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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />Form WC 99 03 02 B Printed in U.S.A. (Ed. 8/00) Page 1 of 4 <br />© 2000, The Hartford <br />WORKERS’ COMPENSATION BROAD FORM ENDORSEMENT <br />Endorsement Number:Policy Number: 22 WEC BA1Z1S <br />Effective Date: 09/01/23 Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address: AOA SIGNS INC <br />214 E CHERRY ST <br />YADKINVILLE NC 27055 <br />Section I of this endorsement expands coverage provided under WC 00 00 00. <br />Section II of this endorsement provides additional coverage usually only provided by endorsement. <br />Section III of this endorsement is a Schedule of Covered States. <br />You may use the index to locate these coverage features quickly: <br />INDEX <br />SUBJECT PAGE <br />SECTION I 2 <br />PARTS ONE and TWO 2 <br />01 We Will Also Pay 2 <br />PART - THREE 2 <br />02 How This Insurance Works 2 <br />PART - SIX 2 <br />03 Transfer of Your Rights and Duties 2 <br />04 Liberalization 2 <br />SECTION II 2 <br />VOLUNTARY COMPENSATION INSURANCE 2 <br />05 Voluntary Compensation Insurance 2 <br />A. How This Insurance Applies 2 <br />B. We will Pay 3 <br />C. Exclusions 3 <br />D. Before We Pay 3 <br />E. Recovery From Others 3 <br />F. Employers’ Liability Insurance 3 <br />EMPLOYERS’ LIABILITY STOP GAP COVERAGE 3 <br />06 Employers’ Liability Stop Gap Coverage 3 <br />A. Stop Gap Coverage Limited Montana, North Dakota, Ohio, Washington, West <br />Virginia and Wyoming <br />3 <br />B. Part One does not Apply 3 <br />C. Application of Coverage 3 <br />D. Additional Exclusions 3 <br />E. West Virginia 3 <br />SECTION III 4 <br />07 Schedule of Covered States 4 <br />DocuSign Envelope ID: 17579A7B-89F6-45AA-B34D-9D6BDE022562