CTR076897_LanceSoft_Inc_COI_CGL_Auto_WC_PL_SAM_exp7.1.26_ALL.pdf

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:

CONTACT

(A/C, No):

FAX

E-MAIL

ADDRESS:

PRODUCER

(A/C, No, Ext):

PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.

If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED

REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

OTHER:

(Per accident)

(Ea accident)

N / A

SUBR

WVD

ADDL

INSD

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS ONLY

AUTOSAUTOS ONLY

NON-OWNED

SCHEDULEDOWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)

DESCRIPTION OF OPERATIONS below If yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

ER

OTH-

STATUTE

PER

LIMITS(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTR

INSR

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCE

DAMAGE TO RENTED

$PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY

PRO-

JECT LOC

CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

CANCELLATION

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

© 1988-2015 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

7/14/2025

Marsh & McLennan Agency LLC 20 North Martingale Road Schaumburg IL 60173

Laura Karr

(847) 247-3042 (847) 440-9126

Laura.Karr@MarshMMA.com

CONTINENTAL CASUALTY COMPANY 20443

LANCINC-01 PHILADELPHIA INDEMNITY INSURAN 18058

LanceSoft, Inc.

2121 Cooperative Way, Suite 130 Herndon VA 20171

ZURICH AMERICAN INSURANCE COMP 16535

Tokio Marine Specialty Insuran 23850 Midvale Indemnity Company 27138

1649957247

B X 2,000,000 X 1,000,000

X Contractual Liab 20,000

2,000,000

4,000,000 X X

PHPK2573591004 7/1/2025 7/1/2026

4,000,000

D 5,000,000

X X

PPK2574633002 7/1/2025 7/1/2026

B X X 10,000,000PHUB871363004 7/1/2025 7/1/2026

10,000,000 X 10,000

C X

N

WC277362304 7/1/2025 7/1/2026

1,000,000

1,000,000

1,000,000 A B E

Crime - Third Party Professional Liability (E&O)

EPLI

2087274915

PHPK2573591004

BCP04699602

7/1/2025 7/1/2025 7/1/2025

7/1/2026 7/1/2026 7/1/2026

Occ/Agg: 5,000,000 Occur: 1,000,000 Occ: 1,000,000

Ded: 50,000 Agg: 3,000,000 Agg: 3,000,000

Proof of Insurance.

Excess Commercial Umbrella - Policy#100042883206 - Effective: 7/1/2025 Expiration: 7/1/2026 - Occurrence: 5,000,000 General Aggregate: 5,000,000 - Insurer affording coverage: Liberty Insurance Underwriters, Inc. The Excess Umbrella sits over the General Liability and Employers Liability.

Excess Employment Practices Liability - Policy#S0008EL00025602- Effective: 7/1/2025 Expiration: 7/1/2026 - ($2M Occurrence/Aggregate Limit; $0 Deductible)- Insurer Affording Coverage: Accelerant Specialty Insurance Co. The Excess Employment Practices Liability sits over the Employment Practices Liability Policy.

See Attached...

The State of Arizona and Dept of Economic Security C/O: myCOI P.O. Box# 501970 8710 Bash Street Indianapolis IN 46256

ACORD 101 (2008/01)

The ACORD name and logo are registered marks of ACORD

© 2008 ACORD CORPORATION. All rights reserved.

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE Page of

AGENCY CUSTOMER ID:

LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

LANCINC-01

1 1

Marsh & McLennan Agency LLC LanceSoft, Inc.

2121 Cooperative Way, Suite 130 Herndon VA 20171

25 CERTIFICATE OF LIABILITY INSURANCE

Insured owns no Autos.

Excess Hired & Non-Owned Automobile - Policy#RTSXS00149- Effective: 7/1/2025 Expiration: 7/1/2026 - $1M Limit- Insurer Affording Coverage: Underwriters at Lloyds of London. Excess Auto policy extends coverage to the Hired & Non-Owned Auto policy.

Cyber and Tech E&O (Network Security & Privacy) - Crum & Forster Specialty Insurance Company - 7/1/2025-7/1/2026 - TCM109210 - Per Claim/Agg.

$5,000,000

Abuse & Molestation - Policy# PHPK2684080001 - Effective: 5/3/2025 - Expiration: 5/3/2026 - Limits of Liability: $1,000,000 Occurrence $1,000,000 Aggregate - Insurer Affording Coverage: Philadelphia Indemnity Insurance Company.

Division Name: ADES - Contract ID: CTR076897

It is agreed that State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees are added as Additional Insureds, when required by written contract, on the General Liability on a primary and non-contributory basis with respect to operations performed by the Named Insured in connection with this project.

It is agreed that State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees are added as Additional Insureds, when required by written contract with respect to operations performed by the Named Insured in connection with this project. Hired and Non-Owned Auto Liability coverage is primary and non-contributory for the Additional Insureds subject to a sublimit of $1,000,000.

It is agreed that the following are added as Additional Insured, when required by written contract, on the General Liability with respect to ongoing operations performed by the Named Insured in connection with this project.

A Waiver of Subrogation in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees applies to the Worker’s Compensation, General Liability and Automobile Liability policies, when required by written contract and where allowed by law.

Umbrella Follows form over Professional Liability($10M sublimit).

POLICY CHANGE DOCUMENT

POLICY NO.:

CHANGE EFFECTIVE CHANGE # REVISION #

DESCRIPTION

PHPK2573591-004

307/01/2025

09/19/2025____________________ Issue Date

Amended:

Additional Insured The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees

Per attached

Philadelphia Indemnity Insurance Company

NAMED INSURED

4369 Marsh & McLennan Agency LLC

LanceSoft, Inc.

MAILING ADDRESS 2121 Cooperative Way Ste 130 Herndon, VA 20171-5370

POLICY PERIOD: FROM TO at 12:01 A.M. Standard Time at your mailing address shown above.

Path ID 18801854

0.00

NO CHANGE

COUNTERSIGNED BY

(Date) (Authorized Representative)

07/01/2025 07/01/2026

In consideration of the premium reflected, the policy is amended as indicated below:

Total Annual 0.00Additional/Return Premium $ Additional/Return Premium $

Total Prorate

NO CHANGE

Insurance Policy

PI-AI-SCH (08/20)

Page of

Additional Insured Schedule

Policy Number:

Philadelphia Indemnity Insurance Company

Named Insured

Encode, Inc.

Named Insured

CG2037 - General Liability

STAFF HC INC

Named Insured

Staff Locum Inc.

Blanket Additional Insured As Required by written contract prior to loss.

1 2

Page of

Additional Insured Schedule

CG2010 - General Liability agencies,boards,commissions,universities officers,officials,agents,and employees C/O: myCOI PO Box 501970, 8710 Bash Street Indianapolis, IN 46250-6970

The State of Arizona,and its departments

2 2

POLICY NUMBER: COMMERCIAL GENERAL LIABILITY

CG 20 10 04 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – SCHEDULED PERSON OR

ORGANIZATION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by:

1. Your acts or omissions; or

2. The acts or omissions of those acting on your behalf;

in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above.

However:

1. The insurance afforded to such additional insured only applies to the extent permitted by law; and

2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply:

This insurance does not apply to "bodily injury" or "property damage" occurring after:

1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or

2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project.

PHPK2573591-004

Per written contractThe State of Arizona,and its departments agencies,boards,commissions,universities officers,officials,agents,and employees

Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13

C. With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance:

If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance:

1. Required by the contract or agreement; or

2. Available under the applicable Limits of Insurance shown in the Declarations;

whichever is less.

This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.

PPK2574633-002

207/01/2025

09/02/2025____________________ Issue Date

Added:

Additional Insured:

State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees

Per attached Schedule

Added:

Waiver of Subrogation State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees

Per attached

Tokio Marine Specialty Insurance Company

NAMED INSURED

4369 Marsh & McLennan Agency LLC

LanceSoft, Inc.

MAILING ADDRESS 2121 Cooperative Way Ste 130 Herndon, VA 20171-5370

POLICY PERIOD: FROM TO at 12:01 A.M. Standard Time at your mailing address shown above.

Path ID 18745052

COUNTERSIGNED BY

(Date) (Authorized Representative)

07/01/2025 07/01/2026

In consideration of the premium reflected, the policy is amended as indicated below:

0.00

NO CHANGE

Total Annual 0.00Additional/Return Premium $ Additional/Return Premium $

Total Prorate

NO CHANGE

Insurance Policy

POLICY NUMBER: COMMERCIAL AUTO

CA 04 44 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page of

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US (WAIVER OF SUBROGATION)

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.

This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.

Named Insured:

Endorsement Effective Date:

SCHEDULE

Name(s) Of Person(s) Or Organization(s):

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization.

PPK2574633-002

07/01/2025

LanceSoft, Inc.

State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees

1 1

POLICY NUMBER: COMMERCIAL AUTO

CA 20 48 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1

DESIGNATED INSURED FOR

COVERED AUTOS LIABILITY COVERAGE

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement.

This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form.

This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.

Named Insured:

Endorsement Effective Date:

SCHEDULE

Name Of Person(s) Or Organization(s): SEE SCHEDULE PI-CA-044

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II – Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I – Covered Autos Coverages of the Auto Dealers Coverage Form.

PPK2574633-002

07/01/2025

LanceSoft, Inc.

PI-CA-044 (09/23)

PI-CA-044 (09/23)

Page of

Includes copyrighted material of Insurance Services Office, Inc., with permission.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

SCHEDULE - DESIGNATED INSURED FOR

COVERED AUTOS LIABILITY COVERAGE

This schedule is used with endorsement CA 20 48 Designated Insured for Covered Autos Liability Coverage to provide additional space to complete the schedule.

SCHEDULE

Name Of Person(s) Or Organization(s):

Encode, Inc

Staff HC, Inc.

Contract for services

Staff Locum Inc.

State of Arizona, and its departments, agencies, boards, commissions, agents, and employees

CA2048 - Commercial Automobile universities, officers, officials, PO Box 501970 c/o myCOI Indianapolis, IN 46250-6970

1 1

Page of

Additional Insured Schedule

CG 20 10 04 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – SCHEDULED PERSON OR

ORGANIZATION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by:

1. Your acts or omissions; or

2. The acts or omissions of those acting on your behalf;

in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above.

However:

1. The insurance afforded to such additional insured only applies to the extent permitted by law; and

2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply:

This insurance does not apply to "bodily injury" or "property damage" occurring after:

1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or

2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project.

Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13

C. With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance:

If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance:

1. Required by the contract or agreement; or

2. Available under the applicable Limits of Insurance shown in the Declarations;

whichever is less.

This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.

CG 24 04 05 09

CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

Name Of Person Or Organization:

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV – Conditions:

We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above.

WORKERS COMPENSATION CHANGE ENDORSEMENT

Insurance for this coverage part provided by: POLICY NUMBER: WC 2773623 - 04

Zurich American Insurance Company

NCCI Company No. 10863

NAMED INSURED

LanceSoft, Inc.

ENDORSEMENT EFFECTIVE DATE

07/01/2025

POLICY NUMBER

WC 2773623 - 04

POLICY TERM: 07/01/2025 TO 07/01/2026 ENDORSEMENT NUMBER 004

Change Description

THE FOLLOWING FORM HAS BEEN AMENDED:

WC 00 03 13 04/84 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

ALL OTHER TERMS AND CONDITIONS REMAIN THE SAME

ANY PREMIUM ADJUSTMENT IS SUBJECT TO AUDIT

U-WC-317-A (07-94)

PREMIUM CHANGE

PRO-RATA FACTOR 1

Additional Coverage Premium STA Return Coverage Premium STA

Additional Taxes & Surcharges STA Return Taxes & Surcharges STA

Total Additional Premium STA Total Return Premium STA

Countersigned: Date By

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 04-84)

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.)

This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.

Schedule

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees P.O. Box 6123, Phoenix, AZ 85005

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective Policy No. Endorsement No.

Insured Premium $

Insurance Company

Countersigned by______________________________Zurich American Insurance Company

07/01/2025 WC 2773623 - 04

LanceSoft, Inc.

Copyright 1983 National Council on Compensation Insurance, Inc.WC124 (4-84)

WC 00 03 13

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 04-84)

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.)

This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.

Schedule

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees P.O. Box 6123, Phoenix, AZ 85005

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective Policy No. Endorsement No.

Insured Premium $

Insurance Company

Countersigned by______________________________Zurich American Insurance Company

07/01/2025 WC 2773623 - 04

LanceSoft, Inc.

Copyright 1983 National Council on Compensation Insurance, Inc.WC124 (4-84)

WC 00 03 13