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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 99 06 57 <br />ENDORSEMENT# <br />This endorsement, effective 12:01 a.m. forms a part of <br />Policy No. RWD3001203-06 issued to Allied Universal Topco, LLC <br />by XL Insurance America, Inc. <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />CANCELLATION NOTIFICATION TO OTHERS ENDORSEMENT <br />This endorsement modifies insurance provided under the following: <br />WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br />12/1 <br />In the event coverage is cancelled for any statutorily permitted reason, other than nonpayment of premium, <br />advanced written notice will be mailed or delivered to person(s) or entity(ies) according to the notification <br />schedule shown below: <br />Number of Days <br />Advanced <br />Name of Person(s) or Entity(ies) <br />Mailing Address: <br />Notice of <br />Cancellation: <br />Per the most current schedule maintained by <br />30 <br />Marsh USA Inc. and furnished to AXA XL no <br />less than 45 days prior to the effective date <br />of the cancellation. <br />All other terms and conditions of the Policy remain unchanged. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless <br />otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to <br />preparation of the policy.) <br />Endorsement Effective <br />insured <br />Allied Universal Topco, LLC <br />Insurance Company <br />XL Insurance America, Inc. <br />Policy No. Endorsement No. <br />RWD3001203-06 Premium$ Included <br />Countersigned by <br />WC 99 06 57 a Ruk Mvegeme d D mmn <br />Ed. 12/10 © 2010 X-L. America, Inc. All Rights Reserved- <br />May <br />litnE u o&AwRw®ev <br />May not be copied without permission. 5 ��K R. G:!/.�aud <br />�� Ruktvtznzgemert[Mzlyst <br />