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WC 99 06 43 Page 1 of 1 <br />(Ed. 01-13) Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission. <br /> 2012 Copyright National Council on Compensation Insurance, Inc. All Rights Reserved. <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 43 <br />BLANKET NOTIFICATION TO OTHERS OF CANCELLATION OR NONRENEWAL ENDORSEMENT <br />This endorsement adds the following to Part Six of the policy. <br />PART SIX <br />CONDITIONS <br />Blanket Notification to Others of Cancellation or Nonrenewal <br />1. If we cancel or non-renew this policy by written notice to you, we will mail or deliver notification that such <br />policy has been cancelled or non-renewed to each person or organization shown in a list provided to us by <br />you if you are required by written contract or written agreement to provide such notification. However, such <br />notification will not be mailed or delivered if a conditional notice of renewal has been sent to you. Such list: <br />a. Must be provided to us prior to cancellation or non-renewal; <br />b. Must contain the names and addresses of only the persons or organizations requiring notification that <br />such policy has been cancelled or non-renewed; and <br />c. Must be in an electronic format that is acceptable to us. <br />2. Our notification as described in Paragraph 1. above will be based on the most recent list in our records as of <br />the date the notice of cancellation or non-renewal is mailed or delivered to you. We will mail or deliver such <br />notification to each person or organization shown in the list: <br />a. Within seven days of the effective date of the notice of cancellation, if we cancel for non-payment of <br />premium; or <br />b. At least 30 days prior to the effective date of: <br />(1) Cancellation, if cancelled for any reason other than nonpayment of premium; or <br />(2) Non-renewal, but not including conditional notice of renewal. <br />3. Our mailing or delivery of notification described in Paragraphs 1. and 2. above is intended as a courtesy only. <br />Our failure to provide such mailing or delivery will not: <br />a. Extend the policy cancellation or non-renewal date; <br />b. Negate the cancellation or non-renewal; or <br />c. Provide any additional insurance that would not have been provided in the absence of this endorsement. <br />4. We are not responsible for the accuracy, integrity, timeliness and validity of information contained in the list <br />provided to us as described in Paragraphs 1. and 2. above. <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 stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement Effective Policy No. Endorsement No. <br />Insured Premium $ <br />Insurance Company <br />POLICY NUMBER: WC 2540616-05 <br />DocuSign Envelope ID: 617B9B2E-5FA3-4D49-A8B0-1A794D1CD9A7