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.1411 <br /> THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br /> WORKERS' COMPENSATION BROAD FORM ENDORSEMENT <br /> EXTENDED OPTIONS <br /> Policy Number: 57 WEC AZ7TWB Endorsement Number: <br /> Effective Date: 10/12/23 Effective hour is the same as stated on the Information Page of the policy. <br /> Named Insured and Address: Lance, Soli & Lunghard, LLP <br /> 203 N BREA BLVD STE 203 <br /> BREA CA 92821 <br /> Section I of this endorsement expands coverage provided under WC 00 00 00. <br /> Section II of this endorsement provides additional coverage usually only provided by endorsement. <br /> Section III of this endorsement is a Schedule of Covered States. <br /> You may use the index to locate these coverage features quickly: <br /> INDEX <br /> SUBJECT PAGE SUBJECT PAGE <br /> SECTION I 2 B. Part One Does Not Apply 3 <br /> PARTS ONE and TWO 2 C. Application of Coverage 3 <br /> 01 We Will Also Pay 2 D. Additional Exclusions 3 <br /> PART-THREE 2 E. West Virginia 3 <br /> 02 How This Insurance Works 2 EXTENDED OPTIONS 4 <br /> PART-SIX 2 01 Employers' Liability Insurance 4 <br /> 03 Transfer of Your Rights and Duties 2 02 Unintentional Failure to Disclose 4 <br /> 04 Liberalization 2 Hazards <br /> SECTION II 2 03 Waiver of Our Right to Recover from 4 <br /> VOLUNTARY COMPENSATION 2 Others <br /> INSURANCE 04 Foreign Voluntary Compensation 4 <br /> 05 Voluntary Compensation Insurance 2 A. How This Reimbursement Applies 4 <br /> A. How This Insurance Applies 2 B. We Will Reimburse 4 <br /> B. We Will Pay 3 C. Exclusions 4 <br /> C. Exclusions 3 D. Before We Pay 5 <br /> D. Before We Pay 3 E. Recovery From Others 5 <br /> E. Recovery From Others 3 F. Reimbursement For Actual Loss 5 <br /> F. Employers' Liability Insurance 3 Sustained <br /> EMPLOYERS' LIABILITY STOP GAP 3 G. Repatriation 5 <br /> ENDORSEMENT H. Endemic Disease 5 <br /> 06 Employers' Liability Stop Gap 3 05 Longshore and Harbor Workers' 5 <br /> Coverage Compensation Act Coverage <br /> A. Stop Gap Coverage Limited to 3 Endorsement <br /> Montana, North Dakota, Ohio, SECTION III 6 <br /> Washington, West Virginia and 01 Schedule of Covered States 6 <br /> Wyoming <br /> ",f Risk MxnsgementDivision <br /> .,.-,M REVIEWED&APPROVED BY: <br /> Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) ®` Risk Management Specialist <br /> Process Date: 10/13/23 Policy I/, <br /> ©2000, The Hartford <br />