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DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 04 <br /> (Ed.4-84) <br /> PENDING RATE CHANGE ENDORSEMENT <br /> A rate change filing is being considered by the proper regulatory authority. The filing may result in <br /> rates different from the rates shown on the policy. If it does, we will issue an endorsement to show the <br /> new rates and their effective date. <br /> If only one state is shown in Item IA. of the Information Page, this endorsement applies to that state. <br /> If more than one state is shown there, this endorsement applies only in the state shown in the <br /> Schedule. <br /> Schedule <br /> State <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 02/08/2017 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 /> W0000404 <br /> Ed.4-84 <br /> W 1983 National Council on Compensation Insurance. <br /> 12 of 24 <br />