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TRAVELERS, WORKERS COMPENSATION <br />AND <br />ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD CT 06183 <br />ENDORSEMENT WC 00 04 22 ( B) <br />POLICYNUMBER: UB-OR340BOA-20-42-c <br />b. $120,000.000, with respect to such Insured Losses occurring in calendar year 2016, the United States Gov- <br />ernment would pay 84% of our Insured Losses that exceed our Insurer Deductible. <br />c. $140,000,000, with respect to such Insured Losses occurring in calendar year 2017, the United States Gov- <br />ernment would pay 83% of our Insured Losses that exceed our Insurer Deductible. <br />d. $160,000,000, with respect to such Insured Losses occurring in calendar year 2018, the United States Gov- <br />ernment would pay 82% of our Insured Losses that exceed our Insurer Deductible. <br />e. $180,000,000, with respect to such Insured Losses occurring in calendar year 2019, the United States Gov- <br />ernment would pay 81 % of our Insured Losses that exceed our Insurer Deductible. <br />f. $200,000,000, with respect to such Insured Losses occurring in calendar year 2020, the United States Gov- <br />ernment would pay 80% of our Insured Losses that exceed our Insurer Deductible. <br />2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any <br />portion of Insured Losses that exceed $100.000,000,000. <br />3. The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in <br />Item 4 of the Information Page or in the Schedule below. <br />Schedule <br />State Rate Premium <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 Policy No. Endorsement No. <br />Insured Premium $ <br />Insurance Company Countersigned by <br />s� RAMa ;';;itDMs[. <br />DATE OF ISSUE: 05-11-20 ST ASSIGN: % REVIEWED&APPROVEDBY <br />© Copyright 2015 National Council on Compensation Insurance, Inc. All Rights Reserved. 99; <br />`AW Rtsk Management Analyst <br />or <br />