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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />MWC 1403 0510 <br />CALIFORNIA -AMENDATORY ENDORSEMENT <br />This endorsement only applies to the California coverage provided by the policy because California is shown in <br />Item 3.A. of the information page. <br />For California coverage part 6, the cancellation condition of the policy is amended to include: <br />If you cancel final premium will be more than pro-rata; it will be based on time this policy was in force, and <br />increased by our short rate cancellation table shown below. Final premium will not be less than the minimum <br />premium. <br />SHORT RATE CANCELLATION TABLE FOR A TERM OF ONE YEAR <br /> <br />PoDcys Percent <br />of <br />Days <br />Percent <br />Days <br />Percent <br />In Fore One Year <br />Premium Policy <br />In Force of <br />One Year Poticy <br />In Force °f <br />One Year <br /> <br />1 Premium Premium <br />................. . 5% 95-98 <br />.................. <br />.. <br />37% 219-223 <br /> <br />.................. 0 <br /> <br />.. <br />69 /o <br />................... <br /> <br /> <br />-4 . 6 99-102 <br />.................. <br />.. <br />38 224-228 <br /> <br />.................. <br /> <br />.. <br />70 <br />•~•••~••~~ ~ ~• • 7 103-105 <br />.................. <br />. <br />39 229-232 <br /> <br />.... <br />71 <br /> <br />-g ~••••••~~• ~••~~••• <br />8 <br />106-109 <br />................... <br /> <br />. <br />40 .............. <br />233-237 . <br /> <br />72 <br /> <br />-8 ~••~~• •••~•~•~~•• <br /> <br />9-10 <br />• 9 <br />110-113 <br />................... <br /> <br />. <br />41 .................. <br />238-241 <br /> <br />.................. .. <br /> <br /> <br />.. <br />73 <br />••~~••~•••••••..... <br /> <br />11-12 . 10 114-116 <br />................... <br />. <br />42 242-246 (8 mos.)..... . 74 <br />.................... <br /> <br />13-14 11 117-120 <br />................... <br />. <br />43 247-250 <br /> <br />.................. <br /> <br />.. <br />75 <br />•••~•••~••~~........ 12 121-124 (4 mos.)...... 44 251-255 <br />... <br />76 <br />15-16 <br />••~•••~••~~......... 13 125-127 <br />................... <br />. <br />45 ............... <br />256-260 .. <br />77 <br />17-18 <br />~••~~••~••.......... <br />14 <br />128-131 <br />................... <br /> <br />. <br />46 .................. <br />261-264 .. <br /> <br />78 <br />19-20 <br />~~•~~••~•••~........ <br /> <br />21-22 <br />15 <br />132-135 <br />.................... <br />47 ................... <br />265-269 <br /> <br />................... . <br /> <br /> <br />. 79 <br />•••~~~••~••~........ <br /> <br />23-25 16 136-138 <br />.................... 48 270-273 <br />(9 mos.)...... <br />80 <br />.................... <br /> <br />26-29 17 139-142 <br />................... 49 274-278 <br /> <br />.................. <br /> <br />. <br />81 <br />••~•••~•••~~•~~..... <br /> <br />30-32 <br />(1 mo <br />) 18 <br /> <br /> <br />19 143-146 <br />.................... 50 279-282 <br /> <br />.................. <br /> <br />. <br />82 <br />. <br />........ <br />33-36 147-149 .................... 51 283-287 <br />................... <br />. <br />83 <br />••••~••~~••......... 20 150-153 (5 mos.)...... 52 288-291 <br />84 <br />37-40 <br />•••••••••••••....... 21 154-156 <br />.................... 53 ................... <br />292-296 <br />. . <br />85 <br />41-43 <br />.................... <br />22 <br />157-160 <br />.................... <br />54 ................... <br />297-301 <br /> <br /> <br />6 <br />447 •~••~•••~••••••••••• <br /> <br />48-51 23 161-164 <br />.................... 55 .................... <br />302-305 (10 mos.).... 87 <br />.................... <br /> <br />52-54 24 165-167 <br />.................... 56 306-310 <br /> <br />.................... <br />88 <br />•~~~ • ~• ~~........ <br /> <br />55-58 25 168-171 <br />.................... 57 311-314 <br /> <br />.................... <br />89 <br />.................... <br /> <br />59-62 (2 mos <br />) 26 <br /> <br />27 172-175 <br />.................... 58 315-319 <br /> <br />~~••~~•••~~••~••~• • <br />90 <br />. <br />...... <br />63-65 176-178 <br />.................... 59 350-323 <br />.................... 91 <br />~~ •~~••~....... <br />66-69 28 179-182 (6 mos.)...... 60 324-328 <br />................... <br />92 <br />~••~~••~•••~••~~.... <br /> <br />70-73 29 183-187 <br />.................... 61 329-332 <br /> <br />.................... <br /> <br />93 <br />•~~• •••~~.•....... <br /> <br />74-76 30 188-191 <br />.................... 62 333-337 (11 mos.).... 94 <br />.................... <br /> <br />77-80 31 192-196 <br />.................... 63 338-342 <br /> <br />.................... <br />95 <br />.................... <br />81-83 32 197-200 .................... 64 343-346 <br />.................... <br />96 <br />~••~~•~~••••••...... <br /> <br /> <br />-87 33 201-205 <br />.................... 65 347-351 <br /> <br />.................... <br />97 <br />.................... <br /> <br />88-91 ) <br />(3 mos 34 <br /> <br /> <br />35 206-209 <br />................... 66 352-355 <br /> <br />.................... <br />98 <br />....... 210-214 (7 mos.)...... 67 356-360 . 99 <br />92-94 .................... 36 215-218 <br />.................... 68 ................... <br />361-365 (12 mos.)..... 100 <br />This endorsement changes the policy to which it is attached and is effective on the date is <br />d <br />l <br /> <br />(The information below is required onl <br />y when this endorsement is issued sue <br />un <br />ess otherwise stated. <br />sub <br /> sequent to prepar ation of the policy.) <br />Endorsement Effective 12/01/2011 Policy No. MW00017162-01 <br />Insured Santa Ana Police Officers Association (a Insurance Company Markel Insurance Company Endorsement No. <br />nonp <br />19 of 28 <br />