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WORKERS' COMPENSATION AND EMPLOYERS LIABILITY POLICY <br />Named Insured. <br />Endorsement Numbe, <br />COmcast Corporation <br />Policy Number <br />Symbor. WLR Number. C66040719 <br />Policy Period; <br />EffecSve Date of Endorsement. <br />12/1119 TO 1211f20 <br />Issued By (Name M Insurance company). <br />Indemnity Insurance Co. of North America <br />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. <br />NOTICE TO OTHERS ENDORSEMENT - SPECIFIC PARTIES <br />A. If we cancel this Policy prior to its expiration date by notice to you or the first Named insured for any <br />reason other than nonpayment of premium, we will endeavor, as set out below, to send written notice of <br />cancellation, via such electronic or other form of notification as we determine, to the persons or <br />organizations listed in the schedule set out below (the "Schedule"). You or your representative must <br />provide us with both the physical and e-mail address of such persons or organizations, and we will utilize <br />such e-mail address or physical address that you or your representative provided to us on such <br />Schedule. <br />B. We will endeavor to send or deliver such notice to the e-mail address or physical address corresponding <br />to each person or organization indicated in the Schedule at least 30 days prior to the cancellation date <br />applicable to the Policy- <br />C. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) <br />or organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have <br />no legal obligation of any kind to any such person(s) or organization(s). Our failure to provide advance <br />notification of cancellation to the person(s) or organization(s) shown in the Schedule shall impose no <br />obligation or liability of any kind upon us, our agents or representatives, will not extend any Policy <br />cancellation date and will not negate any cancellation of the Policy. <br />D. We are not responsible for verifying any information provided to us in any Schedule, nor are we <br />responsible for any incorrect information that you or your representative provide to us. If you or your <br />representative does not provide us with the information necessary to complete the Schedule, we have <br />no responsibility for taking any action under this endorsement. In addition, if neither you nor your <br />representative provides us with e-mail and physical address information with respect to a particular <br />person or organization, then we shall have no responsibility for taking action with regard to such person <br />or entity under this endorsement. <br />E. We may arrange with your representative to send such notice in the event of any such cancellation- <br />F. You will cooperate with us in providing, or in causing your representative to provide, the e-mail address <br />and physical address of the persons or organizations listed in the Schedule. <br />G. This endorsement does not apply in the event that you cancel the Policy. <br />SCHEDULE <br />Name of Certificate Holder <br />E-Mail Address <br />Physical Address <br />City of Santa Ana <br />Risk Management Division <br />20 Civic Center Plaza, 4th floor <br />Santa Ana, CA 92701 <br />WG 99 03 71 (01111) <br />Pane 1 of 2 <br />Risk Mrrnagement Division <br />REVIEWED&APPROVED By., <br />'� Risk Management Analyst <br />