FRIENDS OF SANTA ANA ZOO (FOSAZ) 6 -2016

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ENDORSEMENT AGREEMENT MEDICAL PROVIDER NETWORK 9048876-15 RENEWAL SP HOME OFFICE 3-68-03-58 SAN FRANCISCO EFFECTIVE JULY 1, 2015 AT 12.,01 A.M. PAGE 1 OF 3 ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME FRIENDS OF SANTA ANA ZOO 1801 E CHESTNUT AVE SANTA ANA, CA 92701 ANY CONTRADICTION BETWEEN THE POLICY AND THIS ENDORSEMENT WILL BE CONTROLLED BY THIS ENDORSEMENT. THE STATE COMPENSATION INSURANCE FUND MEDICAL PROVIDER NETWORK IS ESTABLISHED IN ACCORDANCE WITH CALIFORNIA LABOR CODE 4600 ET SEQ AND APPROVED BY THE CALIFORNIA DIVISION OF WORKERS' COMPENSATION ADMINISTRATIVE DIRECTOR. THE INTENT OF THE 2004 LEGISLATION REQUIRING THE ESTABLISHMENT OF THE MEDICAL PROVIDER NETWORK IS INCREASED EMPLOYER CONTROL OVER THE COSTS OF'TREATING'EMPLOYEE'WORK RELATED INJURIES AND DISEASE. PART FOUR OF THE POLICY, YOUR DUTIES IF INJURY OCCURS, IS AMENDED AS FOLLOWS: IT IS AGREED THAT THE POLICYHOLDER SHALL REFER ALL WORK RELATED INJURIES OR DISEASE TO THE STATE COMPENSATION INSURANCE FUND MEDICAL PROVIDER NETWORK AT THE TIME OF AN OCCUPATIONAL INJURY OR UPON KNOWLEDGE OF AN OCCUPATIONAL INJURY OR DISEASE. IT IS FURTHER AGREED THAT WHEN AN EMPLOYEE NOTIFIES THE POLICYHOLDER OF AN OCCUPATIONAL INJURY OR FILES A CLAIM FOR WORKERS' COMPENSATION WITH THE POLICYHOLDER, THE POLICY- HOLDER SHALL ARRANGE AN INITIAL MEDICAL EVALUATION AND BEGIN TREATMENT WITHIN THE MEDICAL PROVIDER NETWORK. THE POLICYHOLDER SHALL NOTIFY THE EMPLOYEE OF HIS OR HER RIGHT CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE.1", OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS, 7 POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHAe' HELD TCP VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMEN LIMITATIONS OF THIS ENDORSEMENT. Cr�O•J�?Yr. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: JANE 26, 2015��'„''�� 2437 At)THORIZED REPRESEN��P 4 PRESIDENT AND CEO