§ 2269.1. California Approved Form Endorsement no. 1c.

CALIFORNIA

APPROVED FORM NO. 1C

Endorsement Agreement Limiting and Restricting This Insurance

WORKMEN'S COMPENSATION AND EMPLOYERS' LIABILITY POLICY AMENDATORY ENDORSEMENT - CALIFORNIA

It is AGREED that such insurance as is afforded by the policy by reason of the designation of California in Item 3 of the declarations is subject to the following provisions:

1. Serious and Willful Misconduct and Additional Compensation for Minor's Illegal Employment not Insured

The policy does not apply to liability for additional compensation imposed on the insured under Sections 4553 and 4557, Division IV, Labor Code of the State of California, by reason of the serious and willful misconduct of the insured or any representative of the insured or by reason of injury to an employee under sixteen years of age and illegally employed at the time of injury.

2. Application of Policy

With respect to Coverage A, Insuring Agreement IV, “Application of Policy” is amended to read as follows:

This policy applies only to injury (1) by accident occurring during the policy period, or (2) by disease caused or aggravated by exposure during the policy period to conditions in the course of employment by the insured.

3. Exclusion under Coverage B -Employers' Liability

Exclusion (b) of the policy is amended to read as follows:

This policy does not apply under coverage B with respect to any employee employed in domestic employment not described in the declarations unless the policy applies under coverage A with respect to such employee.

It is further agreed that the policy, including all endorsements forming a part thereof, constitutes the entire contract of insurance. No condition, provision, agreement, or understanding not set forth in the policy or such endorsement shall affect such contract or any rights, duties, or privileges arising therefrom.

Applicable to and forming part of Policy No. ________________

Issued by the _______________________________________________

To_____________________________________ of __________________

Dated at _____________________this_______day of ______199____

Countersigned _______________________________________________

FAILURE TO SECURE THE PAYMENT OF FULL

COMPENSATION BENEFITS FOR ALL EMPLOYEES AS

REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION

OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION

OF A WORK STOP ORDER, LARGE FINES AND OTHER

SUBSTANTIAL PENALTIES

(Labor Code Section 3710.1, et seq.).

HISTORY

1. New section filed 10-4-60; designated effective 1-1-61 (Register 60, No. 21).

2. Amendment filed 1-21-81; effective thirtieth day thereafter (Register 81, No. 4).

Note

Note: Authority cited: Sections 11732, 11732.1, and 11734, Insurance Code. Reference: Articles 2 and 3 of Chapter 3, Part 3, Division 2, Insurance Code.