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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 33 <br />NOTIFICATION TO OTHERS OF CANCELLATION 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 this policy by written notice to you for any reason other than nonpayment of premium, we will mail <br />or deliver a copy of such written notice of cancellation to the name and address corresponding to each person <br />or organization shown in the Schedule below. Notification to such person or organization will be provided at <br />least 10 days prior to the effective date of the cancellation, as advised in our notice to you, or the longer <br />number of days notice if indicated in the Schedule 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) / <br />Or anization s : Number of Days Notice: <br />PER ATTACHED SCHEDULE OF HOLDERS 30 <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 04/01/2016 <br />Insured <br />Iteris, Inc. <br />Insurance Company <br />American Zurich Insurance Company <br />Policy No. WC019188400 <br />Endorsement No. <br />Premium $ N/A <br />REVi(E Wil D Y,R: �,+'�,.�" p ,�/ �'"i,�iR` K E HEREDIA <br />WC 99 06 33 — __._._ _. y,_. ___.._. amu___ �.._.__ __.... _ __..__ .... .._._------------ — <br />(Ed. 05-10) Includes copyrighted material of National Council on Compensation Insurance, Inc. with its permission. Page 1 of 1 <br />