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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B <br /> POLICY INFORMATION PAGE ENDORSEMENT <br /> Insured: Orange County Gold Aquatics Policy No: TSP4812276 <br /> Policy Period: 5/11/2026 to 5/11/2027 Endorsement No: 1 <br /> Carrier Name: Technology Insurance Company, Inc. Endmt Effective: 5/11/2026/1 <br /> Authorized Rep: <br /> The following item(s) <br /> o Insured's Name(WC 89 06 01) ❑ Item 3.B. Limits(WC 89 0612) <br /> o Policy Number(WC 89 06 02) ❑ Item 3.C.States(WC 89 06 13) <br /> o Effective Date(WC 89 06 03) ❑ Item 3,D.Endorsement Numbers(WC 89 06 14) <br /> o Expiration Date(WC 89 06 04) ❑ Item 4.*Class, Rate,Other(WC 89 04 15) <br /> ❑ Insured's Mailing Address(WC 89 06 05) ❑ Interim Adjustment of Premium(WC 89 04 16) <br /> ❑ Experience Modification(WC 89 04 06) ❑ Carrier Servicing Office(WC 89 06 17) <br /> o Producer's Name(WC 89 06 07) 0 Interstate/Intrastate Risk ID Number(WC 89 0618) <br /> o Change in Workplace of Insured(WC 89 06 08) ❑ Carrier Number(WC 89 06 19) <br /> ❑ Insured's Legal Status(WC 89 06 10) 0 Issuing Agency/Producer Office Address(WC 89 06 25) <br /> ❑ Item 3.A.States(WC 89 0611) <br /> is changed to read: <br /> Blanket waiver of subrogation is added to the policy. <br /> Adding form(s): <br />