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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04 06 01 A <br />(Ed. 12/93) <br />The occurrence of any change in your business or operation which contemplates an activity excluded by our <br />reinsurance treaties. <br />If we cancel your policy for any of the reasons listed in (a) through (f), we will give you 10 days advance written <br />notice, stating when the cancellation is to take effect. Mailing that notice to you at your mailing address shown in <br />Item 1 of the Information Page will be sufficient to prove notice. If we cancel your policy for any of the reasons <br />listed in Items (g) through (1), we will give you 30 days advance written notice; however, we agree that in the event <br />of cancellation and reissuance of a policy effective upon a material change in ownership or operations, notice will <br />not be provided. <br />4. The policy period will end on the day and hour stated in the cancellation notice. <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 0 9 - 0 7 - 2 1 Policy No. WC 80946 00 <br />Insured BACKHAUS DANCE <br />Insurance Company Sirius America Ins Co <br />Countersigned By <br />Endorsement No. <br />Premium $ Incl . <br />Copyright 1998by The Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 194 <br />�oRaN <br />r� -:. ^ecoG< <br />4r <br />q� <br />Risk ManagemedDiviaian <br />cREVIEWED & APPROVED BY.- <br />rRd�-cG " R. v� <br />Risk Management Analyst <br />