Bulletin No October 18, Broadway, Suite 900 Oakland, CA Fax

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WCIRB Bulletin Bulletin 2017-21 October 18, 2017 1221 Broadway, Suite 900 Oakland, CA 94612 415.777.0777 Fax 415.778.7007 www.wcirb.com wcirb@wcirb.com Revised Standard Endorsement Form Farm Schedule Endorsement California (WC 04 04 06 E) The Insurance Commissioner has approved revisions to the attached California Standard Form WC 04 04 06 E, Farm Schedule Endorsement California, for consistency with recent changes made to the California Workers Compensation Uniform Statistical Reporting Plan 1995 (USRP) effective January 1, 2018. Specifically, the description of Classification 0079(1), Strawberry Crops, was amended to include the approved addition of a suffix to Classification 8291(1), Warehouses cold storage. In addition, two editorial changes were made for conformity with the USRP. For your ease of reference, two copies of the captioned Standard Form are attached. One copy identifies the changes and the other is in final format. As with any Standard Form, an insurer may file WC 04 04 06 E, Farm Schedule Endorsement California, with the WCIRB electronically through SERFF and may use the form after receiving the WCIRB s notification indicating that the form has been reviewed as to form and substance and is ready for use. When filing a Standard Form with the WCIRB through SERFF, each insurer must submit a copy of the Standard Form and a cover letter requesting authorization to use the form. Affiliated insurers must each make a separate filing. THE ATTACHED FORM IS ADVISORY ONLY AND INSURERS ARE THEREFORE NOT OBLIGATED OR REQUIRED TO USE IT. Insurers that choose not to use this Standard Form may, but are not obligated to, prepare their own form. Insurers choosing to prepare their own form must submit it to the WCIRB through SERFF, along with a detailed cover letter and Document Submission Form, for review and transmission to the Insurance Commissioner. Insurers may use this form if the Commissioner approves the form in writing or does not take any action on the form within 30 days after the date that the WCIRB submits it to the Commissioner. The revised Standard Endorsement Form is available in the Knowledge Center in WCIRB Connect. 2017 Workers Compensation Insurance Rating Bureau of California. All Rights Reserved. See http:www.wcirb.com/copyright for more information.

WC 04 04 06 DE (Ed. 01-1601-18) FARM SCHEDULE ENDORSEMENT CALIFORNIA Farms including all employees of whatever nature (other than Private Residence Employees) engaged upon or in connection with such farm including managers, superintendents, foremen and any other persons engaged by or on behalf of the employer to perform farm work for a price per unit, contract or measure. Classification of Farm Operations 0079(2) BUSH BERRY CROPS This classification applies to all acreage devoted to the cultivation and harvesting, including field packing, of bush berries, such as raspberries, olallieberries (blackberries), blueberries and boysenberries. The washing, sorting, sizing, grading, packing, precooling or otherwise preparing fresh fruit for shipment (not field packing) shall be separately classified as 2107, Fruit fresh fruit packing and handling. The cultivation and harvesting, including field packing, of strawberries shall be classified as 0079(1), Strawberry Crops. 0044 COTTON FARMS This classification applies to all acreage devoted to the cultivation and harvesting of cotton. Cotton gin operations including cotton compressing shall be separately classified as 0401, Cotton Gin Operation. The purchase and sale of cotton including cotton compressing shall be classified as 0400(1), Cotton Merchants. The contract storage of baled cotton, including cotton compressing, shall be classified as 0400(2), Warehouses cotton. 0036 DAIRY FARMS This classification applies to all acreage devoted to the raising of cows for the production of milk or cream and the raising of replacement dairy heifers. This classification also includes acreage devoted to the raising of goats for milk, cream or meat production. This classification includes growing feed, hay or grain crops when more than 50% of such crops are used by the employer. Cultivation and harvesting of crops that are primarily sold to others shall be assigned to the appropriate Farms Industry Group classification. Milk pasteurization, processing or bottling; dairy products manufacturing; and route drivers who deliver bottled milk to customers and perform no other duties on the farm premises shall be separately classified as 2063, Creameries and Dairy Products Mfg. The raising of beef cattle shall be classified as 0038(1), Stock Farms. The raising of calves for others shall be classified as 0034(2), Sheep Raising and Hog Farms. 0171 FIELD CROPS This classification applies to all acreage devoted to the cultivation and harvesting of hay; alfalfa; all the cereal grains, including but not limited to wheat, barley, rice, feed corn and oats; all sorghums; flax; safflower and maize. Mechanized harvesting operations performed on a fee basis shall be classified as 0050, Farm Machinery Operation. The cultivation and harvesting, including field packing of sweet (edible) corn, shall be classified as 0172, Truck Farms. The cultivation and harvesting of grass sod for use in landscaping shall be 0038(2) LIVESTOCK FEED YARDS including the milling or blending of feed for use in operations This classification applies to the feeding or fattening of livestock, including but not limited to cattle, sheep and hogs, on a fee basis prior to slaughter by separate concerns. This classification includes the transport of animals to and from the feed yard location. This classification includes growing feed, hay or grain crops when more than 50% of such crops are used by the employer. Cultivation and harvesting of crops that are primarily sold to others shall be assigned to the appropriate Farms Industry Group classification. Breeding and raising of livestock shall be separately classified. Livestock butchering operations, including feed yard operations by the same employer, shall be classified as 2081(1), Butchering. The fee -based care and feeding of livestock that are en route to slaughterhouses or to market shall be classified as 2081(2), Stockyards. 0016 ORCHARDS citrus and deciduous fruits This classification applies to all acreage devoted to the cultivation and harvesting, including field packing, of citrus and deciduous fruit crops, including but not limited to oranges, lemons, limes, tangerines, kumquats, grapefruit, plums, peaches, cherries and nectarines. This classification also includes the cultivation and harvesting of avocados, figs (other than Kadota figs) and olives. This classification also includes the cultivation and harvesting of citrus and deciduous fruit crops using trellis systems or dwarf trees. The washing, sorting, sizing, grading, packing, precooling or otherwise preparing of deciduous fruit, olives and avocados for shipment (not field packing) shall be separately classified as 2107, Fruit fresh fruit packing and handling. The washing, sorting, sizing, grading, packing, precooling or otherwise preparing of citrus fruit for shipment (not field packing) shall be separately classified as 2108, Fruit citrus fruit packing and handling. Contract mechanized harvesting operations shall be classified as 0050, Farm Machinery Operation. Contract harvesting operations involving hand labor only shall be classified as 0016. 1 of 3

WC 04 04 06 DE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 01-1601-18) 0045 ORCHARDS nut crops This classification applies to all acreage devoted to the cultivation and harvesting of nut tree crops, including but not limited to almonds, walnuts and pistachios. Hulling, shelling or processing of nuts shall be separately classified as 0096, Nut Hulling, Shelling or Processing. Contract mechanized harvesting operations shall be classified as 0050, Farm Machinery Operation. The cultivation and harvesting of peanuts shall be classified as 0041, Potato Crops. 0041 POTATO CROPS This classification applies to all acreage devoted to the cultivation and harvesting, including field packing, of all types of potatoes, sweet potatoes and yams. This classification also applies to the cultivation and harvesting of peanuts, horseradish, taro root and sugar beets. The washing, sorting, sizing, grading, packing, precooling or otherwise preparing of potatoes, sweet potatoes, yams, horseradish, taro root and sugar beets for shipment (not field packing) shall be separately classified as 8209, Vegetables. 0034(1) POULTRY RAISING, EGG PRODUCTION AND HATCHERIES This classification applies to all acreage devoted to the raising of poultry, including but not limited to chickens, turkeys, quail, geese and squabs. This classification includes the slaughtering of animals and the candling, washing, sorting, grading and packaging of eggs when conducted by the employer. This classification also applies to aquatic farming of fish, oysters, abalone, shrimp and prawns. This classification also applies to the breeding and raising of rabbits, birds, tropical fish and reptiles. The candling, washing, sorting, grading and packaging of eggs performed on a fee basis or by employers not engaged in egg production shall be classified as 8018, Stores wholesale. 0034(2) SHEEP RAISING AND HOG FARMS This classification applies to all acreage devoted to the raising of sheep and hogs. This classification includes the slaughtering of animals when performed by the employer. This classification also applies to the raising of calves for sale to others, miniature horses (not to exceed 38 inches in height), llamas and alpacas. This classification includes growing feed, hay or grain crops when more than 50% of such crops are used by the employer. Cultivation and harvesting of crops that are primarily sold to others shall be assigned to the appropriate Farms Industry Group classification. The feeding and fattening of sheep and hogs prior to slaughter performed on a fee basis at feed yards shall be classified as 0038(2), Livestock Feed Yards. The raising of beef cattle and horses shall be classified as 0038(1), Stock Farms. The raising of replacement dairy heifers shall be classified as 0036, Dairy Farms. Butchering operations shall be classified as 2081(1), Butchering. 0038(1) STOCK FARMS beef cattle and horses This classification applies to all acreage devoted to the raising of beef cattle and horses. This classification includes growing feed, hay or grain crops when more than 50% of such crops are used by the employer. Cultivation and harvesting of crops that are primarily sold to others shall be assigned to the appropriate Farms Industry Group classification. The raising of calves for sale to others shall be classified as 0034(2), Sheep Raising and Hog Farms. The raising of replacement dairy heifers shall be classified as 0036, Dairy Farms. The raising and training of horses with no horse breeding or birthing operations shall be classified as 7207(1), Stables all employees, 8631, Racing Stables all other employees, or 7207(5), Racing Stables harness racing. The raising of miniature horses (not to exceed 38 inches in height) shall be classified as 0034(2), Sheep Raising and Hog Farms. Butchering operations shall be classified as 2081(1), Butchering. 0079(1) STRAWBERRY CROPS This classification applies to all acreage devoted to the cultivation and harvesting, including field packing, of strawberries. The precooling of field packed strawberries shall be separately classified as 8291(1), Warehouses cold storage. The cultivation and harvesting, including field packing, of bush berries shall be classified as 0079(2), Bush Berry Crops. 0172 TRUCK FARMS This classification applies to all acreage devoted to the cultivation and harvesting, including field packing, of garden vegetables, including but not limited to tomatoes, lettuce, carrots, onions, peas and sweet corn. This classification also applies to the cultivation and harvesting of melons, dry peas, dry beans, soybeans, mushrooms, bean sprouts and flower and vegetable seeds. This classification also applies to the cultivation of garden vegetables using hydroponic farming methods and the raising of earthworms and snails. The washing, sorting, sizing, grading, packing, precooling or otherwise preparing of vegetables for shipment (not field packing) shall be separately classified as 8209, Vegetables. The growing of vegetable plants for sale to others shall be 0040 VINEYARDS This classification applies to all acreage devoted to the cultivation and harvesting, including field packing, of all grapes (table, wine or raisin), kiwifruit, jojoba, hops and Kadota figs and also includes the field drying of grapes to produce raisins. The washing, sorting, sizing, grading, packing, precooling or otherwise preparing of fresh grapes for shipment (not field packing) shall be separately classified as 2107, Fruit fresh fruit packing and handling. The drying of grapes within buildings or sheds (not field drying) shall be separately classified as 2102, Fruit or Vegetable Evaporation or Dehydrating. The production of wine shall be separately classified as 2142(1), Wineries. 2 of 3

WC 04 04 06 DE (Ed. 01-1601-18) Premium for all employees performing any type of farm work for a price per unit, contract or measure shall be based upon the total remuneration earned by such persons, and in the absence of adequate payroll records substantiating such earnings, the total contract price shall be deemed to be the total earnings; however, if the entire contract involves the use of motor vehicles or farm machinery with drivers and their helpers, not less than one-fourth (1/4) of the total amount paid for the hire of such equipment and their operating crews shall be deemed to be the total earnings of such drivers and their helpers. Premium payment shall not be required in those cases for which workers compensation insurance has been separately provided and the company is supplied with either a Certificate of Insurance or the name of the Workers Compensation Insurance carrier and the number and effective dates of the policy. When lodging is provided by the employer, the total remuneration shall include the market value of such lodging to the employee. Each farm classification includes normal repair and maintenance of buildings or equipment performed by employees of the farmer. The maintenance of a cow, hogs or chickens for family use, a family orchard or truck garden, or a hay or grain crop raised for the purpose of maintaining work animals on the farm shall be considered usual and incidental to the operation of any type of farm. The payroll for general supervision, chore workers or drivers not connected with any particular crop, fence repair and road building is incidental to any type of farm. Where adequate records showing labor cost distributed by crops are maintained, the payroll of such miscellaneous employees shall be assigned to the various crop classifications in the same proportion as the allocated crop payroll bears to the total allocated payroll. The payroll of employees engaged in the following operations shall be segregated and separately rated: maintenance or repair work by contractors; new construction or alterations, whether done by the insured s employees or by contractors; the operation of farm machinery away from the farm premises by the farmer for others; and the grading, sorting, packing, precooling or otherwise preparing of vegetables or fruit for shipment when conducted in buildings or sheds located on or away from farm premises, whether conducted for others or in connection with the insured s farming activities. Extended Classification Schedule Farm-Related Classifications 0005 NURSERIES propagation and cultivation of nursery stock 0035 FLORISTS cultivating or gardening 0050 FARM MACHINERY OPERATION by contractors including yard employees Note: This endorsement may be used in connection with a policy issued to a farming risk. 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 Endorsement Insured Insurance Company Countersigned By 3 of 3

WC 04 04 06 E (Ed. 01-18) FARM SCHEDULE ENDORSEMENT CALIFORNIA Farms including all employees of whatever nature (other than Private Residence Employees) engaged upon or in connection with such farm including managers, superintendents, foremen and any other persons engaged by or on behalf of the employer to perform farm work for a price per unit, contract or measure. Classification of Farm Operations 0079(2) BUSH BERRY CROPS This classification applies to all acreage devoted to the cultivation and harvesting, including field packing, of bush berries, such as raspberries, olallieberries (blackberries), blueberries and boysenberries. The washing, sorting, sizing, grading, packing, precooling or otherwise preparing fresh fruit for shipment (not field packing) shall be separately classified as 2107, Fruit fresh fruit packing and handling. The cultivation and harvesting, including field packing, of strawberries shall be classified as 0079(1), Strawberry Crops. 0044 COTTON FARMS This classification applies to all acreage devoted to the cultivation and harvesting of cotton. Cotton gin operations including cotton compressing shall be separately classified as 0401, Cotton Gin Operation. The purchase and sale of cotton including cotton compressing shall be classified as 0400(1), Cotton Merchants. The contract storage of baled cotton, including cotton compressing, shall be classified as 0400(2), Warehouses cotton. 0036 DAIRY FARMS This classification applies to all acreage devoted to the raising of cows for the production of milk or cream and the raising of replacement dairy heifers. This classification also includes acreage devoted to the raising of goats for milk, cream or meat production. This classification includes growing feed, hay or grain crops when more than 50% of such crops are used by the employer. Cultivation and harvesting of crops that are primarily sold to others shall be assigned to the appropriate Farms Industry Group classification. Milk pasteurization, processing or bottling; dairy products manufacturing; and route drivers who deliver bottled milk to customers and perform no other duties on the farm premises shall be separately classified as 2063, Creameries and Dairy Products Mfg. The raising of beef cattle shall be classified as 0038(1), Stock Farms. The raising of calves for others shall be classified as 0034(2), Sheep Raising and Hog Farms. 0171 FIELD CROPS This classification applies to all acreage devoted to the cultivation and harvesting of hay; alfalfa; all the cereal grains, including but not limited to wheat, barley, rice, feed corn and oats; all sorghums; flax; safflower and maize. Mechanized harvesting operations performed on a fee basis shall be classified as 0050, Farm Machinery Operation. The cultivation and harvesting, including field packing of sweet (edible) corn, shall be classified as 0172, Truck Farms. The cultivation and harvesting of grass sod for use in landscaping shall be 0038(2) LIVESTOCK FEED YARDS including the milling or blending of feed for use in operations This classification applies to the feeding or fattening of livestock, including but not limited to cattle, sheep and hogs, on a fee basis prior to slaughter by separate concerns. This classification includes the transport of animals to and from the feed yard location. This classification includes growing feed, hay or grain crops when more than 50% of such crops are used by the employer. Cultivation and harvesting of crops that are primarily sold to others shall be assigned to the appropriate Farms Industry Group classification. Breeding and raising of livestock shall be separately classified. Livestock butchering operations, including feed yard operations by the same employer, shall be classified as 2081(1), Butchering. The fee-based care and feeding of livestock that are en route to slaughterhouses or to market shall be classified as 2081(2), Stockyards. 0016 ORCHARDS citrus and deciduous fruits This classification applies to all acreage devoted to the cultivation and harvesting, including field packing, of citrus and deciduous fruit crops, including but not limited to oranges, lemons, limes, tangerines, kumquats, grapefruit, plums, peaches, cherries and nectarines. This classification also includes the cultivation and harvesting of avocados, figs (other than Kadota figs) and olives. This classification also includes the cultivation and harvesting of citrus and deciduous fruit crops using trellis systems or dwarf trees. The washing, sorting, sizing, grading, packing, precooling or otherwise preparing of deciduous fruit, olives and avocados for shipment (not field packing) shall be separately classified as 2107, Fruit fresh fruit packing and handling. The washing, sorting, sizing, grading, packing, precooling or otherwise preparing of citrus fruit for shipment (not field packing) shall be separately classified as 2108, Fruit citrus fruit packing and handling. Contract mechanized harvesting operations shall be classified as 0050, Farm Machinery Operation. Contract harvesting operations involving hand labor only shall be classified as 0016. 1 of 3

WC 04 04 06 E WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 01-18) 0045 ORCHARDS nut crops This classification applies to all acreage devoted to the cultivation and harvesting of nut tree crops, including but not limited to almonds, walnuts and pistachios. Hulling, shelling or processing of nuts shall be separately classified as 0096, Nut Hulling, Shelling or Processing. Contract mechanized harvesting operations shall be classified as 0050, Farm Machinery Operation. The cultivation and harvesting of peanuts shall be classified as 0041, Potato Crops. 0041 POTATO CROPS This classification applies to all acreage devoted to the cultivation and harvesting, including field packing, of all types of potatoes, sweet potatoes and yams. This classification also applies to the cultivation and harvesting of peanuts, horseradish, taro root and sugar beets. The washing, sorting, sizing, grading, packing, precooling or otherwise preparing of potatoes, sweet potatoes, yams, horseradish, taro root and sugar beets for shipment (not field packing) shall be separately classified as 8209, Vegetables. 0034(1) POULTRY RAISING, EGG PRODUCTION AND HATCHERIES This classification applies to all acreage devoted to the raising of poultry, including but not limited to chickens, turkeys, quail, geese and squabs. This classification includes the slaughtering of animals and the candling, washing, sorting, grading and packaging of eggs when conducted by the employer. This classification also applies to aquatic farming of fish, oysters, abalone, shrimp and prawns. This classification also applies to the breeding and raising of rabbits, birds, tropical fish and reptiles. The candling, washing, sorting, grading and packaging of eggs performed on a fee basis or by employers not engaged in egg production shall be classified as 8018, Stores wholesale. 0034(2) SHEEP RAISING AND HOG FARMS This classification applies to all acreage devoted to the raising of sheep and hogs. This classification includes the slaughtering of animals when performed by the employer. This classification also applies to the raising of calves for sale to others, miniature horses (not to exceed 38 inches in height), llamas and alpacas. This classification includes growing feed, hay or grain crops when more than 50% of such crops are used by the employer. Cultivation and harvesting of crops that are primarily sold to others shall be assigned to the appropriate Farms Industry Group classification. The feeding and fattening of sheep and hogs prior to slaughter performed on a fee basis at feed yards shall be classified as 0038(2), Livestock Feed Yards. The raising of beef cattle and horses shall be classified as 0038(1), Stock Farms. The raising of replacement dairy heifers shall be classified as 0036, Dairy Farms. Butchering operations shall be classified as 2081(1), Butchering. 0038(1) STOCK FARMS beef cattle and horses This classification applies to all acreage devoted to the raising of beef cattle and horses. This classification includes growing feed, hay or grain crops when more than 50% of such crops are used by the employer. Cultivation and harvesting of crops that are primarily sold to others shall be assigned to the appropriate Farms Industry Group classification. The raising of calves for sale to others shall be classified as 0034(2), Sheep Raising and Hog Farms. The raising of replacement dairy heifers shall be classified as 0036, Dairy Farms. The raising and training of horses with no horse breeding or birthing operations shall be classified as 7207(1), Stables all employees, 8631, Racing Stables all other employees, or 7207(5), Racing Stables harness racing. The raising of miniature horses (not to exceed 38 inches in height) shall be classified as 0034(2), Sheep Raising and Hog Farms. Butchering operations shall be classified as 2081(1), Butchering. 0079(1) STRAWBERRY CROPS This classification applies to all acreage devoted to the cultivation and harvesting, including field packing, of strawberries. The precooling of field packed strawberries shall be separately classified as 8291(1), Warehouses cold storage. The cultivation and harvesting, including field packing, of bush berries shall be classified as 0079(2), Bush Berry Crops. 0172 TRUCK FARMS This classification applies to all acreage devoted to the cultivation and harvesting, including field packing, of garden vegetables, including but not limited to tomatoes, lettuce, carrots, onions, peas and sweet corn. This classification also applies to the cultivation and harvesting of melons, dry peas, dry beans, soybeans, mushrooms, bean sprouts and flower and vegetable seeds. This classification also applies to the cultivation of garden vegetables using hydroponic farming methods and the raising of earthworms and snails. The washing, sorting, sizing, grading, packing, precooling or otherwise preparing of vegetables for shipment (not field packing) shall be separately classified as 8209, Vegetables. The growing of vegetable plants for sale to others shall be 0040 VINEYARDS This classification applies to all acreage devoted to the cultivation and harvesting, including field packing, of all grapes (table, wine or raisin), kiwifruit, jojoba, hops and Kadota figs and also includes the field drying of grapes to produce raisins. The washing, sorting, sizing, grading, packing, precooling or otherwise preparing of fresh grapes for shipment (not field packing) shall be separately classified as 2107, Fruit fresh fruit packing and handling. The drying of grapes within buildings or sheds (not field drying) shall be separately classified as 2102, Fruit or Vegetable Evaporation or Dehydrating. The production of wine shall be separately classified as 2142(1), Wineries. 2 of 3

WC 04 04 06 E (Ed. 01-18) Premium for all employees performing any type of farm work for a price per unit, contract or measure shall be based upon the total remuneration earned by such persons, and in the absence of adequate payroll records substantiating such earnings, the total contract price shall be deemed to be the total earnings; however, if the entire contract involves the use of motor vehicles or farm machinery with drivers and their helpers, not less than one-fourth (1/4) of the total amount paid for the hire of such equipment and their operating crews shall be deemed to be the total earnings of such drivers and their helpers. Premium payment shall not be required in those cases for which workers compensation insurance has been separately provided and the company is supplied with either a Certificate of Insurance or the name of the Workers Compensation Insurance carrier and the number and effective dates of the policy. When lodging is provided by the employer, the total remuneration shall include the market value of such lodging to the employee. Each farm classification includes normal repair and maintenance of buildings or equipment performed by employees of the farmer. The maintenance of a cow, hogs or chickens for family use, a family orchard or truck garden, or a hay or grain crop raised for the purpose of maintaining work animals on the farm shall be considered usual and incidental to the operation of any type of farm. The payroll for general supervision, chore workers or drivers not connected with any particular crop, fence repair and road building is incidental to any type of farm. Where adequate records showing labor cost distributed by crops are maintained, the payroll of such miscellaneous employees shall be assigned to the various crop classifications in the same proportion as the allocated crop payroll bears to the total allocated payroll. The payroll of employees engaged in the following operations shall be segregated and separately rated: maintenance or repair work by contractors; new construction or alterations, whether done by the insured s employees or by contractors; the operation of farm machinery away from the farm premises by the farmer for others; and the grading, sorting, packing, precooling or otherwise preparing of vegetables or fruit for shipment when conducted in buildings or sheds located on or away from farm premises, whether conducted for others or in connection with the insured s farming activities. Extended Classification Schedule Farm-Related Classifications 0005 NURSERIES propagation and cultivation of nursery stock 0035 FLORISTS cultivating or gardening 0050 FARM MACHINERY OPERATION by contractors including yard employees Note: This endorsement may be used in connection with a policy issued to a farming risk. 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 Endorsement Insured Insurance Company Countersigned By 3 of 3