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Home My WebLink About000175 /Pet( /4 NATIONAL UNION i z r 3i „tea FIRE INSURANCE COMPANY OF PITTSBURGH, PA. pT ECTIp QR N :- A CAPITAL STOCK COMPANY 70 PINE STREET, NEW YORK, N.Y. 10270 (Executive Offices) APPLICATION FOR SPECIFIC EXCESS WORKER'S COMPENSATION AND EMPLOYERS' LIABILITY COVERAGE 1. Name of Employer: WELD COUNTY, COLORADO 2. Address: P.O. Box 758 GREELEY, CO 80632 3. List all Subsidiaries to be Covered: 4. Description of Employer's Operations: County Government 5. List any Operation that will be excluded from coverage: None 6. In what State(s) does the Employer operate as a qualified self-insured? Colorado a) Date Qualified: 1978 7. Description of all locations (use separate sheet if necessary): County Facilities Location Construction Operation TO BE PROVIDED UPON REQUEST 8. a) Limit of Liability Desired: Coverage A - WC Statutory Coverage B - EL $1,000,000 b) Retention (Per Accident): $300,000 SIR -1 - 175 2=9(6194 9. Effective Date of Coverage: From: 12/31/94 To: 12/31/95 10. Present Carrier: National Union Fire Ins. Rate: .1516 Limit of Liability: A:Statutory/s:$1,000,000 Retention: $300,000 11. Claims Service will be provided by: a) Company Employees? How Long Experienced? b) Outside Law Firm? Name: Give details on experience in compensation claims handling: x c) Service Organization? Name: OHMS May we examine the Employer's claims handling procedures at any time? Yes 12. Is a full time company doctor used? Yes If not, what facility is available? Designated Provider Are registered nurses used? 13. Does the Employer have a rehabilitation program? Yes If yes, describe: Vendors are used when necessary 14. Does the Employer have an accident prevention program? Yes If yes, explain: Handled in-house by Dave Warden, Human Resources 15. Does the Employer have a full time safety engineer? Yes, Dave Wardon 16. Give the following information regarding each state to be included in the proposed coverage (Use separate sheet if necessary): Estimated Annual Payroll for Manual Manual State Classifications Code No. Ensuing Year Rate Premium SEE ATTACHED _2- 23019(6/92) 17. a) Give the following prior experience for past five (5) years: Medical Medical Liability Period Claims Indemnity Indemnity Payments Payments (From To ) Frequency Paid Reserved Made Reserved Total SEE ATTACHED b) Describe all individual accidents occurring within the last five (5) years with costs or reserves in excess of $25,000. (Use separate sheet if necessary): Date of Accident Description Paid or Open Amount SEE ATTACHED 19. Describe any occupational disease hazard: None 19. a) During the policy term, will the Employer own, charter or lease any aircraft or watercraft? Yes If yes, describe use, type, number of crew members, pilot data, passenger capacity, model, etc. (Use separate sheet if necessary): Lease aircraft with crew to transport prisoners. b) What is the maximum number of employees allowed by the Employer on an industrial aid or commercial aircraft: N/A 20. Does the Employer have any railroad operations? No If yes, are any of the employees entitled to Federal Employee Liability Act Benefits? Nn If yes, give details: -3- 23018(8/82) 21. Does Employer have any operations subject to the U.S. Longshoremen's and Harbor Worker's or Junes Acts? If yes, give details: No 22. During the past three (3) years, has any insurer cancelled or refused to renew the Employer's Compensation Policy(ies)? No if yes, give name of the insurer and reason: 23. Remarks: The applicant hereby represents that to the best of his/her knowledge the statements set forth in this application are true. If the information supplied on this application changes between the date of the application and the time when the policy is issued, the applicant will immediately notify the Company. NOTICE TO NEW YORK AND OHIO APPLICANTS: "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime." This application does not bind the applicant or the Company to complete the insurance, but it is agreed that this form shall be the basis of the contract should a policy be issued and will be attached to and made part of the policy. Completion of this application by the Employer does not obligate this Company to provide insurance either on the basis requested or on any other basis. Date: /7Z/017r Employe . i Weld C4 my„ Cpiorado By: 41/4 ministrator AGENT/BROKER: Arthur J. Gallagher & Co. - Denver ADDRESS: 7900 E. Union, #200, Denver, CO 80237 23019(6/92) WELD COUNTY, COLORADO 1994/1995 POLICIES ARTHUR J . GALLAGHER & CO .-DENVER /mat % u-F® s� _ . N ;/ 1 . December 12, 1994 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-Insurors' Bond December 31, 1994 to December 31, 1995 Dear Don, I have enclosed your 1994/95 policy notebook with the Insurance Binder and the Certificate of Insurance to the Division of Labor. I will forward the Workers' Compensation Policy when received from the National Union Insurance. National Union has requested that the enclosed application be signed, dated, and returned. Please return to my attention by January 5, 1995. A self-addressed envelope is provided for your convenience. Please sign and return a copy of the Evidence of Insurance Coverages Bound letter that is following. Should you have any questions or concerns please do not hesitate to contact me. HAPPY HOLIDAYS!! ARTHUR J. GALLAGHER & CO. - DENVER erryann ite, AAI Account ssistant :th enclosures th\C:\W%WELD\WOPKCOM\LETTER.REN December 12,1994 it L I z-/r3/ ,y December 12, 1994 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, 1994 to December 31, 1995 Dear Don, As instructed, we have bound coverage per the enclosed documents for Specific Excess Workers' Compensation and Self-Insurors' 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 errya ite, AAI Account Assistant j Accepted and received by: �� Wzr/ ( ame and Title) Date: th\C'.\WP\WELD\WORKCOM\LETTERECB December 12,1994 ACflI\'/® INSU NCE � INDER ISSUE DATE(MM/DD/YV( 12/07/94 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. PP "IICER COMPANY BINDER NO. ARTTIURJ. GALLAGHER&CO. NATIONAL UNION FIRE INSURANCE CO. 941251 P.O.BOX 24809 DATE EFFECTIVE TIME DATE EXPIRATION TIME DENVER, CO 80224 X AM X 12'01 AM 12/31/94 i' 12:01 PM 03/01/95 NOON (303)773-9999 - JOHN MCLAUGIIIJN THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED X COMPANY PER EXPIRING POLICY NO 415-4670 CODE SUB-CODE DESCRIPTION OF OPERATIONS/VEHICLE/PROPERTY (Including Location) INSURED WELD COUNTY, COLORADO P.O.BOX 758 GREELEY,, CO 80632 COVERAGES LIMITS TYPE OF INSURANCE COVERAGE/FORMS AMOUNT DEDUCTIBLES COINSUR PROPERTY CAUSES OF LOSS BASIC BROAD /SPEC. GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ ': :OCCUR: :PERSONAL&ADV.INJURY $ CLAIMS MADE OWNER'S&CONTRACTOR'S PROT. : BEACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ RETRO DATE FOR CLAIMS MADE: / / !MED.EXPENSE(Any one person) $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) :$ BODILY INJURY(Per accident) .$ ALL OWNED AUTOS SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS MEDICAL PAYMENTS :$ NON-OWNED AUTOS PERSONAL INJURY PROT. .$ :(GARAGE LIABILITY UNINSURED MOTORIST :$ AUTO PHYSICAL DAMAGE ALL VEHICLES SCHEDULED VEHICLES ACTUAL CASH VALUE DEDUCTIBLE COLLISION. !(STATED AMOUNT $ OTHER THAN COL'. OTHER EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: / / SELF-INSURED RETENTION $ REFER TO THE ATTACHED STATUTORY LIMITS WORKER'S COMPENSATION EACH ACCIDENT $ REFER AND EMPLOYER'S LIABILITY DISEASE-POLICY LIMIT $ TO THE DISEASE-EACH EMPLOYEE $ ATTACH SPECIAL CONDITIONS/OTHER COVERAGES SPECIFIC EXCESS WORKERS'COMPENSATION-PER THE ATTACHED. NAME&ADDBESS MORTGAGEE ;ADDITIONAL INSURED f LOSS PAYEE LOAN# AUTHORIZ PR if ACORD 16,S{1/9A} gi ACORD CORPORATION 1990 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 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 sus- tained therefrom. ACORD 75S(2/88) WELD COUNTY, COLORADO SPECIFIC EXCESS WORKERS' COMPENSATION COVERAGE Limits: Workers' Compensation Statutory Employers Liability $ 1,000,000 Retentions: $ 300,000 $ 500,000 USL&H Adjustable Rate: .1516 Adjustable Basis (Payroll): $ 24,335,495 Terms/Conditions: • Claims expenses included in definition of loss • U.S. L & H - Included • All States Endorsement • No Commutation Clause • No Asbestos Exclusions • Board Members Included • No Aircraft and Water Exclusions • Bankruptcy/Insolvency Clause 94-1106 WC-WCDND.ATT December 7.1994 Page 1 of 1 ARTHUR J. GALLAGHER & CO. - DENVER P.O. BOX 24809 DENVER, CO 80224 (303)773-9999 FAX (303)773-9776 INSURED: Weld County, Colorado P.O. Box 758 Greeley, CO 80632 BINDER ENDORSEMENT A This endorsement extends the binder expiration date Until Policy Issued as your policy has not yet been received from the insurance company. For attachment to and forming a part of Arthur J. Gallagher & Co. ACORD form 75-S insurance binder # 941251. Effective date: December 31, 1994 Company: National Union Fire Insurance Company Type of Coverage: Specific Excess Workers' Compensation New Expiration Date: Until Policy Issured All other terms and conditions remain the same. Authorized 3Verer,04(41 Date: February 21, 1995 Representative: THIS IS TO BE ATTACHED TO YOUR BINDER. N\HMS.AV\TH\W%WELD\WOHKCOM\BINDER.EXT February 21,1995 CERTIFICATEOF INSURANCE ISSUE DATE(MM/DDNY) 12/08/94 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE ARZHURJ.GALLAGHER&CO. POLICIES BELOW. P.O.BOX 24809 DENVER, CO 80224 COMPANIES AFFORDING COVERAGE (303)773-9999 COMPANY LETTER o'sA NATIONAL UNION FIRE INSURANCE COMPANY JOHN MCLAUGHLIN COMPANY DA INSURED LETTER COMPANY `. WELD COUNTY, COLORADO - LETTER P.O.BOX 758 COMPANY D GREELEY,, CO 80632 LETTER COMPANY E LETTER 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 POUCY EFFECTIVE POLICY EXPIRATION LIMITS LTRDATE(MM/DD/YY) DATE(MM/DD/YY) GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ CLAIMS MADE OCCUR. PERSONAL SADV.INJURY $ OWNER'S&CONTRACTOR'S PROT. EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ MED.EXPENSE(Any one person) $ "UTOMOBILE LIABILITY COMBINED SINGLE ANY AUTO LIMIT ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Person) $ HIRED AUTOS _ BODILY INJURY NON-OWNED AUTOS (Per Accident) $ GARAGE LIABILITY PROPERTY DAMAGE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM A WORKER'S COMPENSATION 415-5237 12/31/94 12/31/95 STATUTORY LIMITS SPECIFIC EXCESS EACH ACCIDENT $ 1,000,000 AND DISEASE-POLICY LIMIT $ EMPLOYER'S LIABILITY DISEASE-EACH EMPLOYEE $ OTHER ORIGINAL MAILED TO CERTIFICATE HOLIER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS SELF INSURED RE'IENITON $300,000 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL asumwowan AHentiOB:MR.JOHN M.BERGEN,ARM CHCM '. MAIL 90 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE DIVISION OF LABOR&EMPLOYMENT,DIV. OF WORKERS'COMP. INSURANCE COMPLIANCE UNIT LEFT, 1120 LINCOLN.STREET, 12TH FL DENVER, CO 80203 'ai' AUTHORIZED REPRESENTATIVE AC0II0 25-S?AO) 4zi ACORD CORPORATION 1990 ARTHUR J. GALLAGHER June 1, 1995 Mr. Don Warden Weld County, Colorado P.O. Box 758 Greeley, CO 80631 Re: Specific Excess Workers' Compensation Policy # 415-52-37 - 12/31/94-95 Term Dear Don: I am happy to enclose your Specific Excess Workers' Compensation policy for the captioned term; this policy replaces binder #941251. I have reviewed this policy for accuracy and it appears to have been issued correctly. Please place this policy in the policy notebook provided when this coverage was bound. The Division of Labor has amended their name and address, so I have requested the following change: • Effective 01/01/95, amend endorsement 54199 (9/92) - Colorado Amendatory Endorsement by changing the authority name and address to reflect: State of Colorado/Division of Labor Workers' Compensation Division Self Management Services 1515 Arapahoe Street, Denver, CO 80202-2117 This change will follow shortly. As an added feature to our policy review, we are now placing a pencil line through any changes in the policy terms and/or conditions and reference is indicated to identify the endorsement that amends that policy term and/or condition. This should help you quickly identify endorsements that alter policy terms and/or conditions. KG\N:\PMS-AV\KG\WELD.CNTIXS-W C\96PoLICV.LTR 7 nlo i Ave.. Suite. 200 fyl ,f ®, Mr. Don Warden June 1, 1995 Page 2 A copy of this policy has also been forwarded to your third party administrator (OHMS). Please review your policy carefully for all terms, conditions, limitations, and exclusions. In particular, please review Part Four - Claims section. Should you have any questions or changes after your review of this policy, please feel free to give me a call. I have also forwarded a copy of this policy to OHMS. We thank you for the opportunity to continue this coverage for Weld County. Sincerely, ARTHUR J. GALLAGHER & CO.-DENVER Karen Graham, CIC Account Manager a John P. McLaughlin, Vice President - Risk Management Services :kg/enclosure KG\N:\RMS-AV\KG\WELD.CNT\XS W C\94POLICY.LTP ARTHUR J. GAL I/.1., June 1 , 1995 Randy Herndon OHMS 700 Broadway, #1132 Denver, CO 80273 Re: Weld County, Colorado 12/31/94 to 12/31/95 Excess Workers' Compensation Policy # 4155237 Dear Randy: I have enclosed a copy of the above policy for your file. Should you have any questions, please feel free to give me a call. Sincerely, ARTHUR J. GALLAGHER & CO.-DENVER Karen Graham, CIC Account Manager c: Mr. Don Warden, Weld County, CO :kg enclosure KG\N'.\RMSAV\/KG\WELD CNT\XS WC\OHMSREN LTR t 1' - NATIONAL UNION POLICY NUMBER: c c� FIRE INSURANCE COMPANY 4155237 OF PITTSBURGH, PA RENEWAL OF: ,.\TECTIO A CAPITAL STOCK COMPANY 4154670 ADMINISTRATIVE OFFICES 70 PINE STREET, NEW YORK, N.Y. 10270-0150 EXCESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INFORMATION PAGE ITEM 1: Named Insured and Mailing Address WELD COUNTY, COLORADO P.O. BOX 758 GREELEY CO 80632-0000 ITEM 2: States (in which coverage is to apply) COLORADO ITEM 3: Policy Period FROM: 12/31/94 TO 12/31/95 12:01 A.M. Standard Time at the Mailing Address shown herein ITEM 4: Our Limit of Indemnity PART ONE: WORKERS COMPENSATION STATUTORY - Each Accident STATUTORY - Each Employee For Disease PART TWO: EMPLOYERS LIABILITY $1 ,000,000 - Each Accident $1 ,000,000 - Each Employee For Disease ITEM 5: Your Retention PART ONE: WORKERS COMPENSATION $300,000 - Each Accident $300,000 - Each Employee For Disease PART TWO: EMPLOYERS LIABILITY $300,000 - Each Accident $300,000 - Each Employee For Disease ITEM 6: Premium and Premium Computation Estimated Total Annual Remuneration $24,335,495 Rates Per $100 of Remuneration 0. 1516 Deposit Premium $36,893 Minimum Premium $36,893 THIS POLICY INCLUDES THESE ENDORSEMENTS: SEE ATTACHED SCHEDULE PRODUCER NAME AND ADDRESS: COUNTERSIGNED BY: ARTHUR J GALLAGHER & CO 7900 EAST UNION AVENUE SUITE # 200 { DENVER CO 8o237-2737 XIfi�;� (AUTHORIZED REPRESENTATIVE) Date Issued 01/13/95 54360(10/92) EXCESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows: GENERAL SECTION A. The Policy This policy includes at its effective date the Information Page and all endorsements listed there. It is a contract of insurance between you (the employer named in Item 1 of the Information Page) and us (the insurer named on the Information Page). 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 endorsement issued by us to be part of this policy. B. Who is Insured You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership or joint venture and if you are a partner in the partnership or a member of the joint venture, you are insured, but only in your capacity as an employer of employees of the partnership or joint venture. C. Workers Compensation Law Workers Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 2 of the Information Page. It includes any amendments to that law which are in effect during the policy period. It does not include any federal workers or workmen's compensation law, any federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D. State State means any state of the United States of America, and the District of Columbia. E. Location This policy covers all of your workplaces in the states listed in Item 2 of the Information Page. F. Qualified Self-Insurer You represent that you are a duly qualified self-insurer under the Workers Compensation Law of each state named in Item 2 of the Information Page and will continue to maintain such qualifications during the term this policy is in effect. If you should terminate such qualifications or if your qualification as a self-insurer is cancelled or revoked while this policy is in force, the amounts payable under this policy will not be increased and you will be responsible for payments within Your Retention. PART ONE WORKERS COMPENSATION INSURANCE A. How This Insurance Applies This insurance applies to losses paid by you as a qualified self-insurer under the Workers Compensation Law for Bodily Injury by Accident or Bodily Injury by Disease. Bodily Injury includes resulting death. 1. Bodily Injury by Accident must occur during the policy period. 2. Bodily Injury by Disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such Bodily Injury by Disease must occur during the policy period. (1) 54361(10/92) —., If you begin work after the effective date of this policy in any state for which you are not insured or are not self-insured for such work, this insurance will apply as though that state were listed in Item 2 of the Information Page but only if you notify us in writing within ninety (90) days from the date you begin such work. B. We Will Indemnify We will indemnify you for your loss as a qualified self-insurer under the Workers Compensation Law in excess of Your Retention as stated in Item 5 of the Information Page but not for more than Our Limit of Indemnity as stated in Item 4 of the Information Page. Loss means amounts actually paid by you as a qualified self-insurer under the Workers Compensation Law and also includes your claim expenses. Your claim expenses are included within Your Retention. Our payments to indemnify you for your claim expenses are included within Our Limit of Indemnity. Your claim expenses mean your litigation costs, interest as required by law on awards or judgments and your claim investigation or legal expenses which can be directly allocated to a specific claim. Claim expenses do not include salaries and travel expenses of your employees, annual retainers, overhead and any fees you paid for claim administration. Your bankruptcy, insolvency or inability to pay will not relieve us from the indemnification of any claim covered by this policy. But under no circumstances will we be required to drop down and replace Your Retention or assume any of your obligations within the retention area. After Your Retention has been reached, indemnification due under this policy will be made by us as if you had not become bankrupt or insolvent but not in excess of Our Limit of Indemnity as stated in Item 4 of the Information Page. Such indemnification will be made to the Trustee in Bankruptcy or as a Court of competent jursidiction may ultimately direct. C. Defense We have no duty to investigate, handle, settle, or defend any claim, suit or proceeding against you. However, we have the right and shall be given the opportunity by you to associate with you in the defense, investigation or settlement of any claim, suit or proceeding which might involve a loss to us. In such an association, you shall promptly cooperate with us in all aspects of defense, investigation or settlement. D. Other Insurance If any other insurance exists protecting you against loss covered by this insurance, this insurance shall apply in excess of the other insurance. However, this provision shall not apply to other insurance which you have procured to apply in excess of the sum of Your Retention and Our Limit of Indemnity under this policy. E. Payments You Must Make You are responsible for any payments in excess of the benefits regularly provided by the Workers Compensation Law including those required because: 1. of your serious and willful misconduct; 2. you knowingly employ an employee in violation of law; 3. you fail to comply with a health or safety law or regulation; 4. you discharge, coerce or otherwise discriminate against any employee in violation of the Workers Compensation Law; or 5. you violate or fail to comply with any Workers Compensation Law. If we make any payments in excess of the benefits regularly provided by the Workers Compensation Law on your behalf, you will reimburse us promptly. (2) 54361(10/92) F. Exclusion We will not indemnify you for any loss arising out of operations for which you have rejected any Workers Compensation Law. G. Recovery From Others We have your rights, and the rights of persons entitled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. Any recovered loss will be allocated as follows: If there is insurance coverage in excess of Our Limit of Indemnity, that insurer's loss will be reimbursed first. The remaining recovered loss, after deducting our recovery expenses, will first be used to reduce our loss. Then we will pay the balance, if any, to you. H. Action Against Us There will be no right of action against us under this insurance unless you have complied with all the terms of this policy. Statutory Provision Terms of this insurance that conflict with the Workers Compensation Law are changed by this statement to conform to that law. PART TWO EMPLOYERS LIABILITY INSURANCE A. How This Insurance Applies This insurance applies to losses paid by you as a qualified self-insurer of Employers Liability for Bodily Injury by Accident or Bodily Injury by Disease. Bodily Injury includes resulting death. 1. The Bodily Injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or incidental to your work in a state or territory listed in Item 2 of the Information Page. 3. Bodily Injury by Accident must occur during the policy period. 4. Bodily Injury by Disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such Bodily Injury by Disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for Bodily Injury by Accident or by Disease must be brought in the United States of America. If you begin work after the effective date of this policy in any state for which you are not insured or are not self-insured for such work this insurance will apply as though that state were listed in Item 2 of the Information Page but only if you notify us in writing within ninety (90) days from the date you begin such work. B. We Will Indemnify We will indemnify you for loss as a qualified self-insurer of Employers Liability in excess of Your Retention as stated in Item 5 of the Information Page but not for more than Our Limit of Indemnity as stated in Item 4 of the Information Page. (3) 54361(10/92) „ Loss means amounts which you legally paid as damages as a qualified self-insurer because of Bodily Injury by Accident or Bodily Injury by Disease and also includes your claim expenses. Bodily Injury includes resulting death. Your claim expenses are included within Your Retention. Our payments to indemnify you for your claim expenses are included within Our Limit of Indemnity. Your claim expenses mean your litigation costs, interest as required by law on awards or judgments and your claim investigation or legal expenses which can be directly allocated to a specific claim. Claim expenses do not include salaries and travel expenses of your employees, annual retainers, overhead and any fees you paid for claim administration. Damages include: 1. damages for which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against such third party as a result of injury to your employee; 2. damages for care and loss of services; and 3. damages for consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee; provided that these damages are the direct consequence of bodily injury that arises out of and in the course of the injured employee's employment by you; and 4. damages because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer. Your bankrupty, insolvency, or inability to pay will not relieve us from the indemnification of any claim covered by this policy. But under no circumstances will we be required to drop down and replace Your Retention or assume any of your obligations within the retention area. After Your Retention has been reached, indemnification due under this policy will be made by us as if you had not become bankrupt or insolvent but not in excess of Our Limit of Indemnity as stated in Item 4 of the Information Page. Such indemnification will be made to the Trustee in Bankruptcy or as a Court of competent jurisdiction may ultimately direct. C. Exclusions This insurance does not cover: 1. liability assumed under a contract; 2. punitive or exemplary damages; 3. bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers; 4. any obligation imposed by a workers compensation, occupational disease, unemployment compensation, or disability benefits law, or any similiar law; 5. bodily injury intentionally caused or aggravated by you; 6. bodily injury occuring outside the United States of America. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America who is temporarily outside the United States of America; 7. damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, or any personnel practices, policies, acts or omissions; 8. bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901-950), the Nonappropriated Fund Instrumentalities Act (5 USC Sections 8171-8173), (4) 54361(10/92) -„ the Outer Continental Shelf Lands Act (43 USC Sections 1331-1356), the Defense Base Act (42 USC Sections 1651.1654), the Federal Coal Mine Health and Safety Act of 1969 (30 USC Sections 901-942), any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws; 9. bodily injury to any person in work subject to the Federal Employers' Liability Act (45 USC Sections 51-60), any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws; 10. bodily injury to a master or member of the crew of any vessel; 11. fines or penalties imposed for violation of federal or state law; 12. damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 USC Sections 1801-1872) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws; 13. damages arising out of operations for which you have violated or failed to comply with any Workers Compensation Law; 14. damages arising out of operations for which you have rejected any Workers Compensation Law. D. Defense We have no duty to investigate, handle, settle or defend any claim, suit or proceeding against you. However, we have the right and shall be given the opportunity by you to associate with you in the defense, investigation or settlement of any claim, suit, or proceeding which might involve a loss to us. In such an association, you shall promptly cooperate with us in all aspects of defense, investigation or settlement. E. Other Insurance If any other insurance exists protecting you against loss covered by this insurance, this insurance shall apply in excess of the other insurance. However, this provision shall not apply to other insurance which you have procured to apply in excess of the sum of Your Retention and Our Limit of Indemnity under this policy. F. Recovery From Others We have your rights, and the rights of persons entitled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. Any recovered loss will be allocated as follows: If there is insurance coverage in excess of Our Limit of Indemnity, that insurer's loss will be reimbursed first. The remaining recovered loss, after deducting our recovery expenses, will first be used to reduce our loss. Then we will pay the balance, if any, to you. G. Actions Against Us There will be no right of action against us under this insurance unless: 1. you have complied with all the terms of this policy; and 2. the amount you owe has been determined with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a defendant in an action against you to determine your liability. (5) 54361(10-92) ,.,...., • PART THREE YOUR RETENTION AND OUR LIMIT OF INDEMNITY A. Your Retention You shall pay for your own account any loss up to the amount stated in Item 5 of the Information Page as Your Retention. B. Our Limit of Indemnity We will indemnify you for loss over the amount stated as Your Retention in Item 5 of the Information Page. Our Limit of Indemnity for Workers Compensation Insurance will not exceed the limits stated in Item 4 of the Information Page. Our Limit of Indemnity for Employers Liability Insurance will not exceed the limits stated in Item 4 of the Information Page. C. How Your Retention and Our Limit of Indemnity Apply Your Retention and Our Limit of Indemnity stated on the Information Page apply to each loss paid by you 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. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. To any one employee for bodily injury or death by disease. Bodily injury by disease does not include disease that results directly from a bodily injury by accident. The inclusion of more than one legal entity as insured in Item 1 of the Information Page will not increase Your Retention or Our Limit of Indemnity. PART FOUR CLAIMS A. Your Claims Reporting Duties You must immediately notify us in writing of any claim, either paid or reserved, for 50% or more of Your Retention stated in Item 5 of the Information Page. You must also give us immediate written notice of any injury involving the following types of accident: 1. a fatality; 2. an 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 second or third degree burn of 25% or more of the body; 6. any accident which causes serious injury to two or more employees; or 7. any disability of more than one year or where it appears reasonably likely that there will be a disability of more than one year. B. Your Claims Handling Duties It is your responsibility to investigate, settle, defend and appeal any claim, suit or other proceeding made against you. However, you must not make any voluntary settlement involving loss to us without our written consent. (6) 54361(10:92) If you do not appeal an award or judgment which exceeds Your Retention, we have the right to take an appeal at our own cost and expense and shall be liable for costs, disbursements and interest related to the appeal. If we elect to appeal, our liability on such an award or judgment shall not exceed Our Limit of Indemnity as stated in Item 4 of the Information Page plus the cost and expense of such appeal. C. Claim Audits We have the right to examine and audit your claims handling and reserving procedures, practices and records while this policy is in force and for three years after the final settlement of all claims. Also you will provide us any claim information which we may request. PART FIVE PREMIUM A. Premium Payments You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. B. Deposit Premium At the beginning of the policy period you must pay us the deposit premium shown on the Information Page. At the end of the policy period: 1. you will owe us the amount by which the final premium is greater than the deposit premium; or 2. we will owe you the amount by which the deposit premium is greater than the final premium; but in any event, we shall retain the policy Minimum Premium shown on the Information Page. C. Final Premium The deposit premium shown on the Information Page is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis which includes payroll and all other remuneration paid or payable during the policy period for the services of: 1. all your officers and employees engaged in work covered by this policy; and 2. all other persons engaged in work that could make us liable under Part One (Workers Compensation Insurance) of this policy. If you do not have payroll records for these persons, the contract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the employers of these persons lawfully secured their workers compensation obligations. If this policy is cancelled, final premium will be determined in the following way: 1. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the Minimum Premium. 2. If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short rate cancellation table and procedure. Final premium will not be less than the short rate share of the Minimum Premium. D. Records You will keep records of information needed to compute premium. You will provide us with copies of those records when we ask for them. E. Audit (7) 54361(10/92) You will let us examiner J audit all your records that relate to this policy. These records include ledgers, journals, registers, vouchers, contracts, tax reports, payroll and disbursement records, and programs for storing and retrieving data. We may conduct the audits during regular business hours during the policy period and within three years after the policy period ends. Information developed by audit will be used to determine final premium. PART SIX CONDITIONS A. Acceptance By acceptance of this policy, you agree that the statements on the Information Page are your agreements and representations, that this policy is issued in reliance upon the truth of such representations, and that this policy embodies all agreements existing between you and us or any of our agents relating to this insurance. B. Cancellation \ ' 1. You ma cancel this policy. You must mail or deliver advance written notice to us stating when the canc ation is to take effect. / 2. )M'e may cancel this policy. If we cancel because of non-payment of premium, we must mail or deliver /to you not less than ten days advance written notice stating when the cancellation is to take effect. If / we cancel for any other reason, we must mail or deliver to you not less than sixty days advance written notice stating when the cancellation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancellation notice. 4. Any of these provisions that conflict with a law that controls the cancellation of the insurance in this policy is changed by this statement to comply with that law. C. Inspection We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurability of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with law, regulations, codes or standards. D. Sole Representative The insured first named in Item 1 of the Information Page will act on behalf of all insureds to give or receive notice of cancellation, accept indemnity, receive return premium or request change in this policy. E. Transfer of Your Rights and Duties Your rights and duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days after your death, we will cover your legal representative as insured. • (8) 54361(10792) IN WITNESS WHEREOF, we have caused this policy to be executed and attested, but this policy shall not be valid unless countersigned by one of our duly authorized representatives, where required by law. „a"jecet SECRETARY PRESIDENT (9) 54361(10/921 FORMS SCHEDULE EFFECTIVE DATE: 12/31/94 NAMED INSURED: WELD COUNTY, COLORADO POLICY NO: 415-52-37 554199 (0992) S56291 (0393) S56317 (0393) EXCESS WORKERS COMPENSATION COLORADO AMENDATORY ENDORSEMENT This endorsement, effective 12:01 A.M. 12/31/94 forms a part of policy No. XWC 415-52-37 issued to WELD COUNTY, COLORADO by NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. CANCELLATION In consideration of the premium charged, it is understood and agreed that Condition B Cancellation of this policy is hereby deleted and replaced by the following: B) Cancellation: 1) You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2) We may cancel this policy. If we cancel because of non-payment of premium, we must send by certified mail not less than ten (10) days advance written notice stating when cancellation is to take effect to you, your agent or representative and to: Division of Workers' Compensation Insurance Management Services \ 1120 Lincoln Street, 12th Floor Denver, Colorado $.0203 Attention: Mr. Johfi M. Berger, ARM, CHCM If we cancel for any other reason, we must send by certified mail not less than Ninety (90) days advance written notice stating when the cancellation is to take effect to you, your agent or representative and to: Division of Workers' Compensation Insurance Management Services 1120 Lincoln Street, 12th Floor Denver, Colorado 80203 Attention: Mr. John M. Berger, ARM, CHCM Mailing that notice to you by certified mail at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3) The policy period will end on the day and hour stated in the cancellation notice. All other terms, conditions and exclusions shall remain the same. a.--.{�G. AUTHORIZED REPRESENTATIVE 54199 (9/92) uia'nave rnov EXCESS WORKERS COMPENSATION ENDORSEMENT This endorsement, effective 12:01 A.M. 12/31/94 forms a part of policy No, XWC 415-52-37 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 coverage for loss under the Workers Compensation Law of a state not designated in Item 2 of the Information Page, provided said designated state is the state of the injured employees' normal employment. All other terms, conditions and exclusions shall remain the same. AtTHORIZED REPRESENTATIVE 56291 (3/93) EXCESS WORKERS COMPENSATION ENDORSEMENT This endorsement, effective 12:01 A.M. 12/31/94 forms a part of policy No. XWC 415-52-37 issued to WELD COUNTY, COLORADO by NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. UNITED STATES LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT ENDORSEMENT (Incidental Operations Endorsement) It is agreed that with respect to operations in the State(s) designated in Item 2 of the Information Page, the term "Workers Compensation Law" includes the United States Longshore and Harbor Workers' Act (33 USC Sections 901-950) and paragraph C of the General Section is amended accordingly. This endorsement does not apply to work subject to the Defense Base Act, the Outer Continental Shelf Lands Act, or the Nonappropriated Fund Instrumentalities Act. This endorsement is provided hereunder due to our reliance upon your warranty of no known USL&H exposure. All other terms, conditions and exclusions shall remain the same. (1/60I&4A ' U//�uKtii AUTHORIZED REPRESENTATIVE gain 7 lq QQ1 - - - ENDORSEMENT# 1 This endorsement, effective 12:01 A.M. DECEMBER 31, 1994 forms a part of Policy No. 415-52-37 issued to WELD COUNTY, COLORADO By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. It is hereby agreed that: With respect to United States Longshore and Harbor Workers' Compensation Act (Incidental Operations), Your Retention stated in Item 5 of the Information Page shall be $500,000.00 All other terms and conditions remain unchanged. U,lG � Endt. # 1 Authorized Representative (01/23/95)scm ,.,C'nnrroc rnov ENDORSEMENT#2 This endorsement, effective 12:01 A.M. DECEMBER 31, 1994 forms a part of Policy No. 415-52-37 issued to WELD COUNTY, COLORADO By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. VOLUNTEER AND BOARD MEMBERS ENDORSEMENT It is hereby agreed that coverage is extended to include Volunteers and Board Members. $2,500.00 Per year shall be included in the payroll for each Volunteer. All other terms and conditions of this policy remain unchanged. Endt. #2 ,v,0^- A a, (01/23/95)scm Authorized Representative A006592 ,.,c',inrn'c rnry ENDORSEMENT# 3 This endorsement, effective 12:01 A.M. DECEMBER 31, 1994 forms a part of Policy No. 415-52-37 issued to WELD COUNTY, COLORADO By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. MINIMUM EARNED PREMIUM It is understood and agreed that in the event of cancellation of this policy by or at the direction of the insured, the Company shall retain a Minimum Earned Premium of $9,223.00. It is further agreed that the provision regarding cancellation by the insured is amended to read: "If the insured cancels this policy, earned premium will be computed in accordance with the customary short-rate table and procedure, or the Minimum Earned Premium stated herein, whichever is greater'. All other terms and conditions of this policy remain unchanged. ditila-K J Qa. Of c�. Endt. #3 Authorized Representative (01/23/95)scm XWCMINI ,.,c'„nvn+c nnnv 'N AR g 9 August 16, 1995 Mr. Don Warden Weld County, Colorado P.O. Box 758 Greeley, CO 80631 Re: Endorsement forSpecific Excess Workers' Compensation Policy # 415-52-37 - 12/31/94-95 Term Dear Don: The enclosed endorsement is for the following change: • Effective 01/01/95, amend endorsement 54199 (9/92) - Colorado Amendatory Endorsement by changing the authority name and address to reflect: State of Colorado/Division of Labor Workers' Compensation Division Self Management Services 1515 Arapahoe Street, Denver, CO 80202-2117 If you have any questions, please do not hesitate to give me a call. Sincerely, ARTHUR J. GALLAGHER & CO.-DENVER Karen Graham, CIC Account Manager c: John P. McLaughlin, Vice President - Risk Management Services :kg/enclosure KG\N'.\HMS AV\KG\WELD.CNT\XS-W C\90PGLICV.END EXCESS WORKERS COMPENSATION COLORADO AMENDATORY ENDORSEMENT REVISED This endorsement, effective 12:01 A.M. 12/31/94 forms a part of Policy No. 415-52-37 issued to WELD COUNTY, COLORADO by NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. CANCELLATION In consideration of the premium, it is understood and agreed that conditions B Cancellation of this policy is hereby deleted and replaced by the following: B) Cancellation: 1) You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2) We may cancel this policy. If we cancel because of non-payment of premium, we must send by certified mail not less than ten (10) days advance written notice stating when cancellation is to take effect to you, your agent or representative and to: State of Colorado/Division of Labor Workers' Compensation Division Self Management Services 1515 Arapahoe Street Denver, Colorado 80202-2117 If we cancel for any other reason, we must send by certified mail not less than Ninety (90) days advance written notice stating when the cancellation is to take effect to you, your agent or representative and to: State of Colorado/Division of Labor Workers' Compensation Division Self Management Services 1515 Arapahoe Street Denver, Colorado 80202-2117 Mailing that notice to you by certified mail at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3) The policy period will end on the day and hour stated in the cancellation notice. All other terms, conditions and exclusions shall remain the sa 54199(9/92) Authorized Representative i nl Cl IDDnVQ rnov Hello