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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 04 A (Ed. 01-23) COVID-19 REPORTING REQUIREMENT ENDORSEMENT—CALIFORNIA In addition to the requirements under Part 4, "Your Duties if Injury Occurs" of your policy, if you have five or more employees and an employee that is not described in California Labor Code section 3212.87 tests positive for COVID-19, you are required to report the following information as provided below. Pursuant to California Labor Code Section 3212.88(i), when you know, or reasonably should know, that an employee has tested positive for COVID-19 between September 17, 2020 and January 1, 2024,you must report to your claims administrator in writing via electronic mail or facsimile within 3 business days all of the following: (1) An employee has tested positive. For purposes of this reporting, do not provide any personally identifiable information regarding the employee who tested positive for COVID-19 unless the employee asserts the infection is work related or has filed a claim form pursuant to California Labor Code Section 5401. (2) The date that the employee tests positive, which is the date the specimen was collected for testing. (3) The specific address or addresses of the employee's specific place of employment during the 14-day period preceding the date of the employee's positive test. (4) The highest number of employees who reported to work at the employee's specific place of employment in the 45-day period preceding the last day the employee worked at each specific place of employment. Labor Code Section 3212.88(j)states that the intentional submission of false or misleading information or the failure to report the above information as required may subject you to a civil penalty in the amount of up to$10,000 to be assessed by the Labor Commissioner. For the purposes of these reporting requirements, California Labor Code Section 3212.88(m) provides the following: (1) "COVID-19" means the 2019 novel coronavirus disease. (2) "Test"or"testing" means a PCR(Polymerase Chain Reaction)test approved for use or approved for emergency use by the United States Food and Drug Administration to detect the presence of viral RNA. "Test"or"testing"does not include serologic testing, also known as antibody testing."Test"or"testing" may include any other viral culture test approved for use or approved for emergency use by the United States Food and Drug Administration to detect the presence of viral RNA which has the same or higher sensitivity and specificity as the PCR test. (3) "A specific place of employment" means the building, store,facility, or agricultural field where an employee performs work at the employer's direction. "A specific place of employment"does not include the employee's home or residence, unless the employee provides home health care services to another individual at the employee's home or residence. Note: This endorsement is only applicable until January 1,2024,unless the repeal date of California Labor Code Section 3212.88 is extended. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Insurance Company Countersigned By WC040604A (Ed. 01-23)