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TRAVELERS, WORKERS COMPENSATION <br />AND <br />ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD CT 06183 <br />ENDORSEMENT WC 89 06 14 (00) — <br />POLICY NUMBER: UB-6P363599-21-42-G <br />POLICY INFORMATION PAGE <br />ENDORSEMENT <br />Item 3.D. Endorsement numbers is changed to read: <br />WC 04 03 06 01 <br />WC 99 03 C3 00 <br />ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. <br />DATE OF ISSUE: 09-23-21 STASSIGN: <br />Rink Managtment DMsimt <br />RWE DS APPRO MBY: <br />Fnaw,6.r.e �'. VttP�l <br />®! <br />Risk Management Analyst <br />