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31anket Notification to Others of Cancellation ZURICW' Policy No. Eff. Date of Pot. Exp. Date of Pot. Eff. Date of End. Producer No. AddT Prem Return Prem. C4641067 03/01/2013 03/01/2016 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the; Workers Compensation policy A. If we cancel this Coverage Part(s) by written notice to the first Named Insured for any reason other than nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation; 1. To the name and address corresponding to each person or organization shown in the Schedule below; and 2. At least 10 days prior to the effective date of the cancellation, as advised in our notice to the first Named Insured, or the longer number of days notice if indicated in the Schedule below. Q. This notice is intended only to be an advance notification to the person(s) or organization(s) named in the Schedule of this endorsement in the event of pending cancellation of coverage. Our failure to provide such advance notification to the person(s) or organization(s) shown in the Schedule of this endorsement will not extend any policy cancellation date nor negate any cancellation of the policy. If notice as described in Paragraph A. of this endorsement is mailed, proof of mailing will be sufficient proof of such notice, SCHEDULE Name and Address of Other Person(s) / Organization(s): Number of Days Notice: All Certificate Holders where Notice of Cancellation is required by written contract with the Named Insured 90 Days All other terms and conditions of this policy remain unchanged. U -WC -332 -A Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. CERT NO.: 23061898 Jamie Cooper 1/14/2015 4:02:58 PM (EST) Page 5 of 6