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WORKERS COMPENSATION CHANGE ENDORSEMENT <br />Insurance for this coverage part provided by: Policy NumberWC 5682678-01 <br />ZURICH AMERICAN INSURANCE COMPANY <br />NCCI Comoanv No.1 0 8 6 3 <br />NAMED INSURED <br />ENDORSEMENT EFFECTIVE DATE <br />I POLICY NUMBER <br />PATRIOT ENVIRONMENTAL <br />11-05-21 <br />WC 5682678-01 <br />POLICYTERM: 11-01-2021 TO 11-01-2022 <br />ENDORSEMENT NUMBER 002 <br />Change Description <br />THE FOLLOWING FORM(S) <br />HAS BEEN A -MENDED: <br />WC 00 03 01 A 02-89 <br />ALTERNATE EMPLOYER ENDORSEMENT <br />PREMIUM CHANGE <br />PRO-RATA FACTOR <br />Additional Coverage Premium <br />STA Return Coverage Premium <br />STA <br />Additional Taxes & Surcharges <br />Return Taxes & Surcharges <br />Total Additional Premium <br />STA Total Return Premium <br />STA <br />Countersigned: Date By <br />PJA Mougement Div slm <br />t - REmEWED�y& APPROvpa_By. <br />Risk Management Specialist <br />