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ARTHUR J. GALLAGHER & CO.-DENVER
March 8, 1993
Mr. Don Warden
Weld County, Colorado
P.O. Box 758
Greeley, CO 80631
Re: Specific Excess Workers' Compensation
Policy # 415-3409 - 12/31/92-93 Term
Dear Don:
I am happy to enclose your Specific Excess Workers'Compensation policy for the term above.
I have requested that two changes be made to this policy, effective 12/31/92:
• The first change, is on endorsement No. 4 Broad Form All States Endorsement,
it should read (on the second line) Compensation Law of a state not designated
in Item (1) of the declarations; in lieu of a state designated in Item (1) of the
declarations.
• The second change, is adding the Volunteer and Board Members Endorsement
at no additional charge.
Don, these changes will follow shortly. Please review your policy carefully for all terms,
conditions, limitations, and exclusions. In particular, please review endorsement No. 3, Claim
Reporting Endorsement. If after reviewing your policy you have any questions or changes,
please feel free to give me a call. I have also forwarded a copy of this policy to Sue Leidolph
• at OHMS.
We thank you for the opportunity to continue this policy and look forward to working with
you for another year.
Sincerely,
ARTH R J. GALLAGHER & CO.-DENVER
Karen Graham, Acc unt Assistant
cc: John P. McLaughlin, Vice President - Risk Management Services
:kg/enclosure
KmY:tWR D.M Q/apot& TRU,tp,a0, Denver, CO 80237-2753 • P.O. Box 24809, Denver, 00 80224
303/773-9999 • Fax 303/773-9776
ARTHUR J. GALLAGHER & CO.-DENVER
MEMORANDUM
TO: Don Warden
Weld County, Colorado
FROM: Karen Graham
DATE: March 8, 1993
RE: Policy Notebook
r-•
Don:
I made a section for your Self-Insurers Workers' Compensation Bond, so you can
move it to this policy notebook.
Regards.
:kg
r
7800 E. Union Ave., Suite 220, Denver, CO 80237-2753 O. Box 24509, Denver, CO 80224
303/773-9999 • Fax 303/773-9776
• NATIONAL UNION
FIRE INSURANCE COMPANY
OF PITTSBURGH, PA.
A CAPITAL STOCK COMPANY 70 Pine Street, New York,N.Y. 10270
(Herein called the Company
JC=C .
NAMED WELD COUNTY, COLORADO
INSURED P.O. BOX 758 P
AND GREELEY, CO 80632
POST
OFFICE P ?`� N
Agrees with the Insured, named in the Declarations made a part hereof, in consideration of the payment of the
premium and in reliance upon the statements in the Declarations and subject to the Limits of Liability, Exclusions,
Conditions and other terms of this policy:
EXCESS WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY POLICY
DECLARATIONS
RENEWAL OF: 415-3175
POLICY
NUMBER: 415-3409
STATE(S) COLORADO
ITEM (to which
1 Coverage is
to apply)
ITEM POLICY From: DECEMBER 31, 1992 To: DECEMBER 31, 1993 12:01 A.M.Standard Time at the
2 PERIOD Post Office Address shown herein
ITEM LIMIT OF STATUTORY WORKERS' COMPENSATION ACT
3 LIABILITY $1,000,000 EMPLOYERS LIABILITY
ITEM RETENTION $300,000 WORKERS' COMPENSATION ACT
4 (each accident) $500,000 USL&H
ESTIMATED TOTAL RATES PER POLICY
PREMIUM ANNUAL $100.00 OF
PREMIUM
ITEM AND REMUNERATION REMUNERATON
5 PREMIUM MINIMUM & DEPOSIT
COMPUTATION $36,000
$23,742,146 . 1516 MINIMUM EARNED PREMIUM
S 9.000
Unless otherwise stated herein, the policy premium as shown above shall also be the minimum premium.
ARTHUR J. GALLAGHER & COMPANY
P.O. BOX 24809
DENVER, CO 80224
DATE OF ISSUE: COUNTERSIGNED BY: thiadett
n I
December 15, 1992 \\\
(AUTHORIZED EP NTATIVE)
3/81 1704(8-76) INSURED
ENDORSEMENT#1
This endorsement,effective 12:01 A.M. 12/31/92 forms a part of
Policy No. 415-34.09 issued to Weld County,Colorado
By National Union Fire Insurance Company of Pittsburgh,Pa.
In consideration of the premium charged,it is agreed that Item#2 of the conditions is amended as follows:
(2) Premium. The Premium for this policy shall be based upon the entire remuneration earned, during the policy
period, by all employees of the insured engaged in the operations described in the declarations together with all
operations necessary, incidental or appurtenant thereto, or connected therewith, whether conducted at such work place
or elsewhere in connection therewith or in relation thereto, subject with respect to each executive officer to maximum
and minimum remuneration of$1.050.00.00 and $350.00 per week, and the insured agrees to pay a premium thereon, at
the time of the final adjustment of the premium at rates to be determined. If the policy is for more than one year,then
upon expiration of each annual period of the policy, or its termination during the policy period,the actual amount of the
remuneration earned by the employees during such policy shall be exhibited to the company,as provided in Conditions 3
thereof, and the earned premium adjusted in accordance therewith at the rates and under the conditions herein
specified. If the insured is liable under any of the said Workers'Compensation Laws for compensation to employees of
any contractor or sub-contractor and does not maintain satisfactory evidence that any such contractor or sub-contractor
•—" has secured his compensation obligation to his employees, then the remuneration of all employees of any such
contractor or sub-contractor shall be included in the return of remuneration upon which the premium for this policy is
computed,provided, however that if the insured does not furnish record of such remuneration, the entire contract price
of the sub-contracted work shall be included as remuneration. Upon delivery of this policy, the insured shall pay the
deposit premium shown in the declarations and the expiration of each annual period, the earned premium shall be
computed thereon and shall be paid to the company except that the deposit premium shown in the declarations and at
the expiration of each annual period, shall be credited against the premium found to be due the company for the last
twelve(12) months of the policy period. The company shall,in any event,retain the annual minimum premium stated in
the declarations for twelve(12) month period.
CC CLACI
Endt.#1 Au Representative
(12/16/92)Is
A000289
ENDORSEMENT#2
This endorsement,effective 12:01 A.M. 12/31/92 forms a part of
Policy No. 415.34-09 issued to Weld County,Colorado
By National Union Fire Insurance Company of Pittsburgh,Pa.
It is hereby agreed that Insuring Agreement (2) (Employers Liability) of the policy does not apply to
the following:
(A) bodily injury to an employee while employed in violation of the law;
(B) bodily injury intentionally caused or aggravated by or at the direction of the Insured;
(C) bodily injury caused by the serious and willful misconduct of the Insured.
It is further agreed that Insuring Agreement (1) of the policy does not apply to payments in excess of
those regularly required by the Workers Compensation laws if such excess payments are required
because of(A) or (C) above.
e )
Endt. #2 A d Representative
(12/16/92)Is
A002689
ENDORSEMENT#3
n
This endorsement,effective 12:01 A.M. 12/31/92 forms a part of
Policy No. 415-34-09 issued to Weld County,Colorado
By National Union Fire Insurance Company of Pittsburgh,Pa.
CLAIM REPORTING ENDORSEMENT
In consideration of the premium charged, and notwithstanding anything in the policy to the contrary it
is agreed that the Insured shall notify the company as soon as practicable after the corporate insurance
department is made aware of the claim, either paid or reserved, for 50% or more of the self-insured
retention stated in Item No.4 of the policy declarations.
It is further agreed that the Insured shall give the company written notice as soon as practicable after
the corporate insurance department is made aware, of any injury involving the following type of
accident:
1. A fatality.
2. Amputation of a major extremity,
3. Any serious head injury(including skull fracture or loss of sight of either or both eyes),
4. Any injury to the spinal cord,
5. Any severe burn case,
6. Any accident which caused serious injury to two or more employees, or
7. Any disability of more than one year or where it appears reasonable likely that there will
be disability of more than one year.
agArgi
Endt. #3 t n ed Representative
(12/16/92)ls
r
A000489
ENDORSEMENT#4
This endorsement,effective 12:01 a.m. 12/31/92 forms a part of
Policy No. 415-34-09 issued to Weld County,Colorado
By National Union Fire Insurance Company of Pittsburgh,Pa.
BROAD FORM ALL STATES ENDORSEMENT
It is hereby agreed that this policy is amended to include the following:
(3) For compensation and other benefits required to be paid by the Insured under the Workers'
Compensation Law of a state designated in Item (1) of the declarations; provided said
designated state is the state of the injured employees'normal employment.
•
Endt.#4 eket444
(12/16/92)Is Aut iz d epresentative
A000689
ENDORSEMENT#5
r�
This endorsement,effective 12:01 A.M. 12/31/92 forms a part of
Policy No. 415-34-09 issued to Weld County,Colorado
By National Union Fire Insurance Company of Pittsburgh,Pa.
It is agreed and understood that item 4(Ultimate Net Loss) is amended as follows:
Ultimate Net Loss. The term "Ultimate Net Loss" as used in this policy shall mean the sum
actually paid in cash in the settlement or satisfaction of losses for which the Insured is liable,
either by adjudication or compromise, with the written consent of the Company. The term
shall include court costs, interest upon awards and judgments and allocated investigation,
adjustment and legal expenses pertaining to losses, but shall exclude all salaries paid to
employees,service company fees and claim administrator fees. Nothing herein contained shall
be construed to mean that the Insured shall be required to enforce by legal action any rights of
subrogation before the Company shall pay any losses for which it may be liable hereunder.
All other terms and conditions of this policy remain unchanged.
Endt. #5 th r ed Representative
(12/16/92)Is
A005992
ENDORSEMENT#6
r
This endorsement,effective 12:01 a.m. 12/31/92 forms a part of
Policy No. 415-34.09 issued to Weld County,Colorado
By National Union Fire Insurance Company of Pittsburgh,Pa.
It is agreed that Item 7. Conditions is amended as follows:
LEGAL COST
Should any claim or claims arise appearing likely to exceed the retention, no costs shall be incurred on
behalf of the Company without it consent being first obtained. Should such claim or claims be adjusted
prior to trial court judgement for a sum or aggregate sum of not more than the retention,then no costs
shall be payable by the Company, if it consents to trial court proceedings continuing, shall contribute to
the costs as defined in Definitions,Item 4.Ultimate Loss.
All other terms and conditions of this policy remain unchanged.
Endt.#6 Auth iz epresentative
(12/16/92)Is
A006892
ENDORSEMENT#7
This endorsement,effective 12:01 A.M. 12/31/92 forms a part of
Policy No. 415-34-09 issued to Weld County,Colorado
By National Union Fire Insurance Company of Pittsburgh,Pa.
UNITED STATES LONGSHOREMENS'AND HARBOR WORKERS'COMPENSATION ACT
ENDORSEMENT
(Incidental Operations Endorsement)
It is agreed with respects to operations in the State(s) designated in Item (1) of the Declarations, the
unqualified term "Workers' Compensation Law" includes the United States Longshoremens' and
Harbor Workers' Act., U.S. Code (1946) Title 33, Section 901-49 and definition (1) is amended
accordingly.
This endorsement does not apply to work subject to the Defense Base Act,the Outer Continental Shelf
Lands Act or the Non-appropriated Fund Instrumentalities Act.
This endorsement is provided hereunder due to the Company's reliance upon the Insured's warranty of
no known US L&H exposure.
All other terms and conditions of this policy remain unchanged.
Endt. #7 A h ' d Representative
(12/16/92)1s
A005892
•
ENDORSEMENT#8
This endorsement,effective 12:01 A.M. 12/31/92 forms a part of
Policy No. 415-34-09 issued to Weld County,Colorado
By National Union Fire Insurance Company of Pittsburgh,Pa.
COLORADO AMENDATORY ENDORSEMENT
It is hereby agreed with respect to cancellation by the Company, Ninety (90) days Notice of
cancellation will be provided except with respect to non-payment of premium in which case ten
(10)days of Notice will be provided.
It is also agreed that Notice of Cancellation will be sent by registered or certified mail to both the
Insured and the authority listed below:
Executive Director of Labor and Employment
Division of Workers'Compensation
Insurance Compliance Unit
1120 Lincoln Street,12th Floor
Denver,CO 80203
All other terms and conditions of this policy remain unchanged.
Endt.#8 A o Representative
(12/16/92)1s
ENDORSEMENT#9
This endorsement,effective 12:01 A.M. 12/31/92 forms a part of
Policy No. 415-34-09 issued to Weld County,Colorado
By National Union Fire Insurance Company of Pittsburgh,Pa.
In consideration of the premium charged, it is hereby agreed that Exclusion (2) is deleted in its
entirety.
All other terms and conditions of this policy remain unchanged.
(-"Leati1/4
Endt.#9 Aut r' Representative
(12/16/92)Is
22304-A
NATIONAL UNION
FIRE INSURANCE COMPANY 70 PINE STREET
NEW YORK,N.Y.10270
OF PITTSBURGH, PA.
n the event the Insured should at'any lime while this contract is in force ter-
•its qualifications as a self-insurer or if such qualifications should be can-
or ✓.�=Cr-
revoked,this contract shall automatically terminate at the same time.
of Injury. When an injury occurs that appears reasonably likely to involve
r on the part of the Company,written notice shall be given by or on behalf of (
;ured to the Company or any of its authorized agents as soon as practicable. �• %,�
iotice shall contain particulars sufficient to identify the Insured and also the
information obtainable at the time. The Insured shall give like notice,with lei
'firll tic nt anti ri,im made nn vrrmml 174 eurh inuvo If thnmefbr cnit nr
EXCESS WORKER'S COMPENSATION AND EMPLOYER'S
LIABILITY INSURANCE POLICY
The Company hereby agrees to indemnify the Insured against excess loss, subject to his/her employment by the Insured either in operations in a state designated
the limitations, conditions and other terms of this policy, which the Insured may in Item 1 of the Declarations or in operations necessary or incidental thereto,
sustain by reason of the liability imposed upon the Insured by law: or
(1) For compensation and other benefits as are specifically provided by the worker's (b) sustained while temporarily outside the United States of America, its
compensation or occupational disease laws of any state(s)named in Item 1 of the territories or possessions,or Canada by any employee of the Insured who is a
Declarations,and citizen or resident of the United States or Canada arising out of and in the
(2) For damages because of bodily injury by accident or disease including death at course of his employment by the Insured in connection with operations in a
r time resulting b because
therefrom, state designated in Item 1 of the Declarations;but this insurance does not ap-
any ply to any suit brought in or any judgment rendered by any court outside the
(a) sustained in the United States of America, its territories or possessions, or United Sates of America,Its territories or possessions,or Canada or to an ac-
Canada by any employee of the Insured arising out of and in the course of tion on such judgment wherever brought.
DEFINITIONS
(1) Worker's Compensation Law. The unqualified term "worker's compensation mean the sum actually paid in cash in the settlement or satisfaction of losses for
law"means the worker's compensation law and any occupational disease law of a which the Insured is liable,either by adjudication or compromise with the written
state designated in Item 1 of the Declarations, but does not include those consent of the Company, after making proper deductions for all recoveries, but
provisions of any such law which provide non-occupational disability benefits. shall exclude all salaries of employees and office expenses of the Insured incurred
(2) State. The word "state" means any State or Territory of the United States of in investigation,adjustment and litigation. Nothing herein contained shall be con-
America and the District of Columbia. strued to mean that the Insured shall be required to enforce by legal action any
(3) Assault and Battery. Under Insuring Agreement(2), assault and battery shall be rights of subrogation before the Company shall pay any loss for which It may be
an accidentunless nd committed n greby ratthe2i,direction of andthe Insured.r liable hereundor. Other loss and legal expenses (including court costs and in-
deemedterest on any judgment or award)incurred with the consent of the Company shall
(4) Ultimate Net Loss. The term "ultimate net loss", as used in this policy, shall be apportioned in proportion to the respective interests as finally determined.
APPLICATION OF POLICY
(1) This policy applies only to injury(i)by accident occurring during the policy period, last exposure,in the employment of the Insured,to conditions causing the disease
or(ii) by disease caused or aggravated by exposure of which the last day of the occurs during the policy period.
EXCLUSIONS
This policy does not apply: therefrom;
(1) Under Insuring Agreement 2, to liability assumed by the Insured under any con- (3) under Insuring Agreement 2,to any obligation for which the Insured or any carrier
tract or agreement,but this exclusion does not apply to a warranty that work per- as his/her insurer may be held liable under the worker's compensation or oc-
formed by or on behalf of the Insured will be done in a workerlike manner. cupational disease law of a state designated in Item 1 of the Declarations, any
(2) under Insuring Agreement 2, to bodily injury by disease unless prior to thirty-six other worker's compensation or occupational disease law, any unemployment
months atter the end of the policy period written claim is is made or suit is brought compensation or disability benefits law,or under any similar law.
against the Insured for damages because of such injury or death resulting (4) to fines,penalties,punitive or exemplary damages.
CONDITIONS
•
(1) Limit of Liability— Retained Limit. The Comapny's limit of liability shall be only premium adjusted in accordance therewith at the rates and under the conditions
for the ultimate net loss,as defined herein, in excess of the amount stated in Item herein specified. If the Insured is liable under any of the said worker's com-
4 of the Declarations (hereinafter called the "retention") and then only up to a pensation laws for compensation to employees of any contractor or sub-contractor
further amount not exceeding the amount stated in Item 3 of the Declarations, and does not maintain satisfactory evidence that any such contractor or sub-
provided that the retention and the Company's limit shall apply separately under contractor has secured his compensation obligations to his employees, then the
Insuring Agreement 1 and 2 to each accident,involving one or more employees. remuneration of all employees of any such contractor or sub-contractor shall be in-
Anything contained in this policy to the contrary notwithstanding, with respect to cluded in the return of remuneration upon which the premium for this policy is
each employee, injury by disease shall be considered a separate accident and be computed, provided, however that if the Insured does not furnish record of such
subject to a separate retention for each accident; and the maximum limit of the remuneration, the entire contract price of the sub-contracted work shall be in-
Company's liability, during the policy period, for all injuries by disease shall be cluded as remuneration. Upon delivery of this policy, the Insured shall pay the
the amount stated in Item 3 of the Declarations. deposit premium shown in the Declarations and at the expiration of each annual
period, the earned premium shall be computed thereon and shall be paid to the
(2) Premium.The premium for this policy shall be based upon the entire remuneration Company except that the deposit premium shown in the Declarations shall be
earned,during the policy period, by all employees of the Insured engaged in the credited against the premium found to be due the Company for the last twelve(12)
zperations described in the Declarations together with all operations necessary, months of the policy period. The Company shall, in any event, retain the annual
• incidental or appurtenant thereto, or connected therewith, whether conducted at minimum premium stated in the Declarations for a twelve(12)month period.
such work place or elsewhere in connection therewith or in relation thereto, sub- (3) Inspection and Audit.The Company and any rating authority having jurisdiction by
ject with respect to each executive officer to a maximum and minimum law shall each be permitted but not obligated to inspect at any reasonable time,
remuneration of$300.00 and $1.00 per week, and the Insured agrees to pay a the workplaces, operations, machinery and equipment covered by this policy.
premium thereon,at the time of the final adjustment of the premium at rates to be Neither the right to make inspections nor the making thereof nor any report
determined. If the policy period is for more than one year, then upon expiration of thereon, shall constitute an undertaking on behalf of or for the benefit of the In-
each annual period of the policy, or its termination during the policy period, the sured or others, to determine or warrant that such workplaces, operations,
actual amount of the remuneration earned by employees during such period shall machinery or equipment are safe or healthful, or are in compliance with any law,
be exhibited to the Company, as provided in Condition 3 hereof, and the earned rule or regulation.
1701'7/76!
The Company and any rating authority having jurisdiction by law shall each be pense,and shall be liable for the taxable costs and disbursements and interest in-
permitted to examine and audit the Insured's payroll records, general ledger, cidental thereto, but in no event shall the liability of the Company for ultimate net
disbursements,vouchers, contracts, tax reports and all other books, documents loss exceed the amount set forth in for any one occurrence plus the cost and ex-
and records of any and every kind at any reasonable time during the policy period pense of such appeal. Item 3 of the Declaration.
and any extension thereof and within three years after termination of this policy,
as far as they show or tend to show or verify the amount of remuneration or other (10)Action Against Company. No action shall lie against the Company unless, as a
r^nremium basis,or relate to the subject matter of this insurance. condition precedent thereto, the Insured shall have fully complied with all the
I- .ualified Self-Insurer. The Insured, by the acceptance of this contract,warrants terms of this policy.
that it has qualified as a self-insurer as provided in the worker's compensation (11)Other Insurance. It the Insured carries other valid and collectible insurance
law and will continue to maintain such qualifications during the period of this con- covering a loss also covered by this contract(other than insurance that is pur-
tract. In the event the Insured should at any time while this contract is in force ter- chased to apply in excess of the sum of the retention and the limit of liability
minate its qualifications as a self-insurer or it such qualifications should be can- hereunder of policies of coinsurance within the limits of this policy),the insurance
celled or revoked,this contract shall automatically terminate at the same time. afforded by this contract shall aptly in excess of and shall not contribute with such
(5) Notice of Injury. When an injury occurs that appears reasonably likely to involve other insurance or reinsurance.
liability on the part of the Company,written notice shall be given by or on behalf of (12)Subrogation. In the event of any payment under this policy,the Company shall be
the Insured to the Company or any of its authorized agents as soon as practicable. subrogated to all rights of recovery therefor of the Insured and any person entitled
Such notice shall contain particulars sufficient to identify the Insured and also the to the benefits of this policy against any person or organization,and the Insured
fullest information obtainable at the time.The Insured shall give like notice,with shall execute and deliver instruments and papers and do whatever else is
full particulars, of any claim made on account of such injury. If thereafter suit or necessary to secure such rights. The Insured shall do nothing after loss to
other proceeding is instituted against the Insured to enforce such claim, the In- prejudice such rights.
sured shall, when requested by the Company, forward to the Company every (13)Changes. Notice to any agent or knowledge possessed by any agent or by any
demand, notice, summons, or other process or true copies thereof, received by other person shall not effect a waiver or a change in any part of this policy or estop
the Insured or the Insured's representatives,together with copies of reports of in- the Company from asserting any right under the terms of this policy;nor shall the
vestigations made by the Insured with respect to such claim,suit or proceeding. terms of this policy be waived or changed,except by endorsement issued to form
(6) Cooperation of the Insured. The Company snail not be called upon to assume a part of this policy,signed by a duly authorized representative of the Company.
charge of the settlement or defense of any claim made or suit or proceedings in- (14)Assignment. Assignment of interest under this policy shall not bind the Company
stituted against the Insured, but shall have the right and shall be given the op- until its consent is endorsed hereon. If, however, during the policy period the In-
portunity to associate with the Insured in the defense and control of any claim, sured shall die,and written notice is given to the Company within thirty days after
suit or proceeding where the claim or suit involves,or appears reasonably likely to the date of such death,this policy shall cover the Insured's legal representative as
involve the Company,in which event the Insured and the Company shall cooperate insured; provided, that notice of cancellation addressed to the Insured named in
in all things in the defense of such claim,suit or proceeding. the Declarations and mailed or delivered,after such death, to the address shown
(7) Legal Costs.Should any claim or claims arise appearing likely to exceed the reten- in this policy shall be sufficient notice to effect cancellation of this policy.
tion, no costs shall be incurred on behalf of the Company without its consent (15)Cancellation. This policy may be cancelled by the Insured by surrender thereof to
being first obtained. Should such claim or claims be adjusted prior to trial court the Company or any of its authorized agents or by mailing to the Company written
judgment for a sum or aggregate sum of not more than the retention,then no costs notice stating when thereafter the cancellation shall be effective. This policy may
shall be payable by the Company.Should,however,the sum or aggregate sum for be cancelled by the Company by mailing to the Insured at the address shown in
which such claim or claims are adjustable prior to the rendering of trial court this policy written notice stating when not less than ten days thereafter such can-
judgment or judgments exceed the retention, then the Company, if it consents to cellation shall be effective. The mailing of notice as aforesaid shall be sufficient
trial court proceedings continuing,shall contribute to the costs in the ratio that its proof of notice. The time of the surrender or the effective date and hour of can-
proportion of the liability for the judgments rendered,or settlement or settlements cellation stated in the notice shall become the end of the policy period. Delivery of
made bears to the whole amount of said judgment or settlement or judgments or such written notice,either by the Insured or by the Company,shall be equivalent
settlements, to mailing,
(al_Loss Payable. The Company shall pay any loss for which it may be liable under If the Insured cancels,earned premium shall be(1)computed in accordance with
ris policy in the following manner: the customary short rate table and procedure and(2)not less than the minimum
(a) if one of the said worker's compensation laws is applicable,payment therefor premium stated in the declarations. If the Company cancels, earned premium
shall first be made by the Insured in accordance with the provisions of the shall be computed pro rata. Premium adjustment may be made at the time can-
law,and the Company shall reimburse the Insured for such loss periodically, cellation is effected and,if not then made,shall be made as soon as practicable af-
at intervals of not less than one month, upon receipt from the Insured of ter cancellation becomes effective. The Company's check or the check of its
proper proofs of payment.No voluntary commutation of compensation awards representative mailed or delivered as aforesaid,shall be a sufficient tender of any
to a lump sum basis shall be made by the Insured without the consent of the refund of premium due to the Insured.
Company. (16)Conformity to Statute.Terms of this policy which are inconflict with the provisions
(b) if none of the said worker's compensation laws is applicable and damages of the worker's compensation law are hereby amended to conform to such law.
are recovered against the Insured, payment therefor shall be made by the (17)Declarations. By acceptance of this policy,the Insured agrees that the statements
Company within thirty(30) days after proper proofs of payment by Insured in the Declarations are his agreements and representations, that this policy is
shall have been received by the Company. issued in reliance upon the truth of such representations and that this policy em-
(9) Appeals. In the event the Insured elects not to appeal a judgment in excess of the bodies all agreements existing between himself and the Company or any of its
retained limit,the Company may elect to take such appeal at its own cost and ex- agents relating to this insurance.
IN WITNESS WHEREOF the Company has caused this policy to be si@ned by its President and Secretary but this policy shall not be valid
unless completed by the attachment hereto of a Declarations page designated as Part Two and countersigned on the aforesaid Declarations
page by a duly authorized representative of the Company.
++,
Secretary President
Hello