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DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B <br /> SECTION I <br /> PARTS ONE and TWO PART THREE <br /> 1. WE WILL ALSO PAY 2. How This Insurance Applies <br /> D. We Will Also Pay of Part One (WORKERS' Paragraph 4.of A. How This Insurance <br /> COMPENSATION INSURANCE); and Applies of Part 3 (Other States Insurance) is <br /> E. We Will Also Pay of Part Two(EMPLOYERS' replaced by the following: <br /> LIABILITY INSURANCE) is replaced by the 4. If you have work on the effective date of this <br /> following: policy in any state not listed in Item 3.A. of the <br /> We Will Also Pay Information Page, coverage will not be <br /> We will also pay these costs, in addition to afforded for that state unless we are notified <br /> other amounts payable under this insurance, within sixty days. <br /> as part of any claim, proceeding, or suit we <br /> defend: PART SIX <br /> 1. reasonable expenses incurred at our 3. Transfer Of Your Rights and Duties <br /> request, INCLUDING loss of earnings; C. Transfer Of Your Rights and Duties of Part 6 <br /> 2. premiums for bonds to release (Conditions) is replaced by the following: <br /> attachments and for appeal bonds in bond Your rights or duties under this policy may not <br /> amounts up to the limit of our liability be transferred without our written consent. <br /> under this insurance; <br /> If you die and we receive notice within sixty <br /> 3. litigation costs taxed against you; days after your death, we will cover your legal <br /> 4. interest on a judgment as required by law representative as insured. <br /> until we offer the amount due under this 4. Liberalization <br /> law; and <br /> If we adopt a change in this form that would <br /> 5. expenses we incur. broaden the coverage of this form without extra <br /> charge, the broader coverage will apply to this <br /> policy. It will apply when the change becomes <br /> effective in your state. <br /> SECTION II <br /> VOLUNTARY COMPENSATION AND EMPLOYERS' to work in a state shown in Item 3.A. of the <br /> LIABILITY COVERAGE Information Page. <br /> 5. Voluntary Compensation Insurance 3. The bodily injury must occur in the United <br /> A. How This Insurance Applies States of America, its territories or <br /> possessions, or Canada, and may occur <br /> This insurance applies to bodily injury by elsewhere if the employee is a United <br /> accident or bodily injury by disease. Bodily States or Canadian citizen, or otherwise <br /> injury includes resulting death. legal resident, and legally employed, in the <br /> 1. The bodily injury must be sustained by any United States or Canada and temporarily <br /> officer or employee not subject to the away from those places. <br /> workers' compensation law of any state 4. Bodily injury by accident must occur <br /> shown in Item 3.A. of the Information during the policy period. <br /> Page. <br /> 5. Bodily injury by disease must be caused <br /> 2. The bodily injury must arise out of and in or aggravated by the conditions of the <br /> the course of employment or incidental officer's or employee's employment. <br /> Form WC 99 03 02 B Printed in U.S.A. (Ed. 8/00) Page 2 of 4 <br />