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TRAVELERS, WORKERS COMPENSATION <br />ONE TOWER SQUARE AND HARTFORD CT 06183 EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 00 00 01 (A) <br />POLICY NUMBER: UB-OR3408OA-20-42-G <br />LISTING OF ENDORSEMENTS <br />EXTENSION OF INFO PAGE <br />We agree that the following listed endorsements form a part of this policy on its effective date. <br />WC <br />00 <br />00 <br />01 <br />A <br />- 001 <br />WC <br />00 <br />00 <br />01 <br />A <br />- 001 <br />WC <br />00 <br />00 <br />01 <br />A <br />- 001 <br />WC <br />00 <br />00 <br />01 <br />A <br />- 001 <br />WC <br />00 <br />04 <br />22 <br />B <br />- 001 <br />WC <br />04 <br />03 <br />01 <br />B <br />- 001 <br />WC <br />99 <br />03 <br />99 <br />00 <br />- 001 <br />WC <br />99 <br />03 <br />F3 <br />00 <br />- 001 <br />WC <br />00 <br />04 <br />21 <br />D <br />- 001 <br />WC <br />99 <br />04 <br />10 <br />00 <br />- 001 <br />WC <br />04 <br />03 <br />17 <br />B <br />- 001 <br />WC <br />04 <br />03 <br />45 <br />A - <br />001 <br />WC <br />04 <br />03 <br />60 <br />B - <br />001 <br />WC <br />04 <br />04 <br />21 <br />00 - <br />001 <br />WC <br />04 <br />04 <br />22 <br />00 - <br />001 <br />WC <br />04 <br />06 <br />01 <br />A - <br />001 <br />INFORMATION PAGE <br />INFORMATION PAGE 2 <br />EXTENSION OF INFORMATION PAGE - SCHEDULE <br />ENDORSEMENT LISTING <br />TERRORISM RISK INS FROG REAUTH ACT ENDT <br />POLICY AMENDATORY ENDORSEMENT-CALIFORNIA <br />CA WORKERS' COMP NOTICE OF NON -RENEWAL <br />CA LIMITS OF LIABILITY ENDT <br />CATASTROPHE (O/T CERT. ACTS OF TERR)ENDT <br />PREMIUM ADJ. FROM EFFECTIVE DATE ENDT. <br />EMPLOYEE INSD BY GENERL EMPLYER EXCLUDED <br />COMPREHENSIVE PERSONAL LIAB POL EXCL <br />EMPLOYERS' LIAR COV AMENDATORY ENDT-CA <br />OPTIONAL PREMIUM INCREASE ENDORSEMENT - CALIFORNIA <br />CALIFORNIA SHORT -RATE CANCELATION ENDT <br />CA CANCELATION ENDT <br />DATE OF ISSUE: 05-11-20 STASSIGN: Page <br />of RlAMknsgmentDMsion <br />RwEWm 6pAPPROVED BY: <br />®' Rnk Management Analyst <br />