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Home My WebLink About000200.tiff G June 6, 2000 Mr. Don Warden Weld County, Colorado P.O. Box 758 Greeley, CO 80632 RE: Excess Workers' Compensation Policy #2392-SC-CO Policy Period: 12/31/1999 to 12/31/2002 Dear Don: Enclosed is your Excess Workers Compensation policy with Midwest Employers Casualty Company. We reviewed the policy for accuracy and found it to be issued as requested. Don, we appreciate the opportunity to place this important insurance coverage for you. If you have any questions or need additional information, please give us a call at (303) 773-9999. Sincerely, )' Sally O. Hayes Assistant Vice Prey dent Enclosure 200 Arthur J. Gallagher & Co. - Denver November 22, 2002 Don Warden Weld County, Colorado P.O. Box 758 Greeley, CO 80632 Re: Excess Workers Compensation Policy $2392SOCO 12/31/02 - 12/31/03 Excess Workers Compensation SIR Bond #19S100729968BCA 12/31/02 - 12/31/03 Dear Don: Enclosed is a binder of insurance for the renewal of your Excess Workers' Compensation coverage, along with an invoice for renewal premium of $39,823. This binder of insurance is considered a legal document, and will keep your coverage in effect until you receive your policy. The Excess Workers Compensation SIR Bond is continuous until cancelled, so a new policy will not be issued; however, a certificate of insurance will be mailed directly to the Department of Labor and Employment showing that the bond was renewed. A copy of the certificate is enclosed for your records. Don, thank you for allowing us the opportunity to place these important coverages for you. If you have questions, or require anything further, please contact either Ty Pixler or myself. Happy Holidays. áior Account Representative Enclosures Cc: Ty Pixler, Sr. Account Manager 7900 East Union Avenue,Suite 200 Denver, CO 80237-2737 303.773.9999 Fax 303.773.9776 Toll Free 800.333.3231 www.ajg.com ACORD INSURANCE BINDER DATE n. 11/21/2002 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT,SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. PRODUCER No(A/C N cart, ,Exty (303)773-9999 COMPANY BINDER# FAX (303)773-9776 Midwest Employers Casualty Co B02112107734 Arthur 3. Gallagher & Co. - Denver Errtc tive EJIrNiAlIt7N DATE TIME DATE TIME 7900 E. Union Suite 200 12/31/2002 12:01 X AM 02/28/2003 X �z:o,AM Denver, CO 80237 PM NOON THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY CODE: I SUB CODE: PER EXPIRING POLICY#: CUSTOMER I 0000301 DESCRIPTION OF OPERATIONSNEHICLES/PROPERTY(Including Location) INSURED Weld County, Colorado Policy #23925000 P.O. Box 758 Greeley, CO 80632 I COVERAGES LIMITS TYPE OF INSURANCE COVERAGE/FORMS DEDUCTIBLE COINS% AMOUNT PROPERTY CAUSES OF LOSS BASIC f BROAD n SPEC GENERAL LIABILITY EACH OCCURRENCE $ I COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any ono fire) $ CLAIMS MADE OCCUR MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ RETRO DATE FOR CLAIMS MADE: PRODUCTS-COMP/OP AGG $ AUTOMOBILE UABILlTY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS MEDICAL PAYMENTS 8 NON-OWNED AUTOS PERSONAL INJURY PROT $ UNINSURED MOTORIST $ $ AUTO PHYSICAL DAMAGE DEDUCTIBLE I ALL VEHICLES SCHEDULED VEHICLES ACTUAL CASH VALUE COLLISION: T STATED AMOUNT $ OTHER THAN COL: OTHER GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE S OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: SELF-INSURED RETENTION $ r I WC STATUTORY LIMITS WORKER'S COMPENSATION E.L.EACH ACCIDENT $ AND EMPLOYER'S LIABIUTY E.L.DISEASE-EA EMPLOYEE S EL.DISEASE-POLICY LIMIT $ SPECIAL Excess Workers Compensation. See attached for limits, terms, FEES $ COON and conditions. Policy Period 12/31/02 - 12/31/03. TAXES $ COVERAGES Premium: $39,823 ESTIMATED TOTAL PREMIUM S NAME&ADDRESS MORTGAGEE ADDITIONAL INSURED LOSS PAYEE LOAN# AUTHORIZED REPRESENTATIVE Karen Graham/BT * -c.—..--- . ACORD 75,5(1913) NOTE:IMPORTANTSTAih IN-ORMA1 ION ON REVERSE SIDE UACUKU CUN)UKA I IQN 1993 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 Florida Except for Auto Insurance coverage, no notice of cancellation or nonrenewal of a binder is required unless the duration of the binder exceeds 60 days. For auto insurance,the insurer must give 5 days prior notice, unless the binder is replaced by a policy or another binder in the same 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 sustained therefrom. AI.UHU 75-S(1/9b) r'i'yi Midwest Employers Casualty Company i w®rtaa=armrnar- Excess Workers Compensation _ BINDER Insured: Weld County,Colorado Policy Number. 2392-SO-CO Submission Number: 36565 Effective Date: December31,2002 Expiration Date: December 31,2003 Service Company: County Technical Services,Inc.(Ctsi) States Covered: CO Includes the following Endorsements: SO.10 Classification of Operations 1O-31 Voluntary Compensation 1O-CO Colorado Endorsement SO-44 Deletion or Late Reporting Penalty 1O-32 USLBH-Limited to State Act IO-e0 90 Day Notice of Cancelle(inn 3O.43 Deletion of Commutation Clause 1O•x9 Communicable Disease Endorsement IO-51 Aircraft Exclusion SPECIFIC. Specific Limit: Statutory Specific Retention: $300,000 EMPLOYERS LIABILITY: Employers Liability Limit: $1,000,0DU Employers Liability Retention: $300,000 AGQREOATF• Aggregate Limit: NA Aggregate Retention(SC of Normal Premium): PM Minimum Aggregate Retention: NA • PREMIUM: Policy Period Estimated Payrolls: $43,857,383 Policy Period Normal Premium: $1,455,934 Rate per$100 of Payroll; 0.0908 Policy Period Minimum Premium: $35,841 Annual Deposit Premium: $39,823 / .• 11#21/02 Midwestfmpfurhscasu Company Oats ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(M/2002 11/21/2002 PRODUCER (303)773_9999 FAX (303)773-9776 I HIS LEH I IFILA it IS ISSUED AS A MA I I tH UI- NFURMA I ION Arthur J. Gallagher & Co. - Denver ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 7900. E. Union Suite 200 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Denver, CO 80237 - INSURERS AFFORDING COVERAGE INSURED Weld County, Colorado INSURERA Midwest Employers Casualty Co .o. Box 758 INSURER B: Travelers Cas.and Surety Comp Greeley, CO 80632 INSURER C. INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INbK TYPE OF INSURANCE POLICY NUMBER YuuOY htrel.I IVE PULILY EXYINA I IUN LTR DATE(MM/DDIYY) DATE(MM/DD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one fire) $ CLAIMS MADE OCCUR MED EMI(My one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO n LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND 2392 SO CO 12/31/2002 12/31/2003 X I TORY LIMITS I I ER EMPLOYERS'LIABILITY A E.L.EACH ACCIDENT $ 1,000,00( E.L.DISEASE-EA EMPLOYEE $ 1,000,00( E.L.DISEASE-POLICY LIMB- $ 1,000,00( OTHER 195100729968BCA 12/31/2002 12/31/2003 Penal Sum: $761,000 Self-Insurer's W/C B Bond DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Self-Insured Retention: $300,000 CERTIFICATE HOLDER I I ADDITIONAL INSURED;INSURER LETTER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE State of Colorado Department of Labor EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL Division of Workers' Compensation 90 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Employers Services 2 Park Central , Suite 600 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 1515 Arapahoe St. OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. Denver, CO 80202-2117 AUTHORIZED REPRESENTATIVE J� Karen Graham/BT ACUNU 25-S(//97) UALURU LUKIUKA I IUN 1981 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ALUKU 25-S(//97) -as's `t g 9St .... Weld County, Colorado 3012 11/21/2002 4 Ty Pixler wt{ 1 of 1 Weld County, Colorado P.O. Box 758 o- ', k°11 Greeley, CO 80632 , 39,823.00 k ,y .,.�OT t Il e; Fri A1‘62""°;‘!'","`?"'"'n " "*' ' Invoice#59509 PAYR EN: F,74e 2392 SO CO hank You PLEAS C)ETACi-i AND RETURN WITH PAYML; Client: Weld County, Colorado Policy #2392 50 CO 12/31/2002-12/31/2003 Midwest Employers Casualty Co 59509 12/31/2002 Renew policy Workers Compensation - Renew policy 39,823.09 I / \\J 1 � \lJ Iv v \\ 39,823.00 l Thank You (Mthur J:Gallagher &Co. Denver I (303)773-9999 ` 11/21/2002 I t Weld County, Colorado 3 012 11/21/2002 Ty Pixler v/ 1 of 1 Weld County, Colorado P.O. Box 758 Greeley, CO 80632 7,230.00 Invoice#59508 19S100729968BCA hv . . You Pt.t.:ASE DETACH AND-RETURN WITH PA4 i'+ I1'. Client: Weld County, Colorado a v 9, 2 "7 �a S ',"' C i s ai �i;i ,,r %_ ...,�a s;. �...ra6u iT_,»3 .. ..,rte°:� :S.., �w,a„ac ,.#�: '.�. aa' ., ,,. . #a4 .>.� Policy #19S1007299688CA 12/31/2002-12/31/2003 Travelers Insurance Company - 59508 12/31/2002 Renew policy Bonds - Renew policy 7,230.00 7,230.00 • Thank You Iar(303)773-99991h1 ghee& Co - Denver 'i �21/2ooz FOLTA kVA kVA Pilig% Fifil WA FA101 Midwest Employers Casualty Company SPECIFIC EXCESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY INDEMNITY POLICY SCHEDULE Policy#: 2392-SO-CO 1. Insured: Weld County, Colorado 2. Mailing Address: P.O. Box 758 Greeley, CO 80632 3. Named States: Colorado 4. Excluded States: None 5. Policy Period: (a) From: December 31, 1999 (b) To: December 31, 2002 Both days at 12:01 A.M.standard time at the Insured's address shown in Item 2 of this schedule. 6. Retention: (a) Each Accident: $300,000 (b) Each Employee for Disease: $300,000 7. Limit Each Accident: (a) Policy Part One,Workers' Compensation: STATUTORY (b) Policy Part Two, Employers Liability: $1,000,000 8. Limit Each Employee for Disease: (a) Policy Part One,Workers' Compensation: STATUTORY (b) Policy Part Two, Employers Liability: $1,000,000 9. Premium: (a) Payroll Divided by 100 Multiplied by: 0.0576 (b) Minimum: $53,460 (c) Deposit: $19,800 SOSCH(1/93) A Member Company of the W . R . Berkley Corporation SCHEDULE (Continued) 9. Premium(Continued): $19,800 Due 01/30/00 $19,800 Due 12/31/00 $19,800 Due 12/31/01 10. Classification of Operations: See Endorsement#1 11. Endorsement Serial Numbers: #1 SO-10 #6 1O-65 #2 1O-CO #7 1O-71 #3 1O-32 #4 SO-43 #5 1O-39 12. Service Company: County Technical Services,Inc. Denver, CO Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY Licensed Resident Agent Date Authorized Representative A Member Company of the W . R . Berkley Corporation Schedule Item 10 is amended to read as follows: 10. Classification of Operations Rate Estimated Estimated per$100 Manual State Code Classification Payroll of Payroll Premium CO 5506 STREET OR ROAD CONSTRUCTION $3,569,780 $14.33 $511,549 CO 7382 BUS COMPANY $229,414 $7.20 $16,518 CO 7720 POLICE OFFICERS &DRIVERS $9,401,793 $4.52 $424,961 CO 8742 SALESPERSONS $1,982,556 $0.78 $15,464 CO 8810 CLERICAL OFFICE OR LIBRARIES $12,484,778 $0.50 $62,424 CO 8831 HOSPITAL-VETERINARY $54,225 $2.87 $1,556 CO 8832 PHYSICIAN &CLERICAL $1,819,910 $0.87 $15,833 CO 8868 SCHOOLS-PROFESSIONAL $1,765,194 $0.75 $13,239 CO 9014 BUILDINGS $60,312 $8.14 $4,909 CO 9015 BUILDINGS $898,125 $6.41 $57,570 CO 9101 SCHOOLS-ALL OTHER $493,382 $6.45 $31,823 CO 9410 MUNICIPAL EMPLOYEE NOC $1,592,017 $2.23 $35,502 Totals: $34,351,486 $1,191,348 (a) Experience Modification Factor: 1.0000000 (b) Other Modification Factor: 1.0000000 Normal Premium: $1,191,348 Endorsement Effective: December 31,1999 Policy No.: 239250-CO Named Insured: Weld County,Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY Authorized Representative Secretary President This endorsement forms part of the policy to which attached,effective on the Inception date of the policy unless otherwise stated herein. 50-10 (1-93) Endorsement#: 1 Colorado Endorsement (Single Self-Insurer: Public Entity, Private Employer or Two or More Private Employers With Same Ownership) Paragraph F of Part Five of the policy is amended to read as follows: F. Cancellation. You may cancel this policy by giving us and the authority shown below at least 90 days advance notice by registered mail stating the cancellation date. We may cancel this policy by giving you and the authority shown below at least 90 days advance notice by registered mail stating the cancellation date. Our mailing of registered notice to your address shown in Schedule Item 2 will be sufficient proof that we cancelled this policy. Executive Director of Labor and Employment Division of Labor 1515 Arapahoe Street Denver, Colorado 80202-2117 If by mutual consent we agree with you to cancel the policy, we will mail to the authority shown above a copy of the cancellation endorsement that you and we have signed. Endorsement Effective: December 31,1999 Policy No.: 2392SO-CO Named Insured: Weld County,Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY Authorized Representative Secretary President This endorsement forms part of the policy to which attached,effective on the inception date of the policy unless otherwise stated herein. 1O-CO (3-95) Endorsement#: 2 Limited Longshoremen's and Harbor Workers' Compensation Act Coverage Part One of the policy shall also apply to loss paid by you because of liability imposed upon you by the Longshoremen's and Harbor Workers' Compensation Act (33 USC Section 901-950). As respects this endorsement, loss shall be limited (by amount and time of payment) to the benefits which would be available under the workers compensation law of the state where the injured employee is normally employed, if that law applied. Endorsement Effective: December 31,1999 Policy No.: 239230-CO Named Insured: Weld County,Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY Authorized Representative Secretary President This endorsement forms part of the policy to which attached,effective on the inception date of the policy unless otherwise stated herein. 1032 (1-93) Endorsement#: 3 Communicable Disease Endorsement In consideration of the premium charged, it is understood and agreed that Part One B of the policy is amended to include the following: Bodily injury to one or more of your employees infected with the same communicable disease manifested during the policy period shown in Schedule Item 5 of the policy will be treated as one loss. The phrase "same communicable disease" shall mean a disease caused by an infectious organism which is directly transmitted from one employee to another in the course of their employment with you. It is further agreed that our limit as respects bodily injury arising from same communicable disease is $500,000. Endorsement Effective: December 31,1999 Policy No.: 2392-SO-CO Named Insured: Weld County,Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY Authorized Representative Secretary President This endorsement forms part of the policy to which attached,effective on the inception date of the policy unless otherwise stated herein. 1039 (153) Endorsement#: 5 Deletion of Commutation Clause Paragraph G of Part Three of the policy is deleted. Endorsement Effective: December 31,1999 Policy No.: 2392-SO-CO Named Insured: Weld County,Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY Authorized Representative Secretary President This endorsement forms part of the policy to which attached,effective on the inception date of the policy unless otherwise stated herein. SO-43 (1-93) Endorsement#: 4 Three Year Policy Period If you cancel the policy prior to the expiration of the three year policy period shown in the Schedule, the following short rate table will apply in place of the customary short rate table. Month When Short Rate Month When Short Rate Cancellation Percentage Cancellation Percentage Effective Effective 1 10% 19 64% 2 15% 20 67% 3 18% 21 69% 4 21% 22 71% 5 24% 23 73% 6 27% 24 75% 7 29% 25 77% 8 32% 26 80% 9 35% 27 82% 10 38% 28 84% 11 41% 29 86% 12 43% 30 88% 13 46% 31 91% 14 50% 32 93% 15 54% 33 95% 16 57% 34 97% 17 60% 35 99% 18 62% 36 100% Endorsement Effective: December 31,1999 Policy No.: 2392.80-CO Named Insured: Weld County,Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY Authorized Representative Secretary President This endorsement forms part of the policy to which attached,effective on the inception date of the policy unless otherwise stated herein. 1055 (1-93) Endorsement#: 6 More Than One Premium Adjustment At the end of each payroll reporting period specified below, send us a report showing the amount of payroll earned by your employees during the period. Payroll Reporting Period Beginning Date Ending Date December 31, 1999 December 31, 2000 December 31, 2000 December 31, 2001 December 31, 2001 December 31, 2002 You must pay us the amount by which the final premium for any payroll reporting period is greater than the deposit premium shown in the Schedule for the period. If, at the end of the last payroll reporting period, the sum of the deposit premiums is greater than the sum of the final premiums, we will pay you the difference. Endorsement Effective: December 31,1999 Policy No.: 2392-SO-CO Named Insured: Weld County,Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY Authorized Representative Secretary President This endorsement forms part of the policy to which attached,effective on the inception date of the policy unless otherwise stated herein. 10-71 (1.93) Endorsement#: 7 MIDWEST EMPLOYERS CASUALTY COMPANY Specific Excess Workers' Compensation and Employers Liability Indemnity 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. Self-Insurance. Your acceptance of this policy indicates that you are now and will remain until the end of the policy period a duly qualified sell-insurer in each state named in Schedule Item 3. If you are not a duly qualified self-insurer with respect to any toss covered by this policy, this policy will apply as if you were. B. Insured. The Insured is named in Item 1 of the Schedule. 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. C. The Policy. This policy includes the Schedule and any attached endorsements. It is a contract of insurance between you (the Insured named in Schedule Item 1)and us(the-Insurer named on the Schedule).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 a part of this policy. Endorsements amending Schedule Items 1.3. 4, 6, 7 or 8 apply with respect to accidents and disease exposures occurring at or after 12:01 A.M. on the endorsements'effective date. D. Policy Period means the period of time covered by this policy as shown in Schedule Item 5. If this policy is cancelled,the policy period will end at 12:01 A.M. on the cancellation date. E. Workers'Compensation Law includes occupational disease law. It does not include the provisions of any law that provides non-occupational disability benefits. F. State means any state of the United States of America and the District of Columbia. PART ONE - WORKERS' COMPENSATION A. How This Part Aoolies. Part One applies to loss paid by you because of liability imposed upon you by the workers'compensation law of any state named in Schedule Item 3. Pari One also apy)lies to loss paid by you because of liability imposed upon you by the workers'compensa- tion law of any other state which is not shown in Schedule Item 4. LIABILITY MUST RESULT FROM BODILY INJURY BY ACCIDENT OR BODILY INJURY BY DISEASE SUSTAINER BY AN EMPLOYEE YOU NORMALLY EMPLOY IN A STATE NAMED IN SCHEDULE ITEM 3. Bodily injury includes resulting death. Bodily injury by accident must occur during the policy period. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 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. Bodily injury by disease does not include disease that results directly from bodily injury by accident. Bodily injury by disease includes cumulative trauma. B. Your Retention. You must retain loss as shown in Schedule Item 6. This retention applies to Part One loss and to Part Two loss together. IT IS IMPORTANT FOR YOU TO UNDERSTAND THAT YOUR RETENTION FOR DISEASE APPLIES SEPARATELY TO EACH EM- PLOYEE. Naming more than one Insured in Schedule Item 1 does not increase your retention. C. Our Indemnity. We will indemnify you for loss paid by you in excess of your retention.This indemnity may be reduced by a late reporting penalty. D. Our Limit. The most toss we will reimburse you for with respect to each accident is shown in Schedule Item 7(a). The most loss we will reimburse you for with respect to each employee for disease is shown in Schedule Item 8(a). Naming more than one Insured in Schedule Item 1 does not increase our limit. E. Late Reporting Penalty. As respects each accident or each employee for disease: 1. If you do not give us written notice within one year of when required by Part Three, our indemnity will be reduced by 15%. 2. If you do not give us written notice within three years of when required by Part Three,our indemnity will be reduced by 40%. F. Loss means the amount actually paid by you for regular benefits provided under the workers'compensation law in effect upon the date the accident or disease exposure occurs. Loss includes: 1. The amount paid by you in settlement of claims for regular benefits under the workers'compensation law; 2. The amount paid by you in satisfaction of awards or judgments for regular benefits under the workers'compensation law; 3. Court costs,interest upon awards and judgments, and allocated investigation,adjustment and legal expenses pertaining to workers' compensation claims.This subparagraph 3 does not include: (i) salaries paid to your employees; (ii) service company fees; (iii) claims administrator fees. G. Exclusions. Part One does not cover: 1. Loss insured by full coverage workers'compensation or employers liability insurance; 2. Loss payable under the workers'compensation law of any state which is not named in Schedule Item 3, if you are protected from the loss by any other insurance; 3. Any loss arising out of operations for which you have rejected any workers'compensation law; MWE-200 (1-93) -1- 4. Punitive or exemplary damages because of bodily injury sustained by any employee; 5. Punitive, exemplary or compensatory damages because of your conduct,or the conduct of anyone acting for you: (a) in the investigation,trial or settlement of any workers'compensation claim; (b) in failing to pay or delay in payment of any workers'compensation claim. 6. Any assessment made upon self-insurers,whether imposed by statute,regulation or otherwise. H. Payments You Must Make. You are responsible(without reimbursement from us)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. I. Other Insurance. If,as respects any state named in Schedule Item 3.any other insurance exists protecting you against loss covered by this insurance,this insurance shall apply in excess of the other insurance. J. Recovery From Others. We have your rights,and the rights of persons entitled to compensation benefits from you,to recover our loss from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. The recovered loss will first be used to reduce our loss.Then we will pay the balance, if any,to you. Expenses of all proceedings to recover from anyone liable for injury covered by this policy will be allocated between you and us in the ratio represented by the allocation of any damages which have been recovered. PART TWO - EMPLOYERS LIABILITY A. How This Part Applies. Part Two applies to loss paid by you for damages imposed upon you by the laws of any state shown in Schedule Item 3. Part Two also applies to loss paid by you for damages imposed upon you by the law of any other state which is not shown in Schedule Item 4. DAMAGES MUST RESULT FROM BODILY INJURY BY ACCIDENT OR BODILY INJURY BY DISEASE SUSTAINED BY AN EMPLOYEE YOU NORMALLY EMPLOY IN A STATE NAMED IN SCHEDULE ITEM 3. Bodily injury includes resulting death. Bodily injury must arise out of and in the course of the injured employee's employment by you. Bodily injury by accident must occur during the policy period. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 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. Bodily injury by disease does not include disease that results directly from bodily injury by accident. Bodily injury by disease includes cumulative trauma. B. Your Retention. You must retain loss as shown in Schedule Item 6.This retention applies to Part One loss and to Part Two loss together. IT IS IMPORTANT FOR YOU TO UNDERSTAND THAT YOUR RETENTION FOR DISEASE APPLIES SEPARATELY TO EACH EM- PLOYEE.Naming more than one Insured in Schedule Item 1 does not increase your retention. C. Our Indemnity. We will indemnify you for loss paid by you in excess of your retention.This indemnity may be reduced by a late reporting penalty. D. Our Limit. The most loss we will reimburse you for with respect to each accident is shown in Schedule Item 7(b).The most loss we will reimburse you for with respect to each employee for disease is shown in Schedule Item 8(b). Naming more than one Insured in Schedule Item 1 does not increase our limit. E. Late Reporting Penalty. As respects each accident or each employee for disease: 1. If you do not give us written notice within one year of when required by Part Three,our indemnity will be reduced by 15%. 2. If you do not give us written notice within three years of when required by Part Three,our indemnity will be reduced by 40%. F. Loss means the amount actually paid by you for damages imposed upon you by law. Loss includes; 1. The amount paid by you in settlement of claims for legal damages; 2. The amount paid by you in satisfaction of awards or judgments for damages; 3. Court costs,interest upon awards and judgments,and allocated investigation,adjustment and legal expenses pertaining to employers liability claims. This subparagraph 3 does not include: (i) salaries paid to your employees; (ii) service company fees; (iii) claims administrator fees. G. Damages includes: 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; and 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 arise out of and in the course of employment,claimed against you in a capacity other than as employer. MWE-200 (1-93) -2- H. Exclusions. Part Two does not cover: 1. Liability assumed under a contract; 2. Loss payable under the law of any state which is not named in Schedule Item 3,if you are protected from the loss by any other insurance; 3. Punitive or exemplary damages because of bodily injury sustained by any employee; 4. Punitive.exemplary or compensatory damages because of your conduct,or the conduct of anyone acting for you: (a) in the investigation, trial or settlement of any employers liability claim; (b) in failing to pay or delay in payment of any employers liability claim. 5. 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; 6. Any obligation imposed by a workers'compensation.occupational disease,unemployment compensation,or disability benefits law,or any similar law; 7. Bodily injury intentionally caused or aggravated by you.This exclusion does not apply to claim expenses(listed in subparagraph 3 of the definition of loss) related to the injury; 8. 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; 9. Bodily injury occurring outside the United States of America.This exclusion does not apply to bodily injury to a citizen or resident of the state(s) listed in Item 3 who is temporarily working outside the United States for the Insured; 10. Damages arising out of operations for which you: (a) have violated or failed to comply with any workers'compensation law,or (b) have rejected any workers'compensation law. I. Other Insurance. If, as respects any state named in Schedule Item 3.any other insurance exists protecting you against loss covered by this insurance, this insurance shall apply in excess of the other insurance. J. Recovery From Others. We have your rights to recover our loss from anyone liable for an injury covered by this insurance. You will do everything necessary to protect those rights for us and to help us enforce them.The recovered loss will first be used to reduce our loss. Then we will pay the balance, if any.to you. Expenses of all proceedings to recover from anyone liable for injury covered by this policy will be allocated between you and us in the ratio represented by the allocation of any damages which have been recovered. PART THREE - CLAIMS A. Your Claims Handling Duties. It is your responsibility to investigate, settle,defend and appeal any claim made against you. It is also your responsibility to investigate,settle,defend and appeal any suit brought or other proceeding instituted against you. B. Your Claims Reporting Duties. It is important for you to understand that"Written Notice"shall contain complete details of the injury,disease or death. Providing loss runs does not constitute notice. 1. You must give us written notice as soon as you learn of any of the following events involving loss which exceeds(or might in the future exceed)50%of your retention: (a) claim; (b) award; (c) verdict; (d) action; (e) suit; (f) proceeding; (g) judgment. 2. You must give us immediate (within 30 days)written notice of any accident involving: (a) fatality; (b) spinal cord injury; (c) a permanent total disability as defined in the workers compensation law; (d) serious burn injury; (e) brain injury; (f) amputation of a major member. 3. You must give us prompt written notice of any claim in which the injured employees disability exceeds 52 weeks, even if the claim is being contested by you; 4. You must give us immediate (within 30 days)written notice of all occurrences involving two or more of your employees. C. Claims Information. You agree to send to us any claim information which we may request. D. Claims Participation By Us. At our own election and expense,we have the right and shall be given the opportunity to participate with you in the settlement,defense or appeal of any claim, suit or proceeding which might involve a loss to us.We have no duty to investigate, handle, settle or defend any claims,suits,or proceedings against you. E. Good Faith Settlements. You shall use diligence, prudence and good faith in the investigation,defense and settlement of all claims and shall not unreasonably refuse to settle any claim which, in the exercise of sound judgment.should be settled.You agree not to make any voluntary settlement involving loss to us without our written consent. F. Proof of Loss. When paid loss exceeds your retention, you must provide us with a payment register listing all payments made on the claim. We will reimburse you the amount you have paid in excess of your retention,within 30 days of receiving in a form acceptable to us,a complete and proper proof of loss. MWE-200 (1-93) _3_ G. Commutation. Beginning thirty-six (36) months after receipt of notice by us of a claim,we may then, or at any time after, submit the claim for commutation. If we so elect,the claim shall be submitted to an actuary or appraiser to be mutually appointed by us and you.Should we both 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. We may pay the lump sum amount,which shall constitute a full and final release of our liability for the claim. However, such lump sum payment shall not constitute a full and final release of our liability if, after the lump sum payment.any supplemental award is made increasing the amount of benefits payable to the Employee and his/her dependents.Any additional liability, at our election, may immediately be commuted via the process above and we may discharge such liability by payment of another lump sum. H. Claim Audit. You will let us or our representative examine and audit claim files upon our request.These audits may be conducted during your regular business hours. PART FOUR - PREMIUM A. Deposit and Adiustment Premiums. At the beginning of the policy period you must pay us the deposit premium shown in the Schedule.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. B. Payroll Report. Within 45 days after the end of the policy period, send us a report showing the amount of payroll earned by your employees during the policy period. The report must show payroll separately for each classification identified in Schedule Item 10. C. Final Premium. The final premium due us for the policy period will be computed as shown in Schedule Item 9(a). Unless this policy is cancelled,final premium will be at least the minimum premium shown in Schedule Item 9(b). If we cancel this policy,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. If you cancel this policy,final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by the customary short rate table and procedure. Final premium will not be less than the short rate portion of the minimum premium. D. Payroll means the gross pay of your employees for the policy period plus other amounts and items received by your employees as part of their pay for the policy period.We will send you a payroll reporting form describing what is included in payroll. E. 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. F. Audit. You will let us or our representatives examine and audit all your payroll records.The audits may be conducted during your regular business hours. PART FIVE - CONDITIONS A. Anreement I 1pon Terms. Your acceptance of this policy means that you agree with us upon the terms of this policy. B. Sole Representative. The Insured first named in Schedule Item 1 will act on behalf of all Insureds to change this policy, accept loss payments, receive return premium and give or receive notice of cancellation. C. Bankruptcy or Insolvency. Your bankruptcy or insolvency will not relieve us from the payment of any claim covered by this policy. After the retention shown on the Schedule has been paid, payments will be made by us as if you had not become bankrupt or insolvent but not in excess of the Insurers Limit of Indemnity. Payment will be made to the Trustee in Bankruptcy or as directed by an appropriate court. D. Transfer of Your Rights and Duties. Your rights or duties under this policy may not be transferred without our written consent. This provision does not apply to duties transferred to a service company or a claims administrator. E. Service and Administration. This Agreement contemplates the concurrent and continued existence of a separate service agreement between you and the Service Company named in Item 12 of the Schedule.You must notify us within 30 days should you decide to change the service company. F. Cancellation. You may cancel this policy by giving us at least thirty(30)days advance notice by registered mail stating the cancellation date.We may cancel this policy by giving you at least thirty(30)days advance notice by registered mail stating the cancellation date. Our mailing of registered notice to your address shown in Schedule Item 2 will be sufficient proof that we cancelled this policy. If you fail to pay premium,we may cancel with 10 days written notice to you. We have executed this policy by printing below the facsimile signatures of our President and Secretary and by the actual signature of our authorized representative on the Schedule. • MIDWEST EMPLOYERS CASUALTY COMPANY`` Countersigned: • -i • SIGNATURE SIGNATURE Authorized Representative Secretary President MWE-200 (I-93) -4- Hello