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EMPLOYERS LIABILITY COVERAGE ENDORSEMENT <br /> This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different <br /> date is indicated below. <br /> f-lie-following attaching-clause"need-bo-completed_onl}twhen-this-endQraement_is_issued_subsequent-to-preps€ation of the-poiEcy.), <br /> =This-endorsement,, effective=12:0t-AM— 3/1/2026 forms-a-part of-Polioy-No:WC066656651 <br /> Issued to SHANNON & WILSON, INC. <br /> By NEW HAMPSHIRE INSURANCE COMPANY <br /> This endorsement applies only to work in the states shown in the Schedule. <br /> A. Part One (Workers Compensation Insurance) does not apply to work in a state shown in the Schedule. <br /> S. Part Two (Employers Liability Insurance) applies to work in states shown in the Schedule as though they were <br /> shown in Item 3.A. of the Information Page, <br /> C. Part Two (Employers Liability Insurance), C. Exclusions is changed by adding these exclusions. <br /> This insurance does not cover: <br /> 13. bodily injury to an employee when you are deprived of common law defenses or are subject to penalty because <br /> of your failure to secure your obligations under the workers compensation law of any state shown in the <br /> Schedule or otherwise fail to comply with that law. <br /> Schedule <br /> States <br /> NORTH OAKOTA WASHINGTON WYOMING <br /> WGOOD3b3G Gnuntersigneo7lby - - -- -- - - - - - - - - - - - - - - - - -r- - _ _ _ __ - - <br /> (Ed. 10104) <br /> (b 2004 National Council on Compensation Insurance,Inc. Authorized Representative <br />