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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 33 NOTIFICATION TO OTHERS OF CANCELLATION ENDORSEMENT This endorsement is used to add the following to Part Six of the policy, PART SIX CONDITIONS A. it we cancel this policy by written notice to you for any reason other than nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation to the name and address Corresponding to each person or organization shown in the Schedule below. Notification to such person or organization will be provided at least 10 days prior to the effective date of the cancellation, as advised In our notice to You, or the longer number of days notice if indicated In the Schedule below. B, If we cancel this policy by written notice to you for nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation to the name and address corresponding to each person or organization shown in the Schedule below at least 10 days prior to the effective date of such cancellation. C. If notice as described In Paragraphs A. or B. of this endorsement Is mailed, proof of mailing will be sufficient proof of such notice. SCHEDULE Name and Address of Other Person(s) / I Orcianization(s): F Number of Das Notice. y I PER ATTACHED SCHEDULE OF HOLDERS 1 30 1 All other terms and conditions of this policy remain unchanged. This endorsement changes the policy to which It is attached and is effective on the date Issued unless otherwise stated, (The Information below Is required only when this endorsement is Issued subsequent to preparation of the policy.) Endorsement Effective: 4/112017 Policy No. WC01 9188401 Endorsement No, Insured: Premium: N/A Iterls, Inc, Insurance Company: American Zurich Insurance Company WC 99 06 33 (Ed. 05-10) 111GIUdes copyrighted material of National Council on Compensation Insurance, Inc. with its permission. Page I of 1 REAEWED BEUNK",E HEREsit A