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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY U-WC-100-A CW (10i15) <br />NOTIFICATION TO OTHERS OF CANCELLATION ENDORSEMENT <br />This endorsement is used to add the following to Part Six of the policy. <br />PART SIX — CONDITIONS <br />F. Notification To Others Of Cancellation <br />1. If we cancel this policy by written notice to you for any reason other than nonpayment of premium, we will <br />deliver electronic notification to each person or organization shown in a Schedule provided to us by you. <br />Such Schedule: <br />a. Must be initially provided to us within 15 days: <br />After the beginning of the policy period shown in the Declarations; or <br />After this endorsement has been added to policy; <br />b. Must contain the names and e-mail addresses of only the persons or organizations requiring <br />notification that this policy has been cancelled; <br />c. Must be in an electronic format that is acceptable to us; and <br />d. Must be accurate. <br />Such Schedule may be updated and provided to us by you during the policy period. Such updated <br />Schedule must comply with Paragraphs b. c. and d. above. <br />2. Our delivery of the electronic notification as described in Paragraph 1. of this endorsement will be based <br />on the most recent Schedule in our records as of the date the notice of cancellation is mailed or delivered <br />to you. Delivery of the notification as described in Paragraph 1. of this endorsement will be completed as <br />soon as practicable after the effective date of cancellation to you. <br />3. Proof of e-mailing the electronic notification will be sufficient proof that we have complied with Paragraphs <br />1, and 2. of this endorsement. <br />4. Our delivery of electronic notification described in Paragraphs 1. and 2. of this endorsement is intended <br />as a courtesy only. Our failure to provide such delivery of electronic notification will not: <br />a. Extend the policy cancellation date; <br />b. Negate the cancellation; or <br />c. Provide any additional insurance that would not have been provided in the absence of this <br />endorsement. <br />5. We are not responsible for the accuracy, integrity, timeliness and validity of information contained in the <br />Schedule provided to us as described in Paragraphs 1. and 2. of this endorsement. <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 08/28/2017 Policy No. W0014633001 <br />Insured Dudek <br />Insurance Company Zurich America Insurance Company <br />Endorsement No. ,p..f. <br />Premium $ <br />AV <br />G P1 <br />Q1?. <br />U-WC100-A CW (10116) <br />Includes copyrighted material of National Council on Compensation Insurance, Inc. used with Its permission. INTERNAL USE ONLY <br />