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C H U B B° Policy Conditions <br />Endorsement <br />Policy Period <br />Effective Date <br />Policy Number <br />Insured <br />Name of Company <br />Date issued <br />This Endorsement applies to the following forms: <br />COMMON POLICY CONDITIONS <br />Conditions <br />Cancellation <br />Policy Conditions <br />MAY 17, 2021 TO MAY 17, 2022 <br />MAY 17, 2021 <br />3602-53-12 TPA <br />CIVICPLUS, LLC <br />GREAT NORTHERN INSURANCE COMPANY <br />DUNE 4, 2021 <br />The following changes are made as respects exposures in the state of Kansas. <br />Under Conditions, Cancellation and When We Do Not Renew are deleted and replaced by the <br />following: <br />We may cancel this policy by mailing or delivering to the first Named Insured written notice of <br />cancellation, stating the reasons for cancellation, at least: <br />• 10 days before the effective date of cancellation if we cancel for nonpayment of premium; or <br />• 30 days before the effective date of cancellation if we cancel for any other reason. <br />If this policy has been in effect for 90 days or more, or if it is a renewal of a policy we issued, we <br />may cancel this policy only for one or more of the following reasons: <br />• nonpayment of premium; <br />• this policy was issued because of a material misrepresentation; <br />• you or any other insured violated any of the material terms and conditions of this policy; <br />• unfavorable underwriting factors, specific to the insured, existed that were not present at the <br />inception of this policy; <br />Kansas Mandatory <br />Form 80-02-9737 (Ed. 3-96) Endorsement <br />Rifil>,i Dhiakm <br />WoEwm & APPROVED BY' <br />/QiG �[£/SP.Qf2 <br />Risk NFanagement Cl eriral Aide <br />