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Attachment Code:D656443 Master ID: 1509060,Certificate ID:21138329 WORKERS COMPENSATION TRAVELERS AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTF'ORD CT 06183 ENDORSEMENT WC 99 06 R3 (00) - POLICY NUMBER: UB-8Yo32268-24-43-c NOTICE OF CANCELLATION TO DESIGNATED PERSONS OR ORGANIZATIONS The following is added to PART SIX—CONDITIONS : Notice Of Cancellation To Designated Persons Or Organizations If we cancel this policy for any reason other than non-payment of premium by you,we will provide notice of such cancellation to each person or organization designated in the Schedule below. We will mail or deliver such notice to each person or organization at its listed address at least the number of days shown for that person or organization before the cancellation is to take effect. You are responsible for providing us with the information necessary to accurately complete the Schedule below. If we cannot mail or deliver a notice of cancellation to a designated person or organization because the name or address of such designated person or organization provided to us is not accurate or complete,we have no responsibility to mail, deliver or otherwise notify such designated person or organization of the cancellation. SCHEDULE Name and Address of Designated Persons or Organizations: Number of Days Notice ANY PERSON OR ORGANIZATION TO WHOM YOU HAVE AGREED IN A WRITTEN CONTRACT THAT NOTICE OF CANCELLATION OF THIS POLICY WILL BE GIVEN 30 , BUT ONLY IF: 1. YOU SEND US A WRITTEN REQUEST TO PROVIDE SUCH NOTICE, INCLUDIN G THE NAME AND ADDRESS OF SUCH PERSON OR ORGANIZATION, AFTER THE FIRST NAMED ZNSURRD RECEIVES NOTICE FROM US OF THE CANCELLATION 0 F THIS POLICY,AND 2. WE RECEIVE SUCH WRITTEN REQUEST AT LEAST 14 DAYS BEFORE THE BEGINNING OF THE APPLICABLE NUMBER OF DAYS SHOWN IN THIS ENDORSEM ENT. ADDRESS: THE ADDRESS FOR THAT PERSON OR ORGANIZATION INCLUDED IN SUCH WRIT TEN REQUEST FROM YOU TO US. All other terms and conditions of this policy remain unchanged. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 11/9/2024 Policy No. UB-8Y03226B-24-43-G Endorsement No. Insurance Company Countersigned by Travelers Property Casualty Company of America Page 1 O DATE OF ISSUE: 10-21-24 ST ASSIGN: APPROVED p 2013 The Travelers Indemnity Company.All rights reserved. By Cynthia Mora at 9:12 am, Nov 19, 2024