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THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. <br />WORKERS’ COMPENSATION BROAD FORM ENDORSEMENT <br />EXTENDED OPTIONS <br />Policy Number:Policy Number:5757WECWECAZ7TWBAZ7TWBEndorsement Number: <br />Effective Date:Effective Date:10/12/2410/12/24Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address:Named Insured and Address:Lance, Soll & Lunghard, LLPLance, Soll & Lunghard, LLP <br />203 N BREA BLVD STE 203203 N BREA BLVD STE 203 <br />BREABREACACA9282192821 <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 />SUBJECTPAGESUBJECTPAGE <br />SECTION I2B.Part One Does Not Apply3 <br />PARTS ONE and TWO2C.Application of Coverage3 <br />01We Will Also Pay2D.Additional Exclusions3 <br />PART - THREE2E.West Virginia3 <br />02How This Insurance Works2EXTENDED OPTIONS4 <br />PART - SIX201Employers’ Liability Insurance4 <br />03Transfer of Your Rights and Duties202Unintentional Failure to Disclose4 <br />04Liberalization2Hazards <br />SECTION II20303Waiver of Our Right to Recover fromWaiver of Our Right to Recover from44 <br />VOLUNTARY COMPENSATION2OthersOthers <br />INSURANCE04Foreign Voluntary Compensation4 <br />05Voluntary Compensation Insurance2A.How This Reimbursement Applies4 <br />A.How This Insurance Applies2B.We Will Reimburse4 <br />B.We Will Pay3C.Exclusions4 <br />C.Exclusions3D.Before We Pay5 <br />D.Before We Pay3E.Recovery From Others5 <br />E.Recovery From Others3F.Reimbursement For Actual Loss5 <br />F.Employers’ Liability Insurance3Sustained <br />EMPLOYERS’ LIABILITY STOP GAP3G.Repatriation5 <br />ENDORSEMENTH.Endemic Disease5 <br />06Employers’ Liability Stop Gap305Longshore and Harbor Workers’5 <br />CoverageCompensation Act Coverage <br />A.Stop Gap Coverage Limited to3Endorsement <br />Montana, North Dakota, Ohio,SECTION III6 <br />Washington, West Virginia and01Schedule of Covered States6 <br />Wyoming <br />Form WC 99 03 03 BPrinted in U.S.A. (Ed. 8/00)Page1 of6 <br />Process Date:09/02/24Policy Expiration Date:10/12/25 <br />© 2000, The Hartford <br />CzDzouijbNpsbbu:;44bn-Pdu3:-3135 <br /> <br />