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SECTION I PARTS ONE and TWO PART THREE 1. WE WILL ALSO PAY 2. How This Insurance Applies D. We Will Also Pay of Part One (WORKERS' Paragraph 4. of A. How This Insurance COMPENSATION INSURANCE); and Applies of Part 3 (Other States Insurance) is E. We Will Also Pay of Part Two replaced by the following: (EMPLOYERS' LIABILITY INSURANCE) is 4. If you have work on the effective date of this replaced by the following: policy in any state not listed in Item 3.A. of the Information Page, coverage will not be We Will Also Pay afforded for that state unless we are notified We will also pay these costs, in addition to within sixty days. other amounts payable under this insurance, as part of any claim, proceeding, or suit we PART SIX defend: 3. Transfer Of Your Rights and Duties 1. reasonable expenses incurred at our request, INCLUDING loss of earnings; C. Transfer Of Your Rights and Duties of Part 6 (Conditions) is replaced by the 2. premiums for bonds to release following: attachments and for appeal bonds in bond amounts up to the limit of our Your rights or duties under this policy may liability under this insurance; not be transferred without our written 3. litigation costs taxed against you; consent. 4. interest on a judgment as required by If you die and we receive notice within sixty law until we offer the amount due under days after your death, we will cover your this law; and legal representative as insured. 5. incur. 4. Liberalization expenses we If we adopt a change in this form that would broaden the coverage of this form without extra charge, the broader coverage will apply to this policy. It will apply when the change becomes effective in your state. SECTION II VOLUNTARY COMPENSATION AND 3. The bodily injury must occur in the EMPLOYERS' LIABILITY COVERAGE United States of America, its territories 5. Voluntary Compensation Insurance or possessions, or Canada, and may occur elsewhere if the employee is a A. How This Insurance Applies United States or Canadian citizen, or This insurance applies to bodily injury by otherwise legal resident, and legally accident or bodily injury by disease. Bodily employed, in the United States or injury includes resulting death. Canada and temporarily away from 1. The bodily injury must be sustained by those places. any officer or employee not subject to 4. Bodily injury by accident must occur the workers' compensation law of any during the policy period. state shown in Item 3.A. of the 5. Bodily injury by disease must be caused Information Page. or aggravated by the conditions of the 2. The bodily injury must arise out of and in the course of employment or incidental to work in a state shown in Item 3.A. of the Information Page. Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 2 of 6 REVIEWED BY: EUNICE HERED{A (P OE2}