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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />ENDORSEMENT EXTENDED OPTIONS - EMPLOYERS' LIABILITY STOP <br />GAP COVERAGE <br />Policy Number: 59 WEC AC9055 Endorsement Number: <br />Effective Date: 07/03/20 Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address: BAY SPROUTS LLC <br />655 S MAIN ST STE 200-317 <br />ORANGE CA 92868 <br />This endorsement changes the Workers' <br />Compensation Broad Form Endorsement Extended <br />Options — Employers' Liability Stop Gap Coverage <br />6. Employers' Liability Stop Gap Coverage <br />Form WC 99 03 56 A Printed in U.S.A. (Ed.7/08) <br />Process Date: 05/25/20 <br />A. This coverage only applies in North Dakota, <br />Ohio, Washington, and Wyoming. <br />E. This paragraph is removed. <br />ew cF RAMwagementDMsian <br />Jy/\'x REVIEWED & APPROVED BY.- <br />V"° <br />Policy E _� RFskPjanagementAnalpt <br />