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POLICY NUMBER: CUP-111325156-21-43 <br />UMBRELLA <br />ISSUE DATE: 06/22/2021 <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />SCHEDULE OF UNDERLYING INSURANCE <br />This endorsement modes insurance provided under the following: <br />EXCESS FOLLOW -FORM AND UMBRELLA LIABILITY INSURANCE <br />Employers Liability <br />Carrier TRAVELERS PROPERTY CASUALTY <br />COMPANY OF AMERICA <br />Policy Number UB-007&940269-21 <br />Policy Period <br />From: 06/Ol/2021 <br />to: 06/01/2022 <br />Automobile Liability <br />Carrier TRAVELERS PROPERTY CASUALTY <br />COMPANY OF AMERICA <br />Policy Number 810-ODONS10047-21 <br />Policy Period <br />From: 06/01/2021 <br />to: 06/01/2022 <br />o� <br />a Employee Benefits Liability <br />^— Carrier TRAVELERS PROPERTY CASUALTY <br />m� COMPANY OF AMERICA <br />Policy Number 630-7R939062-21 <br />Policy Period <br />^- From: 06/01/2021 <br />o� <br />o= to: 06/01/2022 <br />Limits Of Liability <br />Bodily Injury By Accident $1,000,000 <br />Each Accident <br />Bodily Injury By Disease $1,000,000 <br />Policy Limit <br />Bodily Injury By Disease $1,000,000 <br />Each Employee <br />Limits Of Liability <br />Bodily Injury And Property $1,000,000 <br />Damage Combined Single <br />Limit <br />Limits Of Liability <br />Each Employee <br />Aggregate <br />PRODUCER:RUB INTL INS SERVICES OFFICE:BREA/LA/ORANGE C, <br />EU 00 03 08 18 m 2018 The Travelers Indemnity Company. All rights reserved. <br />$1,000,000 <br />$2,000,000 <br />Risk MarugmwdDi slon <br />o. RwEwEo fi MrRwD Br. <br />®' Risk Management Analyst <br />010151 <br />