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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 99 06 62 <br />NOTICE OF CANCEUATION OR NON-RENEWAL TO SPECIFIED PERSONS OR ORGANIZATIONS <br />it <br />This <br />Policy No. <br />(DATE) <br />at 12:01 A.M. standard time, forms a part of <br />FEDERAL INSURANCE COMPANY <br />{NAME OF INSURANCE COMPANY) <br />PART SIX - CONDITIONS: <br />Notice Of Cancellation Or Non-Renewal To Specified Persons Or Organizations <br />1. will <br />-any Person(s)or Orgt()w Sul THIRTY (30) days p to <br />e ffctv de of canellato -l. <br />2.If w c picy pm,will <br />o TEN (1O) ff <br />cancellation. <br />o will ff <br />Any y )(will v c -n w <br />p o )or o g iz i (). <br />SCHEDULE <br />Name(s) and Address(es): <br />ALL PERSONS OR ORGANIZATIONS AS ON FILE WITH US <br />WC99 06 62 (Ed. 01-16) Page 1 of 1 <br />NODCDNCSTTTDC-ONSTRU-T:ON <br />TNCCUT:D:TYUAC:N-N <br />-EWEWEWCITIUNSTONCTVDNUD <br />STNCITIRTN-:S-OUAC-TCSF-EWEW <br />IFSEWEF-EW <br />03/14/2023 <br />NODCDNCSTTTDC-ONSTRU-T:ONCTNCCUT:D:TYUAC:N-N <br />POD:-YCNONOCIFSEWEF-EW <br />DocuSign Envelope ID: A5FFE04F-8470-4F98-AA51-99352A4A6BA6