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CNA • <br /> 10 <br /> 333 S Wabash <br /> Chicago,Illinois 60604 STANDARD WORKERS COMPENSATION <br /> AND EMPLOYERS LIABILITY POLICY <br /> CHANGE ENDORSEMENT - EFFECTIVE 12/11/12 <br /> DATE PROCESSED=122712,REASON= ADDING 30 DAYS NOTICE <br /> OF CANCELLATION <br /> Policy Number From Policy Period To Coverage Is Provided By Agency <br /> WC 5 88073312 09/19/12 09/19/13 CONTINENTAL CASUALTY CO 062611250 <br /> Named Insured And Address Agent <br /> ITEM DAH CORPORATION COSTELLO & SONS INS. BROKERS, INC. <br /> 1. 19119 NORTH CREEK PARKWAY <br /> SUITE 200 1752 LINCOLN AVE. <br /> BOTHELL, WA SAN RAFAEL CA 94901 <br /> 98011 <br /> FEIN NUMBER: 270088667 NCCI CARRIER CODE NO: 10243 <br /> G20472A NOTICE OF CANCELLATION OR MATERIAL CHANGE ENDT 10/93 <br /> ***** ADDED ***** <br /> ti <br /> N <br /> C7 <br /> N <br /> ACCOUNT NUMBER: 3005696100 <br /> DATE OF ISSUE: 12/27/12 <br /> — POLICY ISSUING OFFICE: SAN BRUNO <br /> (WC000001) P-39543-A <br /> EEE <br /> "` <br /> Socastery <br /> Chairmen of the Board <br /> INSU171 <br />