Office: NEW YORK CITY Auditor:

Schedule of Operations

Class Classification of Operations Actual Rate per Earned

Code Exposure $100 Premium
Remun

State - New York

Location 001
8868 School--Professional Employees & Clerical 31,292 0.53 $166
Subtotal for Location # 001 $166
9812 Employers Liability Increased Limits 0.0000 $0

Form No: UWCAUDIT00002XX (09-2015) Policy No: WC 7 12740877

Policy Effective Date: 04/15/2021
Underwriting Company: Valley Forge Insurance Company, 151 N Franklin St, Chicago, IL 60606 Page: 1 of 2
 Workers Compensation And Employers Liability Insurance
Premium Audit Adjustment Statement
Final Audit

Class Classification of Operations Actual Rate per Earned

Code Exposure $100 Premium
Remun

Total Standard premium $166

0900 Expense Constant $200
9740 Terrorism Premium 31,292 0.0550 $17
9741 Catastrophe (O/T Cert Acts Of Terror) 31,292 0.0100 $3
Total Earned Premium $386
0932 NY State Assessment 11.8% $22
9749 NY WC Security Fund Surcharge 0% $0
Total Cost $408

Policy Totals Annual Premium

Total Class Premium $166
Standard Premium $166
Expense Constant $200
Expense Constant State New York
Terrorism Premium $17
Catastrophe Premium $3
Total Earned Premium $386
Taxes, Fees and Surcharges $22
Total Cost $408

Form No: UWCAUDIT00002XX (09-2015) Policy No: WC 7 12740877

Policy Effective Date: 04/15/2021
Underwriting Company: Valley Forge Insurance Company, 151 N Franklin St, Chicago, IL 60606 Page: 2 of 2