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XPSLFST!DPNQFOTBUJPO!BOE!FNQMPZFST <br />MJBCJMJUZ!JOTVSBODF!QPMJDZ <br />In retrn for te payment of te premim and sect to all terms of tis policy, we agree wit yo as follows <br />HFOFSBM!TFDUJPO <br />B/Uif!Qpmjdz lawofeacstateorterritorynamedinItem3.A.ofte <br />InformationPage.Itincldesanyamendmentsto <br />Tispolicyincldesatitseffectiedatete <br />tatlawwicareineffectdringtepolicyperiod.It <br />InformationPageandallendorsementsandscedles <br />doesnotincldeanyfederalworersorwormens <br />listedtere.Itisacontractofinsranceetweenyo <br />compensationlaw,anyfederaloccpationaldisease <br />teemployernamedinItem1ofteInformation <br />laworteproisionsofanylawtatproide <br />PageandsteinsrernamedonteInformation <br />nonoccpational disaility enefits. <br />Page.Teonlyagreementsrelatingtotisinsrance <br />arestatedintispolicy.Tetermsoftispolicymay E/Tubuf <br />notecangedorwaiedeceptyendorsement <br />StatemeansanystateoftenitedStatesof <br />issed y s to e part of tis policy. <br />America, and te District of Colmia. <br />C/Xip!Jt!Jotvsfe <br />F/Mpdbujpot <br />YoareinsredifyoareanemployernamedinItem <br />Tispolicycoersallofyorworplaceslistedin <br />1ofteInformationPage.Iftatemployerisa <br />Items1or4ofteInformationPageanditcoersall <br />partnersip,andifyoareoneofitspartners,yoare <br />oterworplacesinItem3.A.statesnlessyoae <br />insred,tonlyinyorcapacityasanemployerof <br />oterinsranceorareself-insredforsc <br />te partnersips employees. <br />worplaces. <br />D/Xpslfst!Dpnqfotbujpo!Mbx <br />WorersCompensationLawmeansteworersor <br />wormens compensation law and occpational disease <br />QBSU!POF!.!XPSLFST!DPNQFOTBUJPO!JOTVSBODF <br />B/Ipx!Uijt!Jotvsbodf!BqqmjftD/Xf!Xjmm!Efgfoe <br />TisworerscompensationinsranceappliestoWeaeterigtanddtytodefendatorepense <br />odilyinryyaccidentorodilyinryydisease.anyclaim,proceedingorsitagainstyoforenefits <br />Bodily inry incldes reslting deat.payaleytisinsrance.Weaeterigtto <br />inestigateandsettleteseclaims,proceedingsor <br />1.Bodilyinryyaccidentmstoccrdringte <br />sits. <br />policy period. <br />Weaenodtytodefendaclaim,proceedingor <br />2.Bodilyinryydiseasemstecasedor <br />sit tat is not coered y tis insrance. <br />aggraatedyteconditionsofyoremployment. <br />Teemployeeslastdayoflasteposretote E/Xf!Xjmm!Bmtp!Qbz <br />conditionscasingoraggraatingscodily <br />Wewillalsopaytesecosts,inadditiontooter <br />inryydiseasemstoccrdringtepolicy <br />amontspayalendertisinsrance,aspartofany <br />period. <br />claim, proceeding or sit we defend <br />C/Xf!Xjmm!Qbz <br />1.reasonaleepensesincrredatorreest,t <br />Wewillpaypromptlywendeteenefitsreirednot loss of earnings <br />of yo y te worers compensation law. <br />Gpsn!XD!11!11!11!D Printed in .S.A.Qbhf2!pg7 <br />Qspdftt!Ebuf; 11/04/2Qpmjdz!Fyqjsbujpo!Ebuf; 11/04/26 <br /> <br />