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WC 04 03 01 D WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> (Ed. 02-18) <br /> It is further agreed that this policy, including all endorsements forming a part thereof, constitutes the entire contract of insurance. <br /> No condition, provision, agreement, or understanding not set forth in this policy or such endorsements shall affect such contract <br /> or any rights, duties, or privileges arising therefrom. <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 Insurance Company <br /> Countersigned By <br /> 2 of 2 <br /> WC040301 D <br /> (Ed. 02-18) <br />