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Workers Compensation And Employers Liability Insurance <br /> CNA Poilcy tnoorser ent <br /> ► • • : ► ®1[®]►`Rjjj:2►'II'\Ia Sol fj1WSJ:/j1►ILt M:IL11r1®J:++ a►AI:1L11D <br /> =MIR <br /> This endorsement modifies insurance provided under the WORKERS COMPENSATION AND EMPLOYERS <br /> LIABILITY INSURANCE POLICY: <br /> In the event of cancellation or material change that reduces or restricts coverage during the policy period, we <br /> agree to send prior written notice in the manner prescribed, to the person or organization listed in the Schedule. <br /> SCHEDULE <br /> 1. Number of days advance notice: <br /> For nonpayment of premium: <br /> 10 <br /> For any other reason: <br /> 30 <br /> 2. Name and Address of Person or Organization: <br /> Please see list of certificate holders. <br /> All other terms and conditions of the policy remain unchanged. <br /> This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, <br /> takes effect on the Policy Effective Date of said policy at the hour stated in said policy, unless another <br /> effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy <br /> unless another expiration date is shown below. <br /> Form No: CNA87380XX (1 1-2016) Policy No:WC 8018835079 <br /> Endorsement Effective Date: Endorsement Expiration Date: Policy Effective Date:04/01/2025 <br /> Endorsement No: 3; Page: 1 of 1 Policy Page:1 of 1 <br /> Underwriting Company: Valley Forge Insurance Company, 151 N Franklin St, <br /> Chicago, IL 60606 <br /> ° Copyright CNA All Rights Reserved. <br />