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EMPLOYERS LIABOLIITY COVERAGE ENDORSEMENT <br />This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different <br />date is indicated below. <br />--------Flhe-following=attaching-clause'-need_be_completed-only--when-this-endorsement.is-issued-stfsequenL-to_preparation'of the -policy), °°°°°°---- <br />This -endorsement effective 1-2.01 AM— 3/1/2424 —forms-a-part-of Polioy-No—WC 012-01-602(� - — <br />Issued to SHANNON & WI LSON, I NG . <br />By NEW HAMPSHIRE INSURANCE COMPANY <br />This endorsement applies only to work in the states shown in the Schedule. <br />A. Part One (Workers Compensation Insurance) does not apply to work in a state shown in the Schedule. <br />B. Part Two (Employers Liability Insurance) applies to work in states shown in the Schedule as though they were <br />shown in Item 3.A. of the Information Page. <br />C. Part Two (Employers Liability Insurance), C. Exclusions is changed by adding these exclusions. <br />This insurance does not cover: <br />13. bodily injury to an employee when you are deprived of common law defenses or are subject to penalty because <br />of your failure to secure your obligations under the workers compensation law of any state shown in the <br />Schedule or otherwise fail to comply with that law. <br />States <br />Schedule <br />NORTH IDAKOTA WASH1NGTON WYOMING <br />oR,N a RAManagmumtDivision <br />f °� REVIEWED & MPROVm BY. <br />ezv <br />WC 00 03 03 C Countersigned by _ _ _ - - _ _ _ _ _ _ _ — _ _ ` _ _ _ --j— Risk Management Specialist <br />NJ <br />(I`c1. 40104) <br />b 2004 National Council on Compensation Insurance, Inc. Authorized Raniresentative <br />