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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT <br />CAREFULLY. <br />ENDORSEMENT# <br />This endorsement, effective 12:01 A.M. 4/01/2014 forms a part of Policy <br />No. WC013566204 issued to Bureau Veritas North America by National Union Fire Ins Co of <br />Pittsburgh <br />(The above "attaching clause ° need be completed only when this endorsement 13 Issued subsequent to the preparation of the policy). <br />NOTICE OF CANCELLATION AND NONRENEWAL TO CERTIFICATE HOLDER <br />This endorsement modifies insurance provided under the following: <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />We shall provide written notice in accordance with state law in the event this policy is <br />cancelled or nonrenewed, for any reason other than non payment of premium, to those <br />entities set out in the schedule below. <br />Schedule <br />Notice will be mailed to: City of Santa Ana, 20 Civic Center Plaza (M -30), Santa Ana, CA <br />92702 -1988 <br />To the attention of., Clerk of the City Council <br />Contract, Permit or Job Number: (ERS) Program Management; 2509.14.27681. <br />WC 99 00 45 (Ed. 7/03) <br />