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TRAVELERS I' WORKERS COMPENSATION <br /> AND <br /> EMPLOYERS LIABILITY POLICY <br /> ONE TOWER SQUARE <br /> HARTFORD CT 06183 ENDORSEMENT WC 04 06 01 ( B) <br /> POLICY NUMBER: UB-5Y330739-25-I5-G <br /> CALIFORNIA CANCELATION ENDORSEMENT <br /> This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of <br /> the Information Page. <br /> The cancelation condition in Part Six (Conditions) of the policy is replaced by these conditions: <br /> Cancelation: <br /> 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the <br /> cancelation is to take effect. <br /> 2. We may cancel this policy for one or more of the following reasons: <br /> a. Non-payment of premium; <br /> b. Failure to report payroll; <br /> c. Failure to permit us to audit payroll as required by the terms of this policy or of a previous policy issued by <br /> us; <br /> d. Failure to pay any additional premium resulting from an audit of payroll required by the terms of this policy <br /> or any previous policy issued by us; <br /> e. Material misrepresentation made by you or your agent; <br /> f. Failure to cooperate with us in the investigation of a claim; <br /> g. Material failure to comply with federal or state safety orders or written recommendations of our designated <br /> loss control representatives; <br /> h. The occurrence of a material change in the ownership of your business; <br /> i. The occurrence of any change in your business or operations that materially increases the hazard for <br /> frequency or severity of loss; <br /> j. The occurrence of any change in your business or operation that requires additional or different <br /> classification for premium calculation; <br /> k. The occurrence of any change in your business or operation which contemplates an activity excluded by <br /> our reinsurance treaties. <br /> 3. If we cancel your policy for any of the reasons listed in (a) through (f), we will give you 10 days advance <br /> written notice, stating when the cancelation is to take effect. Mailing that notice to you at your mailing address <br /> shown in Item 1 of the Information Page will be sufficient to prove notice. If we cancel your policy for any of <br /> the reasons listed in Items (g) through (k), we will give you 30 days advance written notice; however, we <br /> agree that in the event of cancelation and reissuance of a policy effective upon a material change in <br /> ownership or operations, notice will not be provided. <br /> Form WC 04 06 01 ( B) <br /> DATE OF ISSUE: 03-11-25 ST ASSIGN: Page 1 of 2 <br />