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DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 14 <br /> (Ed.7-90) <br /> NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT <br /> Experience rating is mandatory for all eligible insureds. The experience rating modification factor, if any, <br /> applicable to this policy, may change if there is a change in your ownership or in that of one or more of the <br /> entities eligible to be combined with you for experience rating purposes. Change in ownership includes sales, <br /> purchases, other transfers, mergers, consolidations, dissolutions, formations of a new entity and other changes <br /> provided for in the applicable experience rating plan manual. <br /> You must report any change in ownership to us in writing within 90 days of such change. Failure to report such <br /> changes within this period may result in revision of the experience rating modification factor used to <br /> determine your premium. <br /> This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br /> (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br /> Endorsement Effective 11/17/2015 Policy No. MWC0071930-02 Endorsement No. <br /> Insured: Family Centered Healthcare INC Premium(See Attached) <br /> Insurance Company: Markel Insurance Company Countersigned by <br /> WC000414 <br /> Ed.7-90 <br /> ©1990 National Council on Compensation Insurance. <br /> 4of6 <br />