Laserfiche WebLink
/�� WORKERS COMPENSATION <br /> TRAVELERS <br /> AND <br /> ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br /> HARTFORD CT 06183 ENDORSEMENT WC 99 06 R3 (00) - 004 <br /> POLICY NUMBER: UB-5J743745-25-47-G <br /> NOTICE OF CANCELLATION <br /> TO DESIGNATED PERSONS OR ORGANIZATIONS <br /> The following is added to PART SIX—CONDITIONS : <br /> Notice Of Cancellation To Designated Persons Or Organizations <br /> If we cancel this policy for any reason other than non-payment of premium by you, we will provide notice of such <br /> cancellation to each person or organization designated in the Schedule below. We will mail or deliver such notice <br /> to each person or organization at its listed address at least the number of days shown for that person or organiza- <br /> tion before the cancellation is to take effect. <br /> You are responsible for providing us with the information necessary to accurately complete the Schedule below. <br /> If we cannot mail or deliver a notice of cancellation to a designated person or organization because the name or <br /> address of such designated person or organization provided to us is not accurate or complete, we have no <br /> responsibility to mail, deliver or otherwise notify such designated person or organization of the cancellation. <br /> SCHEDULE <br /> Name and Address of Designated Persons or Organizations: Number of Days Notice <br /> CITY OF SANTA ANA <br /> 20 CIVIC CENTER PLAZA, 4TH FLOOR 30 <br /> SANTA ANA CA 92701 <br /> All other terms and conditions of this policy remain unchanged. <br /> This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise <br /> stated. <br /> (The information below is required only when this endorsement is issued subsequent to preparation of <br /> the policy.) <br /> Endorsement Effective Policy No. Endorsement No. <br /> Insured Premium $ <br /> Insurance Company Countersigned by <br /> DATE OF ISSUE: 04-17-25 ST ASSIGN: Page 1 of 1 <br /> ©2013 The Travelers Indemnity Company.All rights reserved. <br />