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WC POLICY <br /> TRAVELERS J� WORKERS COMPENSATION <br /> AND <br /> ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br /> HARTFORD CT 06183 <br /> ENDORSEMENT WC 00 00 01 (A) <br /> POLICY NUMBER: UB-3T085335-24-14-G <br /> LISTING OF ENDORSEMENTS <br /> EXTENSION OF INFO PAGE <br /> We agree that the following listed endorsements form a part of this policy on its effective date. <br /> WC 00 00 01 A - 001 INFORMATION PAGE <br /> WC 00 00 01 A - 001 INFORMATION PAGE 2 <br /> WC 00 00 01 A - 001 EXTENSION OF INFORMATION PAGE - SCHEDULE <br /> WC 00 00 01 A - 001 ENDORSEMENT LISTING <br /> WC 09 06 07 A - 001 FL WC INS GUARANTY ASSOC SURCH NOTIFIC <br /> WC 24 04 06 D - 001 MISSOURI EMPLOYER PAID MEDICAL ENDT <br /> WC 36 03 06 00 - 001 OREGON LIMITS OF LIABILITY <br /> WC 36 06 02 00 - 001 OREGON CONFIDENTIALITY ENDORSEMENT <br /> WC 36 06 04 00 - 001 OREGON AMENDATORY ENDORSEMENT <br /> WC 99 06 Q2 00 - 001 MO EARLIER NOT OF CAN OR NONRE BY US END <br /> WC 99 06 U5 00 - 001 OHIO CANCELLATION AND NONRENEWAL ENDT <br /> WC 00 01 06 A - 001 LONGSHORE AND HARBOR WC ACT COVERAGE <br /> WC 00 03 01 A - 001 ALTERNATE EMPLOYER ENDORSEMENT <br /> WC 00 03 01 A - 002 ALTERNATE EMPLOYER ENDORSEMENT <br /> WC 00 03 01 A - 003 ALTERNATE EMPLOYER ENDORSEMENT <br /> WC 00 03 01 A - 004 ALTERNATE EMPLOYER ENDORSEMENT <br /> WC 00 03 01 00 - 001 ALTERNATE EMPLOYER ENDORSEMENT <br /> WC 00 03 01 00 - 002 ALTERNATE EMPLOYER ENDORSEMENT <br /> WC 00 03 01 00 - 003 ALTERNATE EMPLOYER ENDORSEMENT <br /> WC 00 03 01 00 - 004 ALTERNATE EMPLOYER ENDORSEMENT <br /> WC 00 03 03 C - 001 EMPLOYERS LIAB COVERAGE ENDT <br /> WC 00 03 11 A - 001 VOLUNTARY COMP AND EMPLOYERS LIAB COV <br /> WC 00 03 13 00 - 001 WAIVER OF OUR RIGHT TO RECOVER <br /> WC 00 03 13 00 - 002 WAIVER OF OUR RIGHT TO RECOVER <br /> WC 00 04 06 00 - 001 PREMIUM DISCOUNT ENDORSEMENT <br /> WC 00 04 06 A - 001 PREMIUM DISCOUNT ENDORSEMENT <br /> WC 00 04 14 00 - 001 NOTIFICATION OF CHANGE IN OWNERSHIP ENDT <br /> WC 00 04 14 A - 001 NOTIFICATION OF CHG IN OWNR ENDT <br /> WC 00 04 22 C - 001 TERRORISM RISK INS PROG REAUTH ACT ENDT <br /> WC 00 04 24 00 - 001 AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT <br /> WC 00 04 25 00 - 001 EXPER RATING MOD FACTOR REVISION ENDT <br /> WC 04 03 01 B - 001 POLICY AMENDATORY ENDORSEMENT-CALIFORNIA <br /> WC 09 04 03 C - 001 FL TRIPRA ENDORSEMENT <br /> DATE OF ISSUE: 05-28-24 ST ASSIGN: APPROVED <br /> By Cynthia Mora at 8:13 am,Oct 31,2024 <br />