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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />NOTIFICATION TO OTHERS OF CANCELLATION ENDORSENMT <br />This endorsement is used to add the following to Part Six of the policy. <br />PART SIX <br />CONDITIONS <br />WC 99 06 33 <br />A. If we cancel this policy by written notice to you for any reason other than nonpayment of premium, we will <br />mail or deliver a copy of such written notice of cancellation to the name and address corresponding to each <br />person or organization shown in the Schedule below. Notification to such person orarganization will be <br />provided at least 10 days prior to the effective date of the cancellation, as advised inour notice to you, or the <br />longer number of days notice if indicated in the Schedule below. <br />B. If we cancel this policy by written notice to you for nonpayment of premium, we will nail or deliver a copy of <br />such written notice of cancellation to the name and address corresponding to eachperson or organization <br />shown in the Schedule below at least 10 days prior to the effective date of such cancellation. <br />C. If notice as described in Paragraphs A. or B. of this endorsement is mailed, proof detailing will be sufficient <br />proof of such notice. <br />SCHEDULE <br />Name and Address of Other Person(s) / Or anizations Number of Days Notice: <br />Any person(s) or organization(s) whom you are required 30 <br />by written contract. <br />All other terms and conditions of this policy remain unchanged. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent topreparation of the policy.) <br />Endorsement Effective 11/13/20 <br />Insured <br />Insurance Company <br />Policy No. WC 0217111-05 <br />WC 99 06 33 <br />INTERNA(MID¢LND) includes copyrighted material of National Council on Compensation Insurance, Inc. wilbilepi <br />Endorement No. <br />Premium $ ---- <br />„ n.,�n RedrMnmgannitDlvielun <br />fb-,AEwm 6 APPRov® By. G1YnA.f P, f "Avjt' GL <br />, <br />- Risk Managemen[Analyst <br />