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Docusign Envelope ID: B576D624-E16E-4D9F-BC67-5703DE54A6F8 <br /> RAVELERS WORKERS COMPENSATION <br /> AND <br /> ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br /> HARTFORD CT 06183 <br /> ENDORSEMENT WC 00 00 01 (A ) <br /> POLICY NUMBER: UB-3R328606-24-I3-G <br /> LISTING OF ENDORSEMENTS <br /> EXTENSION OF INFO PAGE <br /> We agree that the following listed endorsements form a part of this policy on its effective date. <br /> WC 00 00 01 A - 001 INFORMATION PAGE <br /> WC 00 00 01 A - 001 INFORMATION PAGE 2 <br /> WC 00 00 01 A - 001 EXTENSION OF INFORMATION PAGE - SCHEDULE <br /> WC 00 00 01 A - 001 ENDORSEMENT LISTING <br /> WC 54 03 01 00 - 001 ALASKA LIMIT OF LIABILITY ENDT <br /> WC 09 06 07 A - 001 FL WC INS GUARANTY ASSOC SURCH NOTIFIC <br /> WC 24 04 06 D - 001 MISSOURI EMPLOYER PAID MEDICAL ENDT <br /> WC 36 03 06 00 - 001 OREGON LIMITS OF LIABILITY <br /> WC 36 06 02 00 - 001 OREGON CONFIDENTIALITY ENDORSEMENT <br /> WC 36 06 04 00 - 001 OREGON AMENDATORY ENDORSEMENT <br /> WC 99 06 U5 00 - 001 OHIO CANCELLATION AND NONRENEWAL ENDT <br /> WC 00 03 03 C - 001 EMPLOYERS LIAB COVERAGE ENDT <br /> WC 00 03 13 00 - 001 WAIVER OF OUR RIGHT TO RECOVER <br /> WC 00 04 03 00 - 001 EXPERIENCE RATING MODIFICATION FACTOR <br /> WC 00 04 04 00 - 001 PENDING RATE CHANGE ENDORSEMENT <br /> WC 00 04 06 00 - 001 PREMIUM DISCOUNT ENDORSEMENT <br /> WC 00 04 06 A - 001 PREMIUM DISCOUNT ENDORSEMENT <br /> WC 00 04 14 00 - 001 NOTIFICATION OF CHANGE IN OWNERSHIP ENDT <br /> WC 00 04 14 A - 001 NOTIFICATION OF CHG IN OWNR ENDT <br /> WC 00 04 22 C - 001 TERRORISM RISK INS PROG REAUTH ACT ENDT <br /> WC 00 04 24 00 - 001 AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT <br /> WC 00 04 25 00 - 001 EXPER RATING MOD FACTOR REVISION ENDT <br /> WC 04 03 01 B - 001 POLICY AMENDATORY ENDORSEMENT-CALIFORNIA <br /> WC 09 04 03 C - 001 FL TRIPRA ENDORSEMENT <br /> WC 32 03 01 D - 001 NORTH CAROLINA AMENDED COVERAGE ENDT <br /> WC 35 03 03 00 - 001 OK EMP LIAB INTENTIONAL TORT EXCL ENDT <br /> WC 99 03 76 A - 001 WAIVER OF OUR RIGHTS TO RECOVER-CA <br /> WC 99 03 99 00 - 001 CA WORKERS' COMP NOTICE OF NON-RENEWAL <br /> WC 99 03 Al 00 - 001 NOTICE OF CANCELATION <br /> WC 99 03 C3 00 - 001 SPECIAL PROVISIONS ENDT <br /> WC 99 03 D3 A - 001 OHIO EMPLOYERS LIAB COVERAGE ENDT <br /> WC 99 03 D4 A - 001 PUERTO RICO EMPLOYERS LIAB COV ENDT <br /> WC 99 03 F3 00 - 001 CA LIMITS OF LIABILITY ENDT <br /> DATE OF ISSUE: 10-18-24 ST ASSIGN: Page 1 of 6 <br />