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TRAVELERS JW WORKERS COMPENSATION <br />AND <br />ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD CT 06183 ENDORSEMENT WC 99 03 C3 (00) — <br />POLICY NUMBER: UB -9L110474 -19-42-G <br />SPECIAL PROVISIONS ENDORSEMENT <br />STATE APPLICABILITY <br />The listed endorsements are only applicable in the following states: <br />WC 00 03 13 (00)-001 WAIVER OF OUR RIGHT TO RECOVER <br />APPLIES TO STATE(S): AZ <br />WC 00 03 13 (00)-006 WAIVER OF OUR RIGHT TO RECOVER <br />APPLIES TO STATE(S): AZ <br />WC 00 04 14 ( A)-001 NOTIFICATION OF CHG IN OWNR ENDT <br />APPLIES TO STATE(S): AZ <br />WC 00 04 21 ( D)-001 CATASTROPHE (O/T CERT. ACTS OF TERR)ENDT <br />APPLIES TO STATE(S): AZ CA <br />WC 00 04 22 ( B)-001 TERRORISM RISK INS PROG REAUTH ACT ENDT <br />APPLIES TO STATE(S): AZ CA <br />WC 00 04 24 (00)-001 AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT <br />APPLIES TO STATE(S): AZ <br />WC 02 04 01 ( C)-001 AZ ALCOHOL & DRUG FREE WK PLACE PREM END <br />APPLIES TO STATE(S): AZ <br />WC 02 06 01 ( A)-001 AZ CANCELLATION AND NONRENEWAL ENDT <br />APPLIES TO STATE(S): AZ <br />WC 04 03 01 ( B)-001 POLICY AMENDATORY ENDORSEMENT -CALIFORNIA <br />APPLIES TO STATE(S): CA <br />WC 04 03 02 ( D)-001 PARTNERSHIP COVERAGE/EXCLUSION - CA <br />APPLIES TO STATE(S): CA <br />WC 04 03 03 ( C)-001 OFFICERS & DIRECTORS COV/EXCLUSION - CA <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-002 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-003 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-004 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-005 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 17 ( B)-001 EMPLOYEE INSD BY GENERL EMPLYER EXCLUDED <br />APPLIES TO STATE(S): CA <br />WC 04 03 45 ( A)-001 COMPREHENSIVE PERSONAL LIAB POL EXCL <br />APPLIES TO STATE(S): CA <br />WC 04 03 60 ( B)-001 EMPLOYERS' LIAB COV AMENDATORY ENDT-CA <br />APPLIES TO STATE(S): CA <br />WC 04 03 66 (00)-001 PROF CORP COVERAGE/EXCLUSION - CA <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise <br />stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of <br />the policy.) <br />Endorsement Effective Policy No. Endorsement No. <br />Insured <br />Insurance Company <br />Countersigned by <br />Premium $ <br />DATE OF ISSUE: 07-17-19 ST ASSIGN: Page 1 of 2 <br />