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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />90-DAY REPORTING REQUIREMENT - <br />NOTIFICATION OF CHANGE IN OWNERSHIP <br />ENDORSEMENT <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 />You must report any change in ownership to us in writing within 90 days of the date of the change. Change in ownership <br />includes sales, purchases, other transfers, mergers, consolidations, dissolutions, formations of a new entity and other <br />changes provided for in the applicable experience rating plan. Experience rating is mandatory for all eligible insureds. The <br />experience rating modification factor, if any, applicable to this policy, may change if there is a change in your ownership or <br />in that of one or more of the entities eligible to be combined with you for experience rating purposes. <br />Failure to report any change in ownership, regardless of whether the change is reported within 90 days of such change, <br />may result in revision of the experience rating modification factor used to determine your premium. <br />This reporting requirement applies regardless of whether an experience rating modification is currently applicable to this <br />policy. <br />Form WC 00 04 14 A Printed in U.S.A. <br />Process Date: 05/25/20 <br />ew cF RAMwagementDMsian <br />Jy/\'x REVIEWED & APPROVED BY.- <br />,v <br />Polic) WskPjanagementftalpt <br />