HomeMy WebLinkAbout000201.tiff GArthur J. Gallagher & Co. - Denver
April 18, 2003
Don Warden
Weld County, Colorado
P.O. Box 758
Greeley, CO 80632
Re: Workers Compensation
2392 SO CO
12/31/02-12/31/03
Dear Don:
Enclosed is the original Workers Compensation policy for the 12/31/02- 12/31/03 policy
period. We have reviewed the policy for accuracy, and all appears to be in order. Once
you have reviewed the policy, and if you have questions, please contact us.
Thanks, Don.
Sincerely,
Bobbie Taylor
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 201
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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, 2002
(b) To: December 31, 2003
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) Po cy Part One,Workers' Compensation: Statutory
(b) Po icy 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: 0.0908
(b) Minimum: $35,841
(c) Deposit: $39,823
SO-SCH(1/93)
A Member Company of the W . R . Berkley Corporation
SCHEDULE (Continued)
9. Premium (Continued):
$39,823 Due 01/31/03
10. Clasr,fication of Operations: See Endorsement#1
11. Endcrsement Serial Numbers:
#1 SO-10 #6 SO-44
#2 1O-31 #7 1O-51
#3 1O-32 #8 1O-60
#4 1O-39 #9 1O-CO
#5 SO-43
12. Service Company: County Technical Services, Inc. (CTS1)
Denver, CO
Countersigned MIDWEST/ EMPLOYERS CASUALTY COMPANY
S
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 $ 4,337,253 $12.55 $544,325
CO 7382 BUS COMPANY 294,696 $8.09 $23,841
CO 7720 POLICE OFFICERS & DRIVERS 12,870,040 $4.42 $568,856
CO 8742 SALESPERSONS 2,591,056 $0.75 $19,433
CO 8810 CLERICAL OFFICE OR LIBRARIES 14,240,722 $0.46 $65,507
CO 8820 ATTORNEY 1,838,131 $0.71 $13,051
CO 8831 HOSPITAL-VETERINARY 56,406 $3.86 $2,177
CO 8832 PHYSICIAN &CLERICAL 2,320,835 $0.91 $21,120
CO 8868 SCHOOLS-PROFESSIONAL 1,178,097 $0.87 $10,249
CO 9014 BUILDINGS 107,756 $7.59 $8.179
CO 9015 BUILDINGS 1,165,010 $6.58 $76,658
CO 9101 SCHOOLS-ALL OTHER 642,412 $7.80 $50,108
CO 9410 MUNICIPAL EMPLOYEE NOC 2,214,969 $2.34 $51,830
Totals: $ 43,857,383 $1,455,334
(a) Experience Modification Factor: 1.0000000
(b) Other Modification Factor: 1.0000000
Normal Premium: $1,455,334
Endorsement Effective: December 31,2002
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-10 (1-93)
Endorsement#: 1
Voluntary Compensation Endorsement
Part One of the policy shall also apply to payments you gratuitously make to any employee included
within the group described below (or to the employee's dependent) for benefits indicated in the
workers compensation law of the state where the employee is normally employed, but only if that
state is named in Schedule Item 3.
All officers and employees not subject to the Workers' Compensation Law of the state of their
normal employment.
This endorsement does not apply:
(a) unless the gratuitous benefits are paid as a result of an accident or disease exposure occurring
during the policy period and in the course of employment;
(b) if the employee (or dependent) is entitled to benefits under any workers compensation law.
Endorsement Effective: December 31,2002
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.
1O-31 (1.93) 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 31,2002
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.
1O-32 (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 Statutory.
Endorsement Effective: December 31,2002
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.
1O-39 (1-93) Endorsement#: 4
Deletion of Commutation Clause
Paragraph G of Part Three of the policy is deleted.
Endorsement Effective: December 31,2002
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#: 5
Deletion of the Late Reporting Penalty
Paragraph C of Parts One and Two of the policy is amended as follows:
C. Our Indemnity. We will indemnify you for loss paid by you in excess of your
retention.
Paragraph E of Parts One and Two of the policy is deleted from the policy.
Endorsement Effective: December 31,2002
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-44 (4-99) Endorsement#: 6
Aircraft Exclusion
The policy does not apply to loss arising out of the ownership, maintenance, operation, use, loading
or unloading of any aircraft. This exclusion does not apply to regularly scheduled commercial
airlines.
Endorsement Effective: December 31,2002
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.
1O-51 (1-93) Endorsement#: 7
Number of Days Notice Required for Cancellation
Paragraph F of Part Five of the policy is amended to read as follows:
F. Cancellation. You may cancel this policy by giving us at least 90 days advance
notice by registered mail stating the cancellation date. We may cancel this policy by
giving you 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.
Endorsement Effective: December 31,2002
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.
1O-60 (1-93) Endorsement#: 8
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
notif e 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 Eff ctive: December 31,2002
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.
1O-CO (3-95) Endorsement#: 9
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
self-insurer in each state named in Schedule Item 3. If you are not a duly qualified self-insurer with respect to any loss 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 Annlies. 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. Part One also applies 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 SUSTAINED 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 loss 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. I ate 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. Lose 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.
O. EXCI ups. 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) -t-
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 Aoplias. 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 iniury 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 Reoorting 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. Joss 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;
(Hi) 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 tor 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 foss 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
shalt 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 atter 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 tail 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. Agreement I loon 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. Sankruotcy 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:
2 de"--
SIGNATURE SIGNATURE
Authorized Representative Secretary President
MWE-200 (1-93) -4-
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