tss 2. SET FORTH DE DATES CACH BUSINESS WAS IN OPERATION. THE INSURANCE ccupAwy THAT PROVIDED WORKERS' CCEAPENSATON NS -RMCE. THE POLICY NuMBER AND THE EXPERTENCE WOCKFICATEON FACTCR APPLIED TO EACH SUCH POLICY 1 F THE POLICE, WAS wRTTEN WITHOLLT AN EXPERIENCE MODI RADON FACTOR, P‘LASE STATE, THE APPLICANT HEREBY AUTHORIZES AND REO.ESTS