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TRAVELERSJfths <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: UB-OR34080A-20-42-G <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 the <br />policy.) <br />Endorsement Effective <br />Insured <br />Insurance Company <br />Policy No. <br />DATE OF ISSUE: 05-11-20 ST ASSIGN: <br />Countersigned by <br />Endorsement No. <br />Premium $ <br />Rink Management DMsian <br />^ Rene &APPRwmBY: <br />® Risk Management Analyst <br />