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TRAVELERS+, WORKERS COMPENSATION <br />AND <br />ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD CT 06183 ENDORSEMENT WC 99 03 C3 (00) — <br />POLICY NUMBER: UB-6P363599-21-42-G <br />SPECIAL PROVISIONS ENDORSEMENT <br />STATE APPLICABILITY <br />The listed endorsements are only applicable in the following states: <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-012 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-014 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-015 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-016 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-017 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-018 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-019 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-020 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-021 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-022 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-023 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 06 (01)-024 WAIVER OF SUBROGATION <br />APPLIES TO STATE(S): CA <br />WC 04 03 17 ( B)-001 EMPLOYEE INSD BY GENERL EMPLYER EXCLUDED <br />APPLIES TO STATE(S): CA <br />WC 04 03 18 ( C)-001 LLC COVERAGE/EXCLUSION - CA <br />APPLIES TO STATE(S): CA <br />WC 04 03 45 ( A)-001 COMPREHENSIVE PERSONAL LIAB POL EXCL <br />APPLIES TO STATE(S): CA <br />WC 04 03 60 ( B)-001 EMPLOYERS' LIAB COV AMENDATORY ENDT-CA <br />APPLIES TO STATE(S): CA <br />WC 04 04 21 (00)-001 OPTIONAL PREMIUM INCREASE ENDORSEMENT - <br />APPLIES TO STATE(S): CA <br />WC 04 04 22 (00)-001 CALIFORNIA SHORT -RATE CANCELATION ENDT <br />APPLIES TO STATE(S): CA <br />WC 04 06 01 ( A)-001 CA CANCELATION ENDT <br />APPLIES TO STATE(S): CA <br />WC 05 04 02 (00)-001 COLORADO CLASSIFICATION ENDORSEMENT <br />APPLIES TO STATE(S): CO <br />WC 08 06 01 (00)-001 DISTRICT OF COLUMBIA CANCELATION ENDT. <br />APPLIES TO STATE(S): DC <br />WC 18 06 01 (00)-001 MAINE INSPECTION IMMUNITY ENDORSEMENT <br />APPLIES TO STATE(S): ME <br />WC 18 06 03 ( A)-001 MAINE CANCELATION AND NONRENEWAL ENDT <br />APPLIES TO STATE(S): ME <br />DATE OF ISSUE: 09-23-21 STASSIGN: <br />CALIFORNIA <br />Rink Managtment Di%isimt <br />DS{{�A�P'PIRO MBY/: <br />alFi"ort•McfrA <br />[REVI <br />r � ff+(NhE I�. V�C(p/GQE.0 <br />®! <br />Risk Management Analyst <br />