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Insurance for this coverage part provided by: <br />ZURICH AMERICAN INSURANCE COMPANY <br />NCC1 COfnDanv No.l 0 8 6 3 <br />WORKERS COMPENSATION CHANGE ENDORSEMENT <br />Policy Number,WC 5682678-01 <br />NAMED INSURED <br />ENDORSEMENT EFFECTIVE DATE <br />POLICY NUMBER <br />PATRIOT ENVIRONMENTAL <br />11-01-21 <br />WC 5682678-01 <br />POLICYTERM: 11-01-2021 TO 11-01-2022 <br />ENDORSEMENT NUMBER 009 <br />Change Description <br />THE FOLLOWING FORM(S) <br />HAS BEEN ADDED: <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 />�kn�gnt�t��l�t <br />REVIEWED <br />& APPROVED BY: <br />�r Risk Management Specialist <br />