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DocuSign Envelope 10: FC7E9346-8A22-4923-BD05-AA3CA0439841 <br />Attachment Code: D578871 Certificate ID: 16765248 <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC <br />99 06 33 <br />NOTIFICATION TO OTHERS OF CANCELLATION ENDORSEMENT This <br />endorsement is used to add the following to Part Six of the policy. <br />PART SIX <br />CONDITIONS <br />A. If we cancel this policy by written notice to you for any reason other than nonpayment of <br />premium, we will mail or deliver a copy of such written notice of cancellation to the name and <br />address corresponding to each person or organization shown in the Schedule below. Notification to <br />such person or organization will be provided at least 10 days prior to the effective date of the <br />cancellation, as advised in our notice to you, or the longer number of days notice if indicated in the <br />Schedule below. <br />B. If we cancel this policy by written notice to you for nonpayment of premium, we will mail or <br />deliver a copy of such written notice of cancellation to the name and address corresponding to <br />each person or organization shown in the Schedule below at least 10 days prior to the effective <br />date of such cancellation. <br />C. If notice as described in Paragraphs A. or B. of this endorsement is mailed, proof of mailing <br />will be sufficient proof of such notice. <br />SCHEDULE <br />NAME AND ADDRESS OF PERSON(S)1 ORGANIZATION(S) <br />PER ATTACHED CERTIFCATE NUMBER OF DAYS NOTICE: 30 <br />All other terms and conditions of this policy remain unchanged. <br />WC 99 06 33 <br />(Ed. 05-10) <br />