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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). 'I'his endorsement, effective '1.2:01 AM 1/1/2016 forms a part of Policy No. SHE XI"I eAC;I ll?D ACORD 101 Issued to AlX:ON,l Al:C:O\d "Technical Services, Inc. By The Insurance Company of the State of Pennsylvania LIMITED ADVICE OF CANCELLATION TO SCHEDULED ENTITIES (WORKERS' COMPENSATION ONLY) I'his policy is amended as follows: In the event that the Insurer cancels this policy for any reason other than non-payment of premium, and 1. the cancellation effective date is prior to this policy's expiation date; 2. the Named Insured or, if applicable, any other employers named in Item 1 of the Information Page is under an existing contractual obligation to notify a certificate holder(s) when this policy is canceled (hereinafter, the "Certificate l Iolder(s)") and the Named Insured has provided the Insurer, either directly or through its broker of record, either: (a) the name of the entity shown on the certificate, a contact name at such entity and the U.S. Postal Service mailing address of each such entity; or (b) the email address of a contact at each such entity; and 3. prior to the effective date of cancellation, the Named Insured confirms to the Insurer, either directly or through its broker of record, that the persons or organizations sct ford) in the Schedule below, as well as their respective addresses listed, should continue to be a part of the Schedule and, if not, the names of the persons or organisations that should be deleted, the Insurer will provide advice of cancellation (the "Advice") to each such Certificate Ilolder(s) confirmed by the Named Insured in writing to be correctly a part of the Schedule. within 30 days after the Named Insured confirms the accuracy of the Schedule below with the Insurer; provided, however, that if a specific member of clays is not stated above, then the Advice will be provided to such Certificate Iloldcr(s) as soon as reasonable practicable after the Named Insured confirms the accuracy of the Schedule below with the Insurer. Proof of the Insurer einailing the Advice, using the information provided and subsequently confirmed by the Named Insured in writing, will serve as proof that the Insurer has fully satisfied its obligations cinder this endorsement. This endorsement does not affect, in any way, coverage provided under this policy or the cancellation of this policy or the effective crate thereof, nor shall this endorsement invest any rights in any entity not insured under this policy. The following definitions apply to this endorsement 1. Named Insured means the first named employer in Item I of the Information Page of this policy. 2. Insurer means the insurance company shown in the header on the Information Page of this policy. WC990058 (Ed. 04/11) Attachment Code : D461827 Master ID: 1075642, Certificate ID: 13652858 I1""VBk U1iN N BY: ,�°0�_ D.tBtIt E 1R.Vfl:r1(4 C;