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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B <br /> (Ed. 7-01) <br /> POLICY INFORMATION PAGE ENDORSEMENT <br /> The following item(s) <br /> F1 Insured's Name(WC 89 06 01) — Item 33. Limits(WC 89 06 12) <br /> F1 Policy Number(WC 89 06 02) — Item 3.C. States (WC 89 06 13) <br /> F1 Effective Date(WC 89 06 03) X- Item 3.D. Endorsement Numbers(WC 89 06 14) <br /> u Expiration Date(WC 89 06 04) _ Item 4.*Class, Rate, Other(WC 89 04 15) <br /> u Insured's Mailing Address (WC 89 06 05) _ Interim Adjustment of Premium (WC 89 04 16) <br /> u Experience Modification (WC 89 04 06) _ Carrier Servicing Office (WC 89 06 17) <br /> u Producer's Name (WC 89 06 07) _ Interstate/Intrastate Risk ID Number(WC 89 06 18) <br /> u Change in Workplace of Insured (WC 89 06 08) _ Carrier Number(WC 89 06 19) <br /> u Insured's Legal Status(WC 89 06 10) _ Issuing Agency/Producer Office Address (WC 89 06 25) <br /> u Item 3.A.States (WC 89 06 11) <br /> is changed to read: <br /> It is understood and agreed that: <br /> The following forms are added: <br /> WC 00 03 13-Waiver Of Our Right To Recover From Others Endorsement <br /> All other terms and conditions remain unchanged. <br /> *Item 3.D. Change to <br /> Form Number Form Title <br /> WC 89 06 00 B(07-01) Policy Information Page Endorsement <br /> WC 04 03 06 Waiver of Our Right to Recover from Others Endorsement--California <br /> WC 89 06 OOB <br /> (Ed. 7-01) <br /> ©2001 National Council on Compensation Insurance,Inc. <br />