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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 99 04 28 00 - 001 PREMIUM MANUALS AND DUE DATE ENDORSEMENT <br /> WC 99 06 36 B - 001 CANCELLATION AMENDMENT - WASHINGTON <br /> WC 99 06 F4 00 - 001 MANAGED CARE PROGRAM ENDORSEMENT <br /> WC 99 06 K2 A - 001 WEST VIRGINIA EMPLOYERS LIABILITY ENDST <br /> WC 99 06 R3 00 - 002 NOTICE OF CAN TO DESIGN PERSONS OR ORGAN <br /> WC 99 06 R3 00 - 003 NOTICE OF CAN TO DESIGN PERSONS OR ORGAN <br /> WC 99 06 R3 00 - 004 NOTICE OF CAN TO DESIGN PERSONS OR ORGAN <br /> WC 99 06 R3 00 - 006 NOTICE OF CAN TO DESIGN PERSONS OR ORGAN <br /> WC 99 06 R3 00 - 006 NOTICE OF CAN TO DESIGN PERSONS OR ORGAN <br /> WC 99 06 R3 00 - 009 NOTICE OF CAN TO DESIGN PERSONS OR ORGAN <br /> WC 99 06 R3 00 - 011 NOTICE OF CAN TO DESIGN PERSONS OR ORGAN <br /> WC 99 06 R3 00 - 012 NOTICE OF CAN TO DESIGN PERSONS OR ORGAN <br /> WC 99 06 R3 00 - 013 NOTICE OF CAN TO DESIGN PERSONS OR ORGAN <br /> WC 99 06 R3 00 - 014 NOTICE OF CAN TO DESIGN PERSONS OR ORGAN <br /> WC 99 06 R3 00 - 015 NOTICE OF CAN TO DESIGN PERSONS OR ORGAN <br /> WC 99 06 R3 00 - 016 NOTICE OF CAN TO DESIGN PERSONS OR ORGAN <br /> WC 00 04 21 E - 001 CATASTROPHE (O/T CERT ACTS OF TERR) ENDT <br /> WC 00 04 21 F - 001 CATASTROPHE (0/T CERT ACTS OF TERR) ENDT <br /> WC 99 04 08 00 - 001 PREMIUM DISCOUNT ENDORSEMENT <br /> WC 99 04 10 00 - 001 PREMIUM ADJ. FROM EFFECTIVE DATE ENDT. <br /> WC 99 01 19 C - 001 TRIPRA DISCLOSURE ENDORSEMENT <br /> WC 00 03 02 00 - 001 DESIGNATED WORKPLACES EXCLUSION <br /> WC 00 04 19 00 - 001 PREMIUM DUE DATE ENDORSEMENT <br /> WC 09 04 09 00 - 001 FLORIDA PREMIUM DUE DATE ENDORSEMENT <br /> WC 02 04 01 C - 001 AZ ALCOHOL & DRUG FREE WK PLACE PREM END <br /> WC 02 06 01 C - 001 AZ CANCELLATION AND NONRENEWAL ENDT <br /> WC 02 06 03 A - 001 AZ AMENDATORY ENDORSEMENT <br /> WC 03 06 01 B - 001 AR AMENDATORY ENDT <br /> WC 04 03 17 B - 001 EMPLOYEE INSD BY GENERL EMPLYER EXCLUDED <br /> WC 04 03 45 A - 001 COMPREHENSIVE PERSONAL LIAB POL EXCL <br /> WC 04 03 60 B - 001 EMPLOYERS' LIAB COV AMENDATORY ENDT-CA <br /> WC 04 04 01 A - 001 RATING EFFECTIVE DATE ENDORSEMENT <br /> WC 04 04 21 00 - 001 OPTIONAL PREMIUM INCREASE ENDORSEMENT - CALIFORNIA <br /> DATE OF ISSUE: 10-18-24 ST ASSIGN: Page 2 of 6 <br />