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IL 10 (12/06) OLD REPUBLIC INSURANCE <br /> BLANKET NOTIFICATION TO OTHERS CANCELLATION <br /> THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> SCHEDULE <br /> NUMBER OF DAYS NOTICE: 30 <br /> PERSON OR ORGANIZATION : All certificate holders where notice of cancellation is required by <br /> written contract with the named insured subject to the following procedures: <br /> We will mail or deliver notification that such coverage part has been cancelled to each person or <br /> organization shown in an accurate schedule provided to us by the first named insured at inception of the <br /> policy or as periodically updated. <br /> Notice will be mailed or delivered as soon as practicable after an accurate list of names and addresses is <br /> provided to us by the first named insured in response to our request. <br /> A. IF WE CANCEL THIS POLICY BY WRITTEN NOTICE TO THE FIRST <br /> NAMED INSURED FOR ANY REASON OTHER THAN NONPAYMENT OF <br /> PREMIUM, WE WILL MAIL OR DELIVER A COPY OF SUCH WRITTEN <br /> NOTICE OF CANCELLATION: <br /> 1 . TO THE NAMED AND ADDRESS CORRESPONDING TO EACH <br /> PERSON OR ORGANIZATION SHOWN IN THE ABOVE SCHEDULE <br /> AND <br /> 2 . AT LEAST 10 DAYS PRIOR TO THE EFFECTIVE DATE <br /> OF THE CANCELLATION, AS ADVISED IN OUR NOTICE TO <br /> THE FIRST NAMED INSURED, OR THE LONGER NUMBER OF <br /> DAYS NOTICE IF INDICATED IN THE ABOVE SCHEDULE. <br /> B . IF WE CANCEL THIS POLICY BY WRITTEN NOTICE TO THE FIRST <br /> NAMED INSURED FOR NONPAYMENT OF PREMIUM, WE WILL MAIL <br /> OR DELIVER A COPY OF SUCH WRITTEN NOTICE OF <br /> CANCELLATION TO THE NAME AND ADDRESS CORRESPONDING TO <br /> EACH PERSON OR ORGANIZATION SHOWN IN THE ABOVE SCHEDULE <br /> \ / <br /> g a ,. Risk Managzm.ent Division <br /> FORM A _ REVIEWED&APPROVED By: <br /> MWC313940 24 PCL Construction Enterprises,Inc. 07/01/24-07/01/25 ' Risk t4anagement Specialist <br /> Page 1 / \ <br />