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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />NOTIFICATION TO OTHERS OF CANCELLATION ENDORSEMENT <br />This endorsement is used to add the following to Part Six of the policy. <br />PART SIX <br />CONDITIONS <br />WC 99 06 33 <br />A. If we cancel this policy by written notice to you for any reason other than nonpayment of premium, we will mail <br />or deliver a copy of such written notice of cancellation to the name and address corresponding to each <br />person or organization shown in the Schedule below. Notification to such person or organization will be <br />provided at least 10 days prior to the effective date of the cancellation, as advised in our notice to you, or the <br />longer number of days notice if indicated in the Schedule below. <br />B. If we cancel this policy by written notice to you for nonpayment of premium, we will mail or deliver a copy of <br />such written notice of cancellation to the name and address corresponding to each person or organization <br />shown in the Schedule below at least 10 days prior to the effective date of such cancellation. <br />C. If notice as described in Paragraphs A or B. of this endorsement is mailed, proof of mailing will be sufficient <br />proof of such notice. <br />SCHEDULE <br />Name and Address of Other Person(s) / Organization(s): <br />Number of <br />Days Notice: <br />OFFICE OF SURFACE MINING RECLAMATION <br />30 <br />AND ENFORCEMENT, WESTERN REGION <br />1999 BROADWAY, SUITE 3320 <br />DENVER, CO 80202— 3050 <br />All other terms and conditions of this policy remain unchanged. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement Effective <br />Insured <br />Insurance Company <br />Policy No. <br />Endorsement No. <br />Premium $ <br />WC 99 06 33 <br />(Ed. 05-10) Includes copyrighted material of National Council on Compensation Insurance, Inc. with its permission. Pagel of 1 <br />