Laserfiche WebLink
WORKERS COMPENSATION <br />TRAVELERS AND <br />ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD CT 06183 ENDORSEMENT WC 99 06 R3 (00) - 004 <br />POLICY NUMBER: UB-5J743745-20-47-G <br />NOTICE OF CANCELLATION <br />TO DESIGNATED PERSONS OR ORGANIZATIONS <br />The following is added to PART SIX — CONDITIONS: <br />Notice Of Cancellation To Designated Persons Or Organizations <br />If we cancel this policy for any reason other than non-payment of premium by you, we will provide notice of such <br />cancellation to each person or organization designated in the Schedule below. We will mail or deliver such notice <br />to each person or organization at its listed address at least the number of days shown for that person or organiza- <br />tion before the cancellation is to take effect. <br />You are responsible for providing us with the information necessary to accurately complete the Schedule below. <br />If we cannot mail or deliver a notice of cancellation to a designated person or organization because the name or <br />address of such designated person or organization provided to us is not accurate or complete, we have no <br />responsibility to mail, deliver or otherwise notify such designated person or organization of the cancellation. <br />SCHEDULE <br />Name and Address of Designated Persons or Organizations <br />CITY OF SANTA ANA <br />20 CIVIC CENTER PLAZA, 4TH FLOOR <br />SANTA ANA CA 92701 <br />All other terms and conditions of this policy remain unchanged. <br />Number of Days Notice <br />30 <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise <br />stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of <br />the policy.) <br />Endorsement Effective <br />Insured <br />Insurance Company <br />DATE OF ISSUE: 07-27-20 <br />Policy No. <br />ST ASSIGN: <br />© 2013 The Travelers Indemnity Company. All rights reserved. <br />Countersigned by <br />Endorsement No. <br />Premium $ <br />Rime Management Divisinn <br />rREMEWED&{AP'PIRIOeVVEDBY. <br />�� Risk Management Analyst <br />