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SECTION I <br />PARTS ONE and TWOPART THREE <br />1.WE WILL ALSO PAY2.How This Insurance Applies <br />D.WeWillAlsoPayofPartOne(WORKERS’Paragraph4. ofA.How This Insurance <br />COMPENSATION INSURANCE); and <br />AppliesofPart3(OtherStatesInsurance)is <br />E.WeWillAlsoPayofPartTworeplaced by the following: <br />(EMPLOYERS’LIABILITYINSURANCE)is <br />4.Ifyouhaveworkontheeffectivedateofthis <br />replaced by the following: <br />policyinanystatenotlistedinItem3.A.ofthe <br />We Will Also PayInformationPage,coveragewillnotbeafforded <br />forthatstateunlesswearenotifiedwithinsixty <br />Wewillalsopaythesecosts,inadditionto <br />days. <br />otheramountspayableunderthisinsurance, <br />aspartofanyclaim,proceeding,orsuitwe <br />PART SIX <br />defend: <br />3.Transfer Of Your Rights and Duties <br />1.reasonableexpensesincurredatour <br />request,INCLUDING loss of earnings; <br />C.TransferOfYourRightsandDutiesofPart6 <br />(Conditions) is replaced by the following: <br />2.premiumsforbondstorelease <br />attachmentsandforappealbondsin <br />Yourrightsordutiesunderthispolicymaynotbe <br />bondamountsuptothelimitofour <br />transferred without our written consent. <br />liability under this insurance; <br />Ifyoudieandwereceivenoticewithinsixty <br />3.litigation costs taxed against you; <br />daysafteryourdeath,wewillcoveryourlegal <br />representative as insured. <br />4.interestonajudgmentasrequiredby <br />lawuntilweoffertheamountdueunder <br />4.Liberalization <br />this law; and <br />Ifweadoptachangeinthisformthatwouldbroaden <br />5.expenses we incur. <br />thecoverageofthisformwithoutextracharge,the <br />broadercoveragewillapplytothispolicy.Itwill <br />applywhenthechangebecomeseffectiveinyour <br />state. <br />SECTION II <br />VOLUNTARY COMPENSATION AND EMPLOYERS’toworkinastateshowninItem3.A.ofthe <br />LIABILITY COVERAGEInformation Page. <br />5.Voluntary Compensation Insurance3.ThebodilyinjurymustoccurintheUnited <br />StatesofAmerica,itsterritoriesor <br />A.How This Insurance Applies <br />possessions,orCanada,andmayoccur <br />Thisinsuranceappliestobodilyinjuryby <br />elsewhereiftheemployeeisaUnitedStates <br />accidentorbodilyinjurybydisease.Bodily <br />orCanadiancitizen,orotherwiselegal <br />injury includes resulting death. <br />resident,andlegallyemployed,intheUnited <br />1.Thebodilyinjurymustbesustainedby <br />StatesorCanadaandtemporarilyawayfrom <br />anyofficeroremployeenotsubjectto <br />those places. <br />theworkers’compensationlawofany <br />4.Bodilyinjurybyaccidentmustoccurduring <br />stateshowninItem3.A.ofthe <br />the policy period. <br />Information Page. <br />5.Bodilyinjurybydiseasemustbecausedor <br />2.Thebodilyinjurymustariseoutofandin <br />aggravatedbytheconditionsoftheofficer’s <br />the course of employment or incidental <br />or employee’s employment. <br />Form WC 99 03 02 BPrinted in U.S.A. (Ed. 8/00)Page 2 of 4 <br /> <br />