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Workers' Compensation and Employers' Liability Policy <br />Named Insured <br />Endorsement Number <br />Insperity, Inc. FIELDMAN, ROLAPP & ASSOCIATES, INC. dba APPLIED BEST PRACTICES & <br />CITY OF SANTA ANA;CLERK OF THE COUNCIL; <br />FIELDMAN ROLAPP FINANCIAL SERVICES LLC <br />20 CIVIC CENTER PLAZA (M -30) <br />SANTA ANA, CA 92701 <br />19001 Crescent Springs Drive <br />Policy Symbol <br />Policy Number <br />Policy Period <br />Effective Date of Endorsement <br />RWC <br />C4819087A <br />10/01/2014 TO 10/01/2015 <br />10/01/2014 <br />Issued By (Name of Insurance Company) <br />Ace American Insurance Co. <br />Insert the policy number The remainder of the information 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 <br />reason other than nonpayment of premium, we will endeavor, as set out below, to send written notice <br />of cancellation, via such electronic or other form of notification as we determine, to the persons or <br />organizations listed in the schedule set out below (the "Schedule "). You or your representative must <br />provide us with both the physical and e-mail address of such persons or organizations, and we will <br />utilize such e-mail address or physical address that you or your representative provided to us on such <br />Schedule. <br />B. We will endeavor to send or deliver such notice to the e-mail address or physical address <br />corresponding to each person or organization indicated in the Schedule at least 30 days prior to the <br />cancellation date applicable to the Policy. <br />C. The notice referenced in this endorsement is intended only to be a courtesy notification to the <br />person(s) or organization(s) named in the Schedule in the event of a pending cancellation of <br />coverage. We have no legal obligation of any kind to any such person(s) or organization(s). Our <br />failure to provide advance notification of cancellation to the person(s) or organization(s) shown in the <br />Schedule shall impose no obligation or liability of any kind upon us, our agents or representatives, will <br />not extend any Policy cancellation date and will not negate any cancellation of the Policy. <br />D. We are not responsible for verifying any information provided to us in any Schedule, nor are we <br />responsible for any incorrect information that you or your representative provide to us. If you or your <br />representative does not provide us with the information necessary to complete the Schedule, we have <br />no responsibility for taking any action under this endorsement. In addition, if neither you nor your <br />representative provides us with e-mail and physical address information with respect to a particular <br />person or organization, then we shall have no responsibility for taking action with regard to such <br />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 <br />address and 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 />ALL-32688 (01111) <br />Acct #: 1169655 <br />I va 1kp� <br />Authorized Representative <br />Page 1 of 1 <br />--g <br />