CGI_Certificate_of_Insurance_-_Epires_6-1-2025_Part_7.pdf
PDF 64 KB Posted
- Attached to
- Master Agreement AZ|CTR061240
- Contract number
- CTR061240
- Issued by
- Arizona
About this file
This document is a Workers Compensation and Employers Liability Policy Endorsement issued by Travelers Indemnity Company, specifically a Notice of Cancellation to Designated Persons or Organizations. The policy is associated with Policy Number UB-4P332787-24-51-K and involves the State of Arizona, Department of Administration, State Procurement Office located in Phoenix, AZ.
The endorsement outlines the conditions for cancellation notification, stipulating that if the policy is canceled for any reason other than non-payment of premium, Travelers will provide 30 days' notice to the designated organization (State of Arizona Department of Administration). The document emphasizes the insured's responsibility for providing accurate contact information and notes that if the provided contact details are incomplete or inaccurate, Travelers has no obligation to notify the designated organization of cancellation.
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Text version
Endorsement Effective
Countersigned by
Policy No.
Premium $Insured
Insurance Company
Endorsement No.
All other terms and conditions of this policy remain unchanged.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
TO DESIGNATED PERSONS OR ORGANIZATIONS
NOTICE OF CANCELLATION
POLICY NUMBER:
ENDORSEMENT WC 99 06 R3 (00) -
EMPLOYERS LIABILITY POLICY
AND
WORKERS COMPENSATION
Notice Of Cancellation To Designated Persons Or Organizations
Name and Address of Designated Persons or Organizations: Number of Days Notice
The following is added to PART SIX – CONDITIONS :
SCHEDULE
If we cancel this policy for any reason other than non-payment of premium by you, we will provide notice of such cancellation to each person or organization designated in the Schedule below. We will mail or deliver such notice to each person or organization at its listed address at least the number of days shown for that person or organiza-tion before the cancellation is to take effect.
You are responsible for providing us with the information necessary to accurately complete the Schedule below.
If we cannot mail or deliver a notice of cancellation to a designated person or organization because the name or address of such designated person or organization provided to us is not accurate or complete, we have no responsibility to mail, deliver or otherwise notify such designated person or organization of the cancellation.
ONE TOWER SQUARE
HARTFORD CT 06183 027
Page ofDATE OF ISSUE: ST ASSIGN:
© 2013 The Travelers Indemnity Company. All rights reserved.
N425C1 Textbox
STATE OF ARIZONA.DEPARTMENT OF ADMINISTRATION. STATE PROCUREMENT OFFICE
100 N 15TH AVENUE
PHOENIX, AZ 85007
MLBERUBE
Typewriter
UB-4P332787-24-51-K
MLBERUBE
Typewriter 05-14-24
File details come from the government source that posted it. Updated .