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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 99 05 57 <br />ENDORSEMENT <br />This endorsement, effective 12:01 a.m. 11-01-2020 forms a part of <br />Policy No. RWD3001203-04 issued to ALLIED UNIVERSAL TOPCO, LLC <br />by XL Insurance America, Inc. <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />.+7_1:C13fiA7 iI Li5if3Cr7_�iL�7 i�a=i5i.l�[b7:1Ta7:�9�1T1 ii <br />This endorsement modifies insurance provided under the following: <br />iri*Le77.t� �9iIKeP�»�6Ya'tiCePlni7��17Si]'���➢�/_1=If�Yi71�Y�T:7:1rCy�li7�C�1 <br />12110 <br />In the event coverage is cancelled for any statutorily permitted reason, other than nonpayment of premium, <br />advanced written notice will be mailed or delivered to person(s) or entity(ies) according to the notification <br />schedule shown below: <br />Number of Days <br />Name of Person(s) or Entity(ies) <br />Mailing Address: <br />Advanced <br />Notice of <br />Cancellation: <br />Per the most cuffent schedule maintained by <br />30 <br />Marsh USA, Inc. and furnished to AXA XL no <br />less than 45 days prior to the effective date <br />of the cancellation. <br />All other terms and conditions of the Policy remain unchanged. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless <br />otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to <br />preparation of the policy.) <br />Endorsement Effective 11-01-2020 Policy No. RWD3001203-04 Endorsement No. <br />Insured ALLIED UNIVERSAL TOPCO, LLC <br />Insurance Company XL Insurance America, Inc. Countersigned by <br />WC 99 06 57 <br />Ed. 12110 © 2010 X.L. America, Inc. All Rights Reserved. <br />May not be copied without permission. <br />Premium $ Included <br />Rime Management D ivision <br />REVIEWED & APPROVED BYE: <br />�� Risk Management Analyst <br />