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EXTENDED OPTIONS <br />1. Employers' Liability Insurance 4. Foreign Voluntary Compensation and Employers' <br />Item 3.B. of the Information Page is replaced by Liability Reimbursement <br />the following: A. How This Reimbursement Applies <br />B. Employers' Liability Insurance: <br />1. Part Two of the policy applies to work in <br />each state listed in Item 3.A. <br />The Limits of Liability under Part Two are <br />the higher of: <br />Bodily Injury <br />by Accident $500,000 Each Accident <br />Bodily Injury <br />by Disease $500,000 Policy Limit <br />Bodily Injury <br />by Disease $500,000 Each Employee <br />OR <br />2. The amount shown in the Information <br />Page. <br />This provision 1 of EXTENDED OPTIONS does <br />not apply in New York because the Limits Of Our <br />Liability are unlimited. <br />In this provision the limits are changed from <br />$500,000 to $1,000,000 in California. <br />2. Unintentional Failure to Disclose Hazards <br />If you unintentionally should fail to disclose all <br />existing hazards at the inception date of your <br />policy, we shall not deny coverage under this <br />policy because of such failure. <br />3. Waiver of Our Right To Recover From Others <br />A. We have the right to recover our payments <br />from anyone liable for an injury covered by <br />this policy. We will not enforce our right <br />against any person or organization for whom <br />you perform work under a written contract <br />that requires you to obtain this agreement <br />from us. <br />This agreement shall not operate directly or <br />indirectly to benefit anyone not named in the <br />agreement. <br />B. This provision 3. does not apply in the states <br />of Pennsylvania and Utah. <br />Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) <br />This reimbursement provision applies to bodily <br />injury by accident or bodily injury by disease. <br />Bodily injury includes resulting death. <br />1. The bodily injury must be sustained by an <br />officer or employee. <br />2. The bodily injury must occur in the course of <br />employment necessary or incidental to work <br />in a country not listed in Exclusion C.1. of this <br />provision. <br />3. Bodily injury by accident must occur during <br />the policy period. <br />4. Bodily injury by disease must be caused or <br />aggravated by the conditions of your <br />employment. The officer or employee's last <br />exposure to those conditions of your <br />employment must occur during the policy <br />period. <br />B. We Will Reimburse <br />We will reimburse you for all amounts paid by <br />you whether such amounts are: <br />1. voluntary payments for the benefits that <br />would be required of you if you and your <br />officers or employees were subject to any <br />workers' compensation law of the state of <br />hire of the individual employee. <br />2. sums to which Part Two (Employers' Liability <br />Insurance) would apply if the Country of <br />Employment were shown in Item 3.A. of the <br />Information Page. <br />C. Exclusions <br />This insurance does not cover: <br />1. any occurrences in the United States, <br />Canada, and any country or jurisdiction <br />which is the subject of trade or economic <br />sanctions imposed by the laws or regulations <br />of the United States of America in effect as of <br />the inception date of this policy. <br />2. any obligation imposed by a workers' <br />compensation or occupational disease law, <br />or similar law. <br />3. bodily injury intentionally caused or <br />aggravated by you. <br />oR,N F <br />a� <br />RiskMougementDMsian <br />REVIEWED & APPROVED BY. <br />t-I f7Le1J� <br />— J <br />Risk Management Specialist <br />Page 4 of 6 <br />