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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 />- . E Risk Management Division <br />+� \@ REVIEWED & APPROVED BY: <br />5880 Owens Dr . Pleasanton, CA 94588-3900 <br />Mailing Address: P.O. Box 8192 Pleasanton, CA 94588-8792 �_r,- Ri5k Management Specialist <br />