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���,V+������� WORKERS COMPENSATION <br /> AND <br /> ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br /> HARTFORD CT 06183 ENDORSEMENT WC 99 06 R4 (00) - 002 <br /> POLICY NUMBER: UB-B2375005 <br /> NOTICE OF CANCELLATION OR NONRENEWAL <br /> TO DESIGNATED PERSONS OR ORGANIZATIONS <br /> The following is added to PART SIX—CONDITIONS : <br /> Notice Of Cancellation Or Nonrenewal To Designated Persons Or Organizations <br /> If we cancel or non-renew this policy for any reason other than non-payment of premium by you, we will provide <br /> notice of such cancellation or non-renewal to each person or organization designated in the Schedule below. We <br /> will mail or deliver such notice to each person or organization at its listed address at least the number of days <br /> shown for that person or organization before the cancellation or nonrenewal is to take effect. <br /> You are responsible for providing us with the information necessary to accurately complete the Schedule below. <br /> If we cannot mail or deliver a notice of cancellation or nonrenewal to a designated person or organization <br /> because the name or address of such designated person or organization provided to us is not accurate or <br /> complete, we have no responsibility to mail, deliver or otherwise notify such designated person or organization of <br /> the cancellation or nonrenewal. <br /> SCHEDULE <br /> Name and Address of Designated Persons or Organizations: Number of Days Notice: <br /> ANY PERSON OR ORGANIZATION WITH WHOM YOU HAVE AGREED IN A <br /> WRITTEN CONTRACT THAT NOTICE OF CANCELLATION OR NONRENEWAL OF 30 <br /> THIS POLICY WILL BE GIVEN, BUT ONLY IF: <br /> 1. YOU SEE TO IT THAT WE RECEIVE A WRITTEN REQUEST TO PROVIDE <br /> SUCH NOTICE, INCLUDING THE NAME AND ADDRESS OF SUCH PERSON OR <br /> ORGANIZATION, AFTER THE FIRST NAMED INSURED RECEIVES NOTICE FROM <br /> US OF THE CANCELLATION OR NONRENEWAL OF THIS POLICY; AND <br /> 2. WE RECEIVE SUCH WRITTEN REQUEST AT LEAST 14 DAYS BEFORE THE <br /> BEGINNING OF THE APPLICABLE NUMBER OF DAYS SHOWN IN THIS <br /> ENDORSEMENT. <br /> ADDRESS: <br /> THE ADDRESS FOR THAT PERSON OR ORGANIZATION INCLUDED IN <br /> SUCH WRITTEN REQUEST FROM YOU TO US. <br /> All other terms and conditions of this policy remain unchanged. <br /> This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise <br /> stated. <br /> (The information below is required only when this endorsement is issued subsequent to preparation of <br /> the policy.) <br /> Endorsement Effective Policy No. UB-132375005 Endorsement No. <br /> Insured Premium $ <br /> Insurance Company Countersigned by <br /> DATE OF ISSUE: 05-02-25 ST ASSIGN: Page 1 of1 <br /> ©2013 The Travelers Indemnity Company.All rights reserved. <br />