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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />CHANGE IN INFORMATION PAGE <br />INSURER: Hartford Casualty Insurance Company <br />NCCI Company Number: 14397 Audit Period: ANNUAL <br />Policy Effective Date: 06/07/24 Policy Expiration Date: 06/07/25 <br />Policy Number: 72 WEC AMOKNA Endorsement Number: 003 <br />Effective Date: 07/18/24 Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address: BORRONE PETER INC <br />2022 BROADWAY ST <br />REDWOOD CITY CA 94063 <br />FEIN Number: 47-2692178 <br />Producer Name: NETPAY INSURANCE SERVICES INC Producer Code: 72252546 <br />It is agreed that the policy is amended as follows: <br />This is NOT a bill. However, any changes in your premium will be reflected in your next billing statement. You will receive <br />a separate bill from The Hartford. <br />In consideration of an additional premium of $547, it is agreed that: <br />Policy is amended to add the following condition(s): <br />Waiver of Our Right to Recover from Others Endorsement <br />Policy is amended to delete the following condition(s): <br />Waiver of Our Right to Recover from Others Endorsement <br />Policy is amended to revise the following Endorsement Forms reflecting the changes made to your policy. <br />WC000406 <br />WC040306 <br />WC990006A(.1 P) <br />G-4119-0 <br />WC990006A(.2) <br />Countersigned by <br />Form WC 99 00 06 A (1) Printed in U.S.A. <br />Process Date: 07/22/24 <br />ATTY/AGR.2024.136Nesta (2022 Broadway) (Page 26 of 31) <br />Authorized Representative <br />Page 1 <br />Policy Expiration Date: 06/07/25 <br />