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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 )718347-94 <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 . 6 . 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 OOB (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 />