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Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00)Page 4 of 6 <br />EXTENDED OPTIONS <br />1.Employers’ Liability Insurance <br />Item 3.B.of the Information Page is replaced by <br />the following: <br />B.Employers’ Liability Insurance: <br />1.Part Two of the policy applies to work in <br />each state listed in Item 3.A. <br />The Limits of Liability under Part Two are <br />the higher of: <br />Bodily Injury <br />by Accident $500,000 Each Accident <br />Bodily Injury <br />by Disease $500,000 Policy Limit <br />Bodily Injury <br />by Disease $500,000 Each Employee <br />OR <br />2.The amount shown in the Information <br />Page. <br />This provision 1 of EXTENDED OPTIONS does <br />not apply in New York because the Limits Of Our <br />Liability are unlimited. <br />In this provision the limits are changed from <br />$500,000 to $1,000,000 in California. <br />2.Unintentional Failure to Disclose Hazards <br />If you unintentionally should fail to disclose all <br />existing hazards at the inception date of your <br />policy,we shall not deny coverage under this <br />policy because of such failure. <br />3.Waiver of Our Right To Recover From Others <br />A.We have the right to recover our payments <br />from anyone liable for an injury covered by <br />this policy.We will not enforce our right <br />against any person or organization for whom <br />you perform work under a written contract <br />that requires you to obtain this agreement <br />from us. <br />This agreement shall not operate directly or <br />indirectly to benefit anyone not named in the <br />agreement. <br />B.This provision 3.does not apply in the states <br />of Pennsylvania and Utah. <br />4.Foreign Voluntary Compensation and Employers’ <br />Liability Reimbursement <br />A.How This Reimbursement Applies <br />This reimbursement provision applies to bodily <br />injury by accident or bodily injury by disease. <br />Bodily injury includes resulting death. <br />1.The bodily injury must be sustained by an <br />officer or employee. <br />2.The bodily injury must occur in the course of <br />employment necessary or incidental to work <br />in a country not listed in Exclusion C.1.of this <br />provision. <br />3.Bodily injury by accident must occur during <br />the policy period. <br />4.Bodily injury by disease must be caused or <br />aggravated by the conditions of your <br />employment.The officer or employee’s last <br />exposure to those conditions of your <br />employment must occur during the policy <br />period. <br />B.We Will Reimburse <br />We will reimburse you for all amounts paid by <br />you whether such amounts are: <br />1.voluntary payments for the benefits that <br />would be required of you if you and your <br />officers or employees were subject to any <br />workers’compensation law of the state of <br />hire of the individual employee. <br />2.sums to which Part Two (Employers’Liability <br />Insurance)would apply if the Country of <br />Employment were shown in Item 3.A.of the <br />Information Page. <br />C.Exclusions <br />This insurance does not cover: <br />1.any occurrences in the United States, <br />Canada,and any country or jurisdiction <br />which is the subject of trade or economic <br />sanctions imposed by the laws or regulations <br />of the United States of America in effect as of <br />the inception date of this policy. <br />2.any obligation imposed by a workers’ <br />compensation or occupational disease law, <br />or similar law. <br />3.bodily injury intentionally caused or <br />aggravated by you. <br />DocuSign Envelope ID: 27E79A54-51B9-4F19-98C5-1BA1910A416B