WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY 3rd Reprint WC 89 06 09 B Issued July 1, 1996 POLICY TERMINATION/CANCELATION/REINSTATEMENT NOTICE Carrier Name/NCCI Carrier Code Insured’s Name Federal ID No. Insured’s Address Policy Number Policy Effective Date Policy Expiration Date Termination/Cancelation/Nonrenewal The coverage provided by the policy number shown above is being nonrenewed or terminated/canceled, flat, pro rata, or short rate, effective 12:01.am. standard time at the insured’s mailing address for the following reason(s): Reinstatement The coverage provided by the policy number shown above and previously nonrenewed, canceled, or scheduled for cancelation is being reinstated effective 12:01 a.m. standard time at the insured’s mailing address. Issue Date Issuing Office Producer’s Name Date Stamp (For NCCI use only): Notes: 1. If a member of a carrier group, report the name of the specific carrier within the group providing the coverage and the NCCI carrier code identifying the specific carrier. 2. If not a member of a carrier group, report the carrier name and the NCCI carrier code. 3. See manual note pages for special state provisions concerning effective date of notice. 4. The effective date of a nonrenewal must be that of the policy expiration date. The “reason” should be shown as “nonrenewal” and may, at the insurer’s option or as required by statute, list specific reasons for the nonrenewal. ©1997 National Council on Compensation Insurance, Inc. D-50 American LegalNet, Inc. www.FormsWorkflow.com