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TRAVELERSJ� <br />ONE TOWER SQUARE <br />HARTFORD CT 06183 <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />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 18 06 04 (00)-001 ME FINAL PREM AUDIT ENDT <br />APPLIES TO STATE(S): ME <br />WC 18 06 06 (00)-001 ME NOTICE OF FILING FIRST RPT OF INJURY <br />APPLIES TO STATE(S): ME <br />WC 18 06 07 ( A)-001 MAINE EMPLOYMENT REHABILITATION FUND END <br />APPLIES TO STATE(S): ME <br />WC 20 03 01 (00)-001 MA LIMITS OF LIABILITY ENDORSEMENT <br />APPLIES TO STATE(S): MA <br />WC 20 03 02 ( A)-001 MASSACHUSETTS - ASSESMENT CHARGE <br />APPLIES TO STATE(S): MA <br />WC 20 03 03 ( D)-001 MA NOTICE TO POLICYHOLDER ENDORSEMENT <br />APPLIES TO STATE(S): MA <br />WC 20 04 05 (00)-001 MASSACHUSETTS PREMIUM DUE DATE ENDT <br />APPLIES TO STATE(S): MA <br />WC 20 06 01 ( A)-001 MA CANCELLATION ENDORSEMENT <br />APPLIES TO STATE(S): MA <br />WC 31 03 08 (00)-001 NEW YORK LIMIT OF LIABILITY ENDORSEMENT <br />APPLIES TO STATE(S): NY <br />WC 31 03 19 ( J)-001 NY CONST CLASS PREM ADJUST FROG <br />APPLIES TO STATE(S): NY <br />WC 31 04 05 ( A)-001 NY SAFE PTNT HNDLG ACT PRGM ENDT FLAT CR <br />APPLIES TO STATE(S): NY <br />WC 31 06 18 ( A)-001 NEW YORK NOTICE OF RIGHT TO APPEAL <br />APPLIES TO STATE(S): NY <br />WC 99 03 99 (00)-001 CA WORKERS' COMP NOTICE OF NON -RENEWAL <br />APPLIES TO STATE(S): CA <br />WC 99 03 Al (00)-001 NOTICE OF CANCELATION <br />APPLIES TO STATE(S): CO <br />WC 99 03 F3 (00)-001 CA LIMITS OF LIABILITY ENDT <br />APPLIES TO STATE(S): CA <br />WC 99 04 10 (00)-001 PREMIUM ADJ. FROM EFFECTIVE DATE ENDT. <br />APPLIES TO STATE(S): CA <br />WC 99 06 T1 (00)-001 NY NOTICE CANCEL DESIGNATED GOV ENTITY <br />APPLIES TO STATE(S): NY <br />DATE OF ISSUE: 09-23-21 STASSIGN: <br />Rink Managtment Di%isimt <br />i[iEVIEV;IED&AP'PIRO MBY/: <br />®] <br />Risk Management Analyst <br />