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Endorsement Endorsement Effective: Policy No.: Named Insured: New York Endorsement This endorsement applies only to the coverage provided by this Policy because New York is named in Item 3 of the Schedule Page. I. Item 4 of Section G. Your Specific Claims Reporting Duties of Part Four of this Policy is amended as follows: 4. Consequence of Your Failure to Send Us a Timely First Notice of Loss. If we are not provided written notice as required herein, we will not indemnify you for the payments you make in excess of your Retention, unless it is shown not to have been reasonably possible to give such notice within the prescribed time and the notice was given as soon as was reasonably possible. The failure to give notice within the time prescribed by this Policy shall not invalidate any claim made by you, an injured person or any other claimant, unless such failure to provide timely notice has prejudiced us. II. Section G. Your Specific Claims Reporting Duties of Part Four of this Policy is amended to add Item 5 as follows: 5. Written notice given by you or on your behalf to us or any of our licensed agents in the state of New York, with the particulars sufficient to identify you, shall be deemed notice on us. III. Item 4 of Section N. Commutation by Mutual Agreement of Part Four of this Policy is amended as follows: 4. If the commuted value determined by the appraiser above is not acceptable to both parties, they shall either abandon the commutation effort or agree to settle any difference using a panel of three actuaries, one to be chosen by each party, and a third chosen by the two so chosen. If the two actuaries fail to agree on the selection of a third actuary within sixty (60) days of their appointment, each of them shall name two, of whom the other shall decline one and the decision shall be made by drawing lots. All the actuaries shall be regularly engaged in the valuation of workers’ compensation claims and shall be Fellows or Associates in the Casualty Actuarial Society. None of the actuaries shall have a financial interest in nor be a current or former employee of the parties, and all of the actuaries shall be disinterested in the outcome of the commutation. Each party shall submit its case to its actuary within sixty (60) days of the appointment of the third actuary. The decision in writing of any two actuaries (from the panel of three), when filed with the parties hereto shall be final and binding on both parties and we shall pay the amount so determined to be the commuted value of the Claim or Claims. The expense of the actuaries and of the commutation shall be equally divided between both parties. Said commutation shall take place in a New York location or as mutually agreed upon by the parties. Any commutation will require the approval of the New York Workers’ Compensation Board. Subsequent disputes, if any, will not be under the purview of the New York Workers’ Compensation Board. IV. Section C. Bankruptcy or Insolvency of Part Six of this Policy is amended to read as follows: C. Bankruptcy or Insolvency. In the event of your bankruptcy or insolvency or of your failure or default to comply with your obligations under the Workers’ Compensation Law, we shall become jointly liable with you for any loss incurred under this Policy, which exceeds the Retention stated in the Schedule Page. In such event, the Chair of the Workers’ Compensation Board or the Workers’ Compensation Board may require us to pay indemnities under this Policy to someone other than you including, but not limited to the claimant, the Chair, the Aggregate Trust Fund, or any other Special Fund provided by law. Such payment will release us from liability to you to the same extent as if such indemnity had been made to you. CMB-NY (8-13) Page 1 of 4 Date Printed: Page 46 of 201