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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 Ol A <br />Effective December 1, 1993 <br />CALIFORNIA CANCELATION ENDORSEMENT <br />This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. <br />of the Information Page. <br />The cancellation condition in Part Six (Conditions) of the policy is replaced by these conditions: <br />Cancellation: <br />1. You may cancel this policy. You must mail or deliver advance notice to us stating when the cancellation is <br />to take effect. <br />We may cancel this policy for one or more of the following reasons: <br />a. Non-payment of premium; <br />b. Failure to report payroll; <br />c. Failure to permit us to audit payroll as required by the terms of this policy of a previous policy issued <br />by us; <br />d. Failure to pay any additional premium resulting from an audit of payroll required by the terms of this <br />policy or any previous policy issued by us; <br />e. Material misrepresentation made by you or your agent; <br />f. Failure to cooperate with us in the investigation of a claim; <br />g. Failure to comply with federal or state safety orders; <br />h. Failure to comply with written recommendation of our designated loss control representatives; <br />i. The occurrence of a material change in the ownership of your business; <br />j. The occurrence of any change in your business or operations that materially increases the hazard for <br />frequency or severity of loss; <br />k. The occurrence of any change in your business or operations that requires additional or different <br />classification for premium calculation; <br />1. The occurrence of any change in your business or operation which contemplates an activity excluded <br />by our reinsurance treaties. <br />If we cancel your policy for any of the reasons listed in (a) through (f), we will give you 10 days advance <br />written notice, stating when the cancelation is to take effect. Mailing that notice to you at your mailing <br />address shown in Item 1 of the Information Page will be sufficient to prove notice. If we cancel your policy <br />for any of the reasons listed in Item (g) through (1), we will give you 30 days advance written notice; <br />however, we agree that in the event of cancelation and reinsuance of a policy effective upon a material <br />change in ownership or operations, notice will not be provided. <br />The policy period will end on the day and hour stated in the cancellation notice. <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 />WC040601 A <br />© 1998 by the Workers' Compensation Insurance Rating Bureau of Cal'rfomia. All rights reserved. <br />From the WCRIB's Cal'rfomia Workers' Compensation Insurance Forms Manual ©2001 <br />18 of 28 <br />