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SECTION I PARTS ONE and TWO PART THREE 1. WE WILL ALSO PAY 2. How This Insurance Applies D. We Will Also Pay of Part One (WORKERS' Paragraph 4. of A. How This Insurance Applies of COMPENSATION INSURANCE); and Part 3 (Other States Insurance) is replaced by the following: E. We Will Also Pay of Part Two (EMPLOYERS' LIABILITY INSURANCE) is 4. If you have work on the effective date of this replaced by the following: policy in any state not listed in Item 3.A. of the Information Page, coverage will not be afforded We Will Also Pay for that state unless we are notified within sixty We will also pay these costs, in addition to days. other amounts payable under this insurance, as part of any claim, proceeding, or suit we PART SIX defend: 3. Transfer Of Your Rights and Duties 1. reasonable expenses incurred at our C. Transfer Of Your Rights and Duties of Part 6 request, INCLUDING loss of earnings; (Conditions)is replaced by the following: 2. premiums for bonds to release Your rights or duties under this policy may not be attachments and for appeal bonds in transferred without our written consent. bond amounts up to the limit of our liability under this insurance; If you die and we receive notice within sixty days 3. litigation costs taxed against you; after your death, we will cover your legal representative as insured. 4. interest on a judgment as required by law 4. Liberalization until we offer the amount due under this law; and If we adopt a change in this form that would broaden 5. expenses we incur. the coverage of this form without extra charge, the broader coverage will apply to this policy. It will apply when the change becomes effective in your state. SECTION II VOLUNTARY COMPENSATION ANDEMPLOYERS' 3. The bodily injury must occur in the United LIABILITY COVERAGE States of America, its territories or 5. Voluntary Compensation Insurance possessions, or Canada, and may occur elsewhere if the employee is a United States A. How This Insurance Applies or Canadian citizen, or otherwise legal This insurance applies to bodily injury by resident, and legally employed, in the United accident or bodily injury by disease. Bodily States or Canada and temporarily away from injury includes resulting death. those places. 1. The bodily injury must be sustained by 4. Bodily injury by accident must occur during any officer or employee not subject to the the policy period. workers' compensation law of any state 5. Bodily injury by disease must be caused or shown in Item 3.A. of the Information aggravated by the conditions of the Page. 2. The bodily injury must arise out of and in the course of employment or incidental to work in a state shown in Item 3.A. of the Information Page. q oR. s Risk Manag/�e.n,ottDivision A r." REVIEWED&APPROVED BY: Risk Management Specialist • Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) - Page 2 of 6