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WC 04 03 01 D WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />(Ed. 2-18) <br />If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise: <br />If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be <br />less than the pro rata share of the minimum premium. <br />If you cancel, final premium may be more than pro rata; it will be based on the time this policy was in force, and may be <br />increased by our short -rate cancelation table and procedure. Final premium will not be less than the pro rata share of the <br />minimum premium. <br />It is further agreed that this policy, including all endorsements forming a part thereof, constitutes the entire contract of insurance. No <br />condition, provision, agreement, or understanding not set forth in this policy or such endorsements shall affect such contract or any <br />rights, duties, or privileges arising therefrom. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement Effective 09-07-21 Policy No. WC80946 <br />Insured BACKHAUS DANCE <br />Insurance Company Sirius America Ins Co <br />Countersigned By <br />Endorsement No. <br />Premium $ Incl . <br />Page 2 of 2 ; RtsieAQa�WmerdDiMawn <br />H ortaN <br />WC 04 03 01 D 3 r RE�AEWED & APPROVED BY.- <br />(Ed. 2-18) FIIA . JZ. W&VAI <br />© Copyright 2018 by the Workers' Compensation Insurance Rating Bureau of California. All Rights Reserved. Risk Management Analyst <br />