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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 04 04 22 00 - 001 CALIFORNIA SHORT-RATE CANCELATION ENDT <br /> WC 04 06 01 B - 001 CA CANCELATION ENDT <br /> WC 05 04 02 00 - 001 COLORADO CLASSIFICATION ENDORSEMENT <br /> WC 06 03 01 00 - 001 CT APPLICATION OF WORKERS COMPENSATION <br /> WC 06 03 03 C - 001 CONNECTICUT WC FUNDS ENDORSEMENT <br /> WC 06 06 01 A - 001 CT NONRENEWAL AND RENEWAL ENDT <br /> WC 07 04 08 00 - 001 DE MERIT RATING PLAN ENDORSEMENT <br /> WC 07 06 01 00 - 001 DELAWARE NONRENEWAL ENDORSEMENT <br /> WC 08 06 01 00 - 001 DISTRICT OF COLUMBIA CANCELATION ENDT. <br /> WC 09 03 03 00 - 001 FL EMPLRS LIAB COVERAGE ENDT <br /> WC 09 04 01 00 - 001 FLORIDA CONTRACTING PREM ADJUST END <br /> WC 09 04 07 A - 001 FL NON-COOPERATION WITH PREM AUDIT ENDT <br /> WC 09 06 06 00 - 001 FL EMPLOYMENT AND WAGE INFORMATION REL. <br /> WC 10 06 01 C - 001 GA CANC NONRENEWAL AND CHANGE ENDT <br /> WC 12 06 01 F - 001 IL AMENDATORY ENDT <br /> WC 12 06 03 00 - 001 ILLINOIS RENEWAL ENDORSEMENT <br /> WC 15 04 01 A - 001 KANSAS FINAL PREMIUM ENDORSEMENT <br /> WC 15 06 01 A - 001 KANSAS CANCELATION AND NONRENEWAL ENDT. <br /> WC 16 03 05 00 - 001 KY PART ONE WC INSURANCE ENDORSEMENT <br /> WC 16 06 01 00 - 001 KY CANCELATION AND NONRENEWAL ENDT. <br /> WC 16 06 02 00 - 001 KY NOTICE OF APPEAL RIGHTS ENDORSEMENT <br /> WC 17 06 01 J - 001 LOUISIANA AMENDATORY ENDORSEMENT <br /> WC 17 06 02 A - 001 LA COST CONTAINMENT ACT ENDORSEMENT <br /> WC 18 06 01 00 - 001 MAINE INSPECTION IMMUNITY ENDORSEMENT <br /> WC 18 06 03 A - 001 MAINE CANCELATION AND NONRENEWAL ENDT <br /> WC 18 06 04 00 - 001 ME FINAL PREM AUDIT ENDT <br /> WC 18 06 06 00 - 001 ME NOTICE OF FILING FIRST RPT OF INJURY <br /> WC 18 06 07 A - 001 MAINE EMPLOYMENT REHABILITATION FUND END <br /> WC 19 06 01 G - 001 MD CANCELLATION AND NONRENEWAL ENDT <br /> WC 20 03 01 00 - 001 MA LIMITS OF LIABILITY ENDORSEMENT <br /> WC 20 03 02 A - 001 MASSACHUSETTS - ASSESMENT CHARGE <br /> WC 20 03 03 D - 001 MA NOTICE TO POLICYHOLDER ENDORSEMENT <br /> WC 20 04 05 00 - 001 MASSACHUSETTS PREMIUM DUE DATE ENDT <br /> DATE OF ISSUE: 10-18-24 ST ASSIGN: Page 3 of 6 <br />