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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 99 06 35 <br />NOTIFICATION TO OTHERS OF CANCELLATION OR NONRENEWAL ENDORSEMENT <br />This endorsement is used to add the following to Part Six of the policy. <br />PART SIX <br />CONDITIONS <br />A If we cancel or non-renew this policy by written notice to you for any reason other than nonpayment of <br />premium, we will mail or deliver a copy of such written notice of cancellation or non-renewal to the name and <br />address corresponding to each person or organization shown in the Schedule below. Notification to such <br />person or organization will be provided at least 10 days prior to the effective date of the cancellation or non- <br />renewal, as advised in our notice to you, or the longer number of days notice if indicated in the Schedule <br />below. <br />B. If we cancel this policy by written notice to you for nonpayment of premium, we will mail or deliver a copy of <br />such written notice of cancellation to the name and address corresponding to each person or organization <br />shown in the Schedule below at least 10 days prior to the effective date of such cancellation. <br />C. If notice as described in Paragraphs A or B. of this endorsement is mailed, proof of mailing will be sufficient <br />proof of such notice. <br />SCHEDULE <br />Name and Address of Other Person(s) I Organization(s): Number of <br />Days Notice: <br />HILL PROJECT #PON-01324 30 <br />CITY PROJECT 406-1723 <br />FEDERAL PROJECT BHLS-5063(089) <br />CITY" OF SANTA ANA <br />20 CIVIC CENTER PLAZA - ROSS ANNEX (M-22) <br />SANTA ANA, CA 92701 <br /> <br />All other terms and conditions of this policy remain unchanged. <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 Premium $ <br />Insurance Company <br />WC 99 06 35 <br />(Ed 05-10) trch-des :opyrghted nateriai of National „o_ncil on Cornpersation'nsurance. n?. vvrh its permission. Page 1 of 1 <br />nsurN Caoy