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TRAVELERS Jam' ONE TOWER SQUARE HARTFORD CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 04 04 21 (00) POLICYNUMBER: Ua-OR34080A-20-42-G OPTIONAL PREMIUM INCREASE ENDORSEMENT—CALIFORNIA You must provide us, or our authorized representative, access to records necessary to perform a payroll verifica- tion audit. If you fail to provide access within 90 days after expiration of the policy, you are liable to pay a total premium equal to 3 times our current estimate of the annual premium for your policy. In addition, if you fail to provide access after our third request within a 90 day or longer period, you are also liable for our costs in at- tempting to perform the audit unless you provide a compelling business reason for your failure. We will contact you to schedule appointments during normal business hours. We will notify you of your failure to provide access by mailing a certified, return -receipt document stating the increased premium and the total amount of our costs incurred in our attempt(s) to perform an audit. In addition to any other obligations under this contract, 30 days after you receive the notification, you will be obligated to pay the total premium and costs referenced above. If, thereafter, you provide access to your records within three years after the policy expires, or within another mutually agreed upon time, and we succeed in performing the audit to our satisfaction, we will revise your total premium and the costs due to reflect the results of the audit. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Insurance Company Countersigned By DATE OF ISSUE: 05-11-20 ST ASSIGN: Rick Managzment D[vislon REIAEVBED&@APPROVm Sr. Risk Management Analyst