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WORKERS COMPENSATION <br />TRA Y�/ELERS J AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 09 R3 (00) <br />POLICY NUMBER: UB-1 R22558A-20-26-G <br />0 <br />NOTICE OF CANCELLATION <br />TO DESIGNATED PERSONS OR ORGANIZATIONS <br />The following is added to PART SIX — CONDITIONS: <br />Notice Of Cancellation To Designated Persons Or Organizations <br />If we cancel this policy for any reason other than non-payment of premium by you, we will provide notice of such <br />cancellation to each person or organization designated in the Schedule below. We will mail or deliver such notice <br />«a to each person or organization at its listed address at least the number of days shown for that person or organize - <br />lion before the cancellation is to take effect. <br />You are responsible for providing us with the information necessary to accurately complete the Schedule below. <br />42 If we cannot mail or deliver a notice of cancellation to a designated person or organization because the name or <br />M address of such designated person or organization provided to us is not accurate or complete, we have no <br />responsibility to mail, deliver or otherwise notify such designated person or organization of the cancellation, <br />p SCHEDULE <br />tl Number of <br />w Name and Address of Designated Persons or Organizations: Days Notice <br />City of Santa Ana 30 <br />Risk Management Division <br />20 Civic Center Plaza <br />Santa Ana, CA 92702 <br />t� <br />0 <br />0 <br />DATE OF ISSUE: - ST ASSIGN: <br />02013 The Travelers Indemnity Company. All rights reserved. �' j't3 vrexEo&APPROVED BY: <br />.� <br />1 Rnk MnnagementAnaiyst <br />010 <br />