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Irwurance for this coverage part provided by: Policy <br />ZURICH AMERICAN INSURANCE COMPANY <br />NCCI Comoarty Nol0 6 63 <br />NAMED INSURED <br />ENDORSEMENT EFFECTIVE DATE <br />POLICY NUMBER <br />KEENAN & ASSOCIATES INC <br />10 -16 -15 <br />WC 5896463 -03 <br />POLICY TERM: 10 -16 -2015 TO 10 -16 -2016 <br />_ <br />ENDORSEMENT NUMBER 001 <br />Change Description <br />THE FOLLOWING FORM(S) HAS <br />BEEN AMENDED: <br />MAN —CA001 08 -93 <br />WOS— BLANKET — CALIFORNIA <br />THE FOLLOWING FORM(S) HAS <br />BEEN DELETED: <br />WC 04 03 06 04- -84 <br />WAIVER OF RIGHTS TO RECOVER FROM <br />OTHERS <br />PREMIUM CHANGE <br />PRO -RATA FACTOR <br />Additional Coverage Premium NO CHARGE Return Coverage Premium <br />NO CHARGE <br />Additional Taxes & Surcharges <br />Return Taxes & Surchargesmm <br />Total Additional Premium <br />Total Return Premium <br />Countersigned: <br />U- WC- 317- A(07 -94) <br />