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TRAVELERS, WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 99 06 R3 (00) - oo3 POLICY NUMBER: vs-IN45405E-20-14-G NOTICE OF CANCELLATION TO DESIGNATED PERSONS OR ORGANIZATIONS The following is added to PART SIX — CONDITIONS: Notice Of Cancellation To Designated Persons Or Organizations If we cancel this policy for any reason other than non-payment of premium by you, we will provide notice of such cancellation to each person or organization designated in the Schedule below. We will mail or deliver such notice to each person or organization at its listed address at least the number of days shown for that person or organiza- tion before the cancellation is to take effect. You are responsible for providing us with the information necessary to accurately complete the Schedule below. If we cannot mail or deliver a notice of cancellation to a designated person or organization because the name or address of such designated person or organization provided to us is not accurate or complete, we have no responsibility to mail, deliver or otherwise notify such designated person or organization of the cancellation. SCHEDULE Name and Address of Designated Persons or Organizations: CITY OF SANTA ANA ATTN: RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLAZA SANTA ANA CA 92702 All other terms and conditions of this policy remain unchanged. Number of Days Notice 30 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Insured Insurance Company DATE OF ISSUE: 06-30-20 Policy No. ST ASSIGN: a02013 The Travelers Indemnity Company. All rights reserved. Countersigned by Endorsement No. Premium I RimeMwagmientDMsian REVIEWED&APPROVED BY: '� Risk Management Analyst