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Home My WebLink About000174.tiff .4, January 2, 1996 Mr. Don Warden Director of Finance & Administration Weld County, Colorado P.O. Box 758 Greeley, CO 80632 Re: Certificate of Insurance Dear Don, I have enclosed your copy of the certificate of insurance for your excess workers' compensation policy. The original has been mailed directly to the Division of Labor. Please place this certificate in your policy notebook behind the appropriate tab. Should you have any questions or concerns please do not hesitate to contact our office. Sincerely, ARTHUR J. GALLAGHER & CO. - DENVER /zaatIa$. Michele Vanags, Account Assistant :my/Enclosure(s) N:\RMS-AV\MV\WELD\GENC0R\CERT.LTR January 2 1996 174 CERTIFICATE OF INSURANCE WORKER'S COMPENSATION ACT TO: John M. Berger/Insurance Compliance Mgr. Department of Labor & Employment Division of Workers' Compensation 1515 Arapahoe Denver, CO 80202 Gentlemen: This certifies that a Workers' Compensation Excess Insurance Policy has been issued and delivered to the Employer named below, and that by issuance and delivery of said policy and the filing of this certificate of insurance, it is admitted that said excess policy was effective on the date state below and that the coverage provided therein is applicable to benefits under the Workers' Compensation Act of the State ofCO and that said policy shall remain in full force and effect until days after receipt by the Bureau of Workers' Compensation of notice of its cancellation or expiration. Name of Employer Insured: Weld County,Colorado Address:P.O. Box 758, Greeley, CO 80632 Name of Insurer: Frontier Insurance Company Address: P.O. Box 8000 Rock Hill, NY 12775-8000 Policy *: FSO 1105 Effective Date:12/31/95 FORM OF COVERAGE Specific Excess Aggregate Excess "Policy Limit: $ Statutory `Policy Limit: $ Specific Retention: $300,000. Loss Fund Percentage: Policy Term: One Year Minimum Loss Fund: $ Employer's Liability: $1,000,000. Estimated Loss Fund: $ Policy Term *If more than one insurer is providing coverage, you must provide separate ce ficates for each insurer. Insurer: Frontier Insurance Co. Authorized Agent: z P.O. Box 8000 // Rock Hill, NY 12775-8000 ACOItII® CERTIFICATE OF INSURANCE 12/12/1995 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Arthur J. Gallagher & CO. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 24809 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. nenver, CO 80224 — _ COMPANIES AFFORDING COVERAGE 03) 773-9999 COMA PANY FRONTIER INSURANCE COMPANY INSURED COMPANY WELD COUNTY, COLORADO B P.O. BOX 758 COMPANY C GREELEY CO 80632 COMPANY D COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER oA�TEY(MMIDo/nYY�) DATE Y(MM/IDD/YY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $ CLAIMS MADE OCCUR PERSONAL 8 ADV INJURY $ OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ FIRE DAMAGE(My one fire) $ MED EXP(My one person) $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO I ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per parson) HIRED AUTOS ORIGINAL MAILED TO CERTIFICATE HOLDER BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY'. EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ WORKERS COMPENSATION AND X I STATUTORY LIMITS A EMPLOYERS'LMBLRY FS01105 12/31/95 12/31/96 EACH ACCIDENT $1,000,000 THE PROPRIETOR/ X INCL DISEASE-POLICY LIMIT $ PAATNERS,XECUTIVE OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS SELF INSURED RETENTION $300, 000 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPWATKON DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 90 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, TE OF COLORADO/DIVISION OF LABR BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY ATTN: MR. JOHN M. BERGER OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. 1515 ARAPAHOE STREET AUTHORDED REPRESENTATIVE DENVER CO80202-2117 AC'ORD SS (3/93) DACORD CORPORATION ION 1693 January 2, 1996 Mr. Don Warden Director of Finance & Administration Weld County, Colorado P.O. Box 758 Greeley, CO 80632 Re: Current Summary of Insurance Dear Don, I have enclosed your copy of the Current Summary of Insurance for your excess workers' compensation policy and self-insurer's bond. Please place this summary in your policy notebook behind the appropriate tab. Should you have any questions or concerns please do not hesitate to contact our office. Sincerely, ARTHUR J. GALLAGHER & CO. - DENVER Michele Vanags, Account Assistant :my/Enclosure(s) N'.\RMS AV\MV\WELD\GENCOR\LET DW January 2,1996 CURRENT SUMMARY OF INSURANCE PREPARED FOR WELD COUNTY, COLORADO Prepared By: John P. McLaughlin Vice President - Risk Management Services (303) 773-9999 December 18, 1995 It should be emphasized that the description of coverage enclosed is a summary only. The coverage is subject to terms and conditions outlined and certain restrictions, limitations and exclusions contained in the policies of insurance. The description is not a policy of insurance. In the event of any conflict between the enclosed description of coverage and the policy of insurance, the provisions contained in the policy of insurance will govern. 95-1312 M:\CLIENTDOC\WELD-CTY\WC-CSI.95 December 27. 1995 WELD COUNTY, COLORADO SUMMARY OF CURRENT POLICIES TYPE OF POLICY COMPANY POLICY # POLICY PERIOD Excess Worker's Frontier Insurance FS01105 12/31/95-96 Compensation Company Self Insurer's Bond Aetna Casualty & 19S100729968 12/31/91 Surety Company Continuous 95-1312 M'.\CLIENTDOC\WELD-CTY\WC-CS1.95 December 27.1995 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(IA/ 9/23/19 1996 ; PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Arthur J. Gallagher & CO. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE g HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 24809 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Denver, CO 80224 COMPANIES AFFORDING COVERAGE (303) 773-9999 COMPANY A Reliance Insurance Company INSURED COMPANY Occupational Health Care Mgmt B Republic Western Suite 1132 COMPANY 700 Broadway C Denver CO 80273 COMPANY I D COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO DATE(TYPE OF INSURANCE POLICY NUMBEA PLICO EFFECTIVE MIUDDNY) DAATTEE(MMIDD Y EXPIRATION LIMBS A GENERAL LIABILITY 081212739 09/01/96 09/01/97 GENERAL AGGREGATE $2.000.000 X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $2,000.900 CLAIMS MADE OCCUR PERSONAL$ADV INJURY $1,000,000 OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $1.000.000 X Agg applies FIRE DAMAGE(My one tee) $1,000,000 per location MED EXP(Any one person) $10.000 A AUTOMOBILE LIABILITY OB1212739 09/01/96 09/01/97 COMBINED SINGLE LIMIT $1,000,000 ANY AUTO ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY (Per accident) $ NON-OWNED AUTOS PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY. EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM I AGGREGATE $ OTHER THAN UMBRELLA FORM $ B WORKERS COMPENSATION AND RWC0655417 09/01/96 09/01/97 XITORYLINITS I IER EMPLOYERS'LIABILITY EL EACH ACCIDENT $1.000.000 THE PROPRIETOR/ INCL EL DISEASE-POLICY LIMIT $1.000.000 PARTNERS/EXECUTIVE OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE $1,000.000 OTHER A Financial Inst. B241-5848 06/01/96 06/01/97 Limit $i,000,000 Bond Deductible $ 25,000 DESCRWTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS CERTIFICATE HOLDER CANCEU AflON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Weld County EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL Attn: Don Warden 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, P.O. Box 758 BUT FAILURE TO MAIL SUCH NOTICE ALL IMPOSE N OBLIGATION OR LIABILITY Greeley CO 80632 OF ANY KIND UPON THE COM ANY/�R ESP-FRAMES. AUTHORED REPRESENTATIVE ACORO 25-S (1/95) OACOOD'CtcaA71 1988 Hinders,Certificates only Ii WELD COUNTY COLORADO 1995/96 EXCESS WORKERS' COMPENSATION POLICY aith, ��jo is December 12, 1995 Mr. Donald D. Warden, Director Finance and Administration Weld County, Colorado P.O. Box 758 Greeley, CO 80632 Re: Specific Excess Workers' Compensation and Self-Insurers' Bond December 31, 1995 to December 31, 1996 Dear Don, Thank you for renewing the above coverages through Arthur J. Gallagher & Co. I am enclosing a 95/96 policy notebook including, a binder of insurance confirming the Specific Excess Workers' Compensation coverages bound, a tab for your self-insurers' bond should you want to place the bond in this notebook, a copy of the certificate of insurance provided for the Division of Labor and our invoice for the premium of $31,767. The actual policy will replace this binder shortly. I am also enclosing our invoice for the Self-Insurers' Bond renewal premium of $8,250. Should you have any questions, please do not hesitate to give us a call. Happy Holidays, Arthur J. Gallagher & Co. _. 1 LL fl.c - S Michele Vanags, Account Assistant c: John P. McLaughlin, Vice President - Risk Management Services :mv/Enclosure(s) N:\RMS-AV\MV\WELD\WORKCOM\LETTTER REN December 12,1995 V December 12, 1995 Mr. Donald D. Warden, Director Finance and Administration Weld County, Colorado P.O. Box 758 Greeley, CO 80632 Re: Evidence of Insurance Coverages Bound December 31, 1995 to December 31, 1996 Dear Don, As instructed, we have bound coverage per the enclosed documents for Specific Excess Workers' Compensation and Self-Insurers' Bond. Our invoices are also enclosed. Enclosed is an extra copy of this letter. Please sign where indicated as confirmation of receipt and acceptance of coverages bound. A self-addressed envelope is provided for your convenience. Thank you for your prompt attention to the above. Should you have any questions or concerns please do not hesitate to contact our office. Sincerely, ARTHUR J. GALLAGHER & CO. - DENVER Michele Vanags / g Account Assistant 7 / iAccepted and received by: A 1 'V P I �,;(4,,,, 6.7,-- (Name and Title) Date: i :-'`/ 5' . '/ N'.\BMS-AV\MV\WELD\WORKCOM\LETTER.ECB December 12,1995 WELD COUNTY, COLORADO SPECIFIC EXCESS WORKERS' COMPENSATION COVERAGE Limits: Workers' Compensation Statutory Employers Liability $ 1,000,000 Retentions: $ 300,000 Adjustable Rate: .1212 Adjustable Basis (Payroll): $ 26,210,684 Terms/Conditions: • Claims expenses included in definition of loss • U.S. L & H - Included • All States Endorsement • Commutation Clause • Board Members Exclusion N'.\RMSAV\MV\WELD\WORKCOM\RINDER.ATT December 12,1995 ant December 27, 1995 Mr. Don Warden Director of Finance & Administration Weld County, Colorado P.O. Box 758 Greeley, CO 80632 Re: Workers' Compensation Dear Don, I have enclosed a copy of the Workers' Compensation Binder to replace the one sent to you earlier this month. Do to a change in software, the binder sent to you contained incorrect information. Please replace the binder in your policy note book with the one enclosed. Should you have any questions or concerns please do not hesitate to contact our office. Sincerely, ARTHUR J. GALLAGHER & CO. - DENVER Michele Vanags, Account Assistant :mv/Enclosure(s) N\RMS-AV\MV\WELD\WORKCOM\LET.DW December 27.1995 AI:11I.IL® INSURANCE BINDER 12/12i 995 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. PRODUCER I WCNNo, En): 303.773-9999 COMPANY BINDER t arthur J. Gallagher & Co. Frontier Insurance Co. 001141 .O. Box 24809 DATE EFFECTIVE TIME DA EXPIRATION TIME Denver, CO 80224 X 12:01 AM X AM 12/31/95 12 :01 03/01/96 (303) 773-9999 PM NOON -_.-_ THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY CODE: SUB CODE: PER EXPIRING POLICY 5: AGENCY DESCRIPTION OF OPERATIONSNEHICLES/PROPERTY(Including Location CUSTOMER ID: ( tq ) INSURED ASSIGNED POLICY #F501105 WELD COUNTY, COLORADO P.O. BOX 758 GREELEy CO 80632 COPE.RAGE$ LIMITS PROPERTY TYPE AND LOCATION OF PROPERTY COVERAGE/PERILS/FORMS AMOUNT DEDUCTIBLE COINS% LIABILITY COVERAGE/FORMS EACH OCCURRENCE AGGREGATE SCHEDULED FORM COMPREHENSIVE FORM BODILY INJURY $ $ PREMISES/OPERATIONS PROPERTY DAMAGE $ $ PRODUCTS/COMPLETED OPERATIONS RI$PD COMBINED $ $ CONTRACTUAL PER PERSON $ MEDICAL PAYMENTS OTHER: _ PER ACCIDENT $ MEDICAL PAYMENTS PERSONAL INJURY $ PERSONAL INJURY FORM: A B C $ / DBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS MEDICAL PAYMENTS $ NON-OWNED AUTOS PERSONAL INJURY PROT $ GARAGE LIABILITY UNINSURED MOTORIST $ $ AUTO PHYSICAL DAMAGE DEDUCTIBLE ALL VEHICLES SCHEDULED VEHICLES ACTUAL CASH VALUE COLLISION: STATED AMOUNT $ OTHER THAN COL: OTHER EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM SELF-INSURED RETENTION $ STATUTORY LIMITS WORKER'S COMPENSATION REFER TO ATTACHED EACH ACCIDENT $REFER AND - EMPLOYER'S LIABILITY DISEASE-POLICY LIMIT $TO THE DISEASE-EACH EMPLOYEE $ATTACHED SPECIALSPECIFIC EXCESS WORKERS ' COMPENSATION — PER THE ATTACHED CONDITIONS/ OTHER COVERAGES NAME78 ADDRESS MORTGAGEE H ADDITIONAL INSURED LOSS PAYEE LOAN R AUTHo SENT ACOHD 75-N ■3219 y MCTEa itlIPORL ANT STAIR 9NPCRMAjillaniellitetafragararcoaponmiotclogsT.]t CONDITIONS This Company binds the kind(s) of insurance stipulated on the reverse side. The Insurance is subject to the terms, conditions and limitations of the policy(ies) in current use by the Company. This binder may be cancelled by the Insured by surrender of this binder or by written notice to the Company stating when cancellation will be effective. This binder may be cancelled by the Company by notice to the Insured in accordance with the policy conditions. This binder is cancelled when replaced by a policy. If this binder is not replaced by a policy, the Company is entitled to charge a premium for the binder according to the Rules and Rates in use by the Company. Applicable in California When this form is used to provide insurance in the amount of one million dollars ($1,000,000) or more, the title of the form is changed from "Insurance Binder" to "Cover Note". Applicable in Delaware The mortgagee or Obligee of any mortgage or other instrument given for the purpose of creating a lien on real property shall accept as evidence of insurance a written binder issued by an authorized insurer or its agent if the binder includes or is accompanied by: the name and address of the borrower; the name and address of the lender as loss payee; a description of the insured real property; a provision that the binder may not be canceled within the term of the binder unless the lender and the insured borrower receive written notice of the cancel- lation at least ten (10) days prior to the cancellation; except in the case of a renewal of a policy subsequent to the closing of the loan, a paid receipt of the full amount of the applicable premium, and the amount of insurance coverage. Chapter 21 Title 25 Paragraph 2119 Applicable in Nevada Any person who refuses to accept a binder which provides coverage of less than $1,000,000.00 when proof is required: (A) Shall be fined not more than $500.00, and (B) is liable to the party presenting the binder as proof of insurance for actual damages sustained therefrom. ACORD 75-N (1 ) WELD COUNTY, COLORADO SPECIFIC EXCESS WORKERS' COMPENSATION COVERAGE Carrier: Frontier Insurance Company FS01105 Limits: Workers' Compensation Statutory Employers Liability $ 1,000,000 Retention: $ 300,000 Terms/Conditions: • Claims expenses included in definition of loss • U.S. L & H - Included • All States Endorsement • Commutation Clause • Board Members Exclusion 951312 M.ACLIENTDOCA WELD CTY\WC CS!95 December 27. 1995 WELD COUNTY, COLORADO WORKERS' COMPENSATION BOND Carrier: Aetna Casualty and Surety Company A XIV Bond Penal Sum: $ 550,000 (° Terms/Conditions: Continuous until cancelled (° Subject to review by Division of Labor. 951512 M.ACLIENT.DOCAWELD CTY\WC CSL95 December 27. 1995 ROY ROMER Governor /F•CO< 'Pr\ tn . �? , -.“8'\ DEPARTMENT OF LABOR AND EMPLOYMENT JOHN J. DONLON * aJ *,' DIVISION OF WORKERS' COMPENSATION Executive Director \ x rj EMPLOYER SERVICES 1876' 1515 ARAPAHOE STREET DENVER,CO 80202-2117 BARBARA P. KOZELKA (303)575-8873 Director FAX(303)575-8883 January 22, 1996 Mr, Donald Warden Director, Finance & Administration Weld County P.O. Box 758 Greeley, CO 80632 Re: Annual Review Colorado Workers' Compensation Self-Insurance Permit No. 846 , Weld County Dear Mr. Warden: The annual review of the above captioned self-insurance permit is, as of this date, January 22, 1996 incomplete. Please complete this requirement under the RULES GOVERNING THE ISSUANCE OF SELF-INSURANCE PERMITS UNDER THE WORKERS' COMPENSATION ACT, 7.C.C.R. 1101-4 VI.A by furnishing: 1. A copy of the most recent audited financial statement. 2 . A copy of the most recent payroll statement. 3 . A completed Annual Review Data sheet furnishing the total payments and reserves on claims for the current year and each of the preceding four years. 4 . Evidence by certificate that the required excess insurance is currently in force and has the ninety (90) day cancellation clause as required by Colorado Self-Insurance Rules. 5. Check in the amount of $1,600 made payable to: Workers' Compensation Self-Insurance Fund. 6. X A revision of the penal sum of the security instrument to $ 605,000. 7. It is not necessary to submit a complete loss run for permit renewal. However, we reserve the right to request one. A computer summary or "recap sheet" instead of your loss run history will suffice. 8. Other: Actuarial Study. Thank you very much for your attention to this matter. Sincerely, . Ber"'g��er, ARM, C Self-Insurance Adminis rator JMB/jo OrMS OCCUPATIONAL HEALTHCARE MANAGEMENT SERVICES l January 31, 1996 Weld County 915 10th Street P. O. Box 758 Greeley, Co. 80632 Attn: Don Warden Director of Finance Administration Re: Certificate of Insurance Dear Mr. Warden: Enclosed please find a certificate of insurance evidencing error and omissions coverage for OHMS under BCS policy number D/O 961-050 for the period from January 1, 1996 to January 1, 1997. If you have any questions or I can be of further assistance, please do not hesitate to contact me on (303) 831-2752 or (800) 548-1469. Sincerely, Karen-Marie Lesko Senior Group Consultant Enclosure P.O.Box 173682 Denver,Colorado 80217-3682 (303)831-3059 A ROCKY MOUNTAIN HEALTH CARE CORPORATION SUBSIDIARY 1 • This certifies the following entity has coverage with: BCS INSURANCE COMPANY 676 North St. Clair Chicago, Illinois 60611 As follows: 1 4 PARTICIPANT INSURED: Occupational Healthcare Management Services 700 Broadway Denver, Colorado 80273 POLICY NUMBER D/O 961-050 COVERAGE: Errors and Omissions LIMIT OF LIABILITY: $1,000,000 Aggregate Per Policy Period TERM: January 1, 1996 to January 1, 1997 INSURER: BCS Insurance Company Chicago, Illinois CERTIFICATE HOLDER: Weld County 915 10th Street P. O. Box 758 Greely, Colorado 80632 1 Attn: Don Warden Director of Finance &Administration Signed: //d k7. Th.e/P6� Date: January 24, 1996 1 � • • Can March 8, 1996 Mr. Don Warden Director of Finance & Administration Weld County, Colorado P.O. Box 758 Greeley, CO 80632 RE: Excess Workers' Compensation Policy Policy #FS01105 Term 12/31/95-96 Dear Don: Thank you again for renewing your insurance coverages with Arthur J. Gallagher & Co. I am happy to enclose your Excess Workers' Compensation policy captioned above. Your policy has been checked for accuracy and appears to have been issued correctly with exception of the following changes: • Endorsement # 2. Amend to show 90 day notice of cancellation to the Colorado Division of Labor. • Endorsement # 3 Amend all cancellation notices to 90 days with the exception of 10 day notice for non-payment of premium. Please review this policy for all terms, conditions, limitations and exclusions. Upon review of your policy should you have any questions, feel free to contact me. Sincerely, Arthur J. Gallagher & Co. �, t�L C L.J:_�� Q�-�.C.CI Michele Vanags Account Assistant c: Karen Graham, Account Manager Karen Lesko, OHMS :mv/enclosure(s) N'.\RMS AV\MV\WELD\WORKCOM\95-6POL.LTR March 8.1996 EXCESS INSURANCE POLICY A STOCK INSURANCE COMPANY FOR SELF-INSURER OF WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY O 13 testier INSURANCE COMPANY ROCK HILL, NEW YORK 12775-8000 THESE POLICY PROVISIONS WITH THE DECLARATIONS PAGE AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF,COMPLETE THIS POLICY. EWC-1(a) (11/93) TABLE OF CONTENTS Section: Page: General Section. A. The Policy B. Continuous Policy C. Who is Insured D. Workers' Compensation Law E. Qualified Self-Insurer F. State I. Part One-Worker's Compensation Insurance 1 &2 II. Part Two-Employer's Liability Insurance 2 III. Part Three-Other States Insurance 3 IV. Part Four-Insured's Retention and Insurer's Limit of Indemnity: A. Retention by Insured 3 B. Limit of Indemnity by Insurer 3 C. How Retention and Limit of Indemnity Apply 3 D. Occurrence 3 E. Disease 3 V. Part Five-Claim Expenses 3 VI. Part Six-Premium: A. Premium Determination 4 B. Estimated Premium 4 C. Earned Premium 4 VII. Part Seven-Conditions: A. Notice of Accident 4 B. Duties of Insured and Insurer 4 C. Appeals 4 D. Good Faith Settlement 5 E. Subrogation-Recovery From Others 5 F. Commutation 5 G. Actions Against Insurer 5 H. Other Insurance 5 I. Inspection 5 J. Audit 6 K. Assignment 6 L. Bunkruptcy or Insolvency of Insured 6 M. Cancellation 6 N. Service and Administration 6 O. Sole Representative 6 P. Policy Conforms to Law 6 Q. Captions 6 A STOCK COMPANY p � Q rQnt/arINSURANCE COMPANY Rock Hill, New York 12775-8000 POLICY NO. FSO 1105 Excess Workers' Compensation Agreement Declarations Page 1. Insured: Weld County, Colorado 2. Address: P.O. Box 758, Greeley, CO 80632 3. Effective Date: 12/31/95 4. Anniversary Date in each year: December 31st 5. Self-Insured States Covered: Colorado 6. Insured's Retention for each occurrence or for each employee for occupational disease: $ 300,000. 7. Limit of Indemnity for each accident or for each employee for occupational disease: (a) Coverage A. Workers' Compensation $ Statutory (b) Coverage B. Employer's Liability Insurance $ 1,000,000. (c) Combined Limit for W.C. & Employer's Liability $ Statutory 8. Classification of Operations: Estimated Total Rate Per$100 Annual Remunerations/ Remuneration/ Estimated Code No. Manhours Manhours Premium "SEE ENDORSEMENT#1" 9. Premium Rate: .1212 Per$100 of Payroll 10. Minimum Annual Premium: $31,767. 11. Deposit Premium for Payroll Reporting Period: $31,767 12. The Service Company is: OHMS 13. Payroll Reporting Period: Annual Signed at Rock Hill, NY, this thirteenth day of December , 19 95 A • p i — yJp , FRONTJER fNSURANLE COMPANY E-WC-DEC(a) (11/93) ENDORSEMENT #1 CIAS$IF[ TIC OF OPEi TIONS: FOR THE POLICY PERIOD OF 12/31/95 TO 12/31/96 Estimated Total Rate Per $100 Annual Renumerations/ Renumerations/ Estimated Code No. Manhours Manhours Premium 5506 Street & Road $ 3,004,365. 16.74 $ 502,931. 7382 Transit Authority $ 362,986. 13.77 $ 49,983. 7702 Policement/ $ 6,500,250. 4.75 $ 308,762. Ambulance 8742 Salesmen Outside $ 1,363,915 .81 $ 11,048. 8810 Clerical/Office/ $ 9,745,385. .49 $ 47,752. Elected Ofc. 8831 Animal Control $ 46,565. 2.13 $ 992. 8832 Health Dept. $ 690,543. .53 $ 3,660. 8868 School $ 1,440,897. .68 $ 9,798. 9014 Insect Extermination $ 35,969. 12.20 $ 4,410. 9015 Building Op. $ 512,507. 8.14 $ 41,718. ENDORSEMENT #1 (Cont.) Estimated Total Rate Per $100 Annual Renumerations/ Renumerations/ Estimated Code No. Manhours Manhours Premium 9101 School-Other $ 486,207. 9.16 $ 44,537. 9410 Munic. Emp.-Other $ 2,021,095. 1.50 $ 30,316. TOTALS: $26,210,684. MANUAL PREMIUM: $1,055,907. RATE PER $100 OF PAYROLL: 121Z TOTAL DUE: $ 31,767. Nothing herein contained shall vary,alter,waive or extend any of the terms, representations, conditions or agreements of the policy other than as above stated. Attached to and forming a part of Policy No. FSA 1105 of the Frontier Insurance Company Issued to Weld County, Colorado Effective 12/31/95 Authorized Representative ENDORSEMENT #2 t� F AY l £ ICE bFCANCEEMIONgongenimigigmapon ENDORSEMEl T It is understood and agreed that SiQ day notice will be provided to the insured in the event of cancellation. Nothing herein contained shall vary, alter,waive or extend any of the terms, representations, conditions or agreements of the policy other than as above stated. Attached to and forming a part of Policy No. FSO 1105 of the Frontier Insurance Company Issued to Weld County, Colorado Effective 12/31/95 Authorized Representative ENDORSEMENT #3 This Endorsement Changes The Policy. Please Read It Carefully. CQWRAD GANGS CANC LLATION Ail NONRNEWAL' This endorsement modifies insurance provided under the following: EXCESS WORKERS COMPENSATION PART SEVEN - CONDITIONS M. Cancellation is replaced by the following: If this policy has been in effect for less than 60 days, we may cancel this policy by mailing or delivering to the first Named Insured written notice of cancellation at least: 10 days before the effective date of cancellation if we cancel for nonpayment of premium; or 30 days before the effective date of cancellation if we cancel for any other reason. The following is added to the CANCELLATION Cancellation of Policies in Effect of 60 Days or More If this policy has been in effect for 60 days or more, or is a renewal of a policy we issued, we may cancel this policy by mailing through first-class mail to the first Named Insured written notice of cancellation: Including the actual reason, at least 10 days before the effective date of cancellation, if we cancel for nonpayment of premium; or At least 45 days before the effective date of cancellation if we cancel for any other reason. We may only cancel this policy based on one or more of the following reasons: Nonpayment of premium; A false statement knowingly made by the insured on the application for insurance; or Page 1 of 3 ENDORSEMENT #3 (Cont) A substantial change in the exposure or risk other that indicated in the application and underwritten as of the effective date of the policy unless the first Named Insured has notified us of the change and we accept such change. The following is added and supersedes any other provision to the contrary: NON RENEWAL If we decide not to renew this policy, we will mail through first-class mail to the first Named Insured shown in the Declarations written notice of the nonrenewal at least 45 days before the expiration date, or its anniversary date if it is a policy written for a term of more than one year or with no fixed expiration date. If notice is mailed, proof of mailing will be sufficient proof of notice. The following Condition is added: INCREASE IN PREMIUM OR DECREASE IN COVERAGE We will not increase the premium unilaterally or decrease the coverage benefits on renewal of this policy unless we mail through first-class mail written notice of our intention, including the actual reason, to the first Named Insured's last mailing address known to us. At least 45 days before the effective date. Any decrease in coverage during the policy term must be based in one or more of the following reasons: Nonpayment of Premium; A false statement knowingly made by the insured on the application for insurance; or Page 2 of 2 ENDORSEMENT #3 (Cont.) A substantial change in the exposure or risk other that indicated in the application and underwritten as of the effective date of the policy unless the first Named Insured has notified us of the change and we accept such change. If notice is mailed, proof of mailing will be sufficient proof of notice. Nothing herein contained shall vary,alter,waive or extend any of the terms, representations, conditions or agreements of the policy other than as above stated. Attached to and forming a part of Policy No. FSO 1105 of the Frontier Insurance Company Issued to Weld County, Colorado Effective 12/31/95 Authorized Representative Excess Insurance Policy For Self-Insurer of Workers' Compensation and Employer's Liability In return for the payment of the premium and subject to all the terms of this policy,the Insurer agrees with the Insured named in Item 1 of the Declarations Page as follows: GENERAL SECTION A. THE POLICY This policy is a contract of Insurance between the Insured and the Insurer.The only agreements relating to this insurance are stated in this policy.The terms of this policy may not be changed or waived except by an endorsement made a part of this policy. B. CONTINUOUS POLICY This policy is effective at 12:01 a.m.on the effective date stated in Item 3 of the Declarations Page and will remain in effect until cancelled as provided in Part Seven-Conditions,Paragraph M of this policy.All the provisions of this policy shall apply separately to each consecutive 12-month period beginning with the date specified in Item 4 of the Declarations Page as"Anniversary Date"in the same manner as if a separate policy had been written for each such consecutive period. This policy shall be subject to review at each Anniversary Date and possible adjustment of its rates,deposit premium and other terms. The completion of new application forms is an annual requirement to facilitate this review. If changes in manual rates or classifications have been published applicable to the states named in Item 5 of the Declarations,the Company may endorse the policy to provide for corresponding changes in the rate(s)specified in the Declarations. C. WHO IS INSURED The Insured is named in Item 1 of the Declarations Page.If the Insured is a partnership or joint venture,each partner or member of the joint venture is insured only in the capacity as employer of employees of the partnership or joint venture. D. WORKERS' COMPENSATION LAW Workers'Compensation Law means the workers'compensation law and occupational disease law of each state named in Item 5 of the Declarations Page.It includes any amendments to that law which are in effect during the term of this policy.It does not include provisions of any law that provides non-occupational disability benefits. E. QUALIFIED SELF-INSURER The Insured represents that it is a duly qualified self-insurer under the Workers'Compensation Law of each state named in Item 5 of the Declarations Page and will continue to maintain such qualifications during the term this policy is in effect.If the Insured should terminate such qualifications or if qualification of the Insured as a self-insurer is cancelled or revoked while this policy is in force,the amounts payable under this policy will not exceed the amounts which would have been payable if such qualifications had been maintained in full force and effect. F. STATE State means any state of the United States of America and the District of Columbia. PART ONE - WORKERS' COMPENSATION INSURANCE A. The Insurer will indemnify the Insured for loss as a qualified self-insurer under the Workers'Compensation Law in excess of the Insured's retention stated in Item 6 of the Declarations Page, but not for more than the limit of indemnity stated in Item 7 of the Declarations Page. B. Loss means amounts actually paid by the Insured as a self-insurer under the Workers'Compensation Law,including claim expenses. C. This Insurance applies to losses paid by the Insured as a qualified self-insurer under the Workers'Compensation Law for bodily injury by accident or bodily injury by disease, including resulting death, provided: 1. the bodily injury by accident occurs within the effective dates of this policy;or 2. the bodily injury by disease is caused or aggravated by the conditions of employment by the Insured. The em- ployee's last day of last exposure to those conditions of that employment causing or aggravating such bodily injury by disease, must occur within the effective dates of this policy. EWC-1(a)(11/93) -1- D. The Insurer will not indemnify the Insured for any payments made by the Insured in excess of benefits regularly required by the Workers' Compensation Law if such excess payments are required because: 1. of willful and wanton misconduct of the Insured; 2. the Insured employed an employee in violation of law; 3. the Insured failed to comply with a health or safety law or regulation; 4. in violation of the Workers' Compensation Law, the Insured discharged, coerced, or otherwise discriminated against any employee;or 5. the Insured violated or failed to comply with any Workers'Compensation Law. E. The Insurer will not indemnify the Insured for any loss arising out of operations for which the Insured has rejected any Workers' Compensation Law. F. The Insurer will not indemnify the Insured for any loss sustained in,upon,entering or alighting from any Employer owned or leased aircraft unless notification by the Insured was given within thirty(30)days from the date of purchase or lease.Upon purchase or lease an additional premium may be charged. Lease shall mean any rental,the duration of which is thirty(30)days or greater. However, Section F does not apply if coverage is intended as evidence by inclusion in Item 8 of the Declarations Page. PART TWO - EMPLOYER'S LIABILITY INSURANCE A. The Insurer will indemnify the Insured as a qualified self-insurer of employer's liability for loss per occurrence in excess of the Insured's retention stated in Item 6 on the Declarations Page, but not for more than the limits of indemnity stated in Item 7 of the Declarations Page. B. Loss means amounts which the Insured legally paid as damages because of bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. C. This insurance applies to losses paid by the Insured as a qualified self-insurer of employer's liability for bodily injury which arises out of and in the course of the injured employee's employment by the Insured,provided: 1. the bodily injury by accident occurs within the effective dates of this policy;or 2. the bodily injury by disease is caused or aggravated by the conditions of employment by the Insured.The employee's last day of last exposure to those conditions of that employment causing or aggravating such bodily injury by disease must occur within the effective dates of this policy;and the employment is necessary or incidental to work conducted by the Insured in a state listed in Item 5 of the Declarations Page. D. EMPLOYER'S LIABILITY INSURANCE EXCLUDES: 1. liability assumed under a contract; 2. punitive or exemplary damages; 3. bodily injury to an employee while employed in violation of law; 4. bodily injury intentionally caused or intentionally aggravated by or at the direction of the Insured; 5. bodily injury occurring outside the United States of America,its territories or possessions,or Canada.This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily working outside these countries for the Insured; 6. damages arising out of the Insured's violation of law in the discharge of, coercion of, or discrimination against any employee; 7. any obligation imposed by a workers'compensation,occupational disease,unemployment compensation,or disability benefits law, or any similar law;or 8. damages arising out of operations for which the Insured: (a) has violated or failed to comply with any workers'compensation law,or (b) has rejected any workers'compensation law. EWC-1(a)(11/93) -2- PART THREE - OTHER STATES INSURANCE A. This policy applies in other states not shown in Item 5 of the Declarations Page if an employee of the Insured is injured in such a state and if the work of such injured employee of the Insured was within the scope of such employee's employment,at the direction of the In- sured,and was temporary and transitory in such other state provided the Insured is not insured or self-insured in such other state,and 1. such injured employee was regularly employed in a state listed in Item 5 of the Declarations Page; 2. the work in the other state was incidental to the employee's regular work in a state shown in Item 5 of the Declarations Page;and 3. the work of such injured employee was not at a permanent or fixed location of the Insured subject to the Workers'Compensation law in such other state. B. For any workers'compensation benefits awarded under the law of any other state,the Insurer will indemnify the Insured only to the extent that the other state benefits do not exceed benefits which would have been paid to such injured employee under the workers' compensation law of the state in which such employee is regularly employed. C. For any workers' compensation benefits awarded under the U.S. Longshoremen's and Harbor Workers' Compensation Act, the Insurer will indemnify the Insured only to the extent that those benefits do not exceed benefits which would have been paid to such injured employee under the workers'compensation law of the state in which such employee is regularly employed. PART FOUR - INSURED'S RETENTION AND INSURER'S LIMIT OF INDEMNITY A. Retention by Insured The Insured shall pay for its own account without other insurance,all loss up to the amount stated in Item 6 of the Declarations Page as Insured's Retention. B. Limit of Indemnity by Insurer: The Insurer will indemnify the Insured for loss over the amount stated as Insured's Retention in Item 6 of the Declarations Page.The limit of indemnity for Workers'Compensation Insurance will not exceed the limit stated in Item 7a of the Declarations Page.The limit of indemnity for Employer's Liability Insurance will not exceed the limit stated in Item 7b of the Declarations Page.The total indemnity for Workers'Compensation and Employer's Liability Insurance combined will not exceed in any event the limit stated in Item 7c of the Declarations Page.The inclusion of more than one legal entity as Insured in Item 1 of the Declarations Page will not increase the Insured's Retention nor the Insurer's Limit of Indemnity. C. How Retention and Limit of Indemnity Apply: The Insured's Retention and Insurer's Limit of Indemnity stated on the Declarations Page apply to losses paid by the Insured as a qualified self-insurer of Workers'Compensation and Employers' Liability as follows: 1. To one or more employees because of bodily injury or death in any one accident. 2. To any one employee for bodily injury or death by disease. D. Occurrence: 1. Occurrence means each accident or series of accidents or occurrences arising out of any one event. 2. An occurrence is deemed to end 24-hours after the event commences.Each subsequent 24-hours is deemed to be a separate occurrence period. E. Disease: Disease is an accident only if it results directly from bodily injury by accident. PART FIVE - CLAIM EXPENSES A. Claim expenses of the Insured mean its litigation costs, interest as required by law on awards or judgments, and its claim investigation or legal expenses which can be directly allocated to a specific claim, Claim expenses exclude:salaries and travel expenses of employees of the Insured,annual retainers,overhead and any fees it paid for claim administration. B. The Insurer has no duty to investigate,handle,settle or defend any claim,proceeding or suit against the Insured,but the Insurer shall be given the opportunity to defend or participate with the Insured in the defense of any claim,if,in the opinion of the Insurer,its liability under this policy might be involved. EWC-1(a)(11/93) -3- • PART SIX - PREMIUM A. Premium Determination: Premium will be determined on the basis of the entire payroll and other remuneration paid or payable to all employees and officers of the Insured. Remuneration includes 1 and 2 below: 1. Payroll,salaries,commissions,bonuses, overtime pay, pay for holidays,vacations,pay for piece work,payments under profit sharing or incentive plans,the value of lodging,apartments,and meals received by employees as part of their pay,and the value of store certificates, merchandise,credits,or any other substitute for money received by employees as part of their pay. 2. The entire amount received by any other person engaged in work which could make the Insured liable under Part One-Workers' Compensation of this policy.This section 2 will not apply if the Insured gives proof to the Insurer that the employers of these persons lawfully secured their workers' compensation obligations. B. Estimated Premium: The estimated premium shown on the Declarations Page is an estimate and is subject to verification by inspection or audit. C. Earned Premium: The earned premium will be determined at the end of each interim policy adjustment period by use of actual,instead of estimated, premium base. The Insured will promptly pay such earned premium to the Insurer. If the earned premium exceeds premium previously paid,the Insured will promptly pay such excess to the Insurer.If such earned premium is less than premium previously paid,the Insurer will promptly return the balance to the Insured.The earned premium for each 12-month term of this policy will not be less than the Minimum Annual Premium stated in Item 10 of the Declarations Page. PART SEVEN - CONDITIONS A. Notice of Accident: 1. The Insured shall give prompt written notice to the Insurer if a claim for an injury or disease occurs:which appears to involve indemnity by the Insurer;where it appears reasonably likely that there will be disability of more than one year;or where the total incurred is greater than or equal to 50%of the Self-Insured Retention Per Occurrence specified in Item 6 of the Declarations Page. 2. The Insured shall also give immediate but in no event greater than sixty(60)days written notice to the Insurer if an injury of the following type occurs: (a) a fatality; (b) an amputation of a major extremity; (c) any serious head injury(including skull fracture or loss of sight of either or both eyes); (d) any injury to the spinal cord; (e) any second or third degree burn of 25%or more of the body. 3. Notice of accident given to the Insurer shall contain complete details on the injury,disease, or death. If a suit, claim or other proceeding is commenced because of an injury listed in above section 2 or on any injury which appears to involve indemnity by the Insurer,the Insured shall give the Insurer: (a) all notices and legal papers related to the claim, proceeding or suit, or copies of these notices and legal papers;and (b) copies of reports on investigations made by the Insured on such claims, proceedings or suits. 4. Failure to render timely notice of any claim in a prompt, established manner to the Insurer by the Insured,or its designated representative may result in a disclaimer of coverage for the particular claim. B. Duties of Insured and Insurer 1. The Insurer has not duty to investigate, handle,settle or defend any claims, suits,or proceedings against the Insured. 2. The Insurer has the right and shall be given the opportunity by the Insured to associate with the Insured in the defense, investigation, or settlement of any claim, suit or proceeding which appears to involve indemnity by the Insurer. In such association,the Insured and Insurer shall cooperate in all aspects of defense, investigation,or settlement. C. Appeals: If the Insured does not appeal an award or judgment which exceeds the Insured's Retention,the Insurer has the right to take an appeal at its own cost and expense and shall be liable for costs,disbursements and interest related to the appeal.If the Insurer elects to appeal,the liability of the Insurer on such an award or judgment shall not exceed the limit of indemnity in Item 7 of the Declarations Page, plus the cost and expense of such appeal. EWC-1(a)(11/93) -4- D. Good Faith Settlement: The Insured shall use diligence,prudence and good faith in the investigation,defense and settlement of all such claims and shall not unreasonably refuse to settle any claim which, in the exercise of sound judgment,should be settled, provided, however,that the Insured shall not make or agree to any settlement for any sum which would involve the limits of the Insurer's liability hereunder without the approval of the Insurer. E. Subrogation - Recovery From Others: 1. The Insurer has the rightto recover all payments which the Insurer has made to the Insured from anyone liable for such loss.If the Insured recovers from anyone liable for such loss,the Insurer shall first be reimbursed from such recovery to the extent of its payments to the Insured. 2. lithe Insured does not commence an action or proceeding to recover damages from anyone liable for a loss paid by the Insurer, the Insurer has the rights of the Insured to recover damages from anyone liable for such loss.The Insured will do everything necessary to protect those rights and help the Insurer to enforce them.Any such recovery by the Insurer will be allocated as follows: (a) the Insurer will be first reimbursed for all of its payments under this policy; (b) any balance of the recovery which remains after the Insurer has been reimbursed will be paid to the Insured. 3. Expenses of all proceedings to recover from anyone liable for injury covered by this policy will be allocated between the Insured and Insurer in the ratio represented by the allocation of any damages which have been recovered. 4. If such an action or proceeding undertaken solely by the Insurer results in no recovery,all related expenses will be paid by the Insurer. 5. If there is insurance coverage in excess of the Insurer's limit of indemnity under this policy and if subrogation recovery is obtained from anyone liable for loss,any such excess carrier will be reimbursed for any loss paid in excess of the Insurer's limit of indemnity before any reimbursement of the Insurer and Insured under the provisions of this Section E. 6. If there is no insurance coverage in excess of the Insurer's limit of indemnity and if there is a subrogation recovery in excess of the Insurer's limit of indemnity,the Insured will be reimbursed to the extent of any loss paid by the Insured in excess of the Insurer's limit of indemnity, before the Insurer is reimbursed under the provisions of this Section E. F. Commutation: Beginning thirty-six(36)months after receipt of notice by the Insurer of a claim,the Insurer may then,or at any time thereafter,submit such claim for commutation.If the Insurer so elects,the claim shall be submitted to an actuary or appraiser to be mutually appointed by the Insurer and the Insured,or should the Insurer and the Insured fail to agree upon an actuary or appraiser,then each party shall select an actuary or appraiser who shall then select an independent actuary or appraiser who shall fix a lump sum amount,and the Insurer,at its option,may pay the lump sum amount,which payment shall constitute a full and final release of the Insurer's liability for such claim.However,such lump sum payment shall not constitute a full and final release of the Insurer's liability if,subsequent to such lump sum payment,any supplemental award is made increasing the amount of benefits payable to the Employee and his/her dependents, and any additional liability, at the Insurer's election, may immediately be commuted via the process above and the Insurer may discharge any additional liability by payment of another lump sum. G. Actions Against Insurer: There will be no right of action against the Insurer unless the Insured has complied with all the terms of the policy. H. Other Insurance: If the Insured has other insurance,reinsurance,indemnity,or reimbursement agreement applicable to a loss for which the Insured would be indemnified under this policy,the indemnity under this policy will apply in excess of such other insurance,reinsurance, indemnity or reimbursement and will not contribute to such a loss with such other insurance,reinsurance,indemnity or reimburse- ment.This condition does not apply to other insurance,reinsurance,indemnity,or reimbursement which the Insured has procured to apply in excess of the sum of the Insured's retention and the Insurer's limit of indemnity under this policy. I. Inspection: The Insurer has the right at any time,but is not obliged to inspect the Insured's operations and workplaces.Such inspections are not safety inspections. They relate only to the insurability of the workplaces and the premiums to be charged.The Insurer may give reports to the Insured on the conditions found upon inspection.The Insurer does not undertake to perform the duty of any person to provide for the health or safety of the Insured's employees or the public.The Insurer does not warrant that the Insured's workplaces are safe or healthful or that they comply with laws, regulations,codes,or standards. EWC-1(a) (11/93) -5- J. Audit The Insured will keep records needed to compute the premium in accordance with Part Six-Premium and send copies of those records when the Insurer asks for such records.The Insured will also send them to the Insurer at the end of each interim policy adjustment period and upon termination of this policy.The Insurer has the right to examine and audit all records of the Insured which relate to this policy,including ledgers,journals,registers,vouchers,contracts,tax reports,disbursement records and programs for storing and retrieving data.Information developed by audit will be used to determine earned and final premium.The Insurer has the right to conduct audits during regular business hours while this policy is in force and within three years after the final settlement of all claims or payments made on account of bodily injury to employees throughout the term of this policy. K. Assignment: An assignment of interest under this policy will not bind the Insurer unless an endorsement assigning interest under this policy is issued by the Insurer to be part of this policy. L. Bankruptcy or insolvency of Insured: Bankruptcy or insolvency of the Insured will not relieve the Insurer of its duties and liabilities under this policy.After the Insured's retention has been reached,payments due under this policy will be made by the Insurer as if the Insured had not become bankrupt or insolvent but not in excess of the Insurer's limit of indemnity.Such payments will be made to the Trustee in Bankruptcy or as a Court of competent jurisdiction may ultimately direct. M. Cancellation: The Insured and the Insurer may cancel this policy at any time by giving written notice to the other not less than thirty(30)days before cancellation is to be effective. Mailing or delivery of this notice to the Insured's address last known to the Insurer or its agent is sufficient to prove evidence of receipt by the Insured.Notices of Cancellation,if not delivered,are to be sent by certified or registered U.S.Postal Service Mail.If the Insured cancels this policy,earned premium will be determined by the customary short rate table in use by the Insurer. If the Insurer cancels this policy,earned premium will be determined by using the customary prorate table. N. Service and Administration: This Agreement contemplates the concurrent and continued existence of a separate service agreement between the Insured and the Service Company named in Item 12 of the Declarations providing services are approved by the Insurer. Cancellation of the service agreement between the Service Company and the Insured shall operate as notice of cancellation of this Agreement by the Insured,subject to the additional terms of the Cancellation Section of this Agreement. O. Sole Representative: If more than one Insured is named in Item 1 of this policy,the Insured first named in Item 1 of the Declarations Page will act on behalf of all Insureds to give or receive notice of cancellation, receive return premium or indemnity, or request change in this policy. P. Policy Conforms to Law: If terms of this policy are in conflict with any law applicable to this policy,this statement amends this policy to conform to such law. Q. Captions: The headings or captions used in this policy are for the purpose of reference only and shall not otherwise affect the meaning of this policy. IN WITNESS WHEREOF,the Insurer has caused this policy to be signed by its President and Secretary in Rock Hill,NY,but this policy shall not be binding on the Insurer unless countersigned by our authorized representative. p 14i/2_ Secretary President EWC-1(a)(11/93) -6- June 4, 1996 Mr. Don Warden Director of Finance & Administration Weld County, Colorado P.O. Box 758 Greeley, CO 80632 RE: Excess Workers' Compensation Policy Policy #FS01105 Term 12/31/95-96 Dear Don: Enclosed is a copy of endorsement#4. Here are the amendments to the policy that this endorsement makes: Endorsement#4. ► Amends the 60 day notice of cancellation to show 90 days. ► Shows the address where the 90 day notice should be mailed: State of Colorado/Division of Labor Workers' Compensation Division 1515 Arapahoe Street Denver, CO 80202-2117 Please review this policy for all terms, conditions, limitations and exclusions and include in your policy folder. Upon review of your policy should you have any questions, feel free to contact me. Sincerely, & 74 Michele Vengas Ben Goldmanis Account Assistant Intern encl: endorsment#4 REVISED ENDORSEMENT #4 It is hereby understood and agreed that endorsement #2 is deleted in its entirety and replaced as follows: 90 D$Y O it E OF '?C�kI+I+r EU TION It is understood and agreed that 211 day notice will be provided to the insured and the State of Colorado/Division of Labor at the address stated below in the event of cancellation. State of Colorado/Division of Labor Workers' Compensation Division 1515 Arapahoe Street Denver, CO 80202 - 211 7 Nothing herein contained shall vary, alter, waive or extend any of the terms, representations, conditions or agreements of the policy other than as above stated. Attached to and forming a part of Policy No. FSO 1105 of the Frontier Insurance Company Issued to Weld County, Colorado , Effective 03/13/96 i n ! /' Autho4ea eprese five Catit wt June 11, 1996 Don Warden Director of Finance & Administration Weld County P.O. Box 758 Greeley, CO 80632 RE: Change to Colorado Auto Accident Reparations Act Dear Don: The Colorado State Senate has recently passed Senate Bill 96-078 which effects changes in the Colorado Accident Reparations Act, and which have a substantial impact on the PIP statute. Please note that Section 6 of the Act will take effect on January 1, 1997, while the remaining portions of the Act shall take effect on August 1, 1996. Please review the enclosed copy of the Act, and feel free to contact our office with any questions you may have. Sincerely, u er 0. Correspondence only John P. McLaughlin Vice President - Risk Management Services :JPM/mv :Enclosure Juno II.1996 1996 nact )) ,__...../, SENATE BILL 96-078 BY SENATORS Johnson, Alexander, Casey, Dennis, Feeley, Hernandez, Hopper, Martinez, Matsunaka, Meiklejohn, Norton, Pascoe, L. Powers, R. Powers, Rizzuto, Rupert, Schaffer, Schroeder, Tanner, Tebedo, Thiebaut, Wattenberg, Weddig, and Wham; also REPRESENTATIVES Foster, Leyba, and Mace. CONCERNING THE PROVISION OF SERVICES IN CONJUNCTION WITH A CLAIM UNDER A POLICY ISSUED PURSUANT TO THE "COLORADO AUTO ACCIDENT REPARATIONS ACT", AND MAKING AN APPROPRIATION IN CONNECTION THEREWITH. Be it enacted by the General Assembly of the State of Colorado: SECTION 1. 10-3-207 (1) , Colorado Revised Statutes, 1994 Repl . Vol . , as amended, is amended BY THE ADDITION OF A NEW PARAGRAPH to read: 10-3-207. Fees paid by insurance companies. (1) (d) IN ADDITION TO ANY FEE COLLECTED UNDER PARAGRAPH (a) OR (b) OF THIS SUBSECTION (1) , EVERY INSURANCE ENTITY AUTHORIZED TO WRITE PRIVATE PASSENGER AUTOMOBILE INSURANCE COVERAGE SHALL PAY AN ANNUAL FEE NOT TO EXCEED FOUR HUNDRED DOLLARS TO FUND THE COSTS OF ESTABLISHING AND ADMINISTERING THE PIP EXAMINATION PROGRAM ESTABLISHED IN SECTION 10-4-706. SUCH FEE SHALL BE SET BY RULE PROMULGATED BY THE COMMISSIONER. FEES COLLECTED UNDER THIS PARAGRAPH (d) SHALL BE TRANSMITTED TO THE STATE TREASURER, WHO SHALL CREDIT THE SAME TO THE DIVISION OF INSURANCE CASH FUND, CREATED IN SECTION 10-1-103 (3) . SECTION 2. 10-4-706 (1) (b), Colorado Revised Statutes, 1994 Repl . Vol . , is amended to read: Capital letters indicate new material added to existing statutes; dashes through words indicate deletions from existing statutes and such material not part of act. 10-4-706. Required coverages - complying policies - PIP examination program. (1) Subject to the limitations and exclusions authorized by this part 7, the minimum coverages required for compliance with this part 7 are as follows: (b) (I) Compensation without regard to fault, up to a limit of fifty thousand dollars per person for any one accident, for payment of all reasonable and necessary expenses for medical , chiropractic, optometric, podiatric, hospital , nursing, X-ray, dental , surgical , ambulance, and prosthetic services, and nonmedical remedial care and treatment rendered in accordance with a recognized religious method of healing, performed within five years after the accident for bodily injury arising out of the use or operation of a motor vehicle; EXCEPT THAT, TO THE EXTENT THAT THE BENEFITS OFFERED PURSUANT TO PARAGRAPH (c) OF THIS SUBSECTION (1) HAVE NOT BEEN EXHAUSTED, THE REMAINING VALUE OF SUCH BENEFITS SHALL BE AVAILABLE TO THE INSURED OR INJURED PERSON ENTITLED TO BENEFITS FOR TREATMENT PURSUANT TO THIS PARAGRAPH (b) . (II) FOR PURPOSES OF THIS PARAGRAPH (b), THE TREATMENT OF NEUROLOGIC INJURIES ALSO KNOWN AS CLOSED-HEAD INJURIES AND THEIR SEQUELAE, TEMPOROMANDIBULAR JOINT DISORDER, CRANIOMANDIBULAR DISORDER, VESTIBULAR, AUDITORY, OR VISUAL DISORDERS, PSYCHOLOGICAL DISORDERS, AND COGNITIVE DISORDERS, THAT ARE REASONABLE, NECESSARY, AND ARISING OUT OF THE USE OR OPERATION OF A MOTOR VEHICLE, SHALL BE CONSIDERED COVERED MEDICAL OR DENTAL PROCEDURES. SECTION 3. 10-4-706 (1) (c) , Colorado Revised Statutes, 1994 Repl . Vol ., is amended BY THE ADDITION OF A NEW SUBPARAGRAPH to read: 10-4-706. Required coverages - complying policies - PIP examination program. (1) Subject to the limitations and exclusions authorized by this part 7, the minimum coverages required for compliance with this part 7 are as follows: (c) (I.5) FOR PURPOSES OF THIS PARAGRAPH (c), THE TREATMENT OF NEUROLOGIC INJURIES ALSO KNOWN AS CLOSED-HEAD INJURIES AND THEIR SEQUELAE, TEMPOROMANDIBULAR JOINT DISORDER, CRANIOMANDIBULAR DISORDER, VESTIBULAR, AUDITORY, OR VISUAL DISORDERS, PSYCHOLOGICAL DISORDERS, AND COGNITIVE DISORDERS, ARISING OUT OF THE USE OR OPERATION OF A MOTOR VEHICLE, THAT CONTRIBUTES SUBSTANTIALLY TO REHABILITATION, AND WHOSE COST IS REASONABLE IN RELATION TO ITS PROBABLE REHABILITATIVE EFFECT, SHALL BE CONSIDERED A COVERED REHABILITATION TREATMENT OR PROCEDURE. SECTION 4. 10-4-706 (2) , Colorado Revised Statutes, 1994 Repl . Vol . , is amended BY THE ADDITION OF THE FOLLOWING NEW PARAGRAPHS to read: 10-4-706. Required coverages — complying policies — PIP examination program. (2) (h) WITHIN A COUNTY HAVING A POPULATION PAGE 2-SENATE BILL 96-78 IN EXCESS OF ONE HUNDRED THOUSAND, ACCORDING TO THE MOST RECENT CENSUS, NO INSURED OR INJURED PERSON ENTITLED TO BENEFITS WHO IS REQUIRED BY A CONTRACT WITH AN INSURER TO RECEIVE THE BENEFITS DESCRIBED IN PARAGRAPHS (b) AND (c) OF SUBSECTION (1) OF THIS SECTION THROUGH MANAGED CARE ARRANGEMENTS SHALL BE REQUIRED TO TRAVEL MORE THAN THIRTY MILES FROM THAT PERSON'S RESIDENCE TO ANY NETWORK PROVIDER OF CARE FOR TREATMENT WITHOUT HIS OR HER CONSENT. THE INSURER SHALL PAY THE REASONABLE AND NECESSARY COST OF TRANSPORTING THE INSURED OR INJURED PERSON ENTITLED TO BENEFITS. (i) ANY HEALTH CARE PROFESSIONAL WHO REFERS AN INSURED OR INJURED PERSON ENTITLED TO BENEFITS FOR DIAGNOSIS OR TREATMENT TO A FACILITY IN WHICH THE PROFESSIONAL HAS A FINANCIAL INTEREST AS AN OWNER, PARTNER, OR EMPLOYEE SHALL DISCLOSE SUCH INTEREST IN WRITING AT THE TIME OF THE REFERRAL TO THE INSURED OR INJURED PERSON ENTITLED TO BENEFITS, TO THE INSURER AND, IF APPLICABLE, TO THE MANAGED CARE ORGANIZATION. SECTION 5. 10-4-706 (4) , Colorado Revised Statutes, 1994 Repl . Vol . , is amended, and the said 10-4-706 is further amended BY THE ADDITION OF A NEW SUBSECTION, to read: 10-4-706. Required coverage - complying policies - PIP examination program. (4) (a) An insurer issuing policies providing coverages as set forth in this section shall provide written explanations of all available coverages prior to issuing any policy to an insured. After a named insured selects a policy with desired personal injury protection coverage, an insurer shall not be under any further obligation to notify such policyholder in any renewal or replacement policy of the availability of a basic personal injury protection policy or of any alternative personal injury protection coverage. (b) UPON RECEIPT OF A NOTICE FROM AN INSURED OR INJURED PERSON ENTITLED TO BENEFITS THAT A PIP CLAIM IS BEING MADE, THE INSURER SHALL FURNISH TO THE INSURED OR INJURED PERSON ENTITLED TO BENEFITS A FACT SHEET ENUMERATING THE RIGHTS OF SUCH PERSON TO PIP BENEFITS. THE FACT SHEET SHALL ALSO SET OUT DEADLINES BY WHICH THE INSURED OR INJURED PERSON ENTITLED TO BENEFITS IS REQUIRED TO FILE NECESSARY DOCUMENTS OR FORMS WITH THE INSURER AND SHALL PROVIDE A TELEPHONE NUMBER THAT THE INSURED OR INJURED PERSON ENTITLED TO BENEFITS CAN USE TO TELEPHONE THE INSURER. (4.5) ALL MEDICAL DEVICES OR MEDICAL EQUIPMENT PROVIDED TO AN INSURED OR INJURED PERSON ENTITLED TO BENEFITS, AS PART OF SUCH PERSON'S BENEFITS PURSUANT TO PARAGRAPHS (b) AND (c) OF SUBSECTION (1) OF THIS SECTION OR THE EQUIVALENT UNDER SUBSECTION (2) OR (3) OF THIS SECTION, SHALL BE THE PROPERTY OF THE INSURED AND SHALL NOT BE REQUIRED TO BE SURRENDERED TO THE INSURER, UNLESS SUCH MEDICAL DEVICE OR MEDICAL EQUIPMENT WAS RENTED OR LEASED BY THE INSURER, OR UNLESS SUCH MEDICAL DEVICE OR MEDICAL EQUIPMENT IS OF A TYPE COMMONLY FOUND AT A HEALTH, EXERCISE, OR ATHLETIC FACILITY. PAGE 3-SENATE BILL 96-78 SECTION Revised Statutes,Vol . , is amended BYO THE 7 rADDITIONOF�A NEW SUBSECTION to9read:94 Pl 10-4-706. Required coverage - complying policies - PIP examination program. (6) (a) THE GENERAL ASSEMBLY DIRECTS THE COMMISSIONER TO PROMULGATE A RULE, PURSUANT TO THE "STATE ADMINISTRATIVE PROCEDURES ACT", ARTICLE 4 OF TITLE 24, C.R.S. , ESTABLISHING A PIP EXAMINATION PROGRAM FOR THE PURPOSE OF TIMELY INVESTIGATION AND RESOLUTION OF DISPUTED PIP CLAIMS SUBMITTED TO AN INSURANCE COMPANY UNDER THIS PART 7. THE PIP EXAMINATION PROGRAM SHALL BE THE EXCLUSIVE METHOD FOR OBTAINING AN INDEPENDENT MEDICAL EXAMINATION FROM A HEALTH CARE PRACTITIONER OTHER THAN A TREATING PROVIDER RELATING TO A DISPUTED PIP CLAIM, EXCEPT AS PROVIDED IN PARAGRAPH (c) OF THIS SUBSECTION (6) . (bLICENSED) THE PIP HEALTH CARE PRACTITIONERS TON PROGRAM PROVIDE GROUP OF THAT SHALL BE KNOWN AS THE PIP EXAMINATION REVIEW PANEL. THE COMMISSIONER SHALL UTILIZE SUCH PUBLIC AND PRIVATE RESOURCES AS ARE AVAILABLE AND APPROPRIATE IN DETERMINING STANDARDS AND QUALIFICATIONS FOR THE PIP REVIEW PANEL MEMBERS. A HEALTH CARE PRACTITIONER PARTICIPATING IN THE PIP REVIEW PANEL SHALL BE ACTIVELY ENGAGED IN THE PRACTICE OF HIS OR HER PROFESSION AND A MAJORITY OF SUCH PRACTICE AND INCOME SHALL NOT DERIVE FROM WITNESS FEES AND EXAMINATIONS OF PERSONS NOT UNDER THE PRACTITIONER'S CARE AND TREATMENT. IT SHALL BE THE DUTY OF THE PIP EXAMINATION REVIEW PANEL TO PERFORM THE PIP EXAMINATIONS AT THE REQUEST OF THE COMMISSIONER. BENEFIT(c) ANY I INJURED ENTITLED SHAS THE RIGHT TO OBTAIN A PIP EXAMINAT ON WITH A HEALTH CARE PRACTITIONER FROM THE PIP EXAMINATION REVIEW PANEL REGARDING EACH TYPE OF TREATMENT INVOLVED IN THE DISPUTED PORTION OF THE PIP CLAIM; EXCEPT THAT THIS PARAGRAPH (c) SHALL NOT APPLY TO AN INSURER PROVIDING PIP COVERAGE THROUGH MANAGED CARE ARRANGEMENTS, PURSUANT TO SUBSECTION (2) OF THIS SECTION. THE REQUESTING PARTY, WHEN SUBMITTING A REQUEST FOR A PIP EXAMINATION, SHALL SPECIFY THE PROFESSIONAL SPECIALTY OF THE HEALTH CARE PRACTITIONER WHO WILL PERFORM THE PIP EXAMINATION. WHERE PRACTICAL, SUCH PROFESSIONAL SPECIALTY SHALL BE THE SAME AS THAT OF THE TREATING HEALTH CARE PRACTITIONER WHOSE TREATMENT AND OPINION ARE INTENDED TO BE REVIEWED BY THE MEMBER OF THE PIP REVIEW PANEL; EXCEPT THAT PSYCHIATRISTS, PSYCHOLOGISTS, AND NEUROPSYCHOLOGISTS MAY REVIEW ONE ANOTHER'S TREATMENT AND OPINIONS TO THE EXTENT THAT THE REVIEWING EXPERT IS QUALIFIED TO ADDRESS THE SPECIFIC ISSUES WHICH ARISE IN A PARTICULAR CASE. NOTHING IN THIS SECTION SHALL PRECLUDE A MANAGED CARE ORGANIZATION FROM USING ITS USUAL AND CUSTOMARY REVIEW PROCEDURES. (d) THROUGH A REVOLVING SELECTION PROCESS ESTABLISHED BY RULE, THE COMMISSIONER SHALL PREPARE A LIST OF FIVE HEALTH CARE PRACTITIONERS, QUALIFIED TO PERFORM THE PIP EXAMINATION. AND SUBMIT IT TO THE REQUESTING PARTY. WITHIN FIVE DAYS OF RECEIPT, PAGE 4-SENATE BILL 96-78 THE REQUESTING PARTY SHALL STRIKE TWO NAMES FROM THE LIST, AND SUBMIT IT TO THE OPPOSING PARTY. WITHIN FIVE DAYS OF RECEIPT, THE OPPOSING PARTY SHALL STRIKE TWO NAMES FROM THE LIST. THE OPPOSING PARTY SHALL IMMEDIATELY RETURN THE LIST TO THE COMMISSIONER. THE INSURER AND INSURED OR THE INJURED PERSON ENTITLED TO BENEFITS MAY AGREE UPON A HEALTH CARE PRACTITIONER TO PERFORM THE PIP EXAMINATION WITHOUT USING THE REVOLVING SELECTION PROCESS. UPON THE SELECTION OF THE HEALTH CARE PRACTITIONER, THE PIP EXAMINATION SHALL PROCEED AND THE REQUESTING PARTY SHALL PAY THE COSTS OF THE EXAMINATION.HE PIP WHETHERe)THETTREATMENTEALTH THAT HASRE BEENARENDEREDRTOSTHEL INSURED ONE RINJURED PERSON ENTITLED TO BENEFITS IS REASONABLE, NECESSARY, AND IF SUCH CLAIMED INJURY OR CONDITION ARISES OUT OF THE USE OF A MOTOR VEHICLE. (f) A HEALTH CARE PRACTITIONER WHO PERFORMS A PIP EXAMINATION PURSUANT TO THIS SUBSECTION (6) SHALL BE IMMUNE FROM CIVIL LIABILITY IN ANY ACTION BROUGHT BY ANY PERSON BASED UPON SUCH PRACTITIONER'S FINDINGS, OPINIONS, AND CONCLUSIONS, ABSENT THE SHOWING OF MALICE OR BAD FAITH ON THE PART OF THE EXAMINING HEALTH CARE PRACTITIONER. (g) IN THE EVENT THE FINDINGS, OPINIONS, AND CONCLUSION OF THE PIP REVIEW PANEL MEMBER ARE CONTRARY TO THE STATEMENT OF CAUSATION, DIAGNOSIS, PROGNOSIS, PLAN OF TREATMENT, OPINIONS, OR RECOMMENDATIONS OF THE TREATING PRACTITIONER WHOSE ACTIONS HAVE BEEN REVIEWED, ANY PARTY DISSATISFIED WITH SUCH FINDINGS, OPINIONS, AND CONCLUSIONS MAY SEEK AND PAY FOR A SECOND PIP EXAMINATION UNDER THE PROCEDURES SET FORTH IN PARAGRAPHS (c) AND (d) OF THIS SUBSECTION (6) . (h) IN ANY THE ARBITRATION JUDICIAL PROCEEDING COMMENCED INSURER, INSURED, OR THEINJUREDPERSONENTITLED TO BENEF TS, THE FINDINGS, OPINIONS, AND CONCLUSIONS OF THE PIP EXAMINATION SHALL BE PRESUMED TO BE CORRECT, BUT SUCH PRESUMPTION MAY BE REBUTTED BY A PREPONDERANCE OF THE EVIDENCE. IF THERE HAS BEEN A SECOND PIP EXAMINATION PURSUANT TO PARAGRAPH (g) OF THIS SUBSECTION (6) , THE AGREED UPON FINDINGS, OPINIONS, AND CONCLUSIONS OF TWO OF THE THREE HEALTH CARE PRACTITIONERS SHALL BE BINDING UNLESS REBUTTED BY CLEAR AND CONVINCING EVIDENCE IN ANY ARBITRATION OR JUDICIAL PROCEEDING COMMENCED BY THE INSURER, THE INSURED, OR INJURED PERSON ENTITLED TO BENEFITS. NO CIVIL PROCEEDING, INCLUDING BUT NOT LIMITED TO, A PROCEEDING ALLEGING ANY CAUSE OF ACTION UNDER SECTION 10-4-708, OR THE TORT OF BAD FAITH BREACH OF THE INSURANCE CONTRACT, ARISING OUT OF ANY ACTION TAKEN BY THE INSURER THAT IS CONSISTENT WITH THE AGREED UPON FINDINGS, OPINIONS, AND CONCLUSIONS OF TWO OF THE THREE HEALTH CARE PRACTITIONERS SHALL BE BROUGHT OR MAINTAINED AGAINST THE INSURER; EXCEPT THAT THE INSURED OR INJURED PERSON ENTITLED TO BENEFITS MAY BRING A CIVIL PROCEEDING ALLEGING THAT CLEAR AND PAGE 5-SENATE BILL 96-78 CONVINCING EVIDENCE REBUTS.THE FINDINGS, OPINIONS, AND CONCLUSIONS OF TWO OF THE THREE HEALTHCARE PRACTITIONERS. IF THE INSURED OR INJURED PERSON ENTITLED TO BENEFITS IS SUCCESSFUL, THE NO-FAULT INSURER SHALL BE OBLIGATED TO PAY ONLY THE NO-FAULT BENEFITS THAT HAD BEEN DENIED AND THAT WERE THE SUBJECT OF SUCH PROCEEDING. PRIOR I EXAMINATION PANEL RULE, THE COMMISSIONER SHALL APPOINT A PIP EXAMINATION REVIEW PANEL ADVISORY COMMITTEE TO ASSIST THE COMMISSIONER. SUCH COMMITTEE SHALL CONSIST OF APPROPRIATE REPRESENTATION FROM COLORADO LICENSED PHYSICIANS, COLORADO LICENSED CHIROPRACTORS, THE COLORADO HOSPITAL ASSOCIATION, INSURERS LICENSED TO DO BUSINESS IN COLORADO, THE COLORADO DEFENSE LAWYERS ASSOCIATION, THE COLORADO TRIAL LAWYERS ASSOCIATION, CONSUMERS OF AUTOMOBILE INSURANCE, AND ANY OTHERS THE COMMISSIONER DEEMS NECESSARY. (j) THE COMMISSIONER SHALL HAVE THE AUTHORITY TO CONTRACT WITH ANY PERSON OR ENTITY TO DEVELOP THE RULE AND FOR THE ADMINISTRATION OF THE PIP EXAMINATION PROGRAM. SECTION 7. 10-4-708, Colorado Revised Statutes, 1994 Repl . Vol . , as amended, is amended BY THE ADDITION OF A NEW SUBSECTION to read: 10-4-708. Prompt payment of direct benefits. (1.3) THE GENERAL ASSEMBLY DIRECTS THE COMMISSIONER OF INSURANCE TO PROMULGATE A RULE, PURSUANT TO THE "STATE ADMINISTRATIVE PROCEDURES ACT", ARTICLE 4 OF TITLE 24, C.R.S., TO ESTABLISH GUIDELINES FOR THE TIMELY PAYMENT OF PERSONAL INJURY PROTECTION BENEFITS INCLUDING THE PENALTIES FOR THE FAILURE TO TIMELY PAY SUCH BENEFITS OR TO OTHERWISE COMPLY WITH THE RULE. THE GUIDELINES FOR TIMELY PAYMENT ESTABLISHED BY RULE SHALL INCLUDE AT THE MINIMUM A LIST OF THE ITEMS NECESSARY, IN ADDITION TO THE REQUIREMENTS SET FORTH IN SECTION 10-4-706, TO ESTABLISH PROOF OF THE FACT AND AMOUNT OF EXPENSES INCURRED AND SPECIFICALLY INCORPORATING THE NOTICE REQUIREMENTS OF SECTION 10-4-708.5 AND THE PROVIDER OBLIGATIONS IN SECTION 10-4-708.6. SUCH GUIDELINES SHALL ALSO PROVIDE FOR THE COMMENCEMENT OF INVESTIGATIONS BY INSURERS AFTER RECEIPT OF THE ITEMS LISTED IF PAYMENT OF THE EXPENSES IS NOT MADE WITHIN THIRTY DAYS OF THE ITEMS' RECEIPT, TOGETHER WITH WRITTEN NOTICE TO THE INSURED AND PROVIDER OF THE REASONS THE CLAIM HAS NOT BEEN PAID. SECTION 8. 10-4-708.6, Colorado Revised Statutes, 1994 Repl . Vol ., as amended, is amended BY THE ADDITION OF A NEW SUBSECTION to read: 10-4-708.6. Obligations of persons providing services - penalties - availability and maintenance of records. (3) ANY TREATMENT OR PROCEDURE RECOMMENDED BY A MEMBER OF A MANAGED CARE PROVIDER NETWORK PURSUANT TO SECTION 10-4-706 (1) (b) OR (1) (c) OR THE EQUIVALENT COVERAGE IN SECTION 10-4-706 (2) OR (3) SHALL PAGE 6-SENATE BILL 96-78 BE APPROVED OR DENIED WITHIN TWENTY BUSINESS DAYS AFTER RECEIPT OF ALL INFORMATION DEEMED NECESSARY BY THE MANAGED CARE ORGANIZATION TO APPROVE OR DENY THE REQUESTED TREATMENT OR PROCEDURE. SECTION 9. Appropriation. In addition to any other appropriation, there is hereby appropriated, out of any moneys in the division of insurance cash fund not otherwise appropriated, to the department of regulatory agencies for allocation to the division of insurance, for the fiscal year beginning July 1, 1996, the sum- of one hundred thousand dollars ($100,000) , or so much thereof as may be necessary, for the implementation of this act. SECTION 10. Effective date applicability - nonseverability. Section 6 of this act shall take effect January 1 , 1997, and shall apply-to all personal injury protection claims made on or after such date. No portion of section 6 shall be severable from any other portion of such section. The remainder of this act shall take effect August 1, 1996, and shall apply to all personal injury protection claims made on or after such date. • PAGE 7-SENATE BILL 96-78 SECTION 11. Safety clause. The general assembly hereby finds, determines, and declares that this act is necessary for the immediate preservation of the public peace, health, and safety. Orton �.eS., ry PRESIDENT OF SPEAI OF OUSE THE SENATE 0 REPRESS ATIVES -777 Cart-c. cdoan M. Albi 9Judith M. Rodri ue SECRETARY OF CHIEF CLERK OF THE HOUSE THE SENATE OF REPRESENTATIVES APPROVED Q! / 9'4/ tt /. Qs p. Roy Romer GOVERNO THE STATE OF COLORADO PAGE 8-SENATE BILL 96-78 • AO/N:D® CERTIFICATE OF INSURANCE 1DATE(PRAVDD/TY) /30/1996 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Arthur J. Gallagher & CO. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 24809 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Denver, CO 80224 COMPANIES AFFORDING COVERAGE (303) 773-9999 COMPANYA RELIANCE INSURANCE COMPANY INSURED COMPANY OCCUPATIONAL HEALTH CARE MGMT B REPUBLIC WESTERN 700 BROADWAY SUITE 1132 COMPANY C DENVER CO 80273 COMPANY D :COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MM/ODNY) DATE(MMNDNY) GENERAL LIABILITYGENERAL AGGREGATE $2,000,000 A X COMMERCIAL GENERAL LIABILITY OB12121739 09/01/95 09/01/96 PRODUCTS-COMP/OP AGG $2,000,000 CLAIMS MADE LXJ OCCUR PERSONAL&ADV INJURY $1,000,000 OWNER'S&CONTRACTOR'S PROT • OEACH OCCURRENCE s1,000,000 X AGG APPLIES FIRE DAMAGE(My one fire) $1,000,000 PER LOCATION MED EXP(Any one person) $10,000 AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT $ ANY AUTO ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) I PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ WORKERS COMPENSATION AND X STATUTORY LIMITS B EMPLOYERS'LIABILITY RWC0655417 09/01/95 09/01/96 EACH ACCIDENT $1,000,000 THE PROPRIETOR/ INCL DISEASE-POLICY LIMIT $1,000,000 PARTNERS/EXECUTIVE OFFICERS ME'. EXCL DISEASE-EACH EMPLOYEE $1,000,000 OTHER A FINANCIAL B241-58-48 06/01/95 06/01/96 $1, 000, 000 LIMIT INSTIT. BOND $ 25, 000 DED DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS CERTIFICATE HOLDER CANCELi ATIiN:i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, WELD COUNTY BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY DON WARDEN, DIR. OF FINANCE & ADM. OF A IND N THE COMPANY, ITS AGENTS OR REPRESENTATIVES. 915 10TH STREET/P.O. BOX 758 AUTOO R T tor GREELE3 CO 80632 ACORO (3193)::........:.:::::..:::::::::••:•••••••••••••••• • :•:•: • :'...• eAGORD CORPORA ION 1993 ?. Authorized Representative,BMdOTS,Cedifeales ony ROCKY MOUNTAIN HEALTH CARE CORPORATION, ET AL NAMED INSUREDS COLORADO • Rocky Mountain Health Care Corporation • Rocky Mountain Hospital & Medical Services, DBA Blue Cross and Blue Shield of Colorado • Rocky Mountain Life Insurance Company • Consolidated Insurance, Inc. • Rocky Mountain Holding Company • Health Management Systems, Inc. • H.M.O. Colorado, Inc. • Occupational Health Care Management Services, Inc. • General Health Corporation NEW MEXICO • New Mexico Blue Cross and Blue Shield, Inc., AKA Blue Cross and Blue Shield of New Mexico • H.M.O. New Mexico, Inc. • Medical Communications Systems, Inc. NEVADA • Blue Cross and Blue Shield of Nevada • Nevada Group Services, Inc. • H.M.O. Colorado, Inc. DBA H.M.O. Nevada 950219 M:\CIJENT.SCN\RMHCC\RM-NAMED.INS January 30.1996 Page 1 of 1 (As of 08(95) G March 31, 1997 Mr. Don Warden Director of Finance and Administration Weld County, Colorado P.O. Box 758 Greeley, CO 80631 Re: Specific Excess Workers' Compensation Audit Policy #FSO 1105 Dear Don: Enclosed is your Workers' Compensation audit for the above captioned policy for the period of 12/31/95 to 12/31/96. This audit was computed using actual payroll figures as shown and resulted in additional premium of $778.00, and invoice #4209 is also enclosed for this amount. Please remit payment by April 15, 1997 (yes, that day). If for any reason you disagree with the payroll figures used to compute this audit, please contact our office immediately. We have only 30 days to dispute an audit to the Company. If we do not hear from you within the next two (2) weeks, we will assume the audit is accepted and the figures used are correct. If we may be of any assistance, please contact Karen Graham or me. Yours very truly, ��e . Pat Person, MS Account Assistant N:\FMS-AV\PFP\WELD\WOFKCOM\AUDIT.LET 3/31/97 ENDORSEMENT #6 IN tl„ AUDIT END RSEMENT FROM 12/31/95 TO 12/31/96 Item 8. Classifications of Operations: Actual Rate of per $100 Actual Code Classification Payroll Of Payroll Premium 5506 Street or Road $ 3,224,892. 16.74 $ 539,847. 7382 Transit Authority $ 284,007. 13.77 $ 39,108. 7720 Policemen/Ambulance $ 6,616,293. 4.75 $ 314,274. 8742 Salesmen Outside $ 2,182,257. 0.81 $ 17,676. 8810 Clerical $ 9,998,234. 0.49 $ 48,991. 8831 Animal Control $ 44,680. 2.13 $ 952. 8832 Health Dept. $ 1,389,269. 0.53 $ 7,363. 8868 School $ 1,433,485. 0.68 $ 9,748. 9014 Insect Extermination $ 45,584. 12.20 $ 5,561. 9015 Building Op. $ 610,065. 8.14 $ 49,659. 9101 School - Other $ 482,354. 9.16 $ 44,184. 9410 Munic. Emp. - Other $ 541,317. 1.50 $ 8,120. TOTALS: $26,852,437. $ 1,085,483. Rate: (Per $100 of Payroll): X .1212 Earned Premium: $ 32,545. Deposit Premium: $ 31,767. Addl. Premium: $ 778. Nothing herein contained shall vary,alter,waive or extend any of the terms, representations, conditions or agreements of the policy other than as above stated. Attached to and forming a part of Policy No. FSO 1105 of the Frontier Insurance Company Issued to Weld County, Colorado �:f`"�' Effective 12/31/96 y Authorjkedt presentXti,�J ve 7393-0 INVOICE ARTHUR J. GALLAGHER & CO. - DENVER ANIMAS POST OFFICE BOX 24809 \L AI* DENVER. CO 80224 PH. (303) 773-9999 All premiums payable on or before effective date of policy. ACCOUNT NO. DATE 01426 P05 03/31/97 Weld County, Colorado INVOICE NO COMP. NO P.O. Box 758 04209 C17 165 Greeley CO 80632 COV/CHG DATE 12/31/95 PLEASE RETURN THIS PORTION TO INSURE INSURED PROPER CREDIT. NAME THANK YOU! PLEASE DE:rACH AND RETURN THIS PORTION VA;HYOJnREMITTANCE. PAYMENT ENCLOSED r EFFECTIVE INSURED POLICY NUMBER DESCRIPTIO N AMOUNT DATE TO 12/31/95 12/31/96 FSO 1105 Worker's Comp Audit $778.00 -INV: 04209 CLIENT: 01426 AMOUNT DUE AGENCY $778.00 ! Retain 8ottorn Halt for Your Records' ARTHUR J. GALLAGHER & CO. - DENVER Hello