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WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 06 R3 (00) <br />POLICY NUMBER: UB-3P635310 (AOS); UB-3P533004 (MA, WI) <br />NOTICE OF CANCELLATION <br />TO DESIGNATED PERSONS OR ORGANIZATIONS <br />The following is added to PART SIX - CONDITIONS: <br />Notice of Cancellation To Designated Persons Or Organizations <br />If we cancel this policy for any reason other than non-payment of premium by you, we will <br />provide notice of such cancellation to each person or organization designated in the Schedule <br />below. We will mail or deliver such notice to each person or organization at its listed address at <br />least the number of days shown for that person or organization before the cancellation is to take <br />effect. <br />You are responsible for providing us with the information necessary to accurately complete the <br />Schedule below. If we cannot mail or deliver a notice of cancellation to a designated person or <br />organization because the name or address of such designated person or organization provided <br />to us is not accurate or complete, we have no responsibility to mail, delivery or otherwise notify <br />such designated person or organization of the cancellation. <br />SCHEDULE <br />Name and Address of Designated Persons or Organizations: <br />WHERE REQUIRED BY WRITTEN CONTRACT. <br />Number of Days Notice: 30 <br />ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. <br />Attachment Code: D522110 <br />Certificate ID: 16289289 <br />R1.kt <br />lt+nF 6 AmBr <br />atkn n.,genE,,.cie,;�li de <br />