Laserfiche WebLink
WORKERS COMPENSATION CHANGE ENDORSEMENT <br />Insurance for this coverage part provided by: Policy NumberWC 6551240-05 <br />ZURICH AMERICAN INSURANCE COMPANY <br />Nr,r:l Ivn 1 n R ii R <br />NAMED INSURED <br />ENDORSEMENT EFFECTIVE DATE <br />I POLICY NUMBER <br />GCC ENERGY LLC <br />09-01-14 <br />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 />4.30% <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 By. <br />U -WG -317 A (07-94) <br />