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FIELDMAN Rf7l.APG> FINANCIAL SERVICES AG R A I'BD REVIEWED BY `"°"" °'r l-MNICE IIEREDIA (PG 5 OF Cij <br />Workers' Compensation and Employers' Liability Policy <br />Named Insured <br />Endorsement Number <br />Insperity, Inc. FIELDMAN, ROLAPP 8, ASSOCIATES, INC. dba APPLIED BEST PRACTICES & <br />20 CIVIC CENTER PLAZA(M -3P) <br />SANTA ANA, CA 92701 <br />FIELDMAN ROLAPP FINANCIAL SERVICES LLC <br />19001 Crescent Springs Drive <br />Policy Symbol <br />policy Number <br />Policy Porlod <br />Effective Date of Endorsement <br />RWC <br />C4819087A <br />10/01/20'14 TO 10/01/2015 <br />'10101/2014 <br />Issued By (Name of Insurance Company) <br />Ace American Insurance Co. <br />acr,u uy�r uy wirwer_ Ire re,,,e,�!uvrwu,e IIIIU[r11pI141118:o's a.rrp,@.o Ur, ym, A's01144,FOImm 19161,.d sUbsv,,s,l1 Nth, j ms.Py.n of <br />the pnk, <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 />E. 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($) 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 />Gr This endorsement does not apply in the event that you cancel the Policy, <br />SCI-0Et)I II F <br />Name of Certificate Ffoldar E -Mail Address <br />Ph sisal Address <br />_ _ <br />CITY OF SANTA ANA;CLERK OF THE COUNCIL; <br />20 CIVIC CENTER PLAZA(M -3P) <br />SANTA ANA, CA 92701 <br />All other terms and conditions of the Policy remain unchanged. <br />ALL -32888 (01 /11) <br />Accdf: 11696i5 <br />�c� at &,Pb <br />_- <br />Authorized Representative <br />Page 1 of 1 <br />