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WORKERS COMPENSATION AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 06 R3 <br />POLICY NUMBER: <br />UB-1T885681 (AZ, MA, WI), UB-1T88663A (AOS) <br />NOTICE OF CANCELLATION <br />TO DESIGNATED PERSONS OR ORGANIZATIONS <br />The following is added to PART SIX - CONDITIONS: <br />Notice of Cancellation to Designated Persons or Organizations <br />If we cancel this policy for any reason other than non-payment of premium by you, we will provide notice of such <br />cancellation to each person or organization designated in the Schedule below. We will mail or deliver such notice <br />to each person or organization at its listed address in at least the number of days shown for that person or <br />organization before the cancellation is to take effect. <br />You are responsible for providing us with the information necessary to accurately complete the Schedule below. If <br />we cannot mail or deliver a notice of cancellation to a designated person or organization because the name or <br />address of such designated person or organization provided to us is not accurate or complete, we have no <br />responsibility to mail, deliver or otherwise notify such designated person or organization of the cancellation. <br />SCHEDULE <br />Name and Address of Designated Persons or Organizations: <br />ANY PERSON OR ORGANIZATION FOR WHOM YOU HAVE AGREED IN A WRITTEN CONTRACT THAT <br />NOTICE OF CANCELLATION, OF THIS POLICY WILL BE GIVEN, BUT ONLY IF: <br />1. YOU SEE TO IT THAT WE RECEIVE A WRITTEN REQUEST TO PROVIDE SUCH NOTICE, INCLUDING <br />THE NAME AND ADDRESS OF SUCH PERSON OR ORGANIZATION, AFTER THE FIRST NAMED <br />INSURED RECEIVES NOTICE FROM US OF THE CANCELLATION OR MATERIAL LIMITATION OF THIS <br />POLICY; AND <br />2. WE RECEIVE SUCH WRITTEN REQUEST AT LEAST 14 DAYS BEFORE THE BEGINNING OF THE <br />APPLICABLE NUMBER OF DAYS SHOWN IN THIS ENDORSEMENT. <br />THE ADDRESS FOR THAT PERSON OR ORGANIZATION INCLUDED IN SUCH WRITTEN REQUEST <br />FROM YOU TO US <br />Number of Days' Notice <br />30 <br />All other terms and conditions of this policy remain unchanged. <br />Miscellaneous Attachment: M463692 Certificate ID: 22534362 <br />Docusign Envelope ID: 2ECC4EBC-6A30-4243-9E7F-16636E4F3E4BDocusign Envelope ID: 752D86D7-DF31-404C-B79C-D4F81DF70B21