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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC040360A <br />(Ed . 11-99) <br />EMPLOYERS' LIABILITY COVERAGE AMENDATORY ENDORSEMENT -CALIFORNIA <br />The insurance afforded by Part Two (Employers' Liability Insurance) by reason of designation of California in <br />item 3 of the information page is subject to the following provisions: <br />A. "How This Insurance Applies," is amended to read as follows: <br />A. How This Insurance Applies <br />This employers' liability insurance applies to bodily injury by accident or bodily injury by disease. <br />Bodily injury means a physical injury, including resulting death. <br />1. The bodily injury must arise out of and in the course of the injured employee's employment by <br />you. <br />2. The employment must be necessary or incidental to your work in California. <br />3. Bodily injury by accident must occur during the policy period. <br />4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. <br />The employee's last day of last exposure to the conditions causing or aggravating such bodily <br />injury by disease must occur during the policy period. <br />5. If you are sued, the original suit and any related legal actions for damages for bodily injury by <br />accident or by disease must be brought in the United States of America, its territories or <br />possessions, or Canada. <br />C. The "Exclusions" section is modified as follows (all other exclusions in the "Exclusions" section <br />remains as is): <br />1. Exclusion 1 is amended to read as follows: <br />1. Liability assumed under a contract. <br />2. Exclusion 2 is deleted. <br />3. Exclusion 7 is amended to read as follows: <br />7. Damages arising out of coercion, criticism, demotion, evaluation, reassignment, <br />discipline, defamation, harassment, humiliation, discrimination against or <br />termination of any employment, or any personnel practices, policies acts or <br />omissions. <br />4. The following exclusions are added. <br />1. bodily injury to any member of the flying crew of any aircraft. <br />2. bodily injury to an employee when you are deprived of statutory or common law <br />defenses or are subject to penalty because of your failure to secure your <br />obligations under the workers' compensation law(s) applicable to you or <br />otherwise fail to comply with that law. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement Effective 12/01!2011 Policy No. MW00017162-01 Endorsement No. <br />Insured: Santa Ana Police Officers Association (a <br />nonp Premium (See Attached) <br />Insurance Company: Markel Insurance Company Countersigned by <br />WC040360A <br />© 1999 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />From the WCRIB's California Workers' Compensation Insurance Forms Manual m 2001 <br />17 of 28 <br />