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Workers' Compensation and Employers' Liability Policy <br />Named Insured Endorsement Number <br />Insperity, Inc. FIELDIVIAN, ROLAPP & ASSOCIATES, INC. dba APPLIED BEST PRACTICES & FIELDMAN <br />ROLAPP FINANCIAL SERVICES LLC <br />19001 Crescent Springs Drive <br />773;5 Policy Number Policy Period Effect�ve Date of Endorsement <br />I C48653492 10/01/2015 TO 10/01/2016 10/01/2015 <br />Issued By (Name of Insurance Company) <br />Ace American Insurance Co. <br />Insert the policy number. The remainder m the information ismbe completed only when this endorsement missued subsequent to the preparation of <br />the policy <br />NOTICE TO OTHERS ENDORSEmewr - SpEo|FImPARHES <br />A. Ifwm cancel the Policy prior to its expiration date by notice to you m the first Named Insured for any reason other <br />than nonpayment of premium, we will endaavor, as set out below, to send written notice of caooeNation, via such <br />electronic or other form of notification as we determine, to the persons or organizations listed in the schedule met <br />out below (the "Schedule"). You or your vupnamontn1ive must provide w* with both the physical and e-mail <br />oddnooa of such persons or organizations, and we will wWVizv such e-mail address or physical address that you or <br />your representative provided touoon such Schedule. <br />B. We will endeavor to send or defiver such notice to the e-mail address or physical address corresponding, <br />#o each person or organization indicated in the Schedule e{ least 30 days prior 0m the cancellation date applicable <br />to the Policy, <br />C. The notice referenced in this endorsement im Intended only tobea courtesy nofification tm the person(s) or <br />organization(s) nomad in the Schedule in the *vent of a pending cancellation of coverage. We have no <br />legal obligation of any hind to any such person(s) or organ iza&iom(m). Our failure to provide advance notification of <br />cancellation to the person(s) oron0anizaWmm(m) shown in the Schedule shall impose no obligation or liability of <br />any kind upon ua, our agents ur 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 Sohodu|e, nor are we responsible for <br />any incorrect information that you or your representative provide to ua. If you or your representative does not <br />provide uaM0h the information necessary to complete the Gohedu|e, we have no responsibility for taking any <br />action under this endorsement. In odVimn, if neither you nor your representative provides us with e-mail and <br />physical address information with respect to a particular person or o,gemiza0on, 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 w4h us in pmvidinQ, or in causing your representative to pnovide, 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 Ol'SANTA ANA� CLERK 01�1'1 IE COUNCIL <br />20 CIVIC CFNTER. PLAZA (M-30) <br />SANTA ANA, CA 92701 <br />All other terms and conditions of the Policy remain unchanged. <br />Authorized Representative <br />Acot#:1108055 <br />ALL-31688 (01/11) Page 1 of <br />