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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 99 06 57 <br />ENDORSEMENT # <br />This endorsement, effective 12:01 a.m. 01-01-2021 forms a part of <br />Policy No. RWD3001203-05 issued to ALLIED UNIVERSAL TOPCO, LLC <br />by XL Insurance America, Inc. <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />CANCELLATION NOTIFICATION TO OTHERS ENDORSEMENT <br />This endorsement modifies insurance provided under the following: <br />WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br />Ed. 12/10 <br />In the event coverage is cancelled for any statutorily permitted reason, other than nonpayment of premium, <br />advanced written notice will be mailed or delivered to persons) or entity(ies) according to the notification <br />schedule shown below: <br />Number of Days <br />Name of Persons) or Entity(ies) <br />Mailing Address: <br />Advanced <br />Notice of <br />Cancellation: <br />Per the most current schedule maintained by <br />30 <br />Marsh USA, Inc. and furnished to AXA XL no <br />less than 45 days prior to the effective date <br />of the cancellation. <br />All other terms and conditions of the Policy remain unchanged. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless <br />otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to <br />preparation of the policy.) <br />Endorsement Effective 01-01-2021 Policy No. RWD3001203-05 Endorsement No. <br />Insured ALLIED UNIVERSAL TOPCO, LLC <br />Insurance Company XL Insurance America, Inc. Countersigned by <br />WC990657 <br />Ed. 12110 2010 X.L. America, Inc. All Rights Reserved. <br />May not be copied without permission. <br />Premium $ Included <br />�ortaN <br />o - `': c'<< <br />Risk MwaganadDiAsiun <br />REVIEWED & APPROVED BY: <br />Risk Management Analyst <br />