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TRAVELERS+, WORKERS COMPENSATION <br />AND <br />ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD CT 06183 ENDORSEMENT WC 99 03 C3 (00) — <br />POLICY NUMBER: UB-6P363599-21-42-G <br />SPECIAL PROVISIONS ENDORSEMENT <br />STATE APPLICABILITY <br />The listed endorsements are only applicable in the following states: <br />WC 00 03 13 (00)-013 WAIVER OF OUR RIGHT TO RECOVER <br />APPLIES TO STATE(S): CO DC MA ME NY <br />WC 00 04 14 ( A)-001 NOTIFICATION OF CHG IN OWNR ENDT <br />APPLIES TO STATE(S): CO DC ME NY <br />WC 00 04 14 (00)-001 NOTIFICATION OF CHANGE IN OWNERSHIP ENDT <br />APPLIES TO STATE(S): MA <br />WC 00 04 19 (00)-001 PREMIUM DUE DATE ENDORSEMENT <br />APPLIES TO STATE(S): CO DC ME NY <br />WC 00 04 21 ( E)-001 CATASTROPHE (O/T CERT ACTS OF TERR) ENDT <br />APPLIES TO STATE(S): CA CO DC ME NY <br />WC 00 04 22 ( C)-001 TERRORISM RISK INS PROG REAUTH ACT ENDT <br />APPLIES TO STATE(S): CA CO DC MA ME NY <br />WC 00 04 24 (00)-001 AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT <br />APPLIES TO STATE(S): CO DC ME <br />WC 04 03 01 ( W -001 POLICY AMENDATORY ENDORSEMENT-CALIFORNIA <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-001 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-002 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-003 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-004 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-005 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-006 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-007 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-008 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-009 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-010 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-011 WAIVER OF SUBROGATION <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise <br />stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of <br />the policy.) <br />Endorsement Effective Policy No. Endorsement No. <br />Insured <br />Insurance Company Countersigned by <br />DATE OF ISSUE: 09-23-21 STASSIGN: <br />PYE <br />Rink Managtment Di%isimt <br />REVI DSAPPROVm BY: <br />alFi"ort•Mc% <br />®; <br />Risk Management Analyst <br />