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WORKERS, COMPENSATION AND EMPLOYERS, LIABILITY INSURANCE POLICY <br />WC 04 06 01 A <br />(Ed. 12-93) <br />CALIFORNIA CANCELATION ENDORSEMENT <br />This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the information page. <br />The cancelation condition in Part Six (Conditions) of the policy is replaced by these conditions: <br />Cancelation <br />1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. <br />2. We may cancel this policy for one or more of the following reasons: <br />a. Non-payment of premium; <br />b. Failure to report payroll; <br />c. Failure to permit us to audit payroll as required by the terms of this policy or a previous policy issued by us; <br />d. Failure to pay any additional premium resulting from an audit of payroll required by the terms of this policy or any previous policy <br />issued by us; <br />e. Material misrepresentation made by you or your agent; <br />f. Failure to cooperate with us in the investigation of a claim; <br />g. Failure to comply with Federal or State safety orders; <br />h. Failure to comply with written recommendations of our designated loss control representatives; <br />i. The occurrence of a material change in the ownership of your business; <br />j. The occurrence of any change in your business or operations that materially increases the hazard for frequency or severity of loss; <br />k. The occurrence of any change in your business or operation that requires additional or different classification for premium <br />calculation; <br />I. The occurrence of any change in your business or operation which contemplates an activity excluded by our reinsurance treaties. <br />3. If we cancel your policy for any of the reasons listed in (a) through (f), we will give you 10 days advance written notice, stating when the <br />cancelation is to take effect. Mailing that notice to you at your mailing address shown in item 1 of the Information Page will be sufficient <br />to prove notice. If we cancel your policy for any of the reasons listed in items (g) through (I), we will give you 30 days advance written <br />notice; however, we agree that in the event of cancelation and reissuance of a policy effective upon a material change in ownership or <br />operations, notice will not be provided. <br />4. The policy period will end on the day and hour stated in the cancelation notice. <br />This endorsement changes the policy to which it is attached effective on the date issued unless otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement Effective 12/31/2021 <br />Insured GRIFFITH COMPANY <br />Insurance Company <br />Policy No. A-1CW-992818-05 <br />OLD REPUBLIC GENERAL INSURANCE CORPORATION <br />WC 04 06 01 A <br />(Ed. 12-93) <br />Countersigned by <br />Endorsement No. 000 <br />Premium $ <br />o Nye Risk MwaganentDMsian <br />z <br />REVIEWED & APPROVED BY.- <br />-��" Risk Management Analyst <br />