HomeMy WebLinkAbout000176.tiff LETTER OF TRANSMITTAL
To: Mr. Don Warden, Director of Date: August 31 , 1994
Finance & Administration
Weld County, Colorado Policy # 415-4670
P.O. Box 758 Policy Period: 12/31/93-94
Greeley, CO 80631 Re: Specific Excess Workers'
Compensation
ENCLOSURES:
Application(s) X For Your Information/For Your Files
Auto I.D. Card(s) X Per Your Request
Binder(s) Per Our Conversation
X Endorsement(s) For Your Signature and Return
Certificate(s) For Review and Comment
Current Schedule of Insurance
Financial Statement X SEE REMARKS BELOW
Gallagher Bassett Agreement
Graphs/Coverage Diagrams
Invoice(s)/Credit Memo(s)
Driver List
Claims Reports/Loss Runs
Lost Policy Release
Response to Loss Control
Recommendations
MVR(s)
Other
REMARKS: Dear Don,
I have enclosed several endorsements to the above captioned policy. The endorsements add the
Volunteer and Board Members Endorsement, delete Exclusion 2 in its entirety, and amend the name of
the Division of Workers' Compensation.
Please place these endorsements with the policy in your policy notebook.
Should you have any questions, please do not hesitate to contact me.
Sincerely,
cc: From:
ann dney, AAI
ccount ssistant
176
tp\C'.\W%WELD\WORKCOM\TRANS.DW August 31,1990
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June 2, 1994
Mr. Don Warden
Director of Finance & Administration
WELD COUNTY, COLORADO
P.O. Box 758
Greeley, CO 80632
Re: Current Summary of Insurance
Dear Don:
Enclosed is your Current Summary of Insurance document. Please place
this in the front of your policy notebook.
Should you have any questions, please feel free to give me a call.
Sincerely,
ARTHUR J. GALLAGHER & CO.-DENVER
�-n Ls.L_,.
Karen Graham
Account Manager
:kg
enclosure
KG\C:\WP\WELO.CNT\GEN.COIN94CSLLTA June 2,1990
SUMMARY OF CURRENT INSURANCE
PREPARED FOR
WELD COUNTY, COLORADO
Prepared By: John P. McLaughlin
Vice President - Risk Management Services
(303) 773-9999
June 2, 1994
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.
94570 WC-PRO 94 June 2,1996
WELD COUNTY, COLORADO
SUMMARY OF CURRENT POLICIES
Type of Policy Company Policy k Policy Period
Excess Worker's National Union Fire 415-46-70 12/31/93-94
Compensation Insurance
Self Insurer's Bond Aetna Casualty & 19S100729968 12/31/91
Surety Company Continuous
94-510 WC-PRO.94 lam 2,1994
WELD COUNTY, COLORADO
SPECIFIC EXCESS WORKERS' COMPENSATION COVERAGE
Carrier: National Union Fire Insurance Company
#415-46-70
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
• No Commutation Clause
• No Asbestos Exclusions
• Board Members Included
• No Aircraft and Water Exclusions
• Bankruptcy/Insolvency Clause
94.510 W C.PRO.94 lune 2.1994
WELD COUNTY, COLORADO
WORKERS' COMPENSATION BOND
Carrier: Aetna Casualty and Surety Company
A XIV
Bond Penal Sum: $ 300,000 (11
Terms/Conditions: Continuous until cancelled
01 Subject to review by Division of Labor.
94570 WC-I220 94 lure 2, 1994
� iAarys: �y; � a 1t11 ��l� L'alal y�� o ��fprg 5, , " . t
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WELD COUNTY
COLORADO
1993/94
EXCESS WORKERS'
COMPENSATION POLICY
a,
May 27, 1994
Mr. Don Warden
Weld County, Colorado
P.O. Box 758
Greeley, CO 80631
Re: Specific Excess Workers' Compensation
Policy # 415-46-70 - 12/31/93-94 Term
Dear Don:
I am happy to enclose your policy notebook containing your Specific Excess
Workers' Compensation policy for the term above. I included a section for your
Self Insurer's Bond, should you want to pull it forward.
I have reviewed your policy for accuracy and have requested the following
changes effective 12/31/93:
• Endorsement Nos. 4 - Volunteer & Board Member endorsement
& 5 - Deletion of exclusion No. 2 endorsement show an incorrect
effective date of 12/01/93. I have requested that they be amended
to reflect the correct effective date of 12/31/93.
• Amend the Division of Workers' Compensation clause on
Endorsement No. 11 - Colorado Amendatory endorsement to
reflect their new clause:
Division of Workers' Compensation
Insurance Management Services
1120 Lincoln Street, 12th Floor
Denver, CO 80203
attn: Mr. John M. Berger, ARM, CHCM
These changes will follow shortly.
KG\C'.\WP\WELO.CNT%S WC\93POLICY.LTR May D.1994
Mr. Don Warden
May 27, 1994
Page 2
Please review your policy carefully for all terms, conditions, limitations, and
exclusions. In particular, please review endorsement No. 2, Claim Reporting
Endorsement. 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 Sue Leidolph at OHMS.
We thank you for the opportunity to continue this coverage for Weld County.
Sincerely,
ARTHUR J. GALLAGHER & CO.-DENVER
:e--0---A---Q- --N
Karen Graham
Account Manager
c: John P. McLaughlin, Vice President - Risk Management Services
:kg/enclosure
KG\C\WRWELO.CNT\XS-WC\93POLICY.LTR May 27,1994
NATIONAL UNION
FIRE INSURANCE COMPANY
OF PITTSBURGH, PA.
A CAPITAL STOCK COMPANY 70 Pine Street, New York, N.Y. 10270
(Herein called the Company
NAMED WELD COUNTY, COLORADO
INSURED P.O. BOX 758
AND GREELEY, COLORADO 80632POST
OFFICE Y-. TECT/
Agrees with the Insured, named in the Declarations made a part hereof, in consideration of the payment of the
premium and in reliance upon the statements in the Declarations and subject to the Limits of Liability, Exclusions,
Conditions and other terms of this policy:
EXCESS WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY POLICY
DECLARATIONS
RENEWAL OF: 415-3409
POLICY
NUMBER: 415-4670
STATEIS)
ITEM (to which COLORADO
1 Coverage is
to apply)
ITEM POLICY 12:01 A.M.Standard Time at the
From: DECEMBER 31, 1993 To: DECEMBER 31, 1994
2 PERIOD Post Office Address shown herein
ITEM LIMIT OF STATUTORY - WORKERS' COMPENSATION
3 LIABILITY $1,000,000 - EMPLOYERS LIABILITY
ITEM RETENTION $300,000
4 (each accident)
ESTIMATED TOTAL RATES PER POLICY
ANNUAL $100.00 OF PREMIUM
PREMIUM REMUNERATION REMUNERATON
ITEM AND
5 PREMIUM MINIMUM & DEPOSIT
COMPUTATION $23,863,561 . 1516 $36,177
MINIMUM EARNED PREMIUM
$9,044
Unless otherwise stated herein, the policy premium as shown above shall also be the minimum premium.
ARTHUR J. GALLAGHER & COMPANY
7900 E. UNION AVENUE, SUITE 200
DENVER, COLORADO 80237-2757
DATE OF ISSUE: COUNTERSIGNED BY:
DECEMBER 28, 1993
EW/scm (AUTHOR IZ D PRESENTATIVE)
3/81
1704 (8-76)
ENDORSEMENT #1
This endorsement, effective 12:01 A.M. DECEMBER 31, 1993 forms a part of
Policy No. 415-46-70 issued to WELD COUNTY, COLORADO
By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA.
In consideration of the premium charged, it is agreed that Item #2 of the Conditions is amended as follows:
(2) Premium. The Premium for this policy shall be based upon the entire remuneration earned, during
the policy period, by all employees of the insured engaged in the operations described in the declarations
together with all operations necessary, incidental or appurtenant thereto, or connected therewith, whether
conducted at such work place or elsewhere in connection therewith or in relation thereto, subject with
respect to each executive officer to maximum and minimum remuneration of $1,050.00 and $350.00 Per
week, and the insured agrees to pay a premium thereon, at the time of the final adjustment of the premium
at rates to be determined. If the policy is for more than one year, then upon expiration of each annual
period of the policy, or its termination during the policy period, the actual amount of the remuneration
earned by the employees during such policy shall be exhibited to the company, as provided in Conditions 3
thereof, and the earned premium adjusted in accordance therewith at the rates and under the conditions
herein specified. If the insured is liable under any of the said Workers' Compensation Laws for
compensation to employees of any contractor or sub-contractor and does not maintain satisfactory
evidence that any such contractor or sub-contractor has secured his compensation obligation to his
employees, then the remuneration of all employees of any such contractor or sub-contractor shall be
included in the return of remuneration upon which the premium for this policy is computed, provided,
however that if the insured does not furnish record of such remuneration, the entire contract price of the
sub-contracted work shall be included as remuneration. Upon delivery of this policy, the insured shall pay
the deposit premium shown in the declarations and the expiration of each annual period, the earned
premium shall be computed thereon and shall be paid to the company except that the deposit premium
shown in the declarations and at the expiration of each annual period, shall be credited against the
premium found to be due the company for the last twelve (12) months of the policy period. The company
shall, in any event, retain the annual minimum premium stated in the declarations for twelve (12) month
period.
etain
Endt. #1 Au or _d Representative
(12/28/93)scm
A000289
MCI IQFf'C rnDv
•
ENDORSEMENT # 2
This endorsement, effective 12:01 A.M. DECEMBER 31, 1993 forms a part of
Policy No. 415-46-70 issued to WELD COUNTY, COLORADO
By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA.
CLAIM REPORTING ENDORSEMENT
In consideration of the premium charged, and notwithstanding anything in the policy to the contrary
it is agreed that the Insured shall notify the company as soon as practicable after the corporate
insurance department is made aware of the claim, either paid or reserved, for 50% or more of the
self-insured retention stated in Item No. 4 of the policy Declarations.
Is further agreed that the Insured shall give the company written notice as soon as practicable after
the corporate insurance department is made aware, of any injury involving the following type of
accident:
1 . A fatality.
2. Amputation of a major extremity,
3. Any serious head injury (including skull fracture or loss of sight of either or both
eyes),
4. Any injury to the spinal cord,
5. Any severe burn case,
6. Any accident which caused serious injury to two or more employees or,
7. Any disability of more than one year or where it appears reasonably likely that there
will be disabilities of more than one year.
Endt. #2 Au o z d Representative
(12/28/93)scm
A000489
'MCI IOCrVC rnov
ENDORSEMENT #3
This endorsement, effective 12:01 A.M. DECEMBER 31, 1993 forms a part of
Policy No. 415-46-70 issued to WELD COUNTY, COLORADO
By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA.
It is hereby agreed that Insuring Agreement (2) (Employers Liability) of the policy does not apply to
the following:
(A) bodily injury to an employee while employed in violation of the law;
(B) bodily injury intentionally caused or aggravated by or at the direction of the Insured;
(C) bodily injury caused by the serious and willful misconduct of the Insured.
It is further agreed that Insuring Agreement (1) of the policy does not apply to payments in excess
of those regularly required by the Workers Compensation Laws if such excess payments are
required because of (A) or (C) above.
Endt. #3 zed Representative
(12/28/93)scm
A002689
loci iocrve rnov
ENDORSEMENT # 4
This endorsement, effective 12:01 A.M. DECEMBER 01, 1993 forms a part of
Policy No. 415-46-70 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. per year shall be included in the payroll for each volunteer.
All other terms and conditions of this policy remain unchanged.
Endt. #4 Sonlith
(12/28/93)scm Au r Representative
A006592
iniciocrvc rnnv
ENDORSEMENT #4 "REVISED"
This endorsement, effective 12:01 A.M. DECEMBER 31, 1993 forms a part of
Policy No. 415-46-70 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. #4 "Revised" S,A44‘
(08/08/94)scm t ed Representative
A006592
..ic,incn C. rnn„
ENDORSEMENT # 5
This endorsement, effective 12:01 A.M. DECEMBER 01, 1993 forms a part of
Policy No. 415-46-70 issued to WELD COUNTY, COLORADO
By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA.
In consideration of the premium charged, it is hereby agreed that Exclusion (2) is
deleted in its entirety.
01S
Endt. #5 Au d Representative
(12/28/93)scm
A006992
iMCI ioorce rnov
ENDORSEMENT# 5 "REVISED"
This endorsement, effective 12:01 A.M. DECEMBER 31, 1993 forms a part of
Policy No. 415-46-70 issued to WELD COUNTY, COLORADO
By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA.
In consideration of the premium charged, it is hereby agreed that Exclusion (2) is deleted in its entirety.
Endt. # 5 "Revised" A i ed Representative
(08/08/94)scm
A006992
ENDORSEMENT #6
This endorsement, effective 12:01 A.M. DECEMBER 31, 1993 forms a part of
Policy No. 415-46-70 issued to WELD COUNTY, COLORADO
By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA.
It is agreed that Item 4, Definitions (Ultimate Net Loss) is amended as follows:
Ultimate Net Loss: The term "Ultimate Net Loss" as used in this policy shall mean
the sum actually paid in cash in the settlement or satisfaction of losses for which
the Insured is liable, either by adjudication or compromise, with the written consent
of the Company. The term shall include court costs, interest upon awards and
judgments and allocated investigation, adjustment and legal expenses pertaining to
losses, but shall exclude all salaries paid to employees, service company fees and
claim administrator fees. Nothing herein contained shall be construed to mean that
the Insured shall be required to enforce by legal action any rights of subrogation
before the Company shall pay any losses for which it may be liable hereunder.
All other terms and conditions of this policy remain unchanged.
OILS—
Endt. #6 Au or d Representative
12/28/93)scm
A005992
ENDORSEMENT # 7
This endorsement, effective 12:01 A.M. DECEMBER 31, 1993 forms a part of
Policy No. 415-46-70 issued to WELD COUNTY, COLORADO
By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA.
It is agreed and understood that Item 7, conditions is amended as follows:
LEGAL COST
Should any claim or claims arise appearing likely to exceed the retention, no costs shall be incurred on
behalf of the company without its consent being first obtained. Should such claim or claims be adjusted
prior to trial court judgement for a sum or aggregate sum of not more than the retention, then no costs
shall be payable by the company. Should, however, the sum or aggregate sum for which such claim or
claims are adjustable prior to the rendering of trail court judgement or judgements exceed the retention,
then the company, if it consents to trial court proceedings continuing, shall contribute to the costs as
defined in definitions, Item 4, Ultimate Net Loss.
All other terms and conditions remain unchanged.
Endt. #7 Autho z epresentative
112/28/931scm
A006892A
. �
ENDORSEMENT # 8
This endorsement, effective 12:01 A.M. DECEMBER 31, 1993 forms a part of
Policy No. 415-46-70 ssued to WELD COUNTY, COLORADO
By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA.
UNITED STATES LONGSHOREMENS' AND HARBOR WORKERS' COMPENSATION ACT
ENDORSEMENT
(Incidental Operations Endorsement)
It is agreed with respects to operations in the State(s) designated in Item (1) of the
Declarations, the unqualified term "Workers' Compensation Law" includes the United States
Longshoremens' and Harbor Workers' Act., U.S. Code (1946) Title 33, Section 901-49 and
definition (1) is amended accordingly.
This endorsement does not apply to work subject to the Defense Base Act, the Outer
Continental Shelf Lands Act or the Non-appropriated Fund Instrumentalities Act.
This endorsement is provided hereunder due to the Company's reliance upon the Insured's
warranty of no known U S L & H exposure.
All other terms and conditions of this policy remain unchanged.
Endt. #8 Au or Representative `-
(1 2/28/93)scm
A005892
'roe,inert a rnov
ENDORSEMENT #9
This endorsement, effective 12:01 A.M. DECEMBER 31, 1993 forms a part of
Policy No. 415-46-70 issued to WELD COUNTY, COLORADO
By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA
BROAD FORM ALL STATES ENDORSEMENT
It is hereby agreed that this policy is amended to include the following:
(3) For compensation and other benefits required to be paid by the Insured under the Workers'
Compensation Law of a State not designated in Item (1) of the declarations; provided said
designated state is the state of the injured employees' normal employment.
End t. #9 CLAS
(12/28/93)scm Aut ri Representative
A000689
'MCI IOCfI'C rnov
ENDORSEMENT # 10
This endorsement, effective 12:01 A.M. DECEMBER 31, 1993 forms a part of
Policy No. 415-46-70 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 $9,044.00.
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.
Endt. #10 Auth z epresentative
(12/28/93)scm
!MCI IOCrvc rnov
ENDORSEMENT # 11
This endorsement, effective 12:01 A.M. DECEMBER 31, 1993 forms a part of
Policy No. 415-46-70 issued to WELD COUNTY, COLORADO
By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA.
COLORADO AMENDATORY ENDORSEMENT
It is hereby agreed that with respect to Cancellation by the Company Ninety (90) days Notice of
Cancellation will be provided except with respect to non-payment of premium, in which case ten
(10) days notice will be provided.
It is also agreed that Notice of Cancellation will be sent by registered or certified mail to both the
Insured and the authority listed below:
Department of Labor & Employment
Division of Workers' Compensation
Insurance Compliance Unit
1120 Lincoln Street, 12th Floor
Denver, Colorado 80203
All other terms and conditions of this policy remain unchanged.
Endt. #11 A o i d Representative
(12/28/93)scm
A005490
i nlCl ID IYC rnov
ENDORSEMENT# 11 "REVISED"
This endorsement, effective 12:01 A.M. DECEMBER 31, 1993 forms a part of
Policy No. 41546-70 issued to WELD COUNTY, COLORADO
By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA.
COLORADO AMENDATORY ENDORSEMENT
It is hereby agreed that with respect to Cancellation by the Company Ninety (90) days Notice of
Cancellation will be provided except with respect to non-payment of premium, in which case ten (10)
days notice will be provided.
It is also agreed that Notice of Cancellation will be sent by registered or certified mail to both the Insured
and the authority listed below:
Division of Workers' Compensation
Insurance Management Services
1120 Lincoln Street, 12th Floor
Denver, Colorado 80203
Attn: John M. Berger, ARM, CHCM
All other terms and conditions of this policy remain unchanged.
Endt. #11 "Revised" t zed Representative
(08/08/94)scm
A005490
•
NATIONAL UNION
FIRE INSURANCE COMPANY 70 PINE STREET
NEW YORK,N.Y. 10270
OF PITTSBURGH, PA.
•
•
ii
JC7_ �r
-.c•;.TE TI.A,
EXCESS WORKER'S COMPENSATION AND EMPLOYER'S
LIABILITY INSURANCE POLICY
The Company hereby agrees to indemnify the Insured against excess loss. subject to his/her employment by the Insured either in operations in a state designated
the limitations, conditions and other terms of this policy. which the Insured may in Item 1 of the Declarations or in operations necessary or incidental thereto,
sustain by reason of the liability imposed upon the Insured by law: or
(1) For compensation and other benefits as are specifically provided by the worker's (h) sustained while temporarily outside the United States of America, its
compensation or occupational disease laws of any state(s)named in Item 1 of the territories or possessions,or Canada by any employee of the Insured who is a
Declarations,and citizen or resident of the United States or Canada arising out of and in the
course of his employment by the Insured in connection with operations in a
(2) For damages because of bodily injury by accident or disease including death at state designated in Item 1 of the Declarations;but this insurance does notap-
any lime resulting therefrom, ply to any suit brought in or any judgment rendered by any court outside the
(a) sustained in the United States of America, its territories or possessions, or United Sates of America,its territories or possessions,or Canada or to an ac-
Canada by any employee of the Insured arising out of and in the course of Lion on such judgment wherever brought.
DEFINITIONS
(1) Worker's Compensation Law. The unqualified term "worker's compensation mean the sum actually paid in cash in the settlement or satisfaction of losses for
law"means the worker's compensation law and any occupational disease law of a which the Insured is liable, either by adjudication or compromise with the written
state designated in Item 1 of the Declarations, but does not include those' consent of the Company, after making proper deductions for all recoveries, but
provisions of any such law which provide non-occupational disability benefits. shall exclude all salaries of employees and orrice expenses of the Insured incurred
(2) State. The word ''state'' means any State or Territory of the United States of in investigation,adjustment and litigation. Nothing herein contained shall be con-
America and the District of Columbia. strued to mean that the Insured shall be required to enforce by legal action any
(3) Assault and Battery. Under Insuring Agreement(2), assault and battery shall be rights of subrogation before the Company shall pay any loss for which it may be
an accident Ba unless nd committed n by or at the 2), asi and Insured. liable hereunder. Other loss and legal expenses (including court costs and in-
deemed terest on any judgment or award)incurred with the consent of the Company shall
(4) Ultimate Net Loss. The term "ultimate net loss'', as used in this policy, shall be apportioned in proportion to the respective interests as finally determined.
APPLICATION OF POLICY
(1) This policy applies only to injury(I)by accident occurring during the policy period, last exposure,in the employment of the Insured.to conditions causing the disease
or(ii) by disease caused or aggravated by exposure of which the last day of the occurs during the policy period.
EXCLUSIONS
This policy does not apply: therefrom;
(1) Under Insuring Agreement 2, to liability assumed by the Insured under any con- (3) under Insuring Agreement 2,to any obligation for which the Insured or any carrier
tract or agreement,but this exclusion does not apply to a warranty that work per- as his/her insurer may be held liable under the worker's compensation or oc-
formed by or on behalf of the Insured will be done in a workerlike manner. cupational disease law of a state designated in Item 1 of the Declarations, any
(2) under Insuring Agreement 2, to bodily injury by disease unless prior to thirty-six other worker's compensation or occupational disease law, any unemployment
months after the end of the policy period written claim is is made or suit is brought compensation or disability benefits law,or under any similar law.
against the Insured for damages because of such injury or death resulting (4) to fines,penalties,punitive or exemplary damages.
CONDITIONS
(1) Limit of Liability — Retained Limit. The Comapny's limit of liability shall be only premium adjusted in accordance therewith at the rates and under the conditions
for the ultimate net loss,as defined herein, in excess of the amount stated in Item herein specified. If the Insured is liable under any of the said worker's com-
4 of the Declarations (hereinafter called the ''retention'') and then only up to a pensation laws for compensation to employees of any contractor or sub-contractor
further amount not exceeding the amount stated in Item 3 of the Declarations, and does not maintain satisfactory evidence that any such contractor or sub-
provided that the retention and the Company's limit shall apply separately under contractor has secured his compensation obligations to his employees, then the
Insuring Agreement 1 and 2 to each accident.involving one or more employees. remuneration of all employees of any such contractor or sub-contractor shall be in-
Anything contained in this policy to the contrary notwithstanding, with respect to eluded in the return of remuneration upon which the premium for this policy is
each employee, injury by disease shall be considered a separate accident and he computed, provided, however that if the Insured does not furnish record of such
subject to a separate retention for each accident, and the maximum limit of the remuneration, the entire contract price of the sub-contracted work shall be in-
Company's liability, during the policy period. for all injuries by disease shall be eluded as remuneration. Upon delivery of this policy, the Insured shall pay the
the amount stated in Item 3 of the Declarations. deposit premium shown in the Declarations and at the expiration of each annual
period, the earned premium shall be computed thereon and shall be paid to the
(2) Premium.The premium for this policy shall be based upon the entire remuneration Company except that the deposit premium shown in the Declarations shall be
earned, during the policy period, by all employees of the Insured engaged in the credited against the premium found to be due the Company for the last twelve(12)
operations described in the Declarations together with all operations necessary, months of the policy period.The Company shall, in any event, retain the annual
incidental or appurtenant thereto, or connected therewith, whether conducted at minimum premium stated in the Declarations for a twelve(12)month period.
such work place or elsewhere in connection therewith or in relation thereto, sub- (3) Inspection and Audit.The Company and any rating authority having jurisdiction by
ject with respect to each executive officer to a maximum and minimum law shall each be permitted but not obligated to inspect at any reasonable time,
remuneration of$300.00 and $1 00 per week, and the Insured agrees to pay a the workplaces, operations, machinery and equipment covered by this policy.
premium thereon,at the time of the final adjustment of the premium at rates to be Neither the right to make inspections nor the making thereof nor any report
determined. It the policy period is for more than one year, then upon expiration of thereon, shall constitute an undertaking on behalf of or for the benefit of the In-
each annual period of the policy. or its termination during the policy period, the sured or others, to determine or warrant that such workplaces, operations,
actual amount of the remuneration earned by employees during such period shall machinery or equipment are safe or healthful, or are in compliance with any law,
be exhibited to the Company, as provided in Condition 3 hereof, and the earned rule or regulation.
'701 716'.
The Company and any rating authority having jurisdiction by law shall each be pense,and shall be liable for the taxable costs and disbursements and interest in-
permitted to examine and audit the Insured's payroll records, general ledger, cidental thereto, but in no event shall the liability of the Company for ultimate net
disbursements. vouchers, contracts, lax reports and all other books, documents loss exceed the amount set forth in for any one occurrence plus the cost and ex-
and records of any and every kind at any reasonable time during the policy period pense of such appeal. Item 3 of the Declaration.
and any extension thereof and within three years after termination of this policy,
as far as they show or tend to show or verify the amount of remuneration or other (10)Action Against Company. No action shall lie against the Company unless, as a
x premium basis.or relate to the subject matter of this insurance, condition precedent thereto, the Insured shall have fully complied with all the
terms of this policy.
,41 Qualified Self-Insurer. The Insured, by the acceptance of this contract, warrants
that it has qualified as a self-insurer as provided in the worker's compensation (11)Other Insurance. If the Insured carries other valid and collectible insurance
law and will continue to maintain such qualifications during the period of this con- covering a loss also covered by this contract(other than insurance that is pur-
tract. In the event the Insured should at any time while this contract is in force ter- chased to apply in excess of the sum of the retention and the limit of liability
minate its qualifications as a self-insurer or if such qualifications should be can- hereunder of policies of coinsurance within the limits of this policy),the insurance
celled or revoked,this contract shall automatically terminate at the same time. afforded by this contract shall aplly in excess of and shall not contribute with such
other insurance or reinsurance.
(5) Notice of Injury. When an injury occurs that appears reasonably likely to involve
liability on the part of the Company,written notice shall be given by or on behalf of (12)Subrogation. In the event of any payment under this policy,the Company shall be
the Insured to the Company or any of its authorized agents as soon as practicable, subrogated to all rights of recovery therefor of the Insured and any person entitled
Such notice shall contain particulars sufficient to identify the Insured and also the to the benefits of this policy against any person or organization, and the Insured
fullest information obtainable at the time. The Insured shall give like notice, with shall execute and deliver instruments and papers and do whatever else is
full particulars, of any claim made on account of such injury. If thereafter suit or necessary to secure such rights. The Insured shall do nothing after loss to
other proceeding is instituted against the Insured to enforce such claim, the In- prejudice such rights.
sured shall, when requested by the Company, forward to the Company every (13)Changes. Notice to any agent or knowledge possessed by any agent or by any
demand, notice, summons, or other process or true copies thereof, received by other person shall not effect a waiver or a change in any part of this policy or estop
the Insured or the Insured's representatives,together with copies of reports of in- the Company from asserting any right under the terms of this policy; nor shall the
vestigations made by the Insured with respect to such claim,suit or proceeding. terms of this policy be waived or changed,except by endorsement issued to form
(6) Cooperation of the Insured. The Company shall not be called upon to assume a part of this policy,signed by a duly authorized representative of the Company.
charge of the settlement or defense of any claim made or suit or proceedings in- (14)Assignment.Assignment of interest under this policy shall not bind the Company
stituted against the Insured, but shall have the right and shall be given the op- until its consent is endorsed hereon. If. however, during the policy period the In-
portunity to associate with the Insured in the defense and control of any claim, sured shall die,and written notice is given to the Company within thirty days after
suit or proceeding where the claim or suit involves,or appears reasonably likely to the date of such death,this policy shall cover the Insured's legal representative as
involve the Company,in which event the Insured and the Company shall cooperate insured; provided, that notice of cancellation addressed to the Insured named in
in all things in the defense of such claim,suitor proceeding. the Declarations and mailed or delivered, after such death, to the address shown
(7) Legal Costs. Should any claim or claims arise appearing likely to exceed the reten- in this policy shall be sufficient notice to effect cancellation of this policy.
tion, no costs shall be incurred on behalf of the Company without its consent (15)Cancellation. This policy may be cancelled by the Insured by surrender thereof to
being first obtained. Should such claim or claims be adjusted prior to trial court the Company or any of its authorized agents or by mailing to the Company written
judgment for a sum or aggregate sum of not more than the retention,then no costs notice stating when thereafter the cancellation shall be effective. This policy may
shall be payable by the Company.Should, however,the sum or aggregate sum for be cancelled by the Company by mailing to the Insured at the address shown in
which such claim or claims are adjustable prior to the rendering of trial court this policy written notice stating when not less than ten days thereafter such can-
judgment or judgments exceed the retention, then the Company, if it consents to cellation shall be effective. The mailing of notice as aforesaid shall be sufficient
trial court proceedings continuing, shall contribute to the costs in the ratio that its proof of notice. The time 01 the surrender or the effective date and hour of can-
proportion of the liability for the judgments rendered, or settlement or settlements cellation stated in the notice shall become the end of the policy period. Delivery of
made bears to the whole amount of said judgment or settlement or judgments or such written notice, either by the Insured or by the Company, shall be equivalent
settlements. to mailing.
(8) Loss Payable. The Company shall pay any loss for which it may be liable under If the Insured cancels,earned premium shall be(1)computed in accordance with
this policy in the following manner: the customary short rate table and procedure and(2) not less than the minimum
(a) it one of the said worker's compensation laws is applicable,payment therefor premium stated in the declarations. If the Company cancels, earned premium
shall first be made by the Insured in accordance with the provisions of the shall be computed pro rata. Premium adjustment may be made at the time can-
law,and the Company shall reimburse the Insured for such loss periodically, cellation is effected and,if not then made,shall be made as soon as practicable af-
at intervals of not less than one month, upon receipt from the Insured of ter cancellation becomes effective. The Company's check or the check of its
proper proofs of payment. No voluntary commutation of compensation awards representative mailed or delivered as aforesaid, shall be a sufficient tender of any
to a lump sum basis shall be made by the Insured without the consent of the refund of premium due to the Insured.
Company. (16)Conformity to Statute.Terms of this policy which are inconflict with the provisions
(b) if none of the said worker's compensation laws is applicable and damages of the worker's compensation law are hereby amended to conform to such law.
are recovered against the Insured, payment therefor shall be made by the (17)Declarations. By acceptance of this policy,the Insured agrees that the statements
Company within thirty(30)days after proper proofs of payment by Insured in the Declarations are his agreements and representations, that this policy is
shall have been received by the Company. issued in reliance upon the truth of such representations and that this policy em-
(9) Appeals. In the event the Insured elects not to appeal a judgment in excess of the bodies all agreements existing between himself and the Company or any of its
retained limit,the Company may elect to take such appeal at its own cost and ex- agents relating to this insurance.
IN WITNESS WHEREOF the Company has caused this policy to be signed by its President and Secretary but this policy shall not be valid
unless completed by the attachment hereto of a Declarations page designated as Part Two and countersigned on the aforesaid Declarations
page by a duly authorized representative of the Company. 3-
Secretary President
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