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DocuSign Envelope ID: B4147DBA-A745-4301-8830-4D6AA065FFFF <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 34 <br /> NOTIFICATION TO OTHERS OF CANCELLATION, NONRENEWAL OR <br /> REDUCTION OF INSURANCE ENDORSEMENT <br /> This endorsement is used to add the following to Part Six of the policy. <br /> PART SIX <br /> CONDITIONS <br /> A. If we cancel or non-renew this policy by written notice to you for any reason other than nonpayment of <br /> premium, we will mail or deliver a copy of such written notice of cancellation or non-renewal to the name and <br /> address corresponding to each person or organization shown in the Schedule below. Notification to such <br /> person or organization will be provided at least 10 days prior to the effective date of the cancellation or non- <br /> renewal, as advised in our notice to you, or the longer number of days notice if indicated in the Schedule <br /> below. <br /> B. If we cancel this policy by written notice to you for nonpayment of premium, we will mail or deliver a copy of <br /> such written notice of cancellation to the name and address corresponding to each person or organization <br /> shown in the Schedule below at least 10 days prior to the effective date of such cancellation. <br /> C. If coverage afforded by this policy is reduced or restricted, except for any reduction of Limits of Liability due to <br /> payment of claims, we will mail or deliver notice of such reduction or restriction to the name and address <br /> corresponding to each person or organization shown in the Schedule below. Notification to such person or <br /> organization will be provided at least 10 days prior to the effective date of the reduction or restriction, or the <br /> longer number of days notice if indicated in the Schedule below. <br /> D. If notice as described in Paragraphs A., B. or C. of this endorsement is mailed, proof of mailing will be <br /> sufficient proof of such notice. <br /> SCHEDULE <br /> Name and Address of Other Person(s)/ <br /> Number of Days Notice: <br /> Organization(s): <br /> ert Holder <br /> 30 <br /> At the address provided by the cert holder <br /> on Accord 25 Ed. 05-10 <br /> All other terms and conditions of this policy remain unchanged. <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 04/01/2019 Policy No. WC 8343871-23 Endorsement No. <br /> Insured: Bonitz, Inc.(et al) Premium $ <br /> Insurance Company: Zurich American Insurance Company <br /> WC 99 06 34 <br /> (Ed. 05-10) Includes copyrighted material of National Council on Compensation Insurance, Inc.with its permission. Page 1 of 1 <br />