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THE <br /> HARTFOR❑ <br /> THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br /> CHANGE IN INFORMATION PAGE <br /> INSURER: See Attached Endorsement <br /> NCCI Company Number: 14397 <br /> Policy Number: 57 WEC AN1 ML1 Endorsement Number: 003 <br /> Effective Date: 04/16/25 Effective hour is the same as stated on the Information Page of the policy. <br /> Named Insured and Address: WE ARE GROUNDSWELL <br /> 1801 E EDINGER AVE STE 115 <br /> SANTA ANA CA 92705 <br /> FEIN Number: 33-0438086 <br /> It is agreed that the policy is amended as follows: <br /> This is NOT a bill. However, any changes in your premium will be reflected in your next billing statement. You will receive <br /> a separate bill from The Hartford. If you are enrolled in repetitive EFT draws from your bank account, changes in premium <br /> will change future draw amounts. <br /> In consideration of no change in premium, it is agreed that: <br /> Policy is amended to add the following condition(s): <br /> Waiver of Our Right to Recover from Others Endorsement <br /> Policy is amended to delete the following condition(s): <br /> Waiver of Our Right to Recover from Others Endorsement <br /> Policy is amended to add the following Endorsement Forms reflecting the changes made to your policy. <br /> WC000421 E <br /> Policy is amended to revise the following Endorsement Forms reflecting the changes made to your policy. <br /> WC000313 <br /> WC990006B(.1 P) <br /> WC990006B(.2) <br /> WC040306 <br /> Countersigned by <br /> Authorized Representative <br /> Form WC 99 00 06 B (1) Printed in U.S.A. Page 1 <br /> Process Date: 04/16/25 Policy Expiration Date: 10/01/25 <br />