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III i:IRI4kiIBiel :4.1. 4 M14kikI[s]:/_1ki It] 4•'19:I:11e7lill[wMJIIIIIIIA-l"ANA-1111kIDEA N411111111MA <br />AMENDMENT TO WORKERS' COMPENSATION BROAD FORM <br />ENDORSEMENT- EMPLOYERS' LIABILITY STOP GAP COVERAGE <br />Policy Number: 6 WEG B❑3❑P❑ Endorsement Number: <br />Effective Date: 11/04/2❑ Effectie Eolir is to same as stated on t❑e Information Page of tie policy. <br />Named Insured and Address: Beginners Edge Sports Training <br />❑432 E TIERRA B❑E❑A L❑ <br />SCOTTSDALE All 8E260 <br />T❑is endorsement cenges tie Worers❑ <br />Compensation Broad Form Endorsement ❑ <br />Employers- LiaJlity Stop Gap Co erage <br />6. Employers- LiaJlity Stop Gap Coerage <br />A. T❑is coerage only applies in ❑ort❑ Da❑bta, <br />O❑io, WasJngton, and Wyoming <br />E. T❑is paragrap❑ is remoed. <br />Form WC 99 03 58 B Printed in ❑.S.A [Ed. ❑/0811 <br />Process Date: 11 /04/2 ❑ <br />Policy Expiration Date: 11/04/26 <br />