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Workers' Compensation and Employers' Liability Policy <br />Named Insured Endorsement Nu mber <br /> <br /> Po licy Number <br /> Symb ol: WLR <br /> <br /> <br />Issued B y Name of Insurance Com pany <br />ACE AMERICAN INSURANCE COMPANY <br />Insert the p olicy numbe r the rem ainder of the information is to be completed only when this endorsem en t is issued subsequent to the preparation of the policy. <br />NOTICE TO OTHERS ENDORSEMENT - SCHEDULE <br /> <br /> <br /> <br /> <br />B. The Schedule must be initially provided to us within 15 days after: <br />The beginning of the Policy period, if this endorsement is effective as of such date; or <br />This endorsement has been added to the Policy, if this endorsement is effective after the Policy period <br />commences. <br />C. This endorsement must be in an electronic format that is acceptable to us; and must be accurate. <br />Our delivery of the notification as described in Paragraph A . of this endorsement will be based on the most <br />recent Schedule in our records as of the date the notice of cancellation is mailed or delivered to the first Named <br />Insured. <br />We will endeavor to send or deliver such notice to the e-mail address or physical address corresponding to each <br />person or organization indicated in the Schedule at least 30 days prior to the cancellation date applicable to the <br />Policy. <br />The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or <br />organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal <br />obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of <br />cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of <br />any kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate <br />any cancellation of the Policy. <br />We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for <br />any incorrect information that you or your representative provide to us. If you or your representative does not <br />provide us with a Schedule, we have no responsibility for taking any action under this endorsement. In addition, <br />if neither you nor your representative provides us with e-mail and physical address information with respect to a <br />particular person or organization, then we shall have no responsibility for taking action with regard to such <br />person or entity under this endorsement. <br />We may arrange with your representative to send such notice in the event of any such cancellation. <br />You will cooperate with us in providing the Schedule, or in causing your representative to provide the Schedule <br />J. This endorsement does not apply in the event that you cancel the Policy. <br />All other terms and conditions of this Policy remain unchanged. <br /> <br />wc 99 03 70A (08/12) Page 1of <br />11-01-2021 TO 11-01-2022 11-01-2021 <br />C68929507 <br />DocuSign Envelope ID: F8EBDA2B-E1C9-4C03-80ED-E37FE36A5811