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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 60 B <br />(Ed. 01-16) <br />EMPLOYERS' LIABILITY COVERAGE AMENDATORY ENDORSEMENT—CALIFORNIA <br />The insurance afforded by Part Two (Employers' Liability Insurance) by reason of designation of California in item <br />3 of the information page is subject to the following provisions: <br />A. "How This Insurance Applies," is amended to read as follows: <br />A. How This Insurance Applies <br />This employers' liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily <br />injury means a physical injury, including resulting death. <br />1. The bodily injury must arise out of and in the course of the injured employee's employment by you. <br />2. The employment must be necessary or incidental to your work in California. <br />3. Bodily injury by accident must occur during the policy period. <br />4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The <br />employee's last day of last exposure to the conditions causing or aggravating such bodily injury by <br />disease must occur during the policy period. <br />5. If you are sued, the original suit and any related legal actions for damages for bodily injury by <br />accident or by disease must be brought in the United States of America, its territories or <br />possessions, or Canada. <br />C. The "Exclusions" section is modified as follows (all other exclusions in the "Exclusions" section remain as is): <br />1. Exclusion 1 is amended to read as follows: <br />1. liability assumed under a contract. <br />2. Exclusion 2 is deleted. <br />3. Exclusion 7 is amended to read as follows <br />7. damages arising out of coercion, criticism, demotion, evaluation, reassignment, <br />discipline, defamation, harassment, humiliation, discrimination against or termination <br />of any employee, termination of employment, or any personnel practices, policies, <br />acts or omissions. <br />4. The following exclusions are added <br />1. bodily injury to any member of the flying crew of any aircraft. <br />2. bodily injury to an employee when you are deprived of statutory or common law <br />defenses or are subject to penalty because of your failure to secure your obligations <br />under the workers' compensation law(s) applicable to you or otherwise fail to comply <br />with that law. <br />3. liability arising from California Labor Code Section 2810.3 which relates to labor <br />contracting. <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 />© 2015 by the Workers' Compensation Insurance Bureau of California. All Rights Reserved. <br />Endorsement No. <br />Premium $ Incl . <br />�oRaN <br />} z <br />a <br />RiskMmWmerdDiviaian <br />REVIEWED & APPROVED BY.- <br />p R. vj&wd <br />Risk Management Analyst <br />