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OLD REPUBLIC GENERAL INSURANCE CORPORATION <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />CANCELLATION PROVISION <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING. <br />Part Six - Conditions, Item D. Cancellation, Number 2, is changed to read: <br />2. We may cancel this policy. We must mail or deliver to you not less than <br />60 days advance written notice stating when the cancellation <br />is to take effect, unless cancellation is for nonpayment of premium, in which <br />event our obligation is mailing not less than 10 days prior <br />to the effective date of cancellation. Mailing notice to you at your mailing <br />address shown in Item 1 on the Information Page will be sufficient to prove notice. <br />Named Insured <br />Policy Number <br />Policy Period <br />Producer's Name: <br />Producer Number: <br />O'GRADY PAVING, INC. <br />1 CW44181801 <br />07/01/2019 to <br />Endorsement No. <br />Endorsement Effective Date' <br />000 <br />07/01/2019 <br />07/01/2020 OLD REPUBLIC CONTRACTORS INSURANCE AGENCY, INC. <br />0000007000 <br />AUTHORIZED REPRESENTATIVE <br />n7M4,On4 <br />WC 99 03 14 (01/07) <br />55499974 1 OGRAPAV-Cl 1 19-20 WC, Auto, GL, XS I Bolton Certificate Processing 1 5/15/2020 5:47:28 PM (PDT) I Page 9 of 9 <br />