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Policy No. WCJ- Z91- 453980 -073 <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />NOTICE OF CANCELLATION TO THIRD PARTIES <br />This endorsement modifies insurance provided under the following: <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY COVERAGE PART <br />A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons <br />or organizations shown in the Schedule below. In no event does the notice to the third party exceed <br />the notice to the first named insured. <br />B. This advance email notification of a pending cancellation of coverage is intended as a courtesy only. <br />Our failure to provide such advance notification will not extend the policy cancellation date nor negate <br />cancellation of the policy. <br />SCHEDULE <br />Name of Other Person(s) ! <br />Organ ization s : <br />Email Address or mailing address: <br />Number Days Notice: <br />As required by written contract <br />Per schedule on file with company <br />30 -days <br />All other terms and conditions of this policy remain unchanged. <br />WM 90 18 09 10 2010 Liberty Mutual Group of Companies Page I of 1 <br />Ed. 09/01 /2010 All Rights Reservcd <br />