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Workers' CompensationPolicy Forms and Endorsements

ALPHABETICAL INDEX

Forms are listed alphabetically by form title.

The forms included in this section, which WOLTERS KLUWER makes available as stock items, are as follows:

1. Standard and Advisory ‘‘General Use’’ and ‘‘State’’ Endorsements based on National Council on Compensation Insurance (NCCI) text.2. Endorsements containing ‘‘Tables of Rating Values’’ (used in conjunction with ‘‘Retrospective Premium Endorsements’’). Based on NCCI text.3. Specific state endorsements in text provided by local Workers Compensation Boards or Bureaus with corresponding Identification Numbers when

designated.

Monopolistic Jurisdiction: None of the forms listed herein are for use in the following jurisdictions having a "monopolistic" Workers' Compensation program,except where specifically listed: Ohio, North Dakota, Washington, and Wyoming. Certain Employers Liability forms may, of course, be used even though Workers'Compensation is not used.



UNIFORM EDITION BUREAUNUMBER DATE NUMBER TITLE STATE

--------------------------------------------------------GENERAL USE/STATE SPECIFIC

--------------------------------------------------------Alabama

WC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC598 11/96 WC010402 ANNIVERSARY RATING DATE

ENDORSEMENTWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM

ENDORSEMENTWC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATING

PLAN ENDORSEMENTWC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATING

PLAN NOTIFICATION ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM

DIFFERENTIAL ENDORSEMENTWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE

ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE

ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT

(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT

ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOROWNERSHIP INFORMATION

WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT

WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGEENDORSEMENT

WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT

ENDORSEMENTWC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENT

EXCLUSION ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT

EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE

ENDORSEMENTWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION

FACTOR ENDORSEMENTWC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION

FACTOR REVISION ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND

SAFETY ACT COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT

COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED

ENDORSEMENTWC116 04/84 WC 00 03 05 JOINT VENTURE AS INSURED

ENDORSEMENTWC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSION

ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE

ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'

COMPENSATION ACT COVERAGEENDORSEMENT




WC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT

WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC463 11/92 WC 01 04 01 MERIT RATING ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL

AGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT

WC437 02/92 WC 00 03 23 MULTIPLE COORDINATED POLICYENDORSEMENT

WC000323 A 01/06 WC 00 03 23 A MULTIPLE COORDINATED POLICYENDORSEMENT

WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT

WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE INOWNERSHIP

WC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT

WC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITYINSURANCE

WC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT

WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B POLICY INFORMATION PAGE

ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION

ENDORSEMENT - FORMER SELF-INSURERS 1

WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER

ORGANIZATION (PEO) EXCLUSIONENDORSEMENT

WC000320 B 01/06 WC 00 03 20 B PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT

WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE

COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—

AVIATIONWC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—

CHANGESWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—

SHORT FORMWC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN

PREMIUM ENDORSEMENT ONE-YEARPLAN

WC000512 D 01/19 WC 00 05 12 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES

WC000504 D 01/19 WC 00 05 04 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN

WC000513 D 01/19 WC 00 05 13 D




RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES

WC000505 D 01/19 WC 00 05 05 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT

WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES

WC000516 01/10 WC 00 05 16 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)

WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICEENDORSEMENT

WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT

(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT

WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT

WC000203 04/84 WC 00 02 03 VOLUNTARY COMPENSATIONMARITIME COVERAGE ENDORSEMENT

WC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROMOTHERS ENDORSEMENT

AlaskaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC540601 01/13 WC5406010113 ALASKA NOTICE OF INSTALLMENT

OPTION ENDORSEMENTFORM542 03/13 FORM 54-2 ALASKA POLICYHOLDER NOTICE -

ACCESS TO MANUAL INFORMATIONWC540403 01/99 WC5404030199 ALASKA RESIDUAL MARKET SAFE

WORKPLACE INCENTIVEWC540501 B 01/19 WC540501B ALASKA RETROSPECTIVE RATING PLAN


WC540504 B 01/19 WC540504B ALASKA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES

WC540502 B 01/19 WC540502B ALASKA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN

WC540505 01/15 WC540505A ALASKA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES

WC540505 B 01/19 WC540505B ALASKA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES

WC540503 B 01/19 WC540503B ALASKA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT

WC540506 B 01/19 WC540506B ALASKA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES

WC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENT




WC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM

DIFFERENTIAL ENDORSEMENTWC465 09/92 WC 54 04 01 ASSIGNED RISK PREMIUM SURCHARGEWC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGE

ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC573 05/95 WC540602 CANCELLATION AND NONRENEWAL

ENDORSEMENTWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING

MODIFICATION FACTOR ENDORSEMENTWC584 01/96 WC540402 CONTRACTING CLASSIFICATION

PREMIUM ADJUSTMENT ENDORSEMENTWC646 12/03 FORM541CCPAP CONTRACTING CLASSIFICATION

PREMIUM ADJUSTMENT PROGRAMWORKERS COMPENSATION PREMIUMCREDIT APPLICATION


WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,

AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT

WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENTENDORSEMENT

WC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT

WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGEENDORSEMENT

WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATIONFACTOR ENDORSEMENT

WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT

WC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH ANDSAFETY ACT COVERAGE ENDORSEMENT

WC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACTCOVERAGE ENDORSEMENT

WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUMENDORSEMENT

WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED


ENDORSEMENTWC572 05/95 WC540301 LIMIT OF LIABILITY ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE




WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL










WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION


WC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER











WC000513 D 01/19 WC 00 05 13 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES











ArizonaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC020401 C 02/10 WC 02 04 01 C ALCOHOL/DRUG-FREE WORKPLACE

PREMIUM CREDIT ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC020602 08/02 WC 02 06 02 ARIZONA BENEFITS DEDUCTIBLE

ENDORSEMENTWC020601 A 09/15 WC 02 06 01 A ARIZONA CANCELLATION AND

NONRENEWAL ENDORSEMENTWC020301 A 05/17 WC 02 03 01 A ARIZONA EMPLOYEE LEASING

ENDORSEMENTWC020501 03/02 WC 02 05 01 ARIZONA RETROSPECTIVE PREMIUM

ENDORSEMENT LARGE RISKALTERNATIVE RATING OPTION

WC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUMDIFFERENTIAL ENDORSEMENT

WC383 01/90 WC 00 04 13 ASSIGNED RISK PREMIUM SURCHARGEENDORSEMENT

WC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGEENDORSEMENT

WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC330 05/86 WC 02 06 01 CANCELLATION ENDORSEMENT






ENDORSEMENTWC604 01/97 WC0203020197 EMPLOYEE LEASING CLIENT


EXCLUSION ENDORSEMENTWC603 01/97 WC0203010197 EMPLOYEE LEASING ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE







ENDORSEMENTWC605 01/97 WC0203030197 LABOR CONTRACTOR EXCLUSION

ENDORSEMENT




WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGEENDORSEMENT

WC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGEENDORSEMENT






WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015








WC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT









WC000504 D 01/19 WC 00 05 04 D




RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN











ArkansasWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC262 A 04/92 WC 03 06 01 A AMENDATORY ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC030601 B 03/18 WC 03 06 01 B ARKANSAS AMENDATORY

ENDORSEMENTWC030603 B 07/19 WC 03 06 03 B ARKANSAS CONTRACT HAULING

WARRANTY ENDORSEMENTWC030402 A 01/18 WC 03 04 02 A ARKANSAS TABULAR ADJUSTMENT

PROGRAM ENDORSEMENTWC552 01/94 WC030301 ASSIGNED RISK ASSOCIATED OR

SPONSORED POLICY COVERAGEENDORSEMENT

WC553 01/94 WC030302 ASSIGNED RISK MULTIPLECOORDINATED POLICY COVERAGEENDORSEMENT




WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC556 A 10/96 WC030602A1096 BENEFITS DEDUCTIBLE ENDORSEMENT























WC617 10/97 WC0304041097 MANAGED CARE ENDORSEMENTWC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC117 04/84 WC 00 03 06 MEDICAL BENEFITS EXCLUSION

ENDORSEMENTWC118 04/84 WC 00 03 07 MEDICAL BENEFITS REIMBURSEMENT

ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL






WC000414 A 01/19 WC 00 04 14 A




NOTIFICATION OF CHANGE INOWNERSHIP























(New) WC000422 C 01/21 WC000422C




TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT




WC540 03/94 WC030401 WORKERS COMPENSATION INSURANCEPLAN ALTERNATE PREFERRED PLANPREMIUM ENDORSEMENT

WC539 03/94 WC030403 WORKERS COMPENSATION INSURANCEPLAN MERIT RATING ENDORSEMENT

CaliforniaWC040412 11/02 WC0404121102 1999 PREMIUM INCREASE

ENDORSEMENT - CALIFORNIAWC040413 11/02 WC0404131102 2000 PREMIUM INCREASE



ENDORSEMENT - CALIFORNIAWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM


ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC040399 04/16 WC040399 CALIFORNIA CUSTOMIZED LIMITING

AND RESTRICTING ENDORSEMENTAGREEMENT - ENDORSEMENTAGREEMENT LIMITING ANDRESTRICTING THIS INSURANCE

WC040422 01/12 WC040422 CALIFORNIA SHORT-RATECANCELATION ENDORSEMENT

WC535 12/93 WC040601A CANCELLATION ENDORSEMENT(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIED

ACTS OF TERRORISM) PREMIUMENDORSEMENT



WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC565 01/95 WC0403100195 DUTY TO DEFENDWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT

ENDORSEMENTWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT

EXCLUSION ENDORSEMENTWC387 A 10/98 WC040307A1098 EMPLOYEE LEASING ENDORSEMENTWC626 A 10/98 WC040312A1098 EMPLOYEE LEASING ENDORSEMENT

(FOR LEASING ARRANGEMENTS THATDO NOT FALL WITHIN THE SCOPE OFTHE EMPLOYEE)

WC388 A 10/98 WC040308A1098 EMPLOYEE LEASING ENDORSEMENTSHORT FORM




WC625 A 10/98 WC040311A1098 EMPLOYEE LEASING ENDORSEMENTSHORT FORM (FOR LEASINGARRANGEMENTS THAT DO NOT FALLWITHIN THE SCOPE OF THE EMPLOYEELEASING RULE)


WC040360 B 01/15 WC040360B EMPLOYERS’ LIABILITY COVERAGEAMENDATORY ENDORSEMENT -CALIFORNIA

WC040345 A 10/16 WC040345A ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -COMPREHENSIVE PERSONAL LIABILITYPOLICY EXCLUSION

WC040338 B 02/18 WC 04 03 38 B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -DESIGNATED EMPLOYEE(S) EXCLUSION

WC040340 B 02/18 WC 04 03 40 B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -DESIGNATED LOCATION(S) COVERAGE

WC040341 B 02/18 WC 04 03 41 B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -DESIGNATED LOCATION(S) EXCLUSION

WC040344 B 02/18 WC 04 03 44 B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE- DESIGNATED OPERATION(S) ATDESIGNATED LOCATION(S) COVERAGE

WC040343 B 02/18 WC 04 03 43 B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE- DESIGNATED OPERATION(S) ATDESIGNATED LOCATION(S) EXCLUSION

WC040339 B 02/18 WC 04 03 39 B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -DESIGNATED OPERATION(S) COVERAGE

WC040342 B 02/18 WC 04 03 42 B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -DESIGNATED OPERATION(S) EXCLUSION

WC040350 04/16 WC040350 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE- INSURANCE COMPANY AS INSUREDEXCLUSION

WC040337 A 04/16 WC040337A ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -JOINT VENTURE EXCLUSION

WC040336 A 04/16 WC040336A ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE- JOINTLY CONDUCTED OPERATIONSEXCLUSION

WC040332 04/16 WC040332 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -MEDICAL BENEFITS EXCLUSION

WC040303 C 07/18 WC 04 03 03 C ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -OFFICERS AND DIRECTORS COVERAGE /EXCLUSION - CALIFORNIA

WC040302 D 07/18 WC 04 03 02 D ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -PARTNERSHIP COVERAGE / EXCLUSION -CALIFORNIA




WC040333 04/16 WC040333 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE- PARTNERSHIP COVERAGE / JOINTLYAND NOT SEVERALLY EXCLUSION

WC040366 07/18 WC 04 03 66 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE- PROFESSIONAL CORPORATIONCOVERAGE / EXCLUSION CALIFORNIA

WC040331 A 04/16 WC040331A ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE -RESIDING RELATIVES EXCLUSION

WC040317 B 10/16 WC040317B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE(EMPLOYEE INSURED BY GENERALEMPLOYER EXCLUDED)

WC040313 B 10/16 WC040313B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE(LABOR CONTRACTOR AS NAMEDINSURED - EXCLUSION OF LEASEDEMPLOYEES)

WC040315 B 10/16 WC040315B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE(LABOR CONTRACTOR AS NAMEDINSURED WITH LCF DESIGNATION—RESTRICTION OF COVERAGE TO CLIENTWORKERS)

WC040316 B 10/16 WC040316B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE(LABOR CONTRACTOR AS NAMEDINSURED—EXCLUSION OF CLIENT'SEMPLOYEES)

WC040314 B 10/16 WC040314B ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE(LABOR CONTRACTOR AS NAMEDINSURED—RESTRICTION OF COVERAGETO CLIENT WORKERS)

WC7765 05/94 ENDORSEMENT AGREEMENT LIMITINGAND RESTRICTING THIS INSURANCE/WORKERS’ COMPENSATION ANDEMPLOYERS’ LIABILITY POLICYAMENDATORY ENDORSEMENT

WC040410 A 01/18 WC 04 04 10 A ESTIMATED ANNUAL PREMIUMENDORSEMENT—CALIFORNIA


WC040005 07/98 WC0400050798 EXTENSION OF INFORMATION PAGE—CLASSIFICATIONS

WC040004 07/98 WC0400040798 EXTENSION OF INFORMATION PAGE—SCHEDULE OF FORMS

WC040003 07/98 WC0400030798 EXTENSION OF INFORMATION PAGE—SCHEDULE OF LOCATIONS

WC040002 07/98 WC0400020798 EXTENSION OF INFORMATION PAGE—SCHEDULE OF NAMED INSURED

WC040406 G 01/20 WC 04 04 06 G FARM SCHEDULE ENDORSEMENT -CALIFORNIA


WC040001 B 10/14 WC040001B INFORMATION PAGEWC040411 01/04 WC0404110104(CA)




INSOLVENT RATING ADJUSTMENT PLANENDORSEMENT

WC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSUREDENDORSEMENT

PN049907 A 07/15 PN049907A JANUARY 1, 2014 AUDIT REQUIREMENTSFOR POLICIES WITH FINAL PREMIUMOF LESS THAN $10,000 THAT DEVELOPPAYROLL IN HIGH WAGE DUALWAGE CONSTRUCTION OR ERECTIONCLASSIFICATIONS

WC116 04/84 WC 00 03 05 JOINT VENTURE AS INSUREDENDORSEMENT

WC040603 B 01/15 WC040603B LARGE RISK DEDUCTIBLEENDORSEMENT

WC040318 C 07/18 WC 04 03 18 C LIMITED LIABILITY COMPANYCOVERAGE / EXCLUSIONENDORSEMENT-CALIFORNIA



WC247 A 04/92 WC040101A0492 LONGSHOREMEN’S AND HARBORWORKERS COMPENSATION ACTCOVERAGE ENDORSEMENT





PN049903 11/99 PN0499031199 NOTICE REQUIRED BY LAWWC040421 01/08 WC0404210108 OPTIONAL PREMIUM INCREASE

ENDORSEMENT - CAWC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDS

ACT COVERAGE ENDORSEMENTWC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITY

INSURANCEWC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERS

EXCLUSION ENDORSEMENTWC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC166 B 03/98 WC 04 03 01A POLICY AMENDATORY ENDWC040301 D 02/18 WC040301C POLICY AMENDATORY ENDORSEMENT -

CALIFORNIAPN049904 12/01 PN0499041201 POLICY HOLDER NOTICE - CALIFORNIA

INSURANCE GUARANTEE ASSOCIATION(CIGA) SURCHARGE

WC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTPN049908 12/19 PN049908 POLICYHOLDER NOTICE - CALIFORNIA

ASSEMBLY BILL NO 5., INDEPENDENTCONTRACTORS

PN049906 D 01/20 PN 04 99 06 D POLICYHOLDER NOTICE - PAYROLLRECORD AND AUDIT REQUIREMENTSFOR DUAL WAGE CONSTRUCTION ORERECTION CLASSIFICATIONS

PN049902 B 05/02 PN049902B0502




POLICYHOLDER NOTICE (INSURANCERATING LAWS)

PN049901 G 03/19 PN 04 99 01 G POLICYHOLDER NOTICE (YOURRIGHT TO RATING AND DIVIDENDINFORMATION)

WC040407 10/99 WC0404071099 PREMIUM ADJUSTMENT ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION


WC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER



WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC040401 A 01/18 WC 04 04 01 A RATING EFFECTIVE DATE

ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE



CHANGESWC561 01/95 WC0405110195 RETRO PREMIUM ENDORSEMENT—

SHORT FORMWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—

SHORT FORMWC040501 E 01/15 WC040501E RETROSPECTIVE PREM END [CA]WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLAN







WC040602 B 12/06 WC040602B1206 SMALL DEDUCTIBLE ENDORSEMENTWC250 A 01/85 WC040304 SOLE PROPRIETOR COVERAGE

ENDORSEMENT(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAM

REAUTHORIZATION ACT DISCLOSUREENDORSEMENT

WC251 A 01/85 WC040305 VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT

WC122 B 08/91 WC 00 03 11 B




VOLUNTARY COMPENSATION ANDEMPLOYERS LIABILITY COVERAGEENDORSEMENT


WC252 04/84 WC040306 WAIVER OF OUR RIGHT TO RECOVERFROM OTHERS ENDORSEMENT


ColoradoWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM



ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC385 11/90 WC 05 04 02 CLASSIFICATION ENDORSEMENTWC050404 A 01/12 WC 05 04 04 A COLORADO NON-COOPERATION

WITH PREMIUM AUDIT SURCHARGEENDORSEMENT







WC436 02/92 WC 00 03 22 EMPLOYEE LEASING CLIENTEXCLUSION ENDORSEMENT











ENDORSEMENT
















ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC567 03/93 WC050403 PREMIUM CREDIT FOR CERTIFIED

RISK MANAGEMENT PROGRAMSENDORSEMENT

WC266 07/91 WC 00 04 09 PREMIUM DETERMINATIONENDORSEMENT - FORMER SELF-INSURERS 1
























ConnecticutWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC199 04/84 WC 06 03 01 APPLICATION OF WORKERS

COMPENSATION INSURANCEENDORSEMENT

WC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAMENDORSEMENT

WC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATINGPLAN ENDORSEMENT

WC000417 B 01/11 WC 00 04 17 B ASSIGNED RISK LOSS SENSITIVE RATINGPLAN NOTIFICATION ENDORSEMENT




WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIED



WC060402 01/14 WC 06 04 03 CONNECTICUT FOREIGN VOLUNTARYCOMPENSATION AND EMPLOYERSLIABILITY COVERAGE ENDORSEMENT

WC060601 A 10/17 WC 06 06 01 A CONNECTICUT WORKERS'COMPENSATION FUNDS

WC362 01/90 WC 00 04 12




CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT

WC588 07/96 WC060401 CONTRACTING CLASSIFICATIONPREMIUM ADJUSTMENT ENDORSEMENT

NC5000 D 08/19 NC-5000 D CONTRACTING CLASSIFICATIONPREMIUM ADJUSTMENT PROGRAMWORKERS COMPENSATION PREMIUMCREDIT APPLICATION











ENDORSEMENTWC392 04/91 WC 00 03 20 LABOR CONTRACTOR ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE




WC060602 07/08 WC 06 06 02 MANDATORY ARBITRATIONENDORSEMENT









WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENT




WC890600 B 07/01 WC890600B POLICY INFORMATION PAGEENDORSEMENT

WC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09 PREMIUM DETERMINATION







COMPANY ENDORSEMENTWC146 04/84 WC 06 05 01 RETRO PREM SUPP (CT)WC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—














WC122 B 08/91 WC 00 03 11 B







DelawareFORM07-1 10/04 FORM0711004 AGREEMENT BY EXECUTIVE OFFICE

NOTICEFORMDCRB-EX

12/09 DCRB-EXCL AGREEMENT BY EXECUTIVE OFFICER(S)/LLC MEMBER(S) NOT TO BE SUBJECTTO THE DELAWARE WORKERS'COMPENSATION LAW

WC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC184 04/84 WC 07 03 03 AMENDATORY ENDORSEMENT—

FARMING OPERATIONSWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM


ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC375 07/90 WC 07 04 02 CONSTRUCTION CLASSIFICATION

PREMIUM ADJUSTMENT ENDORSEMENTWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING

MODIFICATION FACTOR ENDORSEMENTWC181 04/84 WC 07 04 01 DEDUCTIBLE ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE

ENDORSEMENTWC651 J 07/19 DCCPAP DELAWARE WORKERS COMPENSATION

PREMIUM CREDIT APPLICATIONWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,












ENDORSEMENTWC449 06/92 WC 00 02 04




LIMITED MARITIME COVERAGEENDORSEMENT



WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC117 04/84 WC 00 03 06 MEDICAL BENEFITS EXCLUSION


ENDORSEMENTWC070408 07/99 WC 07 04 08 MERIT RATING PLAN ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL




WC358 07/88 WC 07 06 01 NONRENEWAL ENDORSEMENTWC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENT

OF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015






WC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER







SHORT FORMWC481 10/93 WC 00 05 15 RETROSPECTIVE PREMIUM

ENDORSEMENT - FLEXIBILITY OPTIONSWC414 12/91 WC 00 05 05 A




RETROSPECTIVE PREMIUMENDORSEMENT - LONG TERMCONSTRUCTION PROJECT

WC417 12/91 WC 00 05 14 A RETROSPECTIVE PREMIUMENDORSEMENT - LONG-TERMCONSTRUCTION PROJECT - MULTIPLELINES

WC144 04/84 WC 00 05 10 RETROSPECTIVE PREMIUMENDORSEMENT - NON-RATABLECATASTROPHE ELEMENT ORSURCHARGE

WC412 12/91 WC 00 05 03 A RETROSPECTIVE PREMIUMENDORSEMENT - ONE YEAR PLAN

WC415 12/91 WC 00 05 12 A RETROSPECTIVE PREMIUMENDORSEMENT - ONE YEAR PLAN -MULTIPLE LINES

WC413 12/91 WC 00 05 04 A RETROSPECTIVE PREMIUMENDORSEMENT - THREE YEAR PLAN

WC416 12/91 WC 00 05 13 A RETROSPECTIVE PREMIUMENDORSEMENT - THREE YEAR PLAN -MULTIPLE LINES

WC650 04/84 WC000509 RETROSPECTIVE PREMIUMENDORSEMENT CHANGES

WC000503 D 01/19 WC 00 05 03 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN






WC120 04/84 WC 00 03 09 RURAL ELECTRIFICATIONADMINISTRATION ENDORSEMENT





District of ColumbiaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B




ASSIGNED RISK ADJUSTMENT PROGRAMENDORSEMENT






WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC263 04/84 WC 08 06 01 CANCELLATION ENDORSEMENT
























MIGRANT AND SEASONALAGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT























WC000514 D 01/19 WC 00 05 14 D RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UP




CONSTRUCTION PROJECT—MULTIPLELINES



WC080401 B 01/18 WC 08 04 01 B SAFE WORKPLACE PROGRAMENDORSEMENT






FloridaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEFORM0901 A 11/19 FORM09-01A APPLICATION FOR DRUG-FREE

WORKPLACE PREMIUM CREDITPROGRAM




WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC401 07/90 WC 09 06 05 BENEFITS DEDUCTIBLE ENDORSEMENTNC3011 07/06 FORMSAFETY93 CERTIFICATION EMPLOYER

WORKPLACE SAFETY PROGRAMPREMIUM CREDIT

FORM09-3 11/19 SAFETY 09-3A CERTIFICATION OF EMPLOYERWORKPLACE SAFETY PROGRAMPREMIUM CREDIT

WC399 07/90 WC 09 06 03 COINSURANCE AND DEDUCTIBLEENDORSEMENT

WC400 07/90 WC 09 06 04 COINSURANCE ENDORSEMENTERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOR

OWNERSHIP INFORMATIONWC060603 03/19 WC 06 06 03 CONNECTICUT NOTICE OF

CANCELLATION OR MATERIALCOVERAGE CHANGE TO DESIGNATEDGOVERNMENTAL ENTITYENDORSEMENT


FORM094 E 11/19 FORM 09-4E CONTRACTING CLASS PREM ADJ(FL)WC483 06/87 WC 09 04 01 CONTRACTING CLASSIFICATION

PREMIUM ADJUSTMENT ENDORSEMENTWC217 04/92 WC 00 01 01 A




DEFENSE BASE ACT COVERAGEENDORSEMENT





WC090303 08/05 WC 09 03 03 EMPLOYERS LIABILITY COVERAGEENDORSEMENT





WC090314 07/07 WC 09 03 14 FLORIDA EMPLOYEE LEASINGCOMPANY CLIENT COMPANY DIRECTWORKERS INCLUSION ENDORSEMENT

WC090311 07/07 WC 09 03 11 FLORIDA EMPLOYEE LEASINGCOMPANY CLIENT COMPANYEXCLUSION ENDORSEMENT

WC090312 07/07 WC 09 03 12 FLORIDA EMPLOYEE LEASINGCOMPANY EXCLUSION ENDORSEMENT

WC090310 07/07 WC 09 03 10 FLORIDA EMPLOYEE LEASINGCOMPANY EXTENSION ENDORSEMENT

WC090606 10/98 WC 09 06 06 FLORIDA EMPLOYMENT AND WAGEINFORMATION RELEASE

WC090402 A 05/17 WC 09 04 02 A FLORIDA EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT

WC090406 A 07/14 WC 09 04 06 A FLORIDA FOREIGN VOLUNTARYCOMPENSATION AND EMPLOYERSLIABILITY COVERAGE ENDORSEMENT

FORM095 10/19 FORM 09-5 FLORIDA INFORMATION PAGE NOTESWC090408 A 07/19 WC 09 04 08 A FLORIDA INSUFFICIENT FUNDS

ENDORSEMENTWC090201 01/15 WC 09 02 01 FLORIDA MARITIME COVERAGE

ENDORSEMENTWC090313 07/07 WC 09 03 13 FLORIDA MULTIPLE COORDINATED

POLICY ENDORSEMENTWC090407 07/13 WC 09 04 07 FLORIDA NON-COOPERATION WITH

PREMIUM AUDIT ENDORSEMENTFORM09 A 01/20 FORM 09 A-NOTICE FLORIDA NOTICE OF PENDING

LAW CHANGE TO TERRORISMRISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2007

WC090503 B 01/19 WC 09 05 03 B FLORIDA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN

WC090504 B 01/19 WC 09 05 04 B FLORIDA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN - MULTIPLE LINES

WC090505 A 01/19 WC 09 05 05 A FLORIDA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)




(New) WC090403 C 01/21 WC090403C FLORIDA TERRORISM RISK INSURANCEPROGRAM REAUTHORIZATION ACTENDORSEMENT


WC090607 A 07/19 WC 09 06 07 A GUARANTY ASSOCIATION SURCHARGEENDORSEMENT















ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER




COMPANY ENDORSEMENTWC589 05/95 WC090501 RETRO PREMIUM END (FL)WC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—



SHORT FORMWC414 12/91 WC 00 05 05 A




RETROSPECTIVE PREMIUMENDORSEMENT - LONG TERMCONSTRUCTION PROJECT





WC090502 A 01/08 WC 09 05 02 A RETROSPECTIVE PREMIUMENDORSEMENT FOR NON-RATABLECATASTROPHE ELEMENT ORSURCHARGE







WC090309 01/06 WC 09 03 09 RURAL UTILITIES SERVICEENDORSEMENT





GeorgiaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATING


PLAN NOTIFICATION ENDORSEMENT







WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC370 07/90 WC 10 06 02 BENEFITS DEDUCTIBLE ENDORSEMENTWC379 A 04/93 WC 10 06 01 A CANCELLATION, NON-RENEWAL, AND

CHANGE ENDORSEMENT(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIED





WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC7729 03/94 FORMGID63 DISCLOSURE STATEMENT (FOR USE

WITH EXPERIENCE RATED INSUREDS)WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT







COVERAGE ENDORSEMENTWC100601 C 07/18 WC 10 06 01 C GEORGIA CANCELLATION,

NONRENEWAL, AND CHANGEENDORSEMENT

WC100301 11/99 WC 10 03 01 GEORGIA EMPLOYEE LEASINGENDORSEMENT

WC100402 01/13 WC 10 04 02 GEORGIA NON-COOPERATION WITHPREMIUM AUDIT ENDORSEMENT

WC100304 01/16 WC 10 03 04 GEORGIA PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXTENSIONENDORSEMENT

WC100302 01/16 WC 10 03 02 GEORGIA PROFESSIONAL EMPLOYERORGANIZATION (PEO) MASTER POLICYENDORSEMENT

WC100303 01/16 WC 10 03 03 GEORGIA PROFESSIONAL EMPLOYERORGANIZATION (PEO) MULTIPLECOORDINATED POLICY ENDORSEMENTFOR POLICY COVERING THE PEO

WC100501 B 01/19 WC 10 05 01 B GEORGIA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT ONE-YEAR PLAN

WC100504 B 01/19 WC 10 05 04 B GEORGIA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT ONE-YEAR PLAN—MULTIPLE LINES




WC100502 B 01/19 WC 10 05 02 B GEORGIA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT THREE-YEAR PLAN

WC100505 B 01/19 WC 10 05 05 B GEORGIA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT THREE-YEAR PLAN—MULTIPLE LINES

WC100503 B 01/19 WC 10 05 03 B GEORGIA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT WRAP-UP CONSTRUCTION PROJECT

WC100506 B 01/19 WC 10 05 06 B GEORGIA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENTWRAP–UP CONSTRUCTION PROJECT—MULTIPLE LINES







WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC536 01/94 WC100401 MERIT RATING END [GA]WC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL













WC000320 B 01/06 WC 00 03 20 B




PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT



















HawaiiWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC112 04/84 WC 00 03 01 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM






AUDIT NONCOMPLIANCE CHARGEENDORSEMENT

WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOR

OWNERSHIP INFORMATIONWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING

MODIFICATION FACTOR ENDORSEMENTWC583 01/96 WC520403 CONTRACTING CLASSIFICATION

PREMIUM ADJUSTMENT ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE

ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,










WC520602 01/96 WC 52 06 02 HAWAII NOTIFICATION ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED






WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC329 A 10/89 WC 52 06 01 A MEDICAL BENEFITS DEDUCTIBLE

ENDORSEMENTWC341 03/87 WC 52 04 02 MERIT RATING (HI)WC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL

















WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC597 02/97 WC000326 RESIDUAL MARKET LIMITED OTHER

STATES INSURANCE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE













WC121 04/84 WC 00 03 10




SOLE PROPRIETORS, PARTNERS,OFFICERS AND OTHERS COVERAGEENDORSEMENT



WC140 04/84 WC 52 04 01 VOLUNTEER WORKERS ENDORSEMENTWC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROM

OTHERS ENDORSEMENTIdaho

WC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM





ENDORSEMENTWC458 09/92 WC 11 04 01 ASSIGNED RISK PREMIUM SURCHARGE

ENDORSEMENT - TOTAL MODIFIEDPREMIUM BASIS


WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIED












COVERAGE ENDORSEMENTWC110402 A 07/11 WC 11 04 02 A IDAHO ALCOHOL-AND DRUG-FREE

WORKPLACE PREMIUM CREDITENDORSEMENT

WC110601 07/99 WC 11 06 01




IDAHO COMPENSATIONREIMBURSEMENT OPTIONENDORSEMENT

























CHANGESWC145 04/84 WC 00 05 11




RETRO PREMIUM ENDORSEMENT—SHORT FORM














IllinoisWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC120601 F 01/19 WC 12 06 01 F AMENDATORY END (IL)WC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM







(New) WC000421 E 01/21 WC000421E




CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT



WC464 09/92 WC 12 04 02 CONTRACTING CLASS PREM ADJ [ILWC644 12/03 FORM121CCPAP CONTRACTING CLASSIFICATION

PREMIUM ADJUSTMENT PROGRAM(ILCCPAP) CONFIDENTIAL WORKERSCOMPENSATION PREMIUM CREDITAPPLICATION




EXCLUSION ENDORSEMENTWC120303 A 06/03 WC 12 03 03 A EMPLOYEE LEASING ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE





COVERAGE ENDORSEMENTWC120304 06/99 WC 12 03 04 IL EMPLOYEE LEASING CLIENT

EXCLUSION ENDORSEMENTWC120305 06/99 WC 12 03 05 IL LABOR CONTRACTOR EXCLUSION

ENDORSEMENTWC120308 01/17 WC 12 03 08 ILLINOIS PROFESSIONAL EMPLOYER

ORGANIZATION (PEO) EXTENSIONENDORSEMENT

WC120309 01/17 WC 12 03 09 ILLINOIS PROFESSIONAL EMPLOYERORGANIZATION (PEO) MASTER POLICYENDORSEMENT

WC120603 01/19 WC 12 06 03 ILLINOIS RENEWAL ENDORSEMENTWC120307 06/15 WC 12 03 07 ILLINOIS SOLE PROPRIETORS,

PARTNERS, OFFICERS, MEMBERSOF LIMITED LIABILITY COMPANIES,AND OTHER EXCLUDED EMPLOYEESAND EMPLOYMENTS EXCLUSIONENDORSEMENT

WC120306 A 07/11 WC 12 03 06 A ILLINOIS WORKERS COMPENSATIONAND EMPLOYERS LIABILITY INSURANCEPOLICY EXCLUSION ENDORSEMENT




ENDORSEMENTWC419 04/92 WC 00 01 06 A




LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT COVERAGEENDORSEMENT


WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC150 A 08/92 WC 12 06 02 A MED DEDUCT END [IL]WC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL



FORM635 L 11/11 635L NEW YORK WORKERS COMPENSATIONPREMIUM CREDIT APPLICATION
































IndianaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATING




ENDORSEMENTWC430 01/92 WC 13 06 04 BENEFITS DEDUCTIBLE ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT


WC431 01/92 WC 13 06 02 COINSURANCE AND DEDUCTIBLEENDORSEMENT

WC432 01/92 WC 13 06 03 COINSURANCE ENDORSEMENTERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOR


MODIFICATION FACTOR ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE

ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT



EXCLUSION ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C




EMPLOYERS LIABILITY COVERAGEENDORSEMENT



























COMPANY ENDORSEMENT




WC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—AVIATION

WC340 04/87 WC 00 05 09 A RETRO PREMIUM ENDORSEMENT—CHANGES

WC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—SHORT FORM














IowaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM

ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM




















ENDORSEMENTWC140602 07/02 WC 14 06 02 IOWA EXECUTIVE OFFICERS, SOLE

PROPRIETORS, PARTNERS, MEMBERSAND MANAGERS OF LIMITED LIABILITYCOMPANIES AND OTHERS, BENEFITLEVEL SELECTION ENDORSEMENT

WC140603 01/11 WC 14 06 03 IOWA MEDICAL DEDUCTIBLE PROGRAM—CARRIER REIMBURSED DEDUCTIBLEENDORSEMENT


WC435 02/92 WC 00 03 21 LABOR CONTRACTOR EXCLUSIONENDORSEMENT









WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TO




TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015

















ENDORSEMENT - RATING OPTIONS V -LONG TERM CONSTRUCTION PROJECT







WC000516 01/10 WC 00 05 16




RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT—LARGE RISKALTERNATIVE RATING OPTION (LRARO)







KansasWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM





ENDORSEMENTWC150403 F 01/15 WC 15 04 03 F ASSIGNED RISK RETROSPECTIVE

RATING PLAN ENDORSEMENTWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE

ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC152 A 01/87 WC 15 06 01 A CANCELLATION AND NONRENEWAL

ENDORSEMENT(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIED





WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC312 03/85 WC 15 03 01 DOMESTIC AND AGRICULTURAL

WORKERS’ EXCLUSION ENDORSEMENTWC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT




ENDORSEMENT










ENDORSEMENTWC621 03/98 WC150407A0198 KANSAS ASSIGNED RISKWC150408 A 01/16 WC 15 04 08 A KANSAS ASSIGNED RISK SMALL

EMPLOYER LOSS-FREE POLICYPREMIUM CREDIT ENDORSEMENT

WC150302 01/05 WC 15 03 02 KANSAS HOME AND COMMUNITYBASED SERVICES WAIVER PROGRAMENDORSEMENT

WC150603 07/06 WC 15 06 03 KANSAS PER CLAIMANT BENEFITSDEDUCTIBLE ENDORSEMENT

WC150602 07/06 WC 15 06 02 KANSAS PER OCCURRENCE BENEFITSDEDUCTIBLE ENDORSEMENT

WC150303 B 05/17 WC 15 03 03 B KANSAS PROFESSIONAL EMPLOYERORGANIZATION (PEO) MULTIPLECOORDINATED POLICY ENDORSEMENTFOR POLICY COVERING THE PEO





WC586 03/96 WC150405 LOSS COST CHANGE ENDORSEMENTWC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL









WC585 03/96 WC150404 PENDING LOSS COST (KS)





ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTPN049901 G 03/19 PN 04 99 01 G POLICYHOLDER NOTICE (YOUR

RIGHT TO RATING AND DIVIDENDINFORMATION)




















(New) WC000422 C 01/21 WC000422C








KentuckyWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM



ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOR





WC610 05/97 WC1603030597 EMPLOYEE LEASING (KY)WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT


EXCLUSION ENDORSEMENTWC160302 B 05/17 WC 16 03 02 B EMPLOYEE LEASING ENDORSEMENTWC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE





COVERAGE ENDORSEMENTWC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM

ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED


ENDORSEMENTWC618 12/97 WC1606011297 KENTUCKY CANC/NONREN ENDWC160602 10/99 WC 16 06 02 KENTUCKY NOTICE OF APPEAL RIGHTS





KENTUCKY PART ONE WORKERSCOMPENSATION INSURANCEENDORSEMENT

WC611 05/97 WC1603040597 LABOR CONT EXCL END(KY)WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE





















WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC549 05/97 WC1603010597 REJECTION OF COVERAGE

ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE


AVIATIONWC340 04/87 WC 00 05 09 A




RETRO PREMIUM ENDORSEMENT—CHANGES













LouisianaWC126 04/84 WC 00 04 01 AIRCRAFT PREMIUM ENDORSEMENTWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM







WC537 A 02/96 WC170602A COST CONT ACT END (LA)WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE

ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC391 04/91 WC 00 03 19




EMPLOYEE LEASING CLIENTENDORSEMENT















WC170601 J 08/18 WC 17 06 01 J LOUISIANA AMENDATORYENDORSEMENT

WC170401 11/04 WC 17 04 01 LOUISIANA ANNIVERSARY RATINGDATE ENDORSEMENT

WC170303 12/00 WC 17 03 03 LOUISIANA DUTY TO DEFENDENDORSEMENT

WC170304 02/03 WC 17 03 04 LOUISIANA PROFESSIONAL EMPLOYERORGANIZATION ENDORSEMENT

WC170305 02/03 WC 17 03 05 LOUISIANA PROFESSIONAL EMPLOYERORGANIZATION EXCLUSIONENDORSEMENT

WC170501 C 01/19 WC 17 05 01 C LOUISIANA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT ONE-YEAR PLAN

WC170504 C 01/19 WC 17 05 04 C LOUISIANA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT ONE-YEAR PLAN—MULTIPLE LINES

WC170502 C 01/19 WC 17 05 02 C LOUISIANA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT THREE-YEAR PLAN

WC170505 C 01/19 WC 17 05 05 C LOUISIANA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT THREE-YEAR PLAN - MULTIPLE LINES

WC170503 C 01/19 WC 17 05 03 C LOUISIANA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT WRAP-UP CONSTRUCTION PROJECT

WC170506 C 01/19 WC 17 05 06 C LOUISIANA RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT WRAP-




UP CONSTRUCTION PROJECT - MULTIPLELINES







































MaineWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC599 09/96 WC1804070996 ANNIV MODIFICATION (ME)WC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM



ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC357 D 12/97 WC 18 06 02 D BENEFITS DEDUCTIBLE ENDORSEMENTWC360 A 06/95 WC 18 06 03 A CANC & NONREN END (ME)









ENDORSEMENT








WC395 05/88 WC 18 06 04 FINAL PREM AUD END (ME)WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC153 04/84 WC 18 06 01 INSPECTION IMMUNITY ENDORSEMENTWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED







WC180606 08/99 WC 18 06 06 MAINE NOTICE OF FILING OF FIRSTREPORTS OF INJURY

WC180607 A 07/11 WC 18 06 07 A MAINE SUPPLEMENTAL BENEFITS FUNDENDORSEMENT

WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC356 11/87 WC 18 04 02 A MERIT RAT ENDT [ME]WC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL












WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENT

























MarylandWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11




ASSIGNED RISK PREMIUMDIFFERENTIAL ENDORSEMENT



WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC190601 G 10/17 WC 19 06 01 G CANCELLATION ENDORSEMENT (MD)



WC476 07/93 WC 19 04 01 CONST CLASS PREM [MD]WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING

















WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC190402 A 10/17 WC 19 04 02 A MARYLAND ALCOHOL- AND DRUG-

FREE WORKPLACE PREMIUM CREDITENDORSEMENT

WC190602 01/14 WC 19 06 02 MARYLAND NOTIFICATION OF 45-DAYUNDERWRITING PERIOD ENDORSEMENT

WC448 07/92 WC 00 01 11 MIGRANT AND SEASONALAGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT






SOLEPROP 01/10 WCC FORM IC-02 SOLE PROPRIETOR'S STATUS AS ACOVERED EMPLOYEE






MassachusettsWC126 04/84 WC 00 04 01 AIRCRAFT PREMIUM ENDORSEMENTWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM



ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC474 01/93 WC 20 06 02 BENEFITS DET END [MA]WC386 01/91 WC 20 04 03 CONSTRUCTION CLASSIFICATIONWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING







FACTOR REVISION ENDORSEMENTWC1032 05/19 EXPLANATION OF AUDIT

NONCOMPLIANCE CHARGEWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND



ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04




INSURANCE COMPANY AS INSUREDENDORSEMENT



WC200306 B 06/13 WC 20 03 06 B LIMITED OTHER STATES BENEFITENDORSEMENT

WC242 04/84 WC 20 03 01 LIMITS OF LIABILITY ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'



WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC200307 11/02 WC 20 03 07 MASSACHUSETTS ASSIGNED RISK POOL

ELIGIBILITY ENDORSEMENTWC200603 A 04/15 WC 20 06 03 A MASSACHUSETTS BENEFITS CLAIM

AND AGGREGATE DEDUCTIBLEENDORSEMENT

WC200601 07/08 WC 20 06 01 A MASSACHUSETTS CANCELATIONENDORSEMENT

WC652 B 11/11 MASSACHUSETTS CONSTRUCTIONCLASSIFICATION PREMIUMADJUSTMENT PROGRAM WORKERS’COMPENSATION PREMIUM CREDITAPPLICATION

WC200304 C 04/19 WC 20 03 04 C MASSACHUSETTS EMPLOYEE LEASINGENDORSEMENT

WC200305 A 01/17 WC 20 03 05 A MASSACHUSETTS EXCLUSION OFCOVERAGE FOR LEASED EMPLOYEESENDORSEMENT (LABOR CONTRACTORS)

WC200102 01/14 WC 20 01 02 MASSACHUSETTS NOTIFICATIONENDORSEMENT OF PENDINGLAW CHANGE TO TERRORISMRISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2007

WC200604 11/02 WC 20 06 04 MASSACHUSETTS POLICY DEFINITIONENDORSEMENT

WC200405 06/01 WC 20 04 05 MASSACHUSETTS PREMIUM DUE DATEENDORSEMENT

WC200101 01/08 WC 20 01 01 MASSACHUSETTS TERRORISMRISK INSURANCE PROGRAMREAUTHORIZATION ACT ENDORSEMENT

WC200302 A 09/08 WC 20 03 02 A MASSACHUSETTS-ASSESSMENTCHARGE




WC200303 D 08/10 WC 20 03 03 D NOTICE TO POLICYHOLDERENDORSEMENT







WC380 11/90 WC 20 04 01 PENDING PREMIUM CHANGEENDORSEMENT






WC418 B 01/94 WC 20 04 02 B QUAL LOSS MGMT [MA]WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE

COMPANY ENDORSEMENTWC571 04/95 WC200501 RETRO PREM END [MA]WC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—













WC122 B 08/91 WC 00 03 11 B







MichiganWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC112 04/84 WC 00 03 01 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM


ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING


ENDORSEMENTWC509 04/84 WC 21 03 01 DESIGNATED CONSTRUCTION SITE

COVERAGE ENDORSEMENTWC510 04/84 WC 21 03 02 DESIGNATED CONSTRUCTION SITE

EXCLUSION ENDORSEMENTWC511 04/84 WC 21 03 05 DESIGNATED CONSTRUCTION SITE

EXCLUSION ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC170 04/84 WC 21 06 04 DUAL OR JOINT EMPLOYEE

ENDORSEMENTWC516 04/84 WC 21 06 01 DUAL/JOINT EMP END [MI]WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT






SAFETY ACT COVERAGE ENDORSEMENTWC103 04/84 WC 00 01 04 FEDERAL EMPLOYERS' LIABILITY ACT

COVERAGE ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT



ENDORSEMENTWC491 04/84 WC 21 03 04 LAW ENDORSEMENTWC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE



WC237 04/84 WC 00 04 08




LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT



ENDORSEMENTWC210503 A 06/97 WC 21 05 03 A MICHIGAN RETRO PREM ENDWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL




WC171 A 01/87 WC 21 05 01A NON-RATABLE SPECIFIC DISEASEELEMENT (SUPPLEMENT TORETROSPECTIVE PREMIUMENDORSEMENT)

WC210303 A 06/97 WC 21 03 03 A NOTICE TO POLICYHOLDERENDORSEMENT

WC210102 A 01/20 WC 21 01 02 A NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2007





ENDORSEMENT - FORMER SELFINSURERS


WC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER




COMPANY ENDORSEMENTWC172 04/84 WC 21 05 02 RETRO PREM END [MI]WC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—



SHORT FORMWC144 04/84 WC 00 05 10




RETROSPECTIVE PREMIUMENDORSEMENT - NON-RATABLECATASTROPHE ELEMENT ORSURCHARGE

WC141 04/84 WC 00 05 05 RETROSPECTIVE PREMIUMENDORSEMENT - RATING OPTIONS V -LONG TERM CONSTRUCTION PROJECT

WC137 04/84 WC 00 05 03 RETROSPECTIVE PREMIUMENDORSEMENT - RATING OPTIONS V -ONE YEAR PLAN








WC000501 04/84 WC 00 05 01 RETROSPECTIVE-1YR PLAN-OPTION I, II,III & IV



WC210402 B 01/15 WC 21 04 02 B TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT DISCLOSUREENDORSEMENT

WC530 04/84 WC210101 VOL COMP FED EMP [MI]WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION AND




WC320 10/85 WC 21 06 05 WAIVER/COORD BEN [MI]WC512 01/85 WC 21 03 06 WORKERS’ COMPENSATION PLACEMENT

FACILITY - LIMITS OF LIABILITYENDORSEMENT

MinnesotaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC220000 A 11/03 WC 22 00 00 A AMENDATORY ENDORSEMENT (MN)WC580 09/95 WC220402 ANNIVERSARY RATING DATE

ENDORSEMENT






WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC220601 D 08/06 WC 22 06 01 D CANCELLATION AND NONRENEWAL


MODIFICATION FACTOR ENDORSEMENTWC438 10/92 WC 22 04 01 CONTRACT PREM ADJ [MN]WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE






FACTOR REVISION ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT


ENDORSEMENTWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED








WC220306 08/09 WC 22 03 06 MINNESOTA ALTERNATE EMPLOYERENDORSEMENT [EXCLUDINGEMPLOYERS LIABILITY COVERAGE]

WC220301 01/05 WC 22 03 01 MINNESOTA COMPLIANCE WITHAPPLICABLE TRADE SANCTION LAWSENDORSEMENT

WC220304 01/06 WC 22 03 04 MINNESOTA EMPLOYEE LEASINGENDORSEMENT

WC220620 01/05 WC 22 06 20 MINNESOTA ENTITY ADDRESSSCHEDULE ENDORSEMENT

WC220305 01/06 WC 22 03 05 MINNESOTA EXCLUSION OFCOVERAGE FOR LEASED EMPLOYEESENDORSEMENT

WC220001 09/02 WC 22 00 01 MINNESOTA INFORMATION PAGE ANDNOTES

WC220303 01/06 WC 22 03 03




MINNESOTA THIRD DEGREE OFKINDRED FAMILY MEMBER EXCLUSIONENDORSEMENT

WC220302 01/05 WC 22 03 02 MINNESTOA INDEPENDENTCONTRACTORS COVERAGEENDORSEMENT







WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC220600 01/02 WC 22 06 00 POLICY CHANGE ENDORSEMENTWC220616 A 10/07 WC 22 06 16 A POLICY CHANGE ENDORSEMENTWC220611 01/02 WC 22 06 11 POLICY INFORMATION PAGE

ENDORSEMENT - ADD STATESWC220619 01/02 WC 22 06 19 POLICY INFORMATION PAGE

ENDORSEMENT - CARRIER NUMBERWC220617 01/02 WC 22 06 17 POLICY INFORMATION PAGE

ENDORSEMENT - CARRIER SERVICINGOFFICE

WC220613 01/02 WC 22 06 13 POLICY INFORMATION PAGEENDORSEMENT - CHANGE IN STATE

WC220609 01/02 WC 22 06 09 POLICY INFORMATION PAGEENDORSEMENT - CHANGE INWORKPLACE OF INSURED

WC220615 A 10/07 WC 22 06 15 A POLICY INFORMATION PAGEENDORSEMENT - CLASS, RATE, OTHERCHANGE

WC220604 01/02 WC 22 06 04 POLICY INFORMATION PAGEENDORSEMENT - EFFECTIVE DATE

WC220612 01/02 WC 22 06 12 POLICY INFORMATION PAGEENDORSEMENT - EMPLOYER LIMITS

WC220614 01/02 WC 22 06 14 POLICY INFORMATION PAGEENDORSEMENT - ENDORSEMENTNUMBERS

WC220607 01/02 WC 22 06 07 POLICY INFORMATION PAGEENDORSEMENT - EXPERIENCEMODIFICATION

WC220605 01/02 WC 22 06 05 POLICY INFORMATION PAGEENDORSEMENT - EXPIRATION DATE

WC220610 01/02 WC 22 06 10 POLICY INFORMATION PAGEENDORSEMENT - INSURED'S LEGALSTATUS

WC220606 01/02 WC 22 06 06 POLICY INFORMATION PAGEENDORSEMENT - INSURED'S MAILINGADDRESS

WC220602 01/02 WC 22 06 02 POLICY INFORMATION PAGEENDORSEMENT - INSURED'S NAME




WC220618 01/02 WC 22 06 18 POLICY INFORMATION PAGEENDORSEMENT - INTERSTATE /INTRASTATE RISK I.D. NUMBER

WC220603 01/02 WC 22 06 03 POLICY INFORMATION PAGEENDORSEMENT - POLICY NUMBER

WC220608 01/02 WC 22 06 08 POLICY INFORMATION PAGEENDORSEMENT - PRODUCER'S NAME



















WC547 02/94 WC000309A RURAL ELECTRIFICATIONADMINISTRATION ENDORSEMENT


WC122 B 08/91 WC 00 03 11 B







MississippiWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000418 F 01/11 WC 00 04 18 F ASSIGNED RISK LOSS SENSITIVE RATING






























WC230601 07/18 WC 23 06 01 MISSISSIPPI CANCELLATION,NONRENEWAL, AND RENEWALENDORSEMENT

WC230402 03/16 WC 23 04 02 MISSISSIPPI PAY-AS-YOU-GO PROGRAMENDORSEMENT

WC230401 A 07/17 WC 23 04 01 A MISSISSIPPI-SMALL EMPLOYER LOSS-FREE POLICY PREM C


















SHORT FORMWC000503 D 01/19 WC 00 05 03 D




RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN













MissouriWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC112 04/84 WC 00 03 01 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC439 09/91 WC 24 04 02 ASSIGNED RISK PREMIUMWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM



ENDORSEMENTWC579 10/95 WC2406031095 BENEFITS DED END (MO)WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC158 B 01/96 WC 24 06 01 B CANCELLATION AND NONRENEWAL

ENDORSEMENTWC368 01/90 WC 24 04 01 CONT CLASS PREM AS [MO]WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING


ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSION




WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,AND CATASTROPHIC INDUSTRIALACCIDENTS PREMIUM ENDORSEMENT



WC240406 D 08/16 WC 24 04 06 D EMPLOYER PAID MEDICAL END (MO)WC000303 C 10/04 WC 00 03 03 C EMPLOYERS LIABILITY COVERAGE














WC240604 C 09/19 WC 24 06 04 C MISSOURI AMENDATORYENDORSEMENT

FORM24-1 B 08/16 FORM 24-1 B MISSOURI CONTRACTINGCLASSIFICATION PREMIUMADJUSTMENT PROGRAM WORKERSCOMPENSATION - PREMIUM CREDITAPPLICATION

WC240303 A 01/14 WC 24 03 03 MISSOURI EXCLUSION OF ADDITIONALMESOTHELIOMA BENEFITSENDORSEMENT

WC240302 A 01/14 WC 24 03 02 MISSOURI NOTIFICATION OFADDITIONAL MESOTHELIOMA BENEFITSENDORSEMENT








WC240602 B 07/06 WC 24 06 02 B P&C GUARANTY ASSOCIATIONNOTIFICATION ENDORSEMENT



WC890600 B 07/01 WC890600B POLICY INFORMATION PAGEENDORSEMENT






WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLECOMPANY ENDORSEMENT




WC157 A 12/91 WC 24 05 01 A RETROSPECTIVE PREMIUMSUPPLEMENTAL ENDORSEMENT










WC122 B 08/91 WC 00 03 11 B







MontanaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM


ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC250601 B 04/16 WC 25 06 01 B CANCEL & NONRENEWAL ENDT (MT)



















WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENT




WC117 04/84 WC 00 03 06 MEDICAL BENEFITS EXCLUSIONENDORSEMENT

WC118 04/84 WC 00 03 07 MEDICAL BENEFITS REIMBURSEMENTENDORSEMENT


WC250302 10/99 WC 25 03 02 MONTANA EMPLOYEE LEASING/PROFESSIONAL EMPLOYER CLIENTEXCLUSION ENDORSEMENT

WC250301 A 05/17 WC 25 03 01 A MONTANA EMPLOYEE LEASING/PROFESSIONAL EMPLOYERENDORSEMENT

WC250305 07/02 WC 25 03 05 MONTANA INTENTIONAL INJURYEXCLUSION ENDORSEMENT

WC250303 10/99 WC 25 03 03 MONTANA LABOR CONTRACTOR/PROFESSIONAL EMPLOYERORGANIZATION EXCLUSIONENDORSEMENT

WC250401 A 01/17 WC 25 04 01 A MONTANA NON-COOPERATIONWITH PREMIUM AUDIT SURCHARGEENDORSEMENT















COMPANY ENDORSEMENTWC142 04/84 WC 00 05 08




RETRO PREMIUM ENDORSEMENT—AVIATION











WC542 01/94 WC250602 SAFETY END (MT)WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,

OFFICERS AND OTHERS COVERAGEENDORSEMENT





NebraskaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM



ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC337 C 07/96 WC 26 06 01 C CANC & NONREN END(NE)








WC304 01/95 WC 26 04 02 CONTRACTION CLASS [NE]WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE















WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC393 07/90 WC 26 06 02 MED BENEFITS END [NE]WC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL



WC260401 B 05/17 WC 26 04 01 B NEBRASKA EXPERIENCE RATINGMODIFICATION ENDORSEMENT

WC260403 05/17 WC 26 04 03 NEBRASKA EXPERIENCE RATINGMODIFICATION FACTOR REVISIONENDORSEMENT

WC260303 05/13 WC 26 03 03 NEBRASKA PROFESSIONAL EMPLOYERORGANIZATION (PEO) CLIENTEXCLUSION ENDORSEMENT

WC260304 05/13 WC 26 03 04 NEBRASKA PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT




WC260302 A 05/17 WC 26 03 02 A NEBRASKA PROFESSIONAL EMPLOYERORGANIZATION (PEO) MULTIPLECOORDINATED POLICY ENDORSEMENTFOR POLICY COVERING THE CLIENT

WC260301 A 05/17 WC 26 03 01 A NEBRASKA PROFESSIONAL EMPLOYERORGANIZATION (PEO) MULTIPLECOORDINATED POLICY ENDORSEMENTFOR POLICY COVERING THE PEO





















WC000309 B 01/06 WC 00 03 09 B




RURAL UTILITIES SERVICEENDORSEMENT






NevadaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM



















COVERAGE ENDORSEMENTWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTES














WC270601 C 10/08 WC 27 06 01 C NEVADA CANCEL/NONRENEWAL ENDTWC270302 A 06/12 WC 27 03 02 A NEVADA EMPLOYEE LEASING CLIENT

EXCLUSION ENDORSEMENTWC270303 A 06/12 WC 27 03 03 A NEVADA EMPLOYEE LEASING

EXCLUSION ENDORSEMENTWC270304 A 03/16 WC 27 03 04 A NEVADA EMPLOYEE LEASING MASTER

POLICY BASIS ENDORSEMENTWC270301 C 05/17 WC 27 03 01 C NEVADA EMPLOYEE LEASING MULTIPLE

COORDINATED POLICIES BASISENDORSEMENT

WC270501 A 01/19 WC 27 05 01 A NEVADA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT

WC270502 A 01/19 WC 27 05 02 A NEVADA RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT WRAP-UPCONSTRUCTION PROJECT—MULTIPLELINES








ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC266 07/91 WC 00 04 09




PREMIUM DETERMINATIONENDORSEMENT - FORMER SELF-INSURERS 1


























New HampshireWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC447 04/92 WC 28 06 04 AMENDATORY ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC477 12/92 WC 28 04 01 ASSIGN RISK SUR [NH]WC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM








WC280402 A 07/03 WC 28 04 02 A CERTIFIED MANAGED CARE (NH)ERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOR

















WC237 04/84 WC 00 04 08




LONGSHORE AND HARBOR WORKERS'COMPENSATION ACT RATE CHANGEENDORSEMENT










WC280404 01/08 WC 28 04 04 PENDING RATE CHANGE ENDORSEMENTWC446 03/92 WC 28 06 03 PER ACCID PER DIS (NH)WC445 03/92 WC 28 06 02 PER CLAIM BENE END (NH)WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE














WC000513 D 01/19 WC 00 05 13 D









WC365 A 01/96 WC 28 04 03 A SAFETY INC PROG (NH)WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,


WC200 04/84 WC 28 06 01 SOLE REPRESENTATIVE ENDORSEMENT(New) WC000422 C 01/21 WC000422C TERRORISM RISK INSURANCE PROGRAM

REAUTHORIZATION ACT DISCLOSUREENDORSEMENT




WC280301 B 01/09 WC 28 03 01 B WC/EMPLOYERS LIABILITY COVERAGERES [NH]

New JerseyWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC531 A 01/96 WC290409A APPROVED MANAGED CARE PROGRAM



ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC577 04/96 WC290410 CONSTRUCTION CLASSIFICATIONWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING

MODIFICATION FACTOR ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,






WC000425 05/17 WC 00 04 25




EXPERIENCE RATING MODIFICATIONFACTOR REVISION ENDORSEMENT






NJLRLD 07/06 FORMNJLRLD LARGE RISK - LARGE DEDUCTIBLEPROGRAM NOTICE OF ELECTION

WC497 A 01/94 WC 29 06 01 A LG RISK DED END [NJ]WC290309 A 07/05 WC 29 03 09 A LIMIT OTHER STATE INS ENDT(NJ)WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE







WC290311 04/18 WC 29 03 11 NEW JERSEY EMPLOYEE LEASINGCLIENT ENDORSEMENT

WC290304 A 04/18 WC 29 03 04 A NEW JERSEY EMPLOYEE LEASINGCLIENT EXCLUSION ENDORSEMENT

WC290303 04/18 WC 29 03 03 NEW JERSEY EMPLOYEE LEASINGLABOR CONTRACTOR ENDORSEMENT

WC290305 A 04/18 WC 29 04 11 D NEW JERSEY EMPLOYEE LEASINGLABOR CONTRACTOR EXCLUSIONENDORSEMENT

WC290605 01/05 WC 29 06 05 NEW JERSEY LARGE RISK - LARGEDEDUCTIBLE ENDORSEMENT PERPERSON BASIS

WC290307 04/00 WC 29 03 07 NEW JERSEY SOLE PROPRIETORS ANDPARTNERS COVERAGE ENDORSEMENT

WC290302 B 01/20 WC 29 03 02 B NEW JERSEY WORKERS COMPENSATIONAND EMPLOYERS LIABILITY COVERAGEFOR RESIDENCE EMPLOYEESENDORSEMENT

WC290310 07/04 WC 29 03 10 NEW JERSEY WORKERS' COMPENSATIONINSURANCE PLAN ELIGIBILITYENDORSEMENT

WC290604 A 01/19 WC 29 06 04 A NJ LARGE RISK - LARGE DEDUCTIBLEAGGREGATE LIMIT ENDORSEMENT

WC614 01/98 WC290603 NJ PARTICIPATING PROV ENDWC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUND

INSTRUMENTALITY'S ACT COVERAGEENDORSEMENT

WC106 01/89 NOTICEWC290312 05/18 WC 29 03 12




NOTICE OF CANCELLATION ORMATERIAL COVERAGE CHANGE TODESIGNATED GOVERNMENTAL ENTITYENDORSEMENT

FORMPP1 B 07/07 FORMPP1B NOTICE OF ELECTION - PROPRIETORSAND PARTNERS WORKERS'COMPENSATION AND EMPLOYERS'LIABILITY INSURANCE

NJRR2 01/16 NJRR-2 NOTICE OF ELECTION OFRETROSPECTIVE RATING (MUST BEFILED WITH NJCRIB)


WC290306 B 07/07 WC 29 03 06 B PART 2 EMPLOYERS LIABILITYENDORSEMENT






WC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC205 A 01/86 WC 29 04 07 PREMIUM DISCOUNT ENDORSEMENT -

SCHEDULE XWC290406 Y 01/12 WC 29 04 06 Y PREMIUM DISCOUNT ENDORSEMENT

SCHEDULE YWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER




COMPANY ENDORSEMENTWC290509 C 07/00 WC 29 05 09 C RETRO PREM ENDT PRT2 EXC (NJ)WC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—

AVIATIONWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—

SHORT FORMWC290602 B 01/05 WC 29 06 02 B RETROSPECTIVE ADJUSTMENT

ENDORSEMENTWC290513 C 01/05 WC 29 05 13 C RETROSPECTIVE PREM 1 YEAR (NJ)WC290514 C 01/05 WC 29 05 14 C RETROSPECTIVE PREMIUM 3YRWC290515 C 01/05 WC 29 05 15 C RETROSPECTIVE PREMIUM

ENDORSEMENTWC144 04/84 WC 00 05 10 RETROSPECTIVE PREMIUM

ENDORSEMENT - NON-RATABLECATASTROPHE ELEMENT ORSURCHARGE














WC201 04/84 WC 29 01 01 VOL COMP FED [NJ]WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION AND




New MexicoWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM





OWNERSHIP INFORMATIONWC300305 09/07 WC 30 03 05 CONSUMER DIRECTED PROGRAM


MODIFICATION FACTOR ENDORSEMENTNC5001 01/11 FORM NC-5001 CONTRACTING CLASSIFICATION

PREMIUM ADJUSTMENT PROGRAMAPPLICATION FOR NON-ARD STATES

NC5000 D 08/19 NC-5000 D CONTRACTING CLASSIFICATIONPREMIUM ADJUSTMENT PROGRAM




WORKERS COMPENSATION PREMIUMCREDIT APPLICATION
























WC300402 01/05 WC 30 04 02 NEW MEXICO ASSIGNED RISKSURCHARGE ENDORSEMENT

WC300601 A 03/15 WC 30 06 01 A NEW MEXICO CANCELLATION ANDNONRENEWAL ENDORSEMENT



WC421 04/92 WC 00 01 09 A




OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT






WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
















WC159 04/84 WC 30 03 01 SAFETY DEVICE COVERAGEENDORSEMENT

WC160 04/84 WC 30 03 02 SAFETY DEVICE EXCLUSIONENDORSEMENT

WC121 04/84 WC 00 03 10







WC161 04/84 WC 30 03 03 VOLUNTEER WORKER ENDORSEMENTWC124 04/84 WC 00 03 13 WAIVER OF RIGHT TO RECOVER FROM

OTHERS ENDORSEMENTWC459 A 07/93 WC 30 04 01 A WC PREM ADJ PROG [NM]

New YorkWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC488 01/89 WC 31 06 12 AMBULANCE/FIRE D [NY]WC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM


ENDORSEMENTWC402 A 04/94 WC 31 03 15 A BENEFITS DED END (NY)WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC473 04/93 WC 31 04 01 CONS CLASS PREM AD [NY]WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING


ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC219 04/84 WC 31 03 02 DESIGNATED WORKPLACE(NY)WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,


WC220 04/84 WC 31 06 01 DOMESTIC WORKERS (NY)WC391 04/91 WC 00 03 19 EMPLOYEE LEASING CLIENT



ENDORSEMENTWC423 04/92 WC 00 03 03 B EMPLOYERS’ LIABILITY COVERAGE

ENDORSEMENTWC223 B 01/94 WC 31 03 05 B EXCL OF EXEC OFF (NY)WC222 04/84 WC 31 06 02 EXCLUSION DES [NY]WC224 01/86 WC 31 03 04 EXEC OFF EXCL [NY]WC225 04/84 WC 31 06 03 EXECUTIVE OFFICERS [NY]WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION


FACTOR REVISION ENDORSEMENTWC000104 A 10/04 WC 00 01 04 A FEDERAL EMPLOYERS’ LIABILITY ACT


ENDORSEMENTWC310314 A 08/00 WC 31 03 14 A INCLUSION OF AUXILIARY POLICY

ENDORSEMENTWC227 A 01/87 WC 31 03 06 A INCLUSION OF EXEC (NY)WC310003 B 05/20 WC310003B




INFORMATION PAGE - VOLUNTEERAMBULANCE WORKERS’ BENEFITPOLICY

WC310001 B 05/20 WC310001B INFORMATION PAGE - VOLUNTEERFIREFIGHTERS’ BENEFIT POLICY

WC9941 B 05/20 WC000001E INFORMATION PAGE NOTESWC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED


ENDORSEMENTWC228 04/84 WC 31 03 07 LIABILITY OF MUNICIPALITIES

TO POLICE OFFICERS OR PAIDFIREFIGHTERS - EXCLUSIONENDORSEMENT

WC230 04/84 WC 31 03 09 LIMIT OF LIAB END [NY]WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE




WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC231 04/84 WC 31 03 10 MEDICAL BENEFITS REIMBURSEMENT

ENDORSEMENTWC554 10/94 WC310402 MERIT RATING ENDORSEMENTWC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL



WC310609 A 05/20 WC310609A NEW YORK AMBULANCE DISTRICTLIABILITY EXCLUSION ENDORSEMENTFOR COUNTY OR TOWN POLICIES

WC310319 J 05/20 WC 31 03 19 J NEW YORK CONSTRUCTIONCLASSIFICATION PREMIUMADJUSTMENT PROGRAM EXPLANATORYENDORSEMENT

WC310301 A 05/20 WC310301A NEW YORK COVERAGE FOR ELECTEDOR APPOINTED OFFICERS OF MUNICIPALCORPORATIONS OR OTHER POLITICALSUBDIVISIONS ENDORSEMENT

WC310303 A 05/20 WC310303A NEW YORK EXCESS MEDICALCOVERAGE ENDORSEMENT

WC310611 A 05/20 WC310611A NEW YORK EXCLUSION FORDESIGNATED OFFICERS ANDEMPLOYEES OF AMBULANCE DISTRICTSENDORSEMENT

WC310604 A 05/20 WC310604A NEW YORK FIRE DISTRICT LIABILITYEXCLUSION ENDORSEMENT FORCOUNTY OR TOWN POLICIES

WC310617 B 05/20 WC310617B NEW YORK FOREIGN VOLUNTARYCOMPENSATION AND EMPLOYERS’LIABILITY COVERAGE ENDORSEMENT

WC310308 01/00 WC 31 03 08 NEW YORK LIMIT OF LIABILITYENDORSEMENT

WC310407 10/17 WC 31 04 07




NEW YORK MERIT RATING REVISIONENDORSEMENT

WC310322 A 05/20 WC310322A NEW YORK OPTIONAL CLIENTEXCLUSION ENDORSEMENT

WC310320 A 05/20 WC310320A NEW YORK OPTIONAL PROFESSIONALEMPLOYER ORGANIZATION (PEO)ENDORSEMENT

WC310321 A 05/20 WC310321A NEW YORK OPTIONAL PROFESSIONALEMPLOYER ORGANIZATION (PEO)EXCLUSION ENDORSEMENT

WC310404 B 05/20 WC 31 04 04 B NEW YORK PENDING PAYROLLLIMITATION AND PREMIUMDIFFERENTIAL ENDORSEMENT

WC310317 A 05/20 WC310317A NEW YORK PROFESSIONAL EMPLOYERORGANIZATION (PEO) ENDORSEMENT

WC310318 A 05/20 WC310318A NEW YORK PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXCLUSIONENDORSEMENT

WC310405 A 05/20 WC310405A NEW YORK SAFE PATIENT HANDLINGACT PROGRAM EXPLANATORYENDORSEMENT (FLAT CREDIT)

WC310406 A 05/20 WC310406A NEW YORK SAFE PATIENT HANDLINGACT PROGRAM EXPLANATORYENDORSEMENT (TIERED CREDIT)

WC310313 C 05/20 WC 31 03 13 C NEW YORK SOLE PROPRIETORS,PARTNERS AND MEMBERS OF LLC’S,PSLC’S AND RLLP’S COVERAGEENDORSEMENT

WC310316 C 05/20 WC310316C NEW YORK SOLE PROPRIETORS,PARTNERS AND MEMBERS OFLLC’S, PSLC’S, RLLP’S EXCLUSIONENDORSEMENT

WC310610 A 05/20 WC310610A NEW YORK VOLUNTEER AMBULANCEWORKERS’ BENEFIT LAW GROUPINSURANCE ENDORSEMENT

WC310608 A 05/20 WC310608A NEW YORK VOLUNTEER AMBULANCEWORKERS’ PREMIUM DISCOUNTENDORSEMENT

WC310607 A 05/20 WC310607A NEW YORK VOLUNTEER FIREFIGHTERS’BENEFIT LAW EXTENSION OFEMPLOYERS’ LIABILITY INSURANCEENDORSEMENT

WC310605 A 05/20 WC310605A NEW YORK VOLUNTEER FIREFIGHTERS’BENEFIT LAW GROUP INSURANCEENDORSEMENT

WC310606 A 05/20 WC310606A NEW YORK VOLUNTEER FIREFIGHTERS’PREMIUM DISCOUNT ENDORSEMENT

WC232 04/84 WC 31 03 11 NON/SUBJ EMP END [NY]WC420 04/92 WC 00 01 08 A NON-APPROPRIATED FUND

INSTRUMENTALITY'S ACT COVERAGEENDORSEMENT

WC233 04/84 WC 31 03 12 NON-SUBJECT EXEC [NY]RR50 10/10 RR-50 NOTICE OF ELECTION OF

RETROSPECTIVE RATING PLANNYLR1 10/10 NYLR-1 NOTICE OF ELECTION OF

RETROSPECTIVE RATING PLAN - NEWYORK LARGE RISK RATING OPTION

WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENTOF PENDING LAW CHANGE TO




TERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015


RR1 10/10 RR-1 NOTIFICATION OF COVERAGE - MULTI-STATE RETROSPECTIVE RATING PLAN

WC615 A 01/99 WC310616A NY PREF PROV ORG ENDWC616 A 01/99 WC 31 04 03 A NY PREF PROV ORG PREM ENDWC421 04/92 WC 00 01 09 A OUTER CONTINENTAL SHELF LANDS

ACT COVERAGE ENDORSEMENTWC000000 C 01/15 WC 00 00 00 C PART TWO— EMPLOYERS LIABILITY

INSURANCEWC119 04/84 WC 00 03 08 PARTNERS, OFFICERS AND OTHERS

EXCLUSION ENDORSEMENTWC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC310618 A 05/20 WC 31 06 18 A POLICYHOLDER NOTICE OF RIGHT TO

APPEALWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION










ENDORSEMENT - FLEXIBILITY OPTIONSWC414 12/91 WC 00 05 05 A RETROSPECTIVE PREMIUM

ENDORSEMENT - LONG TERMCONSTRUCTION PROJECT






WC416 12/91 WC 00 05 13 A




RETROSPECTIVE PREMIUMENDORSEMENT - THREE YEAR PLAN -MULTIPLE LINES











WC000420 12/02 WC 00 04 24 TERRORISM RISK INSURANCE ACTENDORSEMENT



WC407 04/91 WC 31 06 13 VOLUNTEER AMBULANCE WORKERS’BENEFIT LAW - EXTENSION OFEMPLOYERS’ LIABILITY INSURANCEENDORSEMENT

WC310002 B 05/20 WC310002B VOLUNTEER AMBULANCE WORKERS’BENEFIT LAW POLICY

WC310000 05/20 WC310000B VOLUNTEER FIREFIGHTERS’ BENEFITLAW POLICY


North CarolinaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC320304 01/09 WC 32 03 04 ALTERNATE EMPLOYER ENDORSEMENT

(EXCLUDING EMPLOYERS LIABILITYCOVERAGE)

WC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC320415 07/16 WC 32 04 15 ASSIGNED RISK ADJUSTMENT PROGRAM

ENDORSEMENTWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM

ENDORSEMENT




WC320418 07/16 WC 32 04 18 ASSIGNED RISK LOSS SENSITIVE RATINGPLAN ENDORSEMENT


WC320417 07/16 WC 32 04 17 ASSIGNED RISK LOSS SENSITIVE RATINGPLAN NOTIFICATION ENDORSEMENT




WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC320601 B 04/20 WC320601B CANCELLATION AND NON-RENEWAL

ENDORSEMENTNCRB-ERM-14 10/16 NCRB-ERM-14 CONFIDENTIAL REQUEST FOR

OWNERSHIP INFORMATION(INTRASTATE RISK)


WC320302 2 11/08 WC 32 03 02 CONTROL INS PROG W/LARGEDEDUCTIBLE











WC103 04/84 WC 00 01 04 FEDERAL EMPLOYERS' LIABILITY ACTCOVERAGE ENDORSEMENT


















WC320301 D 07/18 WC 32 03 01 D NORTH CAROLINA AMENDEDCOVERAGE ENDORSEMENT

WC320303 11/08 WC 32 03 03 NORTH CAROLINA CONTROLLEDINSURANCE PROGRAM - AMENDATORYENDORSEMENT

WC320603 07/18 WC 32 06 03 NORTH CAROLINA NON-INSURANCEGOODS AND/OR SERVICESENDORSEMENT

WC320604 08/18 WC 32 06 04 NORTH CAROLINA NOTICE OFCANCELLATION OR MATERIAL CHANGETO DESIGNATED GOVERNMENTALENTITY ENDORSEMENT

WC320307 04/17 WC 32 03 07 NORTH CAROLINA PROFESSIONALEMPLOYER ORGANIZATION (PEO)CLIENT EXCLUSION ENDORSEMENT

WC320308 04/17 WC 32 03 08 NORTH CAROLINA PROFESSIONALEMPLOYER ORGANIZATION (PEO)CLIENT EXTENSION ENDORSEMENT

WC320305 04/17 WC 32 03 05 NORTH CAROLINA PROFESSIONALEMPLOYER ORGANIZATION (PEO)EXCLUSION ENDORSEMENT

WC320306 04/17 WC 32 03 06 NORTH CAROLINA PROFESSIONALEMPLOYER ORGANIZATION (PEO)EXTENSION ENDORSEMENT




WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTNCDISC2 02/15 DISCLOSURE NO.2 POLICYHOLDER DISCLOSURE NOTICE OF

TERRORISM INSURANCE COVERAGENCDISC1 02/15 DISCLOSURE NO.1 POLICYHOLDER DISCLOSURE NOTICE OF

TERRORISM INSURANCE COVERAGEWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION


WC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A






WC320602 01/10 WC 32 06 02 PRO-RATA CANCELLATIONENDORSEMENT





SHORT FORMWC414 12/91 WC 00 05 05 A RETROSPECTIVE PREMIUM














North DakotaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11




ASSIGNED RISK PREMIUMDIFFERENTIAL ENDORSEMENT


WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING






FACTOR ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND

SAFETY ACT COVERAGE ENDORSEMENTWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED
















WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENTWC581 06/96 WC000325




RESIDUAL MARKET MULTIPLECOMPANY ENDORSEMENT














OhioWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM








FACTOR ENDORSEMENTWC115 04/84 WC 00 03 04




INSURANCE COMPANY AS INSUREDENDORSEMENT
















AVIATIONWC145 04/84 WC 00 05 11 RETRO PREMIUM ENDORSEMENT—














OklahomaWC112 04/84 WC 00 03 01 ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000424 01/17 WC 00 04 24 AUDIT NONCOMPLIANCE CHARGE

ENDORSEMENTWC350602 D 09/16 WC 35 06 02 D BENEFITS DED ENDT (OK)




WC590 07/96 WC350404 CONTRACTING CLASSIFICATIONPREMIUM ADJUSTMENT ENDORSEMENT


WC336 01/87 WC 35 03 02 EMPLOYERS LIAB AM [OK]WC000425 05/17 WC 00 04 25 EXPERIENCE RATING MODIFICATION


SAFETY ACT COVERAGE ENDORSEMENTWC534 12/93 WC350603 FRAUD WARNING END [OK]WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC237 04/84 WC 00 04 08 LONGSHORE AND HARBOR WORKERS'

COMPENSATION ACT RATE CHANGEENDORSEMENT

WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC350403 B 11/01 WC 35 04 03 B MERIT RATING END (OK)WC000414 A 01/19 WC 00 04 14 A NOTIFICATION OF CHANGE IN

OWNERSHIPWC350601 F 02/14 WC 35 06 01 F OKLAHOMA CANCELLATION,

NONRENEWAL AND CHANGEENDORSEMENT

WC350604 08/99 WC 35 06 04 OKLAHOMA ELECTION OF COVNOTIFICATION ENDORSEMENT

WC350303 03/11 WC 35 03 03 OKLAHOMA EMPLOYERS LIABILITYINTENTIONAL TORT EXCLUSIONENDORSEMENT

FORM35-3 C 09/16 FORM 35-3C OKLAHOMA WORKERS COMPENSATIONMANDATORY OPTIONAL DEDUCTIBLEACCEPTANCE/REJECTION FORM


WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC142 04/84 WC 00 05 08 RETRO PREMIUM ENDORSEMENT—


CHANGES















FORM35-4 A 07/06 FORM354A0706 WORKERS COMPENSATION DEDUCTIBLEACCEPTANCE/REJECTION FORM

WC350402 A 01/01 WC 35 04 02 A WORKERS COMPENSATION PREMIUMREDUCTION PROGRAM (WCPR)ENDORSEMENT

OregonWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM





ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC360601 E 01/08 WC 36 06 01 E CANCELATION END (OR)WC405 01/91 WC 36 04 02 CONT CLASS PRE ADJ (OR)WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING

MODIFICATION FACTOR ENDORSEMENTNC5000 D 08/19 NC-5000 D CONTRACTING CLASSIFICATION

PREMIUM ADJUSTMENT PROGRAMWORKERS COMPENSATION PREMIUMCREDIT APPLICATION















WC532 10/93 WC3604041093 GROUP SUPPL EXP [OR]WC000001 C 05/17 WC 00 00 01 C INFORMATION PAGE NOTESWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED






WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC353 01/88 WC 36 04 01 MERIT RATING ENDT (OR)WC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL





WC360604 01/17 WC 36 06 04 OREGON AMENDATORY ENDORSEMENTWC360602 01/11 WC 36 06 02 OREGON CONFIDENTIALITY

ENDORSEMENTWC360603 01/11 WC 36 06 03 OREGON EMPLOYER PAID MEDICAL

CLAIMS ENDORSEMENTWC360404 A 05/17 WC 36 04 04 A OREGON GROUP SUPPLEMENTAL

EXPERIENCE RATING PLANENDORSEMENT

WC360306 01/02 WC 36 03 06 OREGON LIMITS OF LIABILITYENDORSEMENT

WC360406 10/01 WC 36 04 06




OREGON PREMIUM DUE DATEENDORSEMENT




WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC541 01/94 WC 36 03 02 PILOT PROG MED BEN (OR)WC890600 B 07/01 WC890600B POLICY INFORMATION PAGE



WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER
















WC121 04/84 WC 00 03 10





WC162 04/84 WC 36 03 01 UNSAFE EQUIP EXCL [OR]WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION AND




PennsylvaniaWC190 04/84 WC 37 03 01 (PA)CHURCH ENDWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM


ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC370404 C 05/17 WC 37 04 04 C CERT SAFETY COM END(PA)WC279 01/91 WC 37 04 02 CONST CLASS PREM (PA)WC362 01/90 WC 00 04 12 CONTINGENT EXPERIENCE RATING

MODIFICATION FACTOR ENDORSEMENTWC498 08/93 WC 37 04 03 DEDUCTIBLE ENDT [PA]WC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE





WC370604 10/99 WC 37 06 04 EMPLOYER ASSESSMENTENDORSEMENT


WC192 04/84 WC 37 03 03 EXCLUSION OF EMP (PA)WC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION














WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC595 08/96 WC370405 MERIT RATING PLAN(PA)WC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL




WC346 A 08/95 WC 37 06 03 A NOT OF INC OF PREM (PA)WC434 04/84 WC 37 06 02 NOTICE (PA)WC000115 01/20 WC 00 01 15 NOTIFICATION ENDORSEMENT

OF PENDING LAW CHANGE TOTERRORISM RISK INSURANCE PROGRAMREAUTHORIZATION ACT OF 2015




WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC370109 01/05 WC 37 01 09 PENNSYLVANIA - NOTIFICATION

ENDORSEMENT OF PENDING LAWCHANGE TO TERRORISM RISKINSURANCE ACT OF 2002

WC370406 01/05 WC 37 04 06 PENNSYLVANIA - TERRORISM RISKINSURANCE ACT ENDORSEMENT

WC370401 01/17 WC 37 04 01 PENNSYLVANIA AUDITNONCOMPLIANCE CHARGEENDORSEMENT

WC370311 01/13 WC 37 03 11 PENNSYLVANIA MULTIPLECOORDINATED POLICY ENDORSEMENT

WC649 K 07/19 PCCPAP PENNSYLVANIA WORKERSCOMPENSATION PREMIUM CREDITAPPLICATION

WC191 04/84 WC 37 03 02 POLICE/FIRE ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10 PREMIUM DETERMINATION


WC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENTWC193 04/84 WC 37 03 04 PRINCIPAL AS ADDITIONAL INSUREDWC194 04/84 WC 37 03 05 PROF ASSOC ACT EN [PA]WC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER



WC132 04/84 WC 00 04 07 RATE CHANGE ENDORSEMENT




WC195 04/84 WC 37 03 06 REAL ESTATE MGMT END (PA)WC196 04/84 WC 37 03 07 RELIGIOUS INS [PA]WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLE




SHORT FORMWC414 12/91 WC 00 05 05 A RETROSPECTIVE PREMIUM







WC416 12/91 WC 00 05 13 A RETROSPECTIVE PREMIUMENDORSEMENT - THREE YEAR PLAN -MULTIPLE LINES










WC189 04/84 WC 37 06 01 SPECIAL END (PA)WC197 04/84 WC 37 03 08 SPOUSE OF INS END (PA)




WC198 B 03/86 WC 37 03 09 STATUTORY EMPLOYER (PA)WC000420 12/02 WC 00 04 24 TERRORISM RISK INSURANCE ACT

ENDORSEMENTWC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION AND




Rhode IslandWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM






ENDORSEMENTWC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC163 04/84 WC 38 06 01 DIRECT LIAB ST [RI]WC000421 D 01/15 WC 00 04 21 D DOMESTIC TERRORISM, EARTHQUAKES,















ENDORSEMENT




























SHORT FORMWC000503 D 01/19 WC 00 05 03 D




RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN








WC496 06/93 WC 38 06 02 SAFETY INSP END [RI]WC380401 B 01/15 WC 38 04 01 B SHORT RATE CANCELLATION

ENDORSEMENTWC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,





South CarolinaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEFORM39-1 A 09/14 FORM39-1A APPLICATION FOR DRUG - AND

ALCOHOL-FREE WORKPLACE PREMIUMCREDIT PROGRAM

WC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAMENDORSEMENT






WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT(New) WC000421 E 01/21 WC000421E




CATASTROPHE (OTHER THAN CERTIFIEDACTS OF TERRORISM) PREMIUMENDORSEMENT



























WC421 04/92 WC 00 01 09 A




OUTER CONTINENTAL SHELF LANDSACT COVERAGE ENDORSEMENT























(New) WC000422 C 01/21 WC000422C








South DakotaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM






ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC400602 07/90 WC 40 06 02 BENEFITS DEDUCTIBLE ENDORSEMENTWC400605 B 04/06 WC 40 06 05 B CANCELLATION AND NONRENEWAL

ENDORSEMENT(New) WC000421 E 01/21 WC000421E CATASTROPHE (OTHER THAN CERTIFIED














ENDORSEMENT









WC568 01/94 WC400603 MANAGED CARE END [SD]WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC600 09/96 WC4006040996 MED BEN DED END (SD)WC117 04/84 WC 00 03 06 MEDICAL BENEFITS EXCLUSION


ENDORSEMENTWC457 A 01/96 WC 40 04 01 A MERIT RATING END (SD)WC448 07/92 WC 00 01 11 MIGRANT AND SEASONAL
















WC000320 B 01/06 WC 00 03 20 B























TennesseeWC410403 07/12 WC 41 04 03 (TWCIP) LARGE ACCOUNT INCURRED

LOSS PREMIUM ADJUSTMENT PLAN(TAIL PLAN) - ENDORSEMENT ANDNOTICE

WC410404 07/12 WC 41 04 04 (TWCIP) LARGE ACCOUNT INCURREDLOSS PREMIUM ADJUSTMENT PLAN(TAIL PLAN) - RATING ENDORSEMENT

WC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENT




WC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM


ENDORSEMENTWC410401 A 01/08 WC 41 04 01 A ASSIGNED RISK PREMIUM SURCHARGE



















ENDORSEMENTWC410301 01/09 WC 41 03 01 LIMITED OTHER STATES ENDORSEMENTWC419 04/92 WC 00 01 06 A LONGSHORE AND HARBOR WORKERS'






WC420 04/92 WC 00 01 08 A




NON-APPROPRIATED FUNDINSTRUMENTALITY'S ACT COVERAGEENDORSEMENT





























WC410408 03/17 WC 41 04 08 TENNESSEE ASSIGNED RISKADJUSTMENT PROGRAM ENDORSEMENT

WC410402 08/03 WC 41 04 02 TENNESSEE PENDING LOSS COST ANDASSIGNED RISK RATE ENDORSEMENT

WC410405 07/15 WC 41 04 05 TENNESSEE SMALL EMPLOYER PLANENDORSEMENT

WC410406 07/15 WC 41 04 06 TENNESSEE SPECIAL RISK PLANENDORSEMENT

WC410407 07/15 WC 41 04 07 TENNESSEE TABULAR SURCHARGEENDORSEMENT

WC410601 A 09/12 WC 41 06 01 A TENNESSEE WORKERS COMPENSATIONINSURANCE PLAN (TWCIP)REHABILITATION AND TABULARSURCHARGE REDUCTION INCENTIVEPROGRAM PREMIUM ENDORSEMENT





FORM41-3 01/07 FORM4130107 WORKERS' COMPENSATION INSURANCEPLAN - COST REDUCTION SEMINARINCENTIVE PLAN PREMIUM CREDITFORM

FORM41-1 01/07 FORM4110107 WORKERS COMPENSATION INSURANCEPLAN - SMALL EMPLOYER PLAN FORM

FORM41-2 01/07 FORM4120107 WORKERS' COMPENSATION INSURANCEPLAN - SPECIAL RISK PLAN FORM

TexasWC420604 B 01/00 WC 42 06 04 B ACCIDENT/AGGREGATE DEDUCTIBLE

ENDORSEMENTWC548 A 01/02 ERM411 ACCIDENTS INVOLVING TWO OR MORE

PERSONSWC420603 B 01/00 WC 42 06 03 B AGGREGATE DED END (TX)WC126 04/84 WC 00 04 01 AIRCRAFT PREMIUM ENDORSEMENTWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC112 04/84 WC 00 03 01 ALTERNATE EMPLOYER ENDORSEMENTWC564 A 03/97 WC420402A0397 ANNIV RATING DATE (TX)WC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM


ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTWC362 01/90 WC 00 04 12




CONTINGENT EXPERIENCE RATINGMODIFICATION FACTOR ENDORSEMENT

DNE1 A 06/14 DNE-1A DEDUCTIBLE NOTICE OF ELECTIONWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE





WC420406 D 06/14 WC 42 04 06 D EMPLOYEE PROVIDER/CLIENTCOMPANY ENDORSEMENT


WC420305 A 01/00 WC 42 03 05 A EXEMPT EMPL COV END(TX)WC275 A 03/97 WC 42 04 03 A EXPERIENCE RATING (TX)WC551 05/94 ERM12 EXPERIENCE RATING FORMWC128 04/84 WC 00 04 03 EXPERIENCE RATING MODIFICATION

FACTOR ENDORSEMENTWC000102 B 01/15 WC 00 01 02 B FEDERAL COAL MINE HEALTH AND

SAFETY ACT COVERAGE ENDORSEMENTWC103 04/84 WC 00 01 04 FEDERAL EMPLOYERS' LIABILITY ACT













WC601 01/97 WC4203080197 PARTNERS, OFFICERS AND OTHERSEXCLUSION ENDORSEMENT


WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC130 04/84 WC 00 04 05 POLICY PERIOD ENDORSEMENTWC267 07/91 WC 00 04 10




PREMIUM DETERMINATIONENDORSEMENT - FORMER SELF-INSURERS 2

WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000321 A 01/06 WC 00 03 21 A PROFESSIONAL EMPLOYER



WC581 06/96 WC000325 RESIDUAL MARKET MULTIPLECOMPANY ENDORSEMENT











WC602 01/97 WC4203100197 SOLE PROPRIETORSWC420407 03/02 WC 42 04 07 TEXAS - AUDIT PREMIUM AND

RETROSPECTIVE PREMIUMENDORSEMENT

WC420602 A 06/14 WC 42 06 02 A TEXAS ACCIDENT DEDUCTIBLEENDORSEMENT

WC420315 07/15 WC 42 03 15 TEXAS ADVANCE NOTICE OFCANCELLATION TO THE PROFESSIONALEMPLOYER ORGANIZATION (PEO)

(New) WC420301 J 06/20 WC420301J TEXAS AMENDATORY ENDORSEMENTWC420605 06/14 WC 42 06 05 TEXAS CLAIM DEDUCTIBLE

ENDORSEMENTWC420312 07/15 WC 42 03 12 TEXAS COVERED EMPLOYEE

EXCLUSION ENDORSEMENT FOR POLICYCOVERING DIRECT EMPLOYEES OF ACLIENT

WC420404 A 06/14 WC 42 04 04 A




TEXAS GROUP PURCHASE OFWORKERS COMPENSATION INSURANCEENDORSEMENT

WC420408 A 06/14 WC 42 04 08 A TEXAS HEALTH CARE NETWORKENDORSEMENT

WC420606 06/14 WC 42 06 06 TEXAS MEDICAL BENEFITS DEDUCTIBLEENDORSEMENT

WC420601 01/94 WC 42 06 01 TEXAS NOTICE OF MATERIAL CHANGEENDORSEMENT

WC420316 07/15 WC 42 03 16 TEXAS PROFESSIONAL EMPLOYERORGANIZATION (PEO) CLIENTENDORSEMENT

WC420311 07/15 WC 42 03 11 TEXAS PROFESSIONAL EMPLOYERORGANIZATION (PEO) ENDORSEMENT

WC420314 07/15 WC 42 03 14 TEXAS PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXECUTIVEEMPLOYEE EXCLUSION ENDORSEMENT

WC420313 07/15 WC 42 03 13 TEXAS PROFESSIONAL EMPLOYERORGANIZATION (PEO) EXECUTIVEEMPLOYEE INCLUSION ENDORSEMENT

WC420511 06/11 WC 42 05 11 TEXAS RETROSPECTIVE PREMIUMENDORSEMENT SHORT FORM

WC420505 C 01/19 WC 42 05 05 C TEXAS RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT LONG-TERMCONSTRUCTION PROJECT

WC420514 C 01/19 WC 42 05 14 C TEXAS RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT LONG-TERMCONSTRUCTION PROJECT - MULTIPLELINES

WC420510 B 01/15 WC 42 05 10 B TEXAS RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENTNONRATABLE CATASTROPHE ELEMENTOR SURCHARGE

WC420503 D 01/19 WC 42 05 03 D TEXAS RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN

WC420512 D 01/19 WC 42 05 12 D TEXAS RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES

WC420504 D 01/19 WC 42 05 04 D TEXAS RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN

WC420513 D 01/19 WC 42 05 13 D TEXAS RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT THREE-YEARPLAN—MULTIPLE LINES

WC420303 B 01/00 WC 42 03 03 B VOL WORKERS COV ENDT (TX)WC122 B 08/91 WC 00 03 11 B VOLUNTARY COMPENSATION AND



WC420304 B 06/14 WC 42 03 04 B WAIVER OF OUR RIGHT TO RECOVERFROM OTHERS ENDORSEMENT


UtahWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATE







WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOR


















































WC121 04/84 WC 00 03 10





WC430602 07/02 WC 43 06 02 UTAH CANCELLATION ENDORSEMENTWC430303 01/00 WC 43 03 03 UTAH EMPLOYEE LEASING CLIENT

EXCLUSION ENDORSEMENTWC430304 01/00 WC 43 03 04 UTAH EMPLOYEE LEASING COMPANY

EXCLUSION ENDORSEMENTWC430302 A 05/17 WC 43 03 02 A UTAH EMPLOYEE LEASING

ENDORSEMENTWC430305 07/00 WC 43 03 05 UTAH WAIVER OF SUBROGATION

ENDORSEMENTWC490 01/93 WC 43 06 01 UTAH WORKPLACE SAFETY PROGRAM





VermontWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM






ENDORSEMENTWC440603 07/08 WC 44 06 03 BENEFITS DEDUCT ENDORSEMENTWC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENT










FACTOR ENDORSEMENT










ENDORSEMENTWC165 04/84 WC 44 06 01 LAW END [VT]WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE



















WC131 08/84 WC 00 04 06 PREMIUM DISCOUNT ENDORSEMENTWC000406 A 07/95 WC 00 04 06 A PREMIUM DISCOUNT ENDORSEMENTWC000419 01/01 WC 00 04 19 PREMIUM DUE DATE ENDORSEMENT





















WC440602 B 07/14 WC 44 06 02 B VERMONT CANCELLATION ANDNONRENEWAL ENDORSEMENT

WC440401 04/03 WC 44 04 01 VERMONT WORKERS COMPENSATIONINSURANCE PLAN MERIT RATINGENDORSEMENT




VirginiaWC173 A 10/85 WC 45 06 01 ADDITIONAL BENEFITS ENDORSEMENT




WC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM




ENDORSEMENTWC593 05/96 WC450603 BENEFITS DED END (VA)WC403 02/91 WC 00 06 03 BENEFITS DEDUCTIBLE ENDORSEMENTERM-14 02/20 NC790 CONFIDENTIAL REQUEST FOR


MODIFICATION FACTOR ENDORSEMENTWC450604 01/97 WC 45 06 04 CONTRACTING CLASSIFICATION

PREMIUM ADJUSTMENT ENDORSEMENTWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE



















ENDORSEMENT








WC489 07/93 WC 45 06 02 VIRGINIA AMENDATORYENDORSEMENT

WC450303 01/01 WC 45 03 03 VIRGINIA CLIENT COMPANYENDORSEMENT

WC450304 01/01 WC 45 03 04 VIRGINIA CLIENT COMPANY EXCLUSIONENDORSEMENT

FORM453 F 04/20 FORM 45-3F VIRGINIA CONTRACTINGCLASSIFICATION PREMIUMADJUSTMENT PROGRAM (CCPAP)WORKERS COMPENSATION PREMIUMCREDIT APPLICATION

WC450301 01/01 WC 45 03 01 VIRGINIA PEO ENDORSEMENTWC450302 01/01 WC 45 03 02 VIRGINIA PEO EXCLUSION





WashingtonWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM








FACTOR ENDORSEMENTWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED









West VirginiaWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC000415 B 01/10 WC 00 04 15 B ASSIGNED RISK ADJUSTMENT PROGRAM






ENDORSEMENTWC470601 01/06 WC 47 06 01 CANCELLATION ENDORSEMENT





WC113 04/84 WC 00 03 02 DESIGNATED WORKPLACE EXCLUSIONWC000322 A 01/06 WC 00 03 22 A EMPLOYEE LEASING CLIENT












WC000201 B 01/15 WC 00 02 01 B MARITIME COVERAGE ENDORSEMENTWC448 07/92 WC 00 01 11




MIGRANT AND SEASONALAGRICULTURAL WORKER PROTECTIONACT COVERAGE ENDORSEMENT















WC470304 08/09 WC 47 03 04 PROFESSIONAL EMPLOYERORGANIZATION CLIENT COMPANYEXCLUSION ENDORSEMENT

WC470305 08/09 WC 47 03 05 PROFESSIONAL EMPLOYERORGANIZATION EXCLUSIONENDORSEMENT

WC470303 08/09 WC 47 03 03 PROFESSIONAL EMPLOYERORGANIZATION EXTENSIONENDORSEMENT







WC000512 D 01/19 WC 00 05 12 D




RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT ONE-YEARPLAN—MULTIPLE LINES












WC470301 A 07/08 WC 47 03 01 A WEST VIRGINIA EMPLOYERS LIABILITYINSURANCE DELIBERATE INTENTIONEXCLUSION ENDORSEMENT

WC470314 B 07/11 WC 47 03 14 B WEST VIRGINIA WORKERSCOMPENSATION AND EMPLOYERSLIABILITY COVERAGE FOR DOMESTICSERVICE EMPLOYEES ENDORSEMENT

WC470302 07/06 WC 47 03 02 WEST VIRGINIA WORKERSCOMPENSATION INSURANCE RECOVERYFROM OTHERS ENDORSEMENT

WisconsinWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC127 04/84 WC 00 04 02 ANNIVERSARY RATING DATEWC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM



MODIFICATION FACTOR ENDORSEMENTWC607 07/97 WC4804010797 CONTRACTORS PREMIUM ADJUSTMENT

PROGRAMWC217 04/92 WC 00 01 01 A DEFENSE BASE ACT COVERAGE

ENDORSEMENT













WC480603 B 01/01 WC 48 06 03 B FOREIGN COVERAGE END [WI]WC000422 B 01/15 WC 00 04 22 B FOREIGN TERRORISM PREMIUM



ENDORSEMENTWC480601 C 04/01 WC 48 06 01 C LAW ENDORSEMENT (WI)WC449 06/92 WC 00 02 04 LIMITED MARITIME COVERAGE

ENDORSEMENTWC480301 C 12/07 WC 48 03 01 C LIMITED OTHER STATES INSURANCE








WC480319 05/18 WC 48 03 19 NOTICE OF CANCELLATION ORMATERIAL COVERAGE CHANGE TODESIGNATED GOVERNMENTAL ENTITY





WC129 04/84 WC 00 04 04 PENDING RATE CHANGE ENDORSEMENTWC890600 B 07/01 WC890600B




POLICY INFORMATION PAGEENDORSEMENT










SHORT FORMWC480517 B 01/19 WC 48 05 17 B RETROSPECTIVE PREMIUM

ENDORSEMENT - LARGE RISKALTERNATIVE RATING OPTION

WC480507 B 01/19 WC 48 05 07 B RETROSPECTIVE PREMIUMENDORSEMENT LARGE RISKALTERNATIVE RATING OPTION

WC480506 B 01/19 WC 48 05 06 B RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT - LARGE RISKALTERNATIVE RATING OPTION

WC480502 A 01/19 WC 48 05 02 A RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT - LARGE RISKALTERNATIVE RATING OPTION - PLANTYPE

WC480512 07/11 WC 48 05 12 RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT - LARGE RISKALTERNATIVE RATING OPTION (LRARO)

WC480503 A 01/19 WC 48 05 03 A RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT - LARGE RISKALTERNATIVE RATING OPTION (LRARO)

WC480508 B 01/19 WC 48 05 08 B RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT - LARGE RISKALTERNATIVE RATING OPTION (LRARO)

WC480510 B 01/19 WC 48 05 10 B RETROSPECTIVE RATING PLANPREMIUM ENDORSEMENT - WISCONSINLARGE RISK ALTERNATIVE RATINGOPTION (LRARO)




WC000513 D 01/19 WC 00 05 13 D







WC178 04/84 WC 48 06 02 RURAL ELECT COOP (WI)WC000309 B 01/06 WC 00 03 09 B RURAL UTILITIES SERVICE

ENDORSEMENTWC653 A 07/13 WC 48 05 01 A SCHEDULE OF VARIABILITY TO

ENDORSEMENT WC 48 05 01WC654 09/11 WC480506 SCHEDULE OF VARIABILITY TO

ENDORSEMENT WC 48 05 06WC655 A 01/15 WC480512A SCHEDULE OF VARIABILITY TO

ENDORSEMENT WC 48 05 12WC121 04/84 WC 00 03 10 SOLE PROPRIETORS, PARTNERS,





WC480606 B 01/02 WC 48 06 06 B WISCONSIN CANCELLATION ANDNONRENEWAL ENDORSEMENT

WC480605 06/01 WC 48 06 05 WISCONSIN CHANGE OF INSURANCECARRIER NAME ENDORSEMENT

WC480316 04/08 WC 48 03 16 WISCONSIN EMPLOYEE LEASINGCOMPANY CLIENT TERMINATIONENDORSEMENT—MASTER POLICY

WC480314 04/08 WC 48 03 14 WISCONSIN EMPLOYEE LEASINGCOMPANY ENDORSEMENT—MASTERPOLICY

WC480315 04/08 WC 48 03 15 WISCONSIN EMPLOYEE LEASINGCOMPANY ENDORSEMENT—MULTIPLECOORDINATED POLICY (MCP)

WC480304 07/16 WC 48 03 04 WISCONSIN REAL ESTATESALESPERSONS ENDORSEMENT

WC480514 02/12 WC 48 05 14 WISCONSIN RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT - LARGERISK ALTERNATIVE RATING OPTION

WC480519 D 01/19 WC 48 05 19 D WISCONSIN RETROSPECTIVE RATINGPLAN PREMIUM ENDORSEMENT - LARGERISK ALTERNATIVE RATING OPTION(PAID LOSS)

WC623 11/96 WC4806041196 WISCONSIN WAIVER OF SOVEREIGNWC480302 A 01/13 WC 48 03 02 A WISCONSIN WORK-STUDY COVERAGE

ENDORSEMENTWC480520 A 01/19 WC 48 05 20 A WISCONSIN—RETROSPECTIVE RATING

PLAN PREMIUM ENDORSEMENT - LARGERISK ALTERNATIVE RATING OPTION(LRARO)

WC606 03/97 WC4803020397




WORK-STUDY COVERAGEENDORSEMENT

WyomingWC331 05/86 WC 00 04 01 A AIRCRAFT PREMIUM ENDORSEMENTWC269 02/89 WC000301A ALTERNATE EMPLOYER ENDORSEMENTWC467 07/92 WC 49 03 01 AMENDATORY END [WY]WC504 01/90 WC 00 04 11 ASSIGNED RISK PREMIUM








FACTOR ENDORSEMENTWC115 04/84 WC 00 03 04 INSURANCE COMPANY AS INSURED















WC000320 B 01/06 WC 00 03 20 B

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