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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 21 <br /> (Ed.01-08) <br /> OPTIONAL PREMIUM INCREASE ENDORSEMENT—CALIFORNIA <br /> You must provide us, or our authorized representative, access to records necessary to perform a payroll verification audit. If you <br /> fail to provide access within 90 days after expiration of the policy, you are liable to pay a total premium equal to 3 times our <br /> current estimate of the annual premium for your policy. In addition, if you fail to provide access after our third request within a 90 <br /> day or longer period, you are also liable for our costs in attempting to perform the audit unless you provide a compelling business <br /> reason for your failure. <br /> We will contact you to schedule appointments during normal business hours. <br /> We will notify you of your failure to provide access by mailing a certified, return-receipt document stating the increased premium <br /> and the total amount of our costs incurred in our attempt(s)to perform an audit. In addition to any other obligations under this <br /> contract, 30 days after you receive the notification, you will be obligated to pay the total premium and costs referenced above. If, <br /> thereafter, you provide access to your records within three years after the policy expires, or within another mutually agreed upon <br /> time, and we succeed in performing the audit to our satisfaction, we will revise your total premium and the costs due to reflect the <br /> results of the audit. <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 /> WC040421 <br /> (Ed. 01-08) <br />