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TRAVELERS <br />ONE TOWER SQUARE <br />HARTFORD CT 06183 <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />CHANGE DOCUMENT WC 99 99 98 ( A) <br />POLICY NUMBER: UB-6P363599-21-42-G <br />PREM. ANNUAL <br />CLASSIFICATION CODE BASIS RATE PREMIUM <br />SPECIFIC WAIVER 0930 1 .05 0 <br />Specific waiver Minimum Premium is added as follows: <br />STATE MINIMUM PREMIUM <br />CA 0 <br />Item 3.D Form Number is replaced: <br />WC 99 03 C3 00 SPECIAL PROVISIONS ENDT <br />Item 3.D Form Number is added: <br />WC 04 03 06 01 - 024 WAIVER OF <br />CHANGE NO: 30 PAGE 2 OF <br />Risk Managtme dDi%isimt <br />°� RWE D&APPRD EDBY: <br />Fnaw,6.He �'. VttPr�uFP <br />Risk Management Analyst <br />