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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 57 <br />ENDORSEMENT# <br />This endorsement, effective 12:01 a.m., 10-01-2016 forms a part of <br />Policy No, RWD5000148-09 issued to Acco Engineered Systems, Inc. <br />by XL Insurance America, Inc.. <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />CANCELLATION NOTIFICATION TO OTHERS ENDORSEMENT <br />This endorsement modifies insurance provided under the following: <br />WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br />In the event coverage is cancelled for any statutorily permitted reason, other than nonpayment of premium, <br />advanced written notice will be mailed or delivered to person(s) or entity(ies) according to the notification <br />schedule shown below: <br />_.. _... <br />Name of Person(s) or Entity(les) <br />Mailing Address: <br />Number of Days <br />- vance . .__._.. <br />Notice of <br />Cancellation: _ <br />Per the most current schedule maintained by <br />Aon Risk Solutions and furnished to XL Catlin <br />no less than 45 days prior to the effective date <br />of cancellation <br />30 <br />WC 99 06 57 <br />Ed. 12/10 © 2010 X.L. America, Inc. All Rights Reserved. <br />May not be copied without permission. <br />REVIEWED BY: %/�/1 EUNICE HEREDIA IPG oF <br />