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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <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 provided by Part One (Workers Compensation Insurance) because <br />Colorado is shown in Item 3.A. of the Information Page. <br />Section B. Classifications of Part Five (Premium) is amended by adding the following: <br />The assignment of a proper classification resulting in higher premium is allowed only if the misclassification was caused <br />by your failure to provide accurate or complete data. If your operation changes during the policy term, you must notify us <br />within ninety days of the change. Failure to notify us will be considered a failure to provide accurate or complete data. <br />Section E. Final Premium of Part Five is amended by adding this sentence at the end of the first paragraph: <br />Payments to us or to you based on improper classification may be collected or refunded during the term of the policy and <br />for twelve months after the term. <br />Countersigned by <br />Form WC 05 04 02 Printed in U.S.A. <br />Process Date: 05/25/20 <br />cF RAMmVmentDMsian <br />REVIEWED & APPROVED BY.- <br />V"° <br />Policy E _� R.Wjanagementftalpt <br />