INCOMPLETE INFORMATION WITH THE PURPOSE Of AVOIDING OR COVERAGE IT IS A FELONY OF THE THIRD DEGREE OR AS OTHERWISE PUNISHASLE WF THE ANSWER TO EITHER OF THE ABOVE QUESTIONS IS YES, COMPLETE THE FOLLOWING SUPPLEMENTAL OWNERSHIP / COMBINABMLITY QUESTIONS: TMOENTIFY BY WANE. ADORESS, AND FRIN EACH BUSINESS WHICH IS RELATIID BY COMMON OWNERSHIP TO THE APPLICANT BUSINUSS. 2.88T CO ROE OATES CACH BUSINESS WAS IN OPERATION, THE INSURANCE COMPANY THAT PROVIDED WORKERS’ COMPENSATION INSURANCE, THE POLICY NUMBER AND THE EXPERIENCE MODWICATION FACTOR APPLIED TO EACH SUCH POLICY. NOTARY PUBLIC-STATE OF NEW YORK = =—s . -No.01GR6285700 : Quelified in New York County My Commission Expires 07-08-2021 EFTA00313997