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Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00)Page 6 of 6 <br />SECTION III <br />1. SCHEDULE OF COVERED STATES <br />A. This endorsement only applies in the states <br />listed in this Schedule of Covered States. <br />B. If a state, shown in Item 3.A. of the Information <br />Page, approves this endorsement after the <br />effective date of this policy, this endorsement will <br />apply to this policy. The coverage will apply in <br />the new state on the effective date of the state <br />approval <br />C. Schedule of Covered States: <br />CA <br />Countersigned by <br />Authorized Representative <br />Docusign Envelope ID: 5FA274F4-2302-4412-8B02-4B054396DEE8