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Workers Compensation And Employers Liability Insurance <br />Policyholder Notice <br />NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS <br />It is understood and agreed that: <br />If you have agreed under written contract to provide notice of cancellation to a party to whom the Agent of <br />Record has issued a Certificate of Insurance, and if we cancel a policy term described on that Certificate of <br />Insurance for any reason other than nonpayment of premium, then notice of cancellation will be provided to <br />such Certificate Holders at least 30 days in advance of the date cancellation is effective. <br />If notice is mailed, then proof of mailing to the last known mailing address of the Certificate Holder on file with <br />the Agent of Record will be sufficient to prove notice. <br />Any failure by us to notify such persons or organizations will not extend or invalidate such cancellation, or <br />impose any liability or obligation upon us or the Agent of Record. <br />All other terms and conditions of the policy remain unchanged. <br />This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, <br />takes effect on the Policy Effective Date of said policy at the hour stated in said policy, unless another <br />effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy <br />unless another expiration date is shown below. <br />Form No:Policy No: <br />Policy Effective Date: <br />Underwriting Company: <br />WC 7 18235090 <br />Policyholder Notice; Page: 1 of 1 <br />National Fire Insurance Company of Hartford, 151 N Franklin St, Chicago, IL <br />60606 <br />CC68021A (02-2013) <br />03/01/2023 <br />Policy Page: 7 of 62 <br />© Copyright CNA All Rights Reserved. <br />DocuSign Envelope ID: 797C32F6-C1CE-44EB-BF17-813A5939396C