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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br /> WORKERS' COMPENSATION BROAD FORM ENDORSEMENT <br /> EXTENDED OPTIONS <br /> Policy Number: 51WEGBH5UCM Endorsement Number: <br /> Effective Date: 0 810 7/2 024 Effective hour is the same as stated on the Information Page of the policy. <br /> Named Insured and Address: <br /> Proactive Engineering <br /> 200 S.Main Street,Suite <br /> Corona CA 92882 <br /> Section I of this endorsement expands coverage provided under WC 00 00 00. <br /> Section II of this endorsement provides additional coverage usually only provided by endorsement. <br /> Section III of this endorsement is a Schedule of Covered States. <br /> You may use the index to locate these coverage features quickly: <br /> INDEX <br /> SUBJECT PAGE SUBJECT PAGE <br /> SECTION 1 2 B. Part One Does Not Apply 3 <br /> PARTS ONE and TWO 2 C. Application of Coverage 3 <br /> 01 We Will Also Pay 2 D. Additional Exclusions 3 <br /> PART-THREE 2 E. West Virginia 3 <br /> 02 How This Insurance Works 2 EXTENDED OPTIONS 4 <br /> PART-SIX 2 01 Employers' Liability Insurance 4 <br /> 03 Transfer of Your Rights and Duties 2 02 Unintentional Failure to Disclose 4 <br /> 04 Cancellation 2 Hazards <br /> 05 Liberalization 2 03 Waiver of Our Right to Recover from 4 <br /> SECTION II 2 Others <br /> VOLUNTARY COMPENSATION INSURANCE 2 04 Foreign Voluntary Compensation 4 <br /> 06 Voluntary Compensation Insurance A. How This Reimbursement Applies 4 <br /> A. How This Insurance Applies 2 B. We Will Reimburse 4 <br /> B. We Will Pay 2 C. Exclusions 4 <br /> C. Exclusions 3 D. Before We Pay 5 <br /> D. Before We Pay 3 E. Recovery From Others 5 <br /> E. Recovery From Others 3 F. Reimbursement For Actual Loss 5 <br /> F. Employers' Liability Insurance 3 Sustained <br /> EMPLOYERS' LIABILITY STOP GAP 3 G. Repatriation 5 <br /> ENDORSEMENT 3 H. Endemic Disease 5 <br /> 07 Employers' Liability Stop Gap 05 Longshore and Harbor Workers' 5 <br /> Coverage 3 Compensation Act Coverage <br /> A. Stop Gap Coverage Limited to Endorsement <br /> Montana, North Dakota, Ohio, 3 SECTION III 6 <br /> Washington, West Virginia and 0 APPROVED <br /> Wyoming <br /> By Cynthia Mora at 11:34 am, Dec 05, 2024 <br /> F o r m W C 9 9 0 3 0 1 B Printed in U.S.A. (Ed. 8/00) Page 1 of 6 <br /> Process Date: Policy Expiration Date: <br /> © 2000, The Hartford <br />