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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />ARIZONA COUNTERSIGNATURE EXCLUSION 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 />This endorsement applies only to the insurance <br />provided by the policy because Arizona is shown in <br />Item 3.A. of the Information Page. <br />The following wording, as may be contained in this <br />policy, does not apply in Arizona: <br />"This policy is not binding unless countersigned <br />by our authorized representative." <br />Form WC 99 03 71 A Printed in U.S.A. <br />Process Date: 05/25/20 <br />"This endorsement shall not be binding unless <br />countersigned by a duly authorized agent of the <br />company, provided that if this endorsement takes effect <br />as of the effective date of the policy and, at issue of <br />said policy, forms a part thereof, countersigned on the <br />Information Page of said policy by a duly authorized <br />Agent of the company shall constitute valid <br />countersignature of this endorsement." <br />ew cF RAMwagementDMsian <br />Jy/\'x REVIEWED & APPROVED BY.- <br />V"° <br />Policy E _� R.Wjanagementftalpt <br />