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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WCQ9UG57 <br />12/1 <br />ENDORSEK8ENT# <br />This endorsement, effective 12:01 a.m., 01-01'2017 forms part of <br />Policy No. RVVDA435163-11 issued boArcmdieU3,Inc. <br />by XL Insurance America, Inc. <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />CANCELLATION NOTIFICATION TDOTHERS ENDORSEMENT <br />This endorsement modifies insurance provided under the following: <br />WORKERS'COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br />|nthe event coverage is cancelled for any statutorily permitted reason, other than nonpaymentof premium, <br />advanced written notice will be mailed or delivered to person(s) or entity(ies) accordingtothonoUfoation <br />schedule shown below: <br />All other terms and conditions ofthe Policy remain unchanged. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless <br />otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to <br />preparation ofthe pm|icy.) <br />Endorsement Effective 01-01-2017 Policy No. RVVD04351G3'11 Endorsement No. <br />Insured AnnadioU.S..Inc. Premium Included <br />Insurance Company <br />XL Insurance America, Inc. Countersigned by <br />WCQ0OSG' <br />Ed. 12/10 @201OXl.America, Inc. All Rights Reserved. <br />Number of Days <br />Name of Person(s) or Entity(ies) <br />Mailing Address: <br />Advanced <br />Notice of <br />When required in a written agreement, <br />per the most current schedule maintained <br />by Aon Risk Services South, Inc. for <br />Arcadis U.S., Inc., CallisonRTKL, Inc. and <br />On File <br />30 <br />their subsidiaries furnished to XL Catlin <br />45 days prior to the effective date of <br />All other terms and conditions ofthe Policy remain unchanged. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless <br />otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to <br />preparation ofthe pm|icy.) <br />Endorsement Effective 01-01-2017 Policy No. RVVD04351G3'11 Endorsement No. <br />Insured AnnadioU.S..Inc. Premium Included <br />Insurance Company <br />XL Insurance America, Inc. Countersigned by <br />WCQ0OSG' <br />Ed. 12/10 @201OXl.America, Inc. All Rights Reserved. <br />