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J <br />Workers' Compensation and Employers' Liability Policy <br />Named Insured <br />Endorsement Number <br />Insperity, Inc. FIELDMAN, ROLAPP & ASSOCIATES, INC. <br />CITY OF SANTA ANA, CLERK OF THE COUNCIL <br />19001 Crescent springs Drive <br />20 CIVIC CENTER PLAZA (M -30) <br />SANTA ANA, CA 92701 <br />Kingwood, TX 77339 <br />Policy Symbol <br />Policy Number <br />Policy Period <br />Effective Dale of Endorsement <br />C4819087A <br />10/01/2014 TO 10/0112015 <br />10/01/2014 <br />Issued By (Name of Insurance Company) <br />Indemnity Insurance Co. of North America <br />Insert the policy number. The remainder of the infonnatlon Is to be completed only when this endorsement Is Issued subsequent to the preparation of <br />the policy. <br />NOTICE TO OTHERS ENDORSEMENT - SPECIFIC PARTIES <br />A. If we cancel the Policy prior to its expiration date by notice to you or the first Named Insured for any reason other <br />than nonpayment of premium, we will endeavor, as set out below, to send written notice of cancellation, via such <br />electronic or other form of notification as we determine, to the persons or organizations listed in the schedule set <br />out below (the "Schedule "). You or your representative must provide us with both the physical and e-mail <br />address of such persons or organizations, and we will utilize such e-mail address or physical address that you or <br />your representative provided to us on such Schedule. <br />B. We will endeavor to send or deliver such notice to the e-mail address or physical address corresponding <br />to each person or organization indicated in the Schedule at least 30 days prior to the cancellation date applicable <br />to the Policy. <br />C. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or <br />organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no <br />legal obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of <br />cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of <br />any kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate <br />any cancellation of the Policy. <br />D. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for <br />any incorrect information that you or your representative provide to us. If you or your representative does not <br />provide us with the information necessary to complete the Schedule, we have no responsibility for taking any <br />action under this endorsement. In addition, if neither you nor your representative provides us with e-mail and <br />physical address information with respect to a particular person or organization, then we shall have no <br />responsibility for taking action with regard to such person or entity under this endorsement. <br />E. We may arrange with your representative to send such notice in the event of any such cancellation. <br />F. You will cooperate with us in providing, or in causing your representative to provide, the e-mail address and <br />physical address of the persons or organizations listed in the Schedule. <br />G. This endorsement does not apply in the event that you cancel the Policy. <br />SCHEDULE <br />Name of Certificate Holder <br />E -Mail Address <br />Physical Address <br />CITY OF SANTA ANA, CLERK OF THE COUNCIL <br />20 CIVIC CENTER PLAZA (M -30) <br />SANTA ANA, CA 92701 <br />All other terms and conditions of the Policy remain unchanged. <br />Acct#: 1169655 <br />ALL -32688 (01/11) <br />tvw_ 1k <br />Authorized Representative <br />� 1 _ <br />r , <br />/ Page 1 of 1 <br />