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Insurance for this coverage part provided by: <br />ZURICH AMERICAN INSURANCE COMPANY <br />NCCI Comoanv No.10 S 6 3 <br />WORKERS COMPENSATION CHANGE ENDORSEMENT <br />Policy NumberWC 6551240-05 <br />NAMED INSURED <br />ENDORSEMENT EFFECTIVE DATE <br />POLICY NUMBER <br />GCC ENERGY LLC <br />09-01-14 <br />I WC 6551240-05 <br />POLICYTERM: 09-01-2014 TO 09-01-2015 <br />ENDORSEMENT NUMBER 001 <br />Change Description <br />THE FOLLOWING RATING <br />PLAN IS AMENDED: <br />INCREASE LIMITS(9139) <br />STATE: WA AMOUNT: 95.00% TO <br />4.300 <br />THE FOLLOWING FORM(S) <br />HAS BEEN ADDED: <br />WC990633 05-10 <br />NOTIFICATION TO OTHERS OF CANCELLATION <br />PREMIUM CHANGE <br />PRO -RATA FACTOR <br />Additional Coverage Premium <br />NO CHARGE Return Coverage Premium <br />NO CHARGE <br />Additional Taxes & Surcharges <br />Return Taxes & Surcharges <br />Total Additional Premium <br />Total Return Premium <br />Countersigned: Date <br />U -WC -317-A (07-94) <br />