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IN REPLY REFER TO: <br />9048876-21 <br />WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY <br />INSURANCE POLICY <br />STATE COMPENSATION INSURANCE FUND <br />Forms and Endorsements Applicable List Policy <br />FORM NUMBER FORM DESCRIPTION <br />10963A <br />ANNUAL RATING ENDORSEMENT <br />10217 <br />9904 - ENDORSEMENT AGREEMENT - WORDING CHANGE <br />ENDORSEMENT <br />10217 <br />1159 -ENDORSEMENT AGREEMENT- <br />COVID-19 REPORTING REQUIREMENT ENDORSEMENT - <br />CALIFORNIA <br />10217 <br />2029 -ENDORSEMENT AGREEMENT- <br />CALIFORNIA SHORT -RATE CANCELLATION <br />10217 <br />2089 -ENDORSEMENT AGREEMENT - <br />STATUTORY ACCOUNTING PRINCIPLES - BILL RECEIVABLE <br />10217 <br />2437 -ENDORSEMENT AGREEMENT - <br />MEDICAL PROVIDER NETWORK ENDORSEMENT <br />10217 <br />2566 -ENDORSEMENT AGREEMENT - <br />NOTIFICATION ENDORSEMENT OF PENDING LAW CHANGE TO <br />TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION <br />ACT OF 2015 <br />10217 <br />2567 -ENDORSEMENT AGREEMENT - <br />TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION <br />ACT DISCLOSURE ENDORSEMENT <br />10217 <br />2512A -ENDORSEMENT AGREEMENT - <br />EXPERIENCE MODIFICATION <br />10217 <br />3015 -ENDORSEMENT AGREEMENT - <br />EXECUTIVE OFFICERS - MINIMUM/MAXIMUM LIMITS <br />10217 <br />9961 -ENDORSEMENT AGREEMENT - <br />CLASS AND RATES AMENDED <br />10610D <br />POLICY HOLDER NOTICE <br />5880 Owens Dr . Pleasanton, CA 94588-3900 <br />Mailing Address: P.O. Box 8192 • Pleasanton, CA 94588-8792 <br />�oRaN <br />3 <br />Risk ManagementDMsfan <br />REVIEWED & APPROVED BY: <br />z <br />f R. VSA44a <br />Risk Management Analyst <br />