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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 20 06 01 A - 001 MA CANCELLATION ENDORSEMENT <br /> WC 21 03 03 A - 001 MICHIGAN NOTICE TO POLICYHOLDERS <br /> WC 21 03 04 00 - 001 MICHIGAN LAW ENDORSEMENT <br /> WC 22 00 00 A - 001 MN AMENDATORY ENDT <br /> WC 22 03 01 00 - 001 MN COMPLIANCE WITH APPLICABLE TRADE LAW <br /> WC 22 06 01 D - 001 MINNESOTA CANC AND NON RENEWAL ENDT <br /> WC 23 06 01 00 - 001 MS CANC NONRENEWAL AND RENEWAL ENDT <br /> WC 24 03 02 00 - 001 MO NOTIFIC OF ADD MESOTHELIOMA BEN ENDT <br /> WC 24 06 01 B - 001 MO CANCELATION AND NON-RENEWAL ENDT. <br /> WC 24 06 02 B - 001 MO PROPERTY & CASUALTY GUARANTY ASSOC. <br /> WC 24 06 04 C - 001 MISSOURI AMENDATORY ENDORSEMENT <br /> WC 25 03 05 00 - 001 MT INTENTIONAL INJURY EXCLUSION <br /> WC 25 06 01 B - 001 MONTANA AMENDATORY ENDORSEMENT <br /> WC 25 06 02 00 - 001 MONTANA SAFETY ENDORSEMENT <br /> WC 26 04 03 00 - 001 NE EXP RATING MOD FACTOR REV ENDT <br /> WC 26 06 01 C - 001 NE CANCELATION ENDT <br /> WC 27 06 01 C - 001 NV CANCELLATION AND NON RENEWAL ENDT <br /> WC 29 03 06 B - 001 NJ PART TWO EMPLOYERS LIABILITY ENDT. <br /> WC 29 04 10 00 - 001 NJ CONSTRUCTION CLASSIFICATION ENDT. <br /> WC 30 03 01 00 - 001 NM SAFETY DEVICE COVERAGE ENDORSEMENT <br /> WC 30 04 01 A - 001 NM WC PREM ADJ PROGRAM <br /> WC 30 06 01 A - 001 NM CANCELLATION AND NONRENEWAL END <br /> WC 31 03 08 00 - 001 NEW YORK LIMIT OF LIABILITY ENDORSEMENT <br /> WC 31 03 19 N - 001 NY CONST CLASS PREM ADJUST PROG <br /> WC 31 04 05 A - 001 NY SAFE PTNT HNDLG ACT PRGM ENDT FLAT CR <br /> WC 31 06 18 A - 001 NEW YORK NOTICE OF RIGHT TO APPEAL <br /> WC 35 06 01 F - 001 OK CAN, NONRENEWAL AND CHANGE ENDT <br /> WC 35 06 03 00 - 001 OK FRAUD WARNING ENDT <br /> WC 36 06 01 E - 001 OR CANCELLATION ENDORSEMENT <br /> WC 37 04 05 00 - 001 PA MERIT RATING PLAN ENDT <br /> WC 37 06 01 00 - 001 SPECIAL PA ENDT - INSPECTION OF MANUALS <br /> WC 37 06 02 00 - 001 NOTICE INS CONSULTATION SERVICE EXEMPT. <br /> WC 37 06 03 A - 001 PA ACT 86-1986 ENDORSEMENT <br /> DATE OF ISSUE: 10-18-24 ST ASSIGN: Page 4 of 6 <br />