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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 99 35
<br />SPECIAL NOTICE OF CANCELLATION SERVICE
<br />PROVIDED TO IDENTIFIED THIRD PARTIES ENDORSEMENT
<br />As a special service to you, if we cancel this policy for any reason other than non-payment of premium,
<br />within thirty (30) days prior to the effective date of cancellation, we will mail a copy of such written notice
<br />of cancellation to all third persons whose name and address have, during the applicable policy period,
<br />been placed on file with us through your broker of record due to third party contractual requirements
<br />relating to such notice.
<br />As a special service to you, if we cancel this policy for non-payment of premium, within ten (10) days prior
<br />to the effective date of cancellation, we will mail a copy of such written notice of cancellation to all third
<br />persons whose name and address have, during the applicable policy period, been placed on file with us
<br />through your broker of record due to third party contractual requirements relating to such notice.
<br />If we have been provided with an electronic address of such third parties, at our election we may send
<br />notice of cancellation to such third parties by electronic mail.
<br />Notice of cancellation of coverage provided to a certificate holder is a courtesy only. Failure to provide
<br />such notice will not extend the policy cancellation date, negate the cancellation of the policy, nor confer
<br />any rights nor expectations upon the certificate holder nor subject us, our agents nor representatives to
<br />liability for failure to provide notice.
<br />THIS FORM APPLIES ONLY TO THE FOLLOWING STATE(S) IF COVERED BY YOUR POLICY. IF A
<br />STATE IS NOT LISTED BELOW, THIS FORM DOES NOT APPLY IN THAT STATE.
<br />AL, AK, AR, CA, CO, CT, DE, DC, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, MD, MA,
<br />MT, MN, MS, MO, MT, NE, NV, NH, NM, NY, OK, PA, RI, SC, SD, UT, VT, VA, WV
<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 10/01/2024 Policy No. LDC4068970 Endorsement No.
<br />Insured TETRA TECH, INC. Premium $ Included
<br />Insurance Company Safety National Casualty Corporation
<br />Countersigned By
<br />WC 99 99 35 (07 12) Page 1 of 1
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