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DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 08 <br /> (Ed.4-84) <br /> PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT <br /> The policy does not cover bodily injury to any person described in the Schedule. <br /> The premium basis for the policy does not include the remuneration of such persons. <br /> You will reimburse us for any payment we must make because of bodily injury to such persons. <br /> Schedule <br /> Partners Officers Others <br /> Nancy Espersen <br /> Ann Burton <br /> Dave Wilkerson <br /> This endorsement changes the policy to which tt 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 /> EndorsementElfeclive 02/0812017 Policy No. MWC0106102-01 Endorsement No. <br /> Insured: Senior Care of Orange County Inc Premium(See Attached( <br /> Insurance Company: Markel Insurance Company Countersigned by <br /> WC000308 <br /> Ed.4-84 <br /> 011:1S8-1999 Na dug Consul on CompensalIoo Insurance,Inn. <br /> 11 of 24 <br />