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TRAVELERS WORKERS COMPENSATION <br />ONE TOWER SQUARE AND <br />HARTFORD, CT 06183 EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 42 06 01 (00) — 002 <br />POLICY NUMBER: XCUB3974T65A <br />TEXAS NOTICE OF MATERIAL CHANGE ENDORSEMENT <br />This endorsement applies only to the insurance provided by the policy because Texas is shown in item 3.A. of the <br />Information Page. <br />In the event of cancelation or other material change of the policy, we will mail advance notice to the person or <br />organization named in the Schedule. The number of days advance notice is shown in the Schedule. <br />This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. <br />SCHEDULE <br />1. NUMBER OF DAYS ADVANCE NOTICE: 30 (or * *) <br />2. NOTICE WILL BE MAILED TO: <br />SHOWN IN THIS SCHEDULE. <br />ADDRESS: <br />THE ADDRESS FOR THAT PERSON OR ORGANIZATION INCLUDED <br />IN SUCH WRITTEN REQUEST FROM YOU TO US. <br />THIS ENDORSEMENT DOES NOT APPLY WHEN THE REASON <br />FOR CANCELLATION IS NON - PAYMENT OF THE PREMIUM. <br />** Number of days Notice specified in the Certificate of Insurance to all holders of such certificates. <br />DATE OF ISSUE: 10 -23 -14 ST ASSIGN: <br />