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WO 00 04 22 0 WORKERS COMPENSATION AND CMPLOYi?tt8 LIABILITY INSURANCE POLICY <br />(Ed, 1.16) <br />2, Notwithstanding Itom 1 above, the Vnitod Stales Government will not malio any payment under the Act for any <br />pprtlon of Insured Lasses that Mead 4100,000,000.000, <br />3, The premium charge for the coverage your policy provides for Insured Losses is Included In the amount shown In <br />Rain d of tho Information page or In the Schedule below. <br />State <br />Schedule <br />pate <br />Premium <br />This ondorsoment changes the policy to which 11 Is attached and is olfecilve on the date losuod unless olhorwlao stated. <br />(The information below to required only whon this endorsement le Issued subsequent to preparation of the policy,) <br />Rodomomont Effective policy No, <br />Insured <br />Insuranps Company <br />WC 00 04 22 B <br />(Ed. 1.16) <br />Endorsement No. <br />Premium $ <br />Countoraignod By <br />@ copyright got National council on compansatlen insuranee, ruo. All nlghta rrelteNod. <br />REVICWED &APPROVED <br />BY RIS MANAGEMENT i)iV MON <br />q T � <br />l <br />F1 NGN ft, vILLAR ' <br />