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TRAVELERSAM WORKERS COMPENSATION <br />AND <br />ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD CT 06183 <br />ENDORSEMENT WC 04 03 01 ( B) <br />POLICYNUMBER: UH-OR3408OA-20-42-G <br />the balance to you. The final premium will not be less than the highest minimum premium for the classifica- <br />tions covered by this policy. <br />If this policy is canceled, final premium will be determined in the following way unless our manuals provide <br />otherwise: <br />a. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final <br />premium will not be less than the pro rata share of the minimum premium. <br />b. If you cancel, final premium may be more than pro rata; it will be based on the time this policy was in <br />force, and may be increased by our short -rate cancelation table and procedure. Final premium will not be <br />less than the pro rata share of the minimum premium. <br />It is further agreed that this policy, including all endorsements forming a part thereof, constitutes the entire <br />contract of insurance. No condition, provision, agreement, or understanding not set forth in this policy or such <br />endorsements shall affect such contract or any rights, duties, or privileges arising therefrom. <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 />DATE OF ISSUE: 05-11-20 <br />Policy No. <br />Insurance Company <br />ST ASSIGN: <br />Countersigned by <br />© 2011 Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />Endorsement No. <br />ss R16MmugmeydDivision <br />((R''nnI D&APPROVED BY: <br />MAd <br />Rkk Management Analyst <br />