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Workers' Compensation Policy No. WA7-69D-458727-061 <br />NOTICE OF CANCELLATION TO THIRD PARTIES <br />A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or <br />organizations shown in the Schedule below. We will send notice to the email or mailing address listed below at <br />least 10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event <br />does the notice to the third party exceed the notice to the first named insured. <br />B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to <br />provide such advance notification will not extend the policy cancellation date nor negate cancellation of the <br />policy. <br />Name of Other Person(s) / <br />Organization(s): <br />Schedule on file with the <br />company <br />Schedule <br />Email Address or mailing address <br />Schedule on file with the <br />company <br />All other terms and conditions of this policy remain unchanged. <br />Issued To <br />DMS Facility Services, LLC <br />Effective pate <br />10/ 1 /2021-10/ 1 /2022 <br />WC 99 20 75 © 2016 Liberty Mutual Insurance <br />Ed. 12/01/2016 <br />Number Days Notice: <br />30 <br />Premium $ <br />rc;�k Beni nrvisiort <br />wR"EwED 6 APPROVED BY: <br />+ ctze P <br />Rislc Management Cierir lAide <br />