K. The Company shall be subrogated in case of any payment under this Policy, to the extent of such payment, to all rights of recovery therefor vested by law either in this Employer or, in any employe or his dependents claiming hereunder, against persons, corporations, associations or estates.

L. No condition or provision of this Policy shall be waived or altered except by endorsement attached hereto signed by a duly authorized officer of the Company; nor shall notice to any agent, nor shall knowledge possessed by any agent, or by any other person, be held to effect a waiver or change in any part of this contract. The personal pronoun herein used to refer to this Employer or to an injured employe or dependents, shall apply regardless of number or gender.

M. The statements in Items 1 to 6 inclusive, in the Declarations hereinafter contained, are true; those stated as estimates only are believed to be' true. This Policy is issued upon such statements and in consideration of the provisions of the Policy respecting its premium and the payment of the premium in such Declarations expressed.

This space is intended for the attachment of such endorsements as may be executed as in the Policy provided, and, when so executed and attached, they are to be construed as a part of the Policy.

THE X Y COMPANY OF ---------

[Name of state] Compensation Endorsement

Attached to and made a part of Policy No.---------

Issued to ---------

The obligations of Paragraph One (a) of the Policy to which this endorse-, ment is attached include such Workmen's Compensation Laws as are herein cited and described and none other.

--------- [insert reference to statutes, by chapter, section numbers, etc.], and all laws amendatory thereof which may become effective while this Policy is in force.

This Employer, upon the acceptance of this Policy, agrees that at the effective date hereof he is bound by the above cited Workmen's Compensation Law in full compliance with Section --------- thereof and will not file notice of withdrawal under the provisions of that section during the Policy Period.

This Employer, upon the acceptance of this Policy, agrees that the remuneration of employes of any contractor or sub-contractor, who undertakes for this Employer any part of the business operations covered by this Policy under the conditions set forth in Section --------- of such Workmen's Compensation

Law, shall be included in the return of remuneration upon which premium is computed, and such remuneration, so reported, shall, in all respects, be governed by the same terms, conditions and requirements of the policy as the remuneration of the direct employes of this Employer. The requirements of this paragraph shall not apply if this Employer is not liable under said section or is exempted from such liability through compliance with its terms.

This Policy is issued by the Company and is accepted by this Employer with the agreement that the rates of premium are subject to modification in accordance with the rate manual and rating plans established by the ---------

Compensation Inspection Rating Bureau and approved by the --------- Compensation Insurance Board, such modifications if any to be expressed by the endorsement naming the effective date thereof. If a rate promulgated by the Bureau is higher than the rate expressed in the Policy, this Employer shall be permitted to cancel the Policy on a pro rata premium basis, at the rate promulgated by the Bureau, at any time within fifteen days after the date of its promulgation, upon written notice of cancellation given to the Company in accordance with the provisions of Condition B of this Policy.

This endorsement takes effect upon issue, expires concurrently with the policy to which it is attached and is subject to all the conditions and provisions of said policy not inconsistent herewith.

In witness whereof, the X. Y. Company has caused this endorsement to be signed by its President and Secretary; but the same shall not be binding upon the Company unless countersigned by its Authorized Agent.

------, Secretary. ---------, President.

Countersigned and issued at the office of the Company at---------, this--------day of ---------, 19-.

By ---------, Resident Representative in Wisconsin.

Declarations

Item 1.

For the purpose of serving notice, as in the Policy provided, this Employer agrees that this address may be considered as both the residence and business address of this Employer or any representative upon whom notice may be served.

Item 2.

The period during which the Policy shall remain in force, unless canceled as in the Policy provided (herein called the Policy Period), shall be from

---------, 19-, to ---------, 19-, at twelve and one minute o'clock A. M., standard time, as to each of said dates at the place where any operation covered hereby is conducted, as respects that operation, or at the place where any injury covered hereby is sustained, as respects that injury.

Item 3.

Locations of all factories, shops, yards, buildings, premises or other workplaces of this employer, by Town or City, with street and Number............

............................................................................................................................ All business operations, including the operative management and superintendence thereof, conducted at or from the locations and premises defined above as declared in each instance by a disclosure of estimated remuneration of employees under such of the following Divisions as are undertaken by this Employer. 1 All industrial operations upon the premises. 2 All office forces. 3 All repairs or alterations to premises. 4 Specially rated operations on the premises. 5 Operations not on the premises.

CLASSIFICATION OF OPERATIONS

(NOTE: If mora than on classification indicate each other by (b). (c), (d), etc.

Estimated Total Annual Remuneration

Rate per $100 of Remuneration

Estimated Premium

(x) President, any Vice-President, Secretary or Treasurer of corporate Employer who performs duties of Superintendent, Foreman or Workman.

2 (a) Clerical Office Employees 8810 (b) Draughtsmen (engaged exclusively in the profession) - office duties only 8811

3 (a) Additions to, alterations and repairs of Employer's existing buildings or plants (not construction of new building nor maintenance of equipment covered as manufacturing operations) excluding the erection or demolition of structural steel or of any fabricated iron or steel products or structure, and the construction of sewers, tunnels, shafts or subways, excluding also all operations conducted or supervised by contractors operating either as principals or on a percentage basis (unless specifically classified and rated In Division 1) 5602

4 (a) Stamping - metal (if not included in 1) 8210

(b) Blasting (Additional Minimum Premium for this item $25.00) 6280

(c) Railroads (used solely for declared business operations) 7102

•

5 (a) Erection, installation, repair or demonstration of Employer's product, as follows: ---------[manual classification].

(b) Outside Salesmen, collectors and messengers (wherever engaged) who do not deliver merchandise 8742

(c) Drivers and Drivers* Helpers (if not

Included in 1) wherever engaged 7205

(d) Chauffeurs and Chauffeurs' Helpers (if not included in 1) wherever engaged 7380

Minimum Premium for this Policy shall be $......

Estimated Advance Premium S......

Item 4.

The foregoing enumeration and description of employees Include all persons employed in the service of this Employer In connection with the business operations above described to whom remuneration of any nature in consideration of service is paid, allowed or due together with an estimate for the Policy Period of all such remuneration. This enumeration and description with, the estimated remuneration shall also include the President, any Vice-President. Secretary or Treasurer of this Employer If a corporation if actually performing such duties as are ordinarily undertaken by a superintendent, foreman or workman, but any such designated officer not so engaged shall not be Included In such enumeration, description or estimated remuneration. The foregoing estimates of remuneration are offered for the purpose of computing the advance premium. The Company shall be permitted to examine the books of this Employer at any time during the Policy Period and any extension thereof and within one year after its final termination so far as they relate to the remuneration earned by any employee of this Employer while the Policy was in force.

Item 5.

This Employer is conducting no other business operations at this or any other location not herein disclosed - except as herein stated.....................

.........................................................................................................................

Item 6.

No similar insurance has been canceled by any Insurance carrier during the past year - except as herein stated.....................................................................

...............................................................................................................................

In witness whereof, etc. See references under 9 3870.

The X. Y. Company.