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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 01 A <br />(Ed. 2-89) <br />ALTERNATE EMPLOYER ENDORSEMENT <br />This endorsement applies only with respect to bodily injury to your employees while in the course of special or <br />temporary employment by the alternate employer in the state named in Item 2 of the Schedule. Part One (Workers <br />Compensation Insurance) and Part Two (Employers Liability Insurance) will apply as though the alternate employer is <br />insured. If an entry is shown in Item 3 of the Schedule the insurance afforded by this endorsement applies only to work <br />you perform under the contract or at the project named in the Schedule. <br />Under Part One (Workers Compensation Insurance) we will reimburse the alternate employer for the benefits required <br />by the workers compensation law if we are not permitted to pay the benefits directly to the persons entitled to them. <br />The insurance afforded by this endorsement is not intended to satisfy the alternate employer's duty to secure its <br />obligations under the workers compensation law. We will not file evidence of this insurance on behalf of the alternate <br />employer with any government agency. <br />We will not ask any other insurer of the alternate employer to share with us a loss covered by this endorsement. <br />Premium will be charged for your employees while in the course of special or temporary employment by the alternate <br />employer. <br />The policy may be canceled according to its terms without sending notice to the alternate employer. <br />Part Four (Your Duties If Injury Occurs) applies to you and the alternate employer. The alternate employer will <br />recognize our right to defend under Parts One and Two and our right to inspect under Part Six. <br />Schedule <br />Alternate Employer <br />ANY PERSON OR ORGANIZATION TO WHOM OR TO WHICH YOU ARE REQUIRED TO <br />ADD AS AN ALTERNATE EMPLOYER IN A WRITTEN CONTRACT OR WRITTEN <br />AGREEMENT EXECUTED PRIOR TO LOSS, EXCEPT WHERE SUCH CONTRACT OR <br />AGREEMENT IS POHIBITED BY LAW <br />Address <br />2. State of Special or Temporary Employment <br />ANY STATE LISTED IN ITEM 3 A. OF THE INFORMATION PAGE <br />3. Contract or Project <br />ANY WRITTEN CONTRACT OR AGREEMENT <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 to preparation of the policy.) <br />Endorsement Effective 11-01-21 Policy No. WC 5682678-01 Endorsement No. 009 <br />Insured PATRIOT ENVIRONMENTAL SERVICES, INC. <br />Insurance Company ZURICH AMERICAN INSURANCE COMPANY <br />Countersigned By <br />WC000301 A <br />(Ed. 2-89) <br />O 1984, 1988 National Council on Compensation Insurance. <br />Premium $ INCL . <br />°-- _ Risk Manugemwnt Division <br />REVIEWEE> & APPROVW BY. <br />�� Risk Management Specialist <br />