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Endorsement Endorsement Effective: Policy No.: Named Insured: This endorsement applies only to the coverage provided by this Policy because New York is named in Item 3 of the Schedule Page. NOTICE TO POLICYHOLDER The Specific Limit of Workers’ Compensation Excess Indemnity shown in Items 7(a) or 8(a) of the Schedule Page, whichever is applicable, is the maximum amount we will indemnify you under Part One of this Policy for each accident or each Employee for disease. You will be solely responsible to pay any Loss under Part One that you are liable for that is in excess of the Specific Limit for Part One, without reimbursement from us, notwithstanding prior exhaustion of your Specific Retention. Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY Authorized Representative Secretary President This endorsement forms part of the Policy to which attached, effective on the inception date of the Policy unless otherwise stated herein. All other terms and conditions of the Policy remain unchanged. CMB-NY-NOT-SXS (1-14) Date Printed: Page 52 of 201