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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 21 F <br /> (Ed.08-2022 Countrywide, Ed.07-2022 in Texas) <br /> CATASTROPHE(OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT <br /> This endorsement is notification that we are charging premium to cover the losses that may occur in the event of a Catastrophe <br /> (Other Than Certified Acts of Terrorism)as that term is defined below.Your policy provides coverage for workers compensation <br /> losses caused by a Catastrophe(Other Than Certified Acts of Terrorism).Coverage for such losses is subject to all terms, <br /> definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. This <br /> premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance <br /> Program Reauthorization Act Disclosure Endorsement attached to this policy. <br /> For purposes of this endorsement, Catastrophe(Other Than Certified Acts of Terrorism) is defined as: A single event or peril <br /> resulting in a group of claims with aggregate workers compensation losses in excess of$50 million.This$50 million threshold <br /> applies per occurrence, across all states for which claims arise from a single event or peril. <br /> The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe(Other <br /> Than Certified Acts of Terrorism)is shown in Item 4 of the Information Page or in the Schedule below. <br /> Schedule <br /> State Rate Premium <br /> CA $0.01 $16.00 <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 Policy No. Endorsement No. <br /> Insured Premium: <br /> Insurance Company Countersigned by <br /> WC000421 F <br /> (Ed.08-2022 Countrywide, Ed.07-2022 in Texas) <br /> 1 of 1 <br /> ©Copyright 2021 National Council on Compensation Insurance, Inc.All Rights Reserved. <br />