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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />WORKERS' COMPENSATION BROAD FORM ENDORSEMENT <br />EXTENDED OPTIONS <br />Policy Number: 72 WEC AC61_88 Endorsement Number: <br />Effective Date: 01/21/19 Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address: The Amergroup Inc <br />980 PARK CENTER DR STE J <br />VISTA CA 92081 <br />Section I of this endorsement expands coverage provided under WC 00 00 00. <br />Section II of this endorsement provides additional coverage usually only provided by endorsement. <br />Section III of this endorsement is a Schedule of Covered States. <br />You may use the index to locate these coverage features quickly: <br />SUBJECT <br />SECTION I <br />PARTS ONE and TWO <br />01 We Will Also Pay <br />PART -THREE <br />02 How This Insurance Works <br />PART - SIX <br />03 Transfer of Your Rights and Duties <br />04 Liberalization <br />SECTION II <br />VOLUNTARY COMPENSATION <br />INSURANCE <br />05 Voluntary Compensation Insurance <br />A. How This Insurance Applies <br />B. We Will Pay <br />C. Exclusions <br />D. Before We Pay <br />E. Recovery From Others <br />F. Employers' Liability Insurance <br />EMPLOYERS' LIABILITY STOP GAP <br />ENDORSEMENT <br />06 Employers' Liability Stop Gap <br />Coverage <br />A. Stop Gap Coverage Limited to <br />Montana, North Dakota, Ohio, <br />Washington, West Virginia and <br />Wyoming <br />Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) <br />Process Date: 01/22/19 <br />INDEX <br />PAGE <br />2 <br />2 <br />2 <br />2 <br />2 <br />2 <br />2 <br />2 <br />2 <br />2 <br />2 <br />2 <br />3 <br />3 <br />3 <br />3 <br />3 <br />3 <br />3 <br />3 <br />SUBJECT <br />B. Part One Does Not Apply <br />C. Application of Coverage <br />D. Additional Exclusions <br />E. West Virginia <br />EXTENDED OPTIONS <br />01 Employers' Liability Insurance <br />02 Unintentional Failure to Disclose <br />Hazards <br />03 Waiver of Our Right to Recover from <br />Others <br />04 Foreign Voluntary Compensation <br />A. How This Reimbursement Applies <br />B. We Will Reimburse <br />C. Exclusions <br />D. Before We Pay <br />E. Recovery From Others <br />F. Reimbursement For Actual Loss <br />Sustained <br />G. Repatriation <br />H. Endemic Disease <br />05 Longshore and Harbor Workers' <br />Compensation Act Coverage <br />Endorsement <br />SECTION III <br />01 Schedule of Covered States <br />REVIEWED & APPROVEb <br />By Risk MANAGEMENT DiViSiON <br />PAGE <br />3 <br />3 <br />3 <br />3 <br />4 <br />4 <br />4 <br />4 <br />4 <br />4 <br />4 <br />4 <br />5 <br />5 <br />5 <br />Tkn�Page 1 of 6 <br />FRANCI r ate:01/21/20 <br />© 2000, The Hartford <br />Yt),,--U <br />