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CALIFORNIA CANCELATION ENDORSEMENT <br />This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the <br />Information Page. <br />The cancelation condition in Part Six (Conditions) of the policy is replaced by these conditions: <br />Cancelation: <br />1.You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation is to <br />take effect. <br />2.We may cancel this policy for one or more of the following reasons: <br />a.Non-payment of premium; <br />b.Failure to report payroll; <br />c.Failure to permit us to audit payroll as required by the terms of this policy or of a previous policy issued by us; <br />d.Failure to pay any additional premium resulting from an audit of payroll required by the terms of this policy or <br />any previous policy issued by us; <br />e.Material misrepresentation made by you or your agent; <br />f.Failure to cooperate with us in the investigation of a claim; <br />g.Material failure to comply with federal or state safety orders or written recommendations of our designated <br />loss control representatives; <br />h.The occurrence of a material change in the ownership of your business; <br />i.The occurrence of any change in your business or operations that materially increases the hazard for <br />frequency or severity of loss; <br />j.The occurrence of any change in your business or operation that requires additional or different classification <br />for premium calculation; <br />k.The occurrence of any change in your business or operation which contemplates an activity excluded by our <br />reinsurance treaties. <br />3.If we cancel your policy for any of the reasons listed in (a) through (f), we will give you 10 days advance written <br />notice, stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in <br />Item 1 of the Information Page will be sufficient to prove notice. If we cancel your policy for any of the reasons <br />listed in Items (g) through (k), we will give you 30 days advance written notice; however, we agree that in the event <br />of cancelation and reissuance of a policy effective upon a material change in ownership or operations, notice will <br />not be provided. <br />4.If we mail the notice to you, the stated periods of notice and your right to remedy the condition will be extended by <br />5 days if the place of mailing and your mailing address is within California, 10 days if the place of mailing or your <br />mailing address is outside of California and 20 days if the place of mailing or your mailing address is outside of the <br />United States. <br />5.The policy period will end on the day and hour stated in the cancelation notice. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Countersigned By <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> (Ed. 01-22) <br />WC 04 06 01 B <br />(Ed. 01-22) <br />WC 04 06 01 B <br />Endorsement Effective Policy No.Endorsement No. <br />Insured <br />Insurance Company <br />Policy #WD3A42745710 <br /> <br />DocuSign Envelope ID: C10679F1-1CB4-4972-85FA-7681F5B2296F