ADAMS STREETER CIVIL ENGINEERS, INC.

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SECTION I PARTS ONE and TWO the Information Page, coverage will not be 1. WE WILL ALSO PAY afforded for that state unless we are notified D. We Will Also Pay of Part One (WORKERS' within sixty days. COMPENSATION INSURANCE); and PART SIX E. We Will Also Pay of Part Two (EMPLOYERS' LIABILITY INSURANCE) is replaced by the 3. Transfer Of Your Rights and Duties following: C. Transfer Of Your Rights and Duties of Part 6 We Will Also Pay (Conditions) is replaced by the following: We will also pay these costs, in addition to Your rights or duties under this policy may not other amounts payable under this insurance, be transferred without our written consent. as part of any claim, proceeding, or suit we If you die and we receive notice within sixty defend: days after your death, we will cover your legal 1. reasonable expenses incurred at our representative as insured. request, INCLUDING loss of earnings; 4. Cancellation 2. premiums for bonds to release Paragraph 2. of D. Cancellation of Part 6 attachments and for appeal bonds in bond (Conditions) is replaced by the following: amounts up to the limit of our liability 2. We may cancel this policy. We must mail or under this insurance; deliver to you not less than 15 days advance 3. litigation costs taxed against you; written notice stating when the cancellation is 4. interest on a judgment as required by law to take effect. Mailing that notice to you at until we offer the amount due under this your mailing address shown in Item 1 of the law; and Information Page will be sufficient to prove notice. 5. expenses we incur. 5. Liberalization PART THREE If we adopt a change in this form that would broaden the coverage of this form without extra 2. How This Insurance Applies charge, the broader coverage will apply to this Paragraph 4. of A. How This Insurance Applies policy. It will apply when the change becomes of Part 3 (Other States Insurance) is replaced by effective in your state. the following: 4. If you have work on the effective date of this policy in any state not listed in Item 3.A. of SECTION II VOLUNTARY COMPENSATION AND EMPLOYERS' 2. The bodily injury must arise out of and in LIABILITY COVERAGE the course of employment or incidental to 6. Voluntary Compensation Insurance work in a state shown in Item 3.A. of the Information Page. A. How This Insurance Applies 3. The bodily injury must occur in the United This insurance applies to bodily injury by States of America, its territories or accident or bodily injury by disease. Bodily possessions, or Canada, and may occur injury includes resulting death. elsewhere if the employee is a United 1. The bodily injury must be sustained by any States or Canadian citizen, or otherwise officer or employee not subject to the legal resident, and legally employed, in the workers' compensation law of any state United States or Canada and temporarily shown in Item 3.A. of the Information away from those places. Page. APPROVED By Cynthia Mora at 11:34 am, Dec 05, 2024 Form WC 99 03 01 B Printed in U.S.A. (Ed. 8/00) Page 2 of 6