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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 01 A <br />(Ed. 12-93) <br />CALIFORNIA CANCELATION ENDORSEMENT <br />This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the <br />Information page. <br />The cancelation condition in Part Six (Conditions) of the policy is replaced by these conditions: <br />cancelation <br />1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation is to <br />take effect. <br />2. We may cancel this policy for one or more of the following reasons: <br />a. Non-payment of premium; <br />b. Failure to report payroll; <br />c. Failure to permit us to audit payroll as required by the terms of this policy or of a previous policy issued by us; <br />d. Failure to pay any additional premium resulting from an audit of payroll required by the terms of this policy or any <br />previous policy issued by us; <br />e. Material misrepresentation made by you or your agent; <br />f. Failure to cooperate with us in the investigation of a claim; <br />g. Failure to comply with Federal or State safety orders; <br />h. Failure to comply with written recommendations or our designated loss control representatives; <br />1. The occurrence of a material change in the ownership of your business; <br />j. The occurrence of any change in your business or operations that materially increases the hazard for frequency or <br />severity of loss; <br />k. The occurrence of any change in your business or operation that requires additional or different classification for <br />premium calculation; <br />I. The occurrence of any change in your business or operation which contemplates an activity excluded by our <br />reinsurance treaties. <br />3. If we cancel your policy for any of the reasons listed in (a) through (f), we will give you 10 days advance written notice, <br />stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the <br />Information Page will be sufficient to prove notice. If we cancel your policy for any of the reasons listed in Items (g) <br />through (1), we will give you 30 days advance written notice; however, we agree that in the event of cancelation and <br />reinsuance of a policy effective upon a material change in ownership or operations, notice will not be provided. <br />4. The policy period will and on the day and hour stated in the cancelation notice. <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 Policy No. Endorsement No. <br />Insured <br />Insurance Company <br />Countersigned by <br />Premium $ <br />WC 04 06 01 A <br />(Ed. 12-93) <br />