KOSMONT & ASSOCIATES, INC. (dba KOSMONT COMPANIES) (3) - 2017

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Workers' Compensation and Employers' Liability Policy Named Insured Entlorsement Number Insperity, Inc, UC/F City of Santa Ann KOSMONT & ASSOCIATES, INC. 20 Civic Center Plaza (M-25) Santa Ana, CA 92702 19001 Crescent Springs Drive Kingwood, TX 77339 Policy Symbol Policy Number Policy Period Effective Date of Endorsement 2 10/01/2017 TO 10/01/2018 10/01/2017 Issued By (Name of Insurance Company) Ace American Insurance Co. Insert the policy number. The remainder of the information is to be completed only when this endorsement is Issued subsequent to the preparation of the policy. NOTICE TO OTHERS ENDORSEMENT - SPECIFIC PARTIES A, If we cancel the Policy prior to its expiration date by notice to you or the first Named Insured for any reason other than nonpayment of premium, we will endeavor, as set out below, to send written notice of cancellation, via such electronic or other form of notification as we determine, to the persons or organizations listed in the schedule set out below (the "Schedule"). You or your representative must provide us with both the physical and e-mail address of such persons or organizations, and we will utilize such e-mail address or physical address that you or your representative provided to us on such Schedule. B. We will endeavor to send or deliver such notice to the e-mail address or physical address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the cancellation date applicable to the Policy. C. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any cancellation of the Policy. D. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for any incorrect information that you or your representative provide to us. If you or your representative does not provide us with the information necessary to complete the Schedule, we have no responsibility for taking any action under this endorsement. In addition, if neither you nor your representative provides us with e-mail and physical address information with respect to a particular person or organization, then we shall have no responsibility for taking action with regard to such person or entity under this endorsement. E. We may arrange with your representative to send such notice in the event of any such cancellation. P, You will cooperate with us in providing, or in causing your representative to provide, the e-mail address and physical address of the persons or organizations listed in the Schedule. G. This endorsement does not apply in the event that you cancel the Policy. SCHEDULE Name of Certificate Holder E -Mail Address Physical Address City of Santa Ann 20 Civic Center Plaza (M-25) Santa Ana, CA 92702 All other terns and conditions of the Policy remain unchanged. I iC�lE��F2, � Authorized Representative Acct#: 1171322 ALL -32688 (01/11) Page 1 of 1