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Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00)Page 3 of 6 <br />officer’s or employee’s employment.The <br />officer’s or employee’s last day of last <br />exposure to the conditions causing or <br />aggravating such bodily injury by disease <br />must occur during the policy period. <br />B.We Will Pay <br />We will pay an amount equal to the benefits <br />that would be required of you as if you and <br />your employees were subject to the workers’ <br />compensation law of any state shown in Item <br />3.A.of the Information Page.We will pay <br />those amounts to the persons who would be <br />entitled to them under the law. <br />C.Exclusion <br />This insurance does not cover: <br />1.any obligation imposed by workers’ <br />compensation or occupational disease <br />law or any similar law. <br />2.bodily injury intentionally caused or <br />aggravated by you. <br />3.officers or employees who have elected <br />not to be subject to the state workers’ <br />compensation law. <br />4.partners or sole proprietors not covered <br />under the Standard Sole Proprietors, <br />Partners,Officers and Others Coverage <br />Endorsement. <br />D.Before We Pay <br />Before we pay benefits to the persons <br />entitled to them, they must: <br />1.Release you and us,in writing,of all <br />responsibility for the injury or death. <br />2.Transfer to us their right to recover from <br />others who may be responsible for the <br />injury or death. <br />3.Cooperate with us and do everything <br />necessary to enable us to enforce the <br />right to recover from others. <br />If the persons entitled to the benefits of this <br />insurance fail to do those things,our duty to <br />pay ends at once.If they claim damages <br />from you or from us for the injury or death, <br />our duty to pay ends at once. <br />E.Recovery From Others <br />If we make a recovery from others,we will <br />keep an amount equal to our expenses of <br />recovery and the benefits we paid.We will <br />pay the balance to the persons entitled to it. <br />If the persons entitled to the benefits of this <br />insurance make a recovery from others,they <br />must reimburse us for the benefits we paid them. <br />F.Employers’ Liability Insurance <br />Part Two (Employers’Liability Insurance)applies <br />to bodily injury covered by this endorsement as <br />though the State of Employment was shown in <br />Item 3.A. of the Information Page. <br />This provision 5.does not apply in New Jersey or <br />Wisconsin. <br />EMPLOYERS’ LIABILITY STOP GAP COVERAGE <br />6.Employers’ Liability Stop Gap Coverage <br />A.This coverage only applies in Montana,North <br />Dakota,Ohio,Washington,West Virginia and <br />Wyoming. <br />B.Part One (Workers’Compensation Insurance) <br />does not apply to work in states shown in <br />Paragraph A above. <br />C.Part Two (Employers’Liability Insurance)applies <br />in the states,shown in Paragraph A.,as though <br />they were shown in Item 3.A.of the Information <br />Page. <br />D.Part Two,Section C.Exclusions is changed by <br />adding these exclusions. <br />This insurance does not cover; <br />5.bodily injury intentionally caused or <br />aggravated by you or in Ohio bodily injury <br />resulting from an act which is determined by <br />an Ohio court of law to have been committed <br />by you with the belief than an injury is <br />substantially certain to occur.However,the <br />cost of defending such claims or suits in Ohio <br />is covered. <br />13.bodily injury sustained by any member of the <br />flying crew of any aircraft. <br />14.any claim for bodily injury with respect to <br />which you are deprived of any defense or <br />defenses or are otherwise subject to penalty <br />because of default in premium under the <br />provisions of the workers’compensation law <br />or laws of a state shown in Paragraph A. <br />E.This insurance applies to damages for which you <br />are liable under West Virginia Code Annot.S 23- <br />4-2. <br />DocuSign Envelope ID: 27E79A54-51B9-4F19-98C5-1BA1910A416B