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QBSU!GJWF!.!QSFNJVN <br />A.Pvs!Nbovbmt is amended y adding tis sentence <br />In tis part, "or manals" means manals approed or prescried y te Teas Department of Insrance. <br />C.Sfnvofsbujpo <br />mer 2 is amended to read <br />2.AlloterpersonsengagedinwortatwoldmaeslialenderPartOneWorersCompensationInsrance <br />oftispolicy.Tisparagrap2willnotapplyifyogiesprooftatteemployersoftesepersonslawflly <br />secred worers compensation insrance. <br />D.Qsfnjvn!Qbznfout is amended y adding tis sentence <br />Te illing statement or inoice for adit additional premims and/or retrospectie additional premims estalises te <br />date te premim is de. <br />E.Gjobm!Qsfnjvn <br />mer 2 is amended to read <br />2.Ifyocancel,finalpremimwillecalclatedprorataasedontetimetispolicywasinforce.Finalpremim <br />will not e less tan te pro rata sare of te minimm premim. <br />QBSU!TJY!.!DPOEJUJPOT <br />A.Jotqfdujpo is amended y adding tis sentence <br />Yor failre to comply wit te safety recommendations made as a reslt of an inspection may case te policy to e <br />canceled y s. <br />C.Usbotgfs!pg!Zpvs!Sjhiut!boe!Evujft is amended to read <br />Yorrigtsanddtiesndertispolicymaynotetransferredwitotorwrittenconsent.Ifyodie,coeragewill <br />eproidedforyorsriingsposeoryorlegalrepresentatie.Tisappliesonlywitrespecttoteiractinginte <br />capacity as an employer and only for te worplaces listed in Items 1 and 4 on te Information Page. <br />D.Dbodfmmbujpo is amended to read <br />1.Yomaycanceltispolicy.Yomstmailordelieradancenoticetosstatingwentecancellationistotae <br />effect. <br />2.Wemaycanceltispolicy.Wemayalsodeclinetorenewit.Wemstgieyowrittennoticeofcancellationor <br />nonrenewal.Tatnoticewillesentcertifiedmailordelieredtoyoinperson.Acopyoftewrittennoticewill <br />e sent to te Teas Department of Insrance-Diision of Worers Compensation. <br />3.oticeofcancellationornonrenewalmstesenttoyonotlatertante30tdayeforetedateonwicte <br />cancellationornonrenewalecomeseffectie,ecepttatwemaysendtenoticenotlatertante10tday <br />eforetedateonwictecancellationornonrenewalecomeseffectieifwecancelordonotrenewecase <br />of <br />a.Frad in otaining coerage <br />.Misrepresentation of te amont of payroll for prposes of premim calclation <br />c.Failre to pay a premim wen payment was de <br />d.Anincreaseinteaardforwicyoseecoeragetatresltsfromanactionoromissionandtatwold <br />prodceanincreaseinterate,incldinganincreaseecaseoffailretocomplywitreasonale <br />recommendationsforlosscontrolortocomplywitinareasonaleperiodwitrecommendationsdesignedto <br />redce a aard tat is nder yor control <br />e.AdeterminationyteCommissionerofInsrancetattecontinationoftepolicywoldplacesin <br />iolation of te law, or wold e aardos to te interests of sscriers, creditors, or te general plic. <br />4.IfanoterinsrancecompanynotifiesteTeasDepartmentofInsrance-DiisionofWorersCompensationtat <br />itisinsringyoasanemployer,scnoticemsteacancellationoftispolicyeffectiewenteoterpolicy <br />starts. <br />Add te following to te policy <br />QBSU!TFWFO!.!PVS!EVUZ!UP!ZPV!GPS!DMBJN!OPUJGJDBUJPO <br />A.Dmbjnt!Opujgjdbujpo <br />Wearereiredtonotifyyoofanyclaimtatisfiledagainstyorpolicy.Tereafterwemstnotifyyoofany <br />proposaltosettleaclaimor,onreceiptofawrittenreestfromyo,ofanyadministratieordicialproceeding <br />relatingtoteresoltionofaclaim,incldingaenefitreiewconferencecondctedyteTeasDepartmentof <br />Insrance-Diision of Worers Compensation.Yo may, in writing, elect to waie tis notification reirement. <br />Wemst,ontewrittenreestfromyo,proideyowitalistofclaimscargedagainstyorpolicy,payments <br />madeandreseresestalisedoneacclaim,andastatementeplainingteeffectofclaimsonyorpremimrates. <br />Wemstfrnistereestedinformationtoyoinwritingnolatertante30tdayaftertedatewereceieyor <br />reest.TeinformationisconsideredtoeproidedontedateteinformationisreceiedytenitedStates <br />Postal Serice or is personally deliered. <br />Gpsn!XD!53!14!12!M Printed in .S.A.Qbhf3!pg4 <br /> <br />