WE ARE GROUNDSWELL (OC HUMAN RELATIONS)

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it THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT Policy Number: 57 WEC AN1 MI-1 Endorsement Number: 003 Effective Date: 04/16/25 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: WE ARE GROUNDSWELL 1801 E EDINGER AVE STE 115 SANTA ANA CA 92705 This endorsement is notification that your insurance of the Treasury pursuant to the Terrorism Risk carrier is charging premium to cover the losses that Insurance Act of 2002 (as amended) but that meets may occur in the event of a Catastrophe (Other Than all of the following criteria: Certified Acts of Terrorism) as that term is defined a. It is an act that is violent or dangerous to human below. Your policy provides coverage for workers life, property, or infrastructure; compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism). This b. The act results in damage within the United premium charge does not provide funding for States, or outside of the United States in the case Certified Acts of Terrorism contemplated under the of the premises of United States missions or air Terrorism Risk Insurance Program Reauthorization carriers or vessels as those terms are defined in Act Disclosure Endorsement (WC 00 04 22 C), the Terrorism Risk Insurance Act of 2002 (as attached to this policy. amended); and c. It is an act that has been committed by an For purposes of this endorsement, the following individual or individuals as part of an effort to definitions apply: coerce the civilian population of the United States o Catastrophe (Other Than Certified Acts of or to influence the policy or affect the conduct of Terrorism): Any single event, resulting from an the United States Government by coercion. Earthquake, Noncertified Act of Terrorism, or o Catastrophic Industrial Accident: A chemical release, Catastrophic Industrial Accident, which results in large explosion, or small blast that is localized in aggregate workers compensation losses in nature and affects workers in a small perimeter the excess of$50 million. size of a building. o Earthquake: The shaking and vibration at the The premium charge for the coverage your policy surface of the earth resulting from underground provides for workers compensation losses caused by a movement along a fault plane or from volcanic Catastrophe (Other Than Certified Acts of Terrorism) is activity. shown in Item 4 of the Information Page or in the o Noncertified Act of Terrorism: An event that is not Schedule below. certified as an Act of Terrorism by the Secretary Schedule State Rate Premium See Attached Schedule Form WC 00 04 21 E Printed in U.S.A. Process Date: 04/16/25 Policy Expiration Date: 10/01/25