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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 37 06 04 00 - 001 PA EMPLOYER ASSESSMENT ENDORSEMENT <br /> WC 38 04 01 B - 001 RI SHORT RATE CANCELLATION ENDORSEMENT <br /> WC 38 06 01 00 - 001 RHODE ISLAND DIRECT LIABILITY STATUTE <br /> WC 38 06 02 00 - 001 RI SAFETY INSPECTION ENDT <br /> WC 39 06 01 00 - 001 SC CANCELLATION AND NONRENEWAL ENDT <br /> WC 42 03 01 L - 001 TEXAS AMENDATORY ENDORSEMENT <br /> WC 42 03 04 B - 001 TX WAIVER OF OUR RIGHT TO RECOVER <br /> WC 43 03 05 00 - 001 UTAH WAIVER OF SUBROGATION ENDORSEMENT <br /> WC 43 06 01 00 - 001 UT WORKPLACE SAFETY PROG ENDT <br /> WC 43 06 02 00 - 001 UTAH CANCELLATION ENDORSEMENT <br /> WC 44 06 01 00 - 001 VERMONT LAW ENDORSEMENT <br /> WC 44 06 02 C - 001 VT CANCELLATION AND NONRENEWAL ENDT <br /> WC 45 06 02 00 - 001 VA AMENDATORY ENDT <br /> WC 47 06 01 00 - 001 WEST VIRGINIA CANCELLATION ENDORSEMENT <br /> WC 48 06 01 C - 001 WISCONSIN LAW ENDORSEMENT <br /> WC 48 06 06 B - 001 WISCONSIN CANCELLATION AND NON RENEWAL <br /> WC 52 06 02 15 - 001 HAWAII NOTIFICATION ENDORSEMENT <br /> WC 54 06 01 A - 001 AK NOTICE OF INSTALLMENT OPTION ENDT <br /> WC 54 06 02 00 - 001 ALASKA CANCELATION AND NONRENEWAL ENDT <br /> WC 99 03 J9 00 - 001 KS WAIVER OF OUR RIGHT TO RECOVER <br /> WC 99 06 46 00 - 001 ILLINOIS AMENDATORY ENDORSEMENT <br /> WC 99 06 P5 00 - 001 WC AND EMPL LIAB INFO PAGE-OK AMEND ENDT <br /> WC 99 06 S1 00 - 001 AK NOTICE OF CAN TO DESIGN PERSON OR ORG <br /> WC 99 06 S1 00 - 002 AK NOTICE OF CAN TO DESIGN PERSON OR ORG <br /> WC 99 06 S1 00 - 003 AK NOTICE OF CAN TO DESIGN PERSON OR ORG <br /> WC 99 06 S1 00 - 004 AK NOTICE OF CAN TO DESIGN PERSON OR ORG <br /> WC 99 06 S1 00 - 005 AK NOTICE OF CAN TO DESIGN PERSON OR ORG <br /> WC 99 06 S1 00 - 005 AK NOTICE OF CAN TO DESIGN PERSON OR ORG <br /> WC 99 06 S1 00 - 006 AK NOTICE OF CAN TO DESIGN PERSON OR ORG <br /> WC 99 06 S1 00 - 006 AK NOTICE OF CAN TO DESIGN PERSON OR ORG <br /> WC 99 06 S1 00 - 007 AK NOTICE OF CAN TO DESIGN PERSON OR ORG <br /> WC 99 06 S1 00 - 007 AK NOTICE OF CAN TO DESIGN PERSON OR ORG <br /> WC 99 06 S1 00 - 008 AK NOTICE OF CAN TO DESIGN PERSON OR ORG <br /> DATE OF ISSUE: 10-18-24 ST ASSIGN: Page 5 of 6 <br />