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TRAVELERS Jw WORKERS COMPENSATION <br />AND <br />ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD CT 06183 <br />ENDORSEMENT WC 99 04 10 (00) <br />POLICY NUMBER: UE-OR3408OA-20-42-c <br />PREMIUM ADJUSTMENT FROM EFFECTIVE DATE ENDORSEMENT <br />It is agreed that the premium for the policy is subject to an experience modification not available at the time of <br />policy issuance. Such experience modification, when determined, will be stated in an endorsement issued to <br />form a part of the policy. <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 />DATE OF ISSUE: 05-11-20 ST ASSIGN: <br />„��...., RieleMn„gm,ot onasiun <br />., REVIEWED&APPROVEDBY: <br />®� F"hHU.Ft z Va'u �� <br />® R¢k Nlanagemen[Anayrt <br />