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lk <br />TRAVELERS]- <br />ONE TOWER SQUARE <br />HARTFORD CT 06183 <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 04 03 17 ( B) <br />POLICY NUMBER: US-OR3408OA-20-42-G <br />ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING <br />THIS INSURANCE <br />Employee Insured by General Employer Excluded <br />The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary <br />notwithstanding, this policy DOES NOT INSURE: <br />NO LIABILITY FOR Any liability you may have as the special employer of an employee who is not on <br />EMPLOYEE INSURED BY your payroll at the time of injury, based upon your representation that: (1) you have <br />GENERAL EMPLOYER entered into a valid and enforceable agreement pursuant to Labor Code Section <br />3602(d) with the employee's general employer under which the general employer <br />agrees to secure the payment of compensation for such employee and (2) the <br />general employer has obtained workers' compensation coverage for the employee. <br />This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer <br />actually obtains coverage for the excluded liability and (2) such coverage remains in effect for the term of this policy. <br />Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or <br />limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive <br />or limit the terms, conditions, agreements or limitations in this endorsement. <br />It is further agreed that "remuneration" when used as a premium basis for such insurance as is afforded by this policy <br />shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. <br />FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS <br />REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER <br />TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES AND OTHER SUBSTANTIAL PENALTIES <br />(Labor Code Section 3710.1, et seq.). <br />DATE OF ISSUE: 05-11-20 ST ASSIGN: <br />y . IUek Managemetti D islm <br />RWn D & APPRov® Br. <br />Risk Management Analyst <br />