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� TRAVELERSJ WORKERS COMPENSATION <br />AND <br />ONE TOWER SQUARE HARTFORD CT 06183 <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 06 R4 (00) -007 <br />POLICY NUMBER: UB-3T085335-25-14-G <br />NOTICE OF CANCELLATION OR NONRENEWAL <br />TO DESIGNATED PERSONS OR ORGANIZATIONS <br />The following is added to PART SIX -CONDITIONS : <br />Notice Of Cancellation Or Nonrenewal To Designated Persons Or Organizations <br />If we cancel or non-renew this policy for any reason other than non-payment of premium by you, we will provide <br />notice of such cancellation or non-renewal to each person or organization designated in the Schedule below. We <br />will mail or deliver such notice to each person or organization at its listed address at least the number of days <br />shown for that person or organization before the cancellation or nonrenewal is to take effect. <br />You are responsible for providing us with the information necessary to accurately complete the Schedule below. <br />If we cannot mail or deliver a notice of cancellation or nonrenewal to a designated person or organization <br />because the name or address of such designated person or organization provided to us is not accurate or <br />complete, we have no responsibility to mail, deliver or otherwise notify such designated person or organization of <br />the cancellation or nonrenewal. <br />SCHEDULE <br />Name and Address of Designated Persons or Organizations: Number of Days Notice: <br />ANY PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION TO WHOM YOU HAVE AGREED IN A WRITTEN 30 CONTRACT THAT NOTICE OF CANCELLATION OF THIS POLICY WILL BE GIVEN, BUT ONLY IF: <br />1.YOU SEND US A WRITTEN REQUEST TO PROVIDE SUCH NOTICE,INCLUDING THE NAME AND ADDRESS OF SUCH PERSON OR ORGANIZATION,AFTER THE FIRST NAMED INSURED RECEIVES NOTICE FROM US OF THECANCELLATION OF THIS POLICY; AND <br />2.WE RECEIVE SUCH WRITTEN REQUEST AT LEAST 14 DAYS BEFORE THEBEGINNING OF THE APPLICABLE NUMBER OF DAYS SHOWN IN THIS SCHEDULE <br />ADDRESS:THE ADDRESS FOR THAT PERSON OR ORGANIZATION INCLUDED IN SUCH WRITTEN REQUEST FROM YOU TO US. <br />All other terms and conditions of this policy remain unchanged. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise <br />stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of <br />the policy.) <br />Endorsement Effective <br />Insured <br />Insurance Company <br />DATE OF ISSUE: 06-09-25 <br />Policy No. <br />Countersigned by <br />ST ASSIGN: <br />© 2013 The Travelers Indemnity Company. All rights reserved. <br />Endorsement No. <br />Premium$ <br />Page 1 ofl <br />Docusign Envelope ID: 03EC0D15-D674-4D12-9ED3-8A2C214EE218