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TRAVELERS, WORKERS COMPENSATION <br />AND <br />ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD CT 06183 <br />ENDORSEMENT WC 04 03 45 (A) <br />POLICY NUMBER: UB-OR34080A-20-42-G <br />ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS <br />INSURANCE <br />Comprehensive Personal Liability Policy Exclusion <br />The insurance under this policy is limited as follows: It is AGREED that, any thing in this policy to the contrary <br />notwithstanding, this policy DOES NOT INSURE: <br />THIS POLICY DOES <br />Any liability you may have for any injury to any employee(s) who is covered for workers' <br />NOT INSURE ANY <br />compensation benefits on a policy also affording comprehensive personal liability insurance <br />EMPLOYEE(S) <br />which has been issued to this insured. <br />COVERED BY A <br />COMPREHENSIVE <br />PERSONAL <br />LIABILITY 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 of 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 />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 Policy No. Endorsement No. <br />Insured Premium $ <br />Insurance Company Countersigned by <br />Risk MmagnnentDMsian <br />DATE OF ISSUE: 05-11-20 ST ASSIGN: W REmEWED&APPROVED BY. <br />ZMZ <br />Risk Nlanagemenl Analyst <br />