S.A. POLICE OFFICERS ASSOC 2 - 2013

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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 01 A Ed. 3-98 POLICY AMENDATORY ENDORSEMENT -CALIFORNIA It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of Califomia in item 3 of the information Page is subject to the following provisions. 1. Minors Illegally Employed -Not Insured. This policy does not cover liability for additional compensation imposed on you under Section 4557, Division IV, Labor Code of the State of Califomia, by reason of injury to an employee under sixteen years of age and illegally employed at the time of the injury. 2. Punitive or Exemplary Damages -Uninsurable. This policy does not cover punitive or exemplary damages where insurance of liability therefore is prohibited by law or contrary to public policy. 3. Increase In Indemnity Payment -Reimbursement. You are obligated to reimburse us for the amount of increase in indemnity payments made pursuant to Subdivision (d) of Section 4650 of the Califomia Labor Code, if the late indemnity payment which gives rise to the increase in the amount of payment is due less than seven (7) days after we receive the completed claim form from you. You are obligated to reimburse us for any increase in indemnity payments not covered under this policy and will reimburse us for any increase in indemnity payment not covered under the policy when the aggregate total amount of the reimbursement payments paid in a policy year exceeds one hundred dollars ($100). If we notify you in writing, within 30 days of the payment, that you are obligated to reimburse us, we will bill you for the amount of increase in indemnity payment and collect it no 4. Application of Policy. Part One, "Workers Compensation Insurance", A, "How This Insurance Applies", is amended to read as follows: This workers compensation insurance applies to bodily injury by accident or disease, including death resulting therefrom. Bodily injury by accident must occur during the policy period. Bodily injury by disease must be caused or aggravated by the conditions of your employment. Your employee's exposure to those conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. Rate Changes. The premium and rates with respect to the insurance provided by this policy by reason of the designation of California in Item 3 of the inforrnation Page are subject to change if ordered by the Insurance Commissioner of the State of California pursuant to Section 11737 of the Califomia Insurance Code. 6. Long Term Policy. If this policy is written for a period longer than one year, all the provisions of this policy shall apply separately to each consecutive twelve-month period or, if the first or last consecutive period is less than twelve months, to such period of less than twelve months, in the same manner as if a separate policy had been written for each consecutive period. 7. Statutory Provision. Your employee has a first lien upon any amount which becomes owing to you by us on account of this policy, and in the case of your legal incapacity to receive the money and pay it to the claimant, we will pay it directly to the claimant. It is further agreed that this policy, including all endorsements forming a part thereof, constitutes the entire contract of insurance. No condition, provision, agreement, or understanding not set forth in this policy or such endorsements shall affect such contract or any rights, duties, or privileges arising therefrom. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement 12/01/2011 Policy Endorsement Effective No MW00017162-01 No. Insured Santa Ana Police Officers Association anon Insurance ~ P Company Markel Insurance Company Countersigned By: ©1998 by the Workers' Compensation Insurance Rating Bureau of Califomia. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual ©2001 16 of 28