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UIJT!FOEPSTFNFOU!DIBOHFT!UIF!QPMJDZ/QMFBTF!SFBE!JU!DBSFGVMMZ/ <br />QPMJDZ!BNFOEBUPSZ!FOEPSTFNFOU!.!DBMJGPSOJB <br />Qpmjdz!Ovncfs;6WEGB3PFoepstfnfou!Ovncfs; <br />Fggfdujwf!Ebuf;11/04/2Effectie or is te same as stated on te Information Page of te policy. <br />Obnfe!Jotvsfe!boe!Beesftt;Beginners Edge Sports Training <br />432 E TIERRA BEA L <br />SCOTTSDALEA8260 <br />Itisagreedtat,anytingintepolicytotecontraryandwillreimrsesforanyincreaseinindemnity <br />notwitstanding,scinsranceasisaffordedytispaymentnotcoeredndertepolicywente <br />policyyreasonoftedesignationofCaliforniainItemaggregatetotalamontoftereimrsement <br />3ofteInformationPageissecttotefollowingpaymentspaidinapolicyyeareceedsone <br />proisionsndred dollars 100. <br />Ifwenotifyyoinwriting,witin30daysofte <br />payment,tatyoareoligatedtoreimrses,we <br />1.NjopstJmmfhbmmzFnqmpzfe.OpuJotvsfe/Tis <br />willillyoforteamontofincreaseinindemnity <br />policydoesnotcoerliailityforadditional <br />paymentandcollectitnolatertantefinaladit. <br />compensationimposedonyonderSection4, <br />Yowillae60days,followingnoticeofte <br />DiisionI,LaorCodeofteStateofCalifornia, <br />oligationtoreimrse,toappealtedecisionofte <br />yreasonofinrytoanemployeendersiteen <br />insrer to te Department of Insrance. <br />yearsofageandillegallyemployedattetimeof <br />inry.4.BqqmjdbujpopgQpmjdz/PartOne,"Worers <br />CompensationInsrance",A,"owTisInsrance <br />2.QvojujwfpsFyfnqmbszEbnbhft.Vojotvsbcmf/ <br />Applies", is amended to read as follows <br />Tispolicydoesnotcoerpnitieoreemplary <br />damageswereinsranceofliailitytereforisTisworerscompensationinsranceappliesto <br />proiited y law or contrary to plic policy.odilyinryyaccidentordisease,incldingdeat <br />resltingterefrom.Bodilyinryyaccidentmst <br />3.JodsfbtfjoJoefnojuzQbznfou. <br />occrdringtepolicyperiod.Bodilyinryy <br />Sfjncvstfnfou/Yoareoligatedtoreimrse <br />diseasemstecasedoraggraatedyte <br />sforteamontofincreaseinindemnity <br />conditionsofyoremployment.Yoremployees <br />paymentsmadeprsanttoSdiisiondof <br />eposretotoseconditionscasingoraggraating <br />Section460ofteCaliforniaLaorCode,ifte <br />scodilyinryydiseasemstoccrdringte <br />lateindemnitypaymentwicgiesrisetote <br />policy period. <br />increaseinteamontofpaymentisdeless <br />tanseendaysafterwereceiete.SbufDibohft/Tepremimandrateswit <br />completedclaimformfromyo.Yoarerespecttoteinsranceproidedytis <br />oligatedtoreimrsesforanyincreaseinpolicy y reason of te designation ofCalifornia in <br />indemnity payments not coered nder tis policy <br />Gpsn!XD!15!14!12!CC Printed in .S.A.Qbhf2!pg3 <br />Qspdftt!Ebuf;11/04/2Qpmjdz!Fyqjsbujpo!Ebuf;11/04/26 <br /> <br />