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POLICY NUMBER: CUP-OJ605520-21-47 <br />UMBRELLA <br />ISSUE DATE: 01/29/2021 <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />SCHEDULE OF UNDERLYING INSURANCE <br />This endorsement modifies insurance provided under the following: <br />EXCESS FOLLOW -FORM AND UMBRELLA LIABILITY INSURANCE <br />Employers Liability <br />Carrier STATE COMPENSATION INSURANCE <br />FUND <br />Policy Number9114062-15 <br />Policy Period <br />From: 03/14/2020 <br />to: 03/14/2021 <br />Carrier <br />Policy Number <br />Policy Period <br />From: <br />to: <br />Carrier <br />Policy Number <br />Policy Period <br />From: <br />to: <br />Limits Of Liability <br />Bodily Injury By Accident <br />Each Accident <br />Bodily Injury By Disease <br />Policy Limit <br />Bodily Injury By Disease <br />Each Employee <br />Limits Of Liability <br />Limits Of Liability <br />PRODUCER:HALL & COMPANY OFFICE: SPECIALIST A&E 21 <br />EU 00 03 08 18 O 2018 The Travelers Indemnity Company. All rights reserved. <br />$1,000,000 <br />$1,000,000 <br />$1,000,000 <br />��oRaN <br />r <br />RiskMamagemeritDWiaian <br />REVIEWED & APPROVED BY.- <br />p L" R. Vi&,Wd <br />Risk Management Analyst <br />