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39 <br /> Workers' Compensation and Employers' Liability Policy <br /> Named Insured Endorsement Number <br /> VCO PARENT, LLC <br /> 5501 VIRGINIA WAY Policy Number <br /> SUITE 120 Symbol: RWC Number: (25)7183-47-94 <br /> Policy Period Effective Date of Endorsement <br /> 09-15-2024 TO 09-15-2025 09-15-2024 <br /> Issued By(Name of Insurance Company) <br /> ACE AMERICAN INSURANCE COMPANY <br /> Insert the policy number.The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. <br /> This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br /> POLICY INFORMATION PAGE ENDORSEMENT <br /> The following item(s) <br /> 1. ❑ insured's Name 11. ❑ Item 3.13. Limits <br /> 2. ❑ Policy Number 12. ❑ Item 3.C. States <br /> 3. ❑ Effective Date 13. ❑X Item 3.D. Endorsement Numbers <br /> 4. ❑ Expiration Date 14. ❑ Item 4. *Class, Rate, Other <br /> 5. ❑ insured's Mailing Address 15. ❑ Interim Adjustment of Premium <br /> 6. ❑ Experience Modification 16. ❑ Carrier Servicing Office <br /> 7. ❑ Producer's Name 17. ❑ Interstate/Intrastate Risk ID Number <br /> 8. ❑ Change in Workplace(s) of Insured 18. ❑ Carrier Number <br /> 9. ❑ insured's Legal Status 19. ❑ Issuing Agency/Producer Office Address <br /> 10. ❑ Item 3.A. States <br /> is changed to read: <br /> THE FOLLOWING ENDORSEMENT (S) HAVE BEEN ADDED/REVISED TO THE POLICY: <br /> WC 000301A ALTERNATE EMPLOYER ENDORSEMENT <br /> THE FOLLOWING ENDORSEMENT (S) HAVE BEEN DELETED FROM THE POLICY: <br /> WC 190602 MD MARYLAND NOTIFICATION OF 45—DAY UNDERWRITING PERIOD <br /> ENDORSEMENT <br /> Authorized Representative <br /> WC 99 06 0013(08/14) ©Includes copyright material of the National Council on Compensation CKE-1 U76A <br /> Insurance, Inc. used with its permission. Page 1 of 1 <br /> 09-27-2024 NAS <br /> UNDERWRITER COPY <br />