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Home My WebLink About000263.tiff DON Warden - MECC App.xls Page 1 Midwest Employers Casualty Company INDIVIDUAL 13801 Riverport Drive, Suite 200 SELF-INSURANCE Maryland Heights, MO 63043-4810 APPLICATION FOR EXCESS WORKERS'COMPENSATION COVERAGE New Application Effective Date: 12/31/02 Renewal of Policy Number: 2392 SO CO To Be Quoted By: 11/1/02 1. Name of Applicant (as shown on self-insurance permit): Weld County,Colorado 2. Address: P.O.Box 758,Greeley,CO Zip: 80632 3. Applicant Phone Number: 970-356-4000 6% yr-t 18 ,r �/' 4. Federal Employers Identification Number: O y ' �6Oc) - d )3 5. Describe operations to be covered;subsidiaries to be covered if any. (Attach copy of current and comprehensive engineering inspection reports,annual report,or 10k report and products brochure.) County Government 6. Describe any substantial or unusual changes in operations that are planned or have taken place in the past five years: NO C 7. Date qualified as a self-insured: 1978 8. States to be self-insured: Colorado 9. Are there other states or jurisdictions included for self-insurance that would not be covered by the insurance requested by this application? Yes No If yes,list: 10. Do any employees receive supplemental benefits in addition to workers'compensation benefits? Yes 11. Provide details of any OSHA or State OSHA violation within the past 5 years: NONE 12. Does the applicant have any employees who may be subject to the Longshoremen and Harbor Workers Act,Jones Act or Federal Employee's Liability Act? (Unless endorsed,our policy does NOT include federal acts coverage.) Yes No If yes,describe: 13. Do the operations of the applicant include volunteer or dpnated labor? Yes ' No If yes,describe: Shp.Q(+ Pkc _ 1 - Y`0 t' &scup-u.fi 14. Does applicant have any foreign operations or employees who travel to foreign countries? Yes No If yes,describe: 15. Is applicant engaged in the manufacture,production,refining,storage,distribution,or transportation of gases,gasoline or flammables? Yes No If yes,describe: 263 CN Warden MECC Ap..A•x(s ...:�,_M,.,,.a.M,.,.�,. ..��..,. .._ ,... .. • 16. Are there any occupational disease exposures involved in the applicant's operations? (asbestos: silica;dusts;toxic,injurious or hazardous chemicals;caustics,fumes,radiation,communicable Yes � No diseases and any other O.D.exposures)t If yes,describe steps taken to control: t IAkXC.. Si'\120a.\ l Y�K ('].jl?4 es - CutrinU.-lItc JAL d1S.o_14-; � • yvya,►wk ,Me ..4oc A1.f,L-e tire -fa p 'C l c 2iX pc.) , 17. Does applicant perform any underground,subaqueous,or tunneling operations'? Yes No a If yes,describe: 18. Do the operations of the applicant include wrecking or demolition of structures? Yes No If yes,describe: 19. Do the operations of the applicant involve exposure to heights? Yes No' If yes,describe: Yes No 20. Does applicant now(or have future plans to)own,lease or charter watercraft? If yes,describe watercraft,use,number of crew members,passenger capacity and whether craft is owned,leased,or chartered. 21. Does applicant own,lease,or charter aircraft? (If yes.Aircraft Questionnaire must be completed.) Yes No 22. Complete the following information on owned or leased vehicles:ic (;(4,714/ ` a. Number of: passenger cars qd ?I w Kg/ iss tractors --eO b. Number of commerical vehicles owned by: applicant in owner-operator C) c. Is applicant responsible for W.C.coverage on owner-operators? Yes o If no,does applicant obtain certificate of W.C.insurance from such operators? es ' No d. With respect to commercial vehicles: /YEA 1. States in which vehicles operate: 2. Average number of persons in each unit: 3. Does applicant transport chemicals,hazardous materials,explosives,explosive material,flammable material,or any petroleum products? Yes No If yes,provide full details: �►. Yes ('rip) 23. Does applicant provide any transportation for employees to or from the workplace? `.� If yes,describe the type of conveyance,frequency of trips and number of employees (total number and number per conveyance involved): 24. Policy Coverages and Limits. Current Carrier: (Y1 tduipst Col 1 ( eizS C1rA , � A, . Present ProgramYFRs JNSUR `J �aTE ciATF T ha.— SPECIFIC LIABILI ED RATE EXCES LOSS ESTIMAT TERM EXCESS TY RETEN 5 FUND EU LOSS LOSS ' LIMIT - Statutory 1,000,000 300,000 0.0576 _ _ — Coverage Desired: YERS NCIIR nATF FATE SPECIFIC LIABILI I ED EXCES LOSS FUND EXCESS FY IRETEN - S - LIMIT Statutory 1,000,000 300,000 I . DON Warden - MECC App.xis Page 3 25. Gross Payroll Distribution by Classification Code. a. Projected payroll. Provide the following information regarding each state or jurisdiction: (If more space is needed, use a separate page.) �{ 17/31/ 19/31/ UO-ut as-UU 9o-8 d.7-. o /V° POLICY PERIOD: 02-03 01-02 Audite Audite Audite Audite /� Est. Est. Cie" V ROPP STATE CnnF CLA.SSIFICA�ION 'CTIVE st PRIOR 2nd PRIOR 3rd PRIOR 'th PRIOR 5th PRIOR YSAN Street ��$ CO 5506 and 9 1r,� Al (/y 9:14`` 4,029,734 3,913,762 3,506,488 3,381,605 Wa4edit CO 7382 Amhorit '4y(o9 me 2- 250,876 243,908 221,540 222,047 yolicem .230 CO 7720 an/ jjt OppV 11, 9),070 10,827,608 9,939,706 9,087,574 8,504,592 SeIorda CO 8742 Outside ' S //r I 9b<go 2.292.428 2,200,114 1,931,748 1,871,525 fir ,037_ / ClencaV J 7. / CO 8810 Office/EI P1.2 7L /3, 91001 12, 29,640 12,080,283 10,841,444 10,520,056 6820 smigid1ey l,Y , 13 IT 1Y37 o 1,499,824 1,359,210 1,016,990 O.z3 Animal 00 S CO 8831 Control 90 3SD 52,151 52,870 55,863 53,691 Health CO 8832 Dept., $2, 1p/r�' - .2 3/S 1b 2,031,003 1,-67,990 1,'28,884 1,639,879 / 8u0fo06i q� CO 8868 Prof/Libr /y/1� // .Z 7J- 1,037,636 1,956,198 1, 88,399 1,'17,846 ✓ eraackri / CO 9014 Examin /D7 1 03, G/L 78,000 67,020 59,221 58,725 BWlding '7/1 CO 9015 Operati II 1 4 0/ / 0 x;02. 1,028,921 1,005,520 879,986 $03,001 uU School `` "! CO 9101 -other ,q/• 7 707/ 491,872 479,928 510,602 518,795 Municip 9r� / CO 9410 al �t /7, a �P q,7,Dr/ 1,859,400 1,-03,468 1,541,471 1,513,229 4/ employ if s7 'rid Totals: 8 70 �� v 0 36,'09,269 36,910,591 33,512,430 31,021,981 /b y 2— b. Is there any significant change to the payroll distribution by classification code in the last five years? Yes No c. If yes,describe reason for change(s): 26. Loss Experience and Historical Activity. The following loss information may be provided via an electronic data dump*or loss runs: INnPM MFnir: Tr1TAI IIDN NI I1' - AL ,a� INCUR a STATE ICY PEF LAITY PFSFR RFCFR RED DATE- YAIU'" PAID Attach Loss Runs Electronic file detailing the insured's loss experience by policy period. Data elements should include all claims,open/closed status,payment activity including paid/reserved/total incurred amounts split by medical and indemnity,and a state or location code with a related definition for that code. Include allocated claims expenses as part of indemnity "" Valuation date must be within the past six months Page 4 DON Warden - MECC App.xts CLA{MS BEN WITHV b STATE PERIO PAYRO ED Fxcl11 CLAIMS PaYM[N • LL Rt reN CNPs are defined as claims reported and closed without any payment being made. c. Are CNP claims included in the totals for open and closed claims? Yes No Don't Know d. If yes,indicate the approximate percentage of total claims that are CNPs: % Don't Know 27. Individual claims in excess of$50,000 incurred(past 5 years). (The following information may be provided via an electronic data dump or loss runs. If more space is needed, use a separate page.) f1ATF 1PTIf1N _ Tf1TAI Tarp .Nfl AF TUTAL RESER INCUR EMPLO STATE OF OF -PAP LOSS - ALLID ye RED PEES r- 1 - 28. Total number of employees: / v y 2.- 29. Concentration of Risk. Give the following information regarding each location. (If more space is needed,use a separate page.) TOTAL NUMBER TOTAL NUMBER LOCAT ON/ADDRESS STATE ZIP EMPLOYEES IN EMPLOYEES IN TOTAL CODE ALL SHIFTS MAX SHIFT PAYROLL oce 12,. 41- :/41-J aj - / 6 c;"? ole . . 30. Loss Prevention. DON Warden - MECC App.xis Page 5 a. Loss Prevention Service Company Information:n' ^—� d / i 1. Name of service company f.o tbrll TY I C C-41 1c `L ' S , CCT5� 2. Address of service company /4304 .2d Cit a)Al ST t (LP U n -ei)?, Co "roc..96 b. Do you have dedicated safety professiopa Is on staff which are not hµma esources personnel? Yes No Cvn-k-r-tJ- w r 1' `u1�.r1YY TP-C4g0tc...Y .Cez f tic. c. Do you have safety committees? No No d. If yes,do they have management participation? Yes No e. Do you provide new hire safety training? Yes No f. Do you provide job specific safety training thereafter? Yes No g. Do you have a cost allocation system in place which links workers'compensation costs —. to the department or facility? , I No h. Do you have any incentive plans in place linking individual and department workplace safety ti 4 to a rewards system? '�f1o��1e S TD-YL d GA A"M1'4Y^�� Tf .SA`� � ✓lU u Yes o 31. Claims Handling. Ilf no service company MECC Self-Administration Questionnaire must be completed.) a. Service Company Information: �' CC 1. Name of service company [I Cili l Ty TPc Hit) __C/3 C S ?Z-ice- I SS nn c 2. Address of service company L 700 P R N y ✓ oft ' - IW Ih'jyl 1 P6 Qo 2,0 3. Phone number ?0 - Vi$ / -'0,5`07 4. Contact name for this account: 71-11 PP) 0-/1 ll"f ill hit,/ b. Are claims handled to conclusion? If no,give details. �9(,/l,, -{-, es No c. What is normal length of service contract? •3 Y P ZS t^%/ ` " off?1' tin 0-r, 0,4 6*h est 3ye i S d. Does applicant agree to let the excess carrier know about any changes in the service company i or in the kind or amount of services to be performed by the service company? a No e. Do you have an alternative duty return to work program in place for all departments? C. No f. Do you provide in-house medical attention for first aid injuries? Yes No g. If so,who provides the treatment? ClagiNI/'u K- — Ms aan V ` ki-nct at aS,(Jr._ h. Do you have a process in place in which all injuries are intemally investigated and reported to your claim servicing company within 24 hours? Yes' No i. Do you conduct regular or quarterly claim reviews with your claim servicing company? ''j No j. Check the following managed care programs that apply to your program: ��-- PPO ontracted rici other ee Scheduling nurse case management j Florida Any person who knowingly and with intent to injure,defraud,or deceive any insurer files a statement of claim or an application containing any false,incomplete,or misleading information is guilty of a felony of the third degree. New Jersey Any person who i< 2 ncludes any false or misleading information on an application for an insurance p is subject to criminal and civil penalties. New York Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information,or conceals DON Warden - MECC App.xis Page 6 for the purpose of misleading,information concerning any fact material thereto,commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Other States Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing false or deceptive statement is guilty of insurance fraud. 2_ 14i e i i y1(401-16 Date Applicant's Signature Title 7 WieVeleA)oria id )) , iri f' Ad fh IA), Print Applicant's Name Print Applicant's Title j e S b)QYIS - 1—c) Tf 2 / l Oy (.•t�l I ! "�I PCB I6 f� / ov,,, ,7„.+- Colorado Counties Casualty& Property Pool V (� , Building Values as of July 9,2002 71) } -To t -To--R I F✓ripu34 ecs L--n1 ),,Aer5 1314-y ituU- Est. # County Address City Zip "'__"____ "--- 1611 WELD EAST 2ND-JOHNSTOWN MAIN SHOP JOHNSTOWN 80534'- _.__ u 1612 WELD EAST 2ND-JOHNSTOWN SMALL SHOP#2 JOHNSTOWN 80534 �ZU_....�,_.... ..-_..,,�--_._42Z_ _..__ /7 / / 1613 WELD EAST 2ND-JOHNSTOWN FUEL SHED#3 JOHNSTOWN 80534, _. _, _ 1614 WELD 1500 2ND ST OLD COUNTY SHOP GREELEY 80631 y ....: _.:.. -.._-_ ~.. ,, ~~ YM �c y�G/ ....•. 1615 WELD 4TH&MAPLE-SOUTHWEST COMPLEX 1 OF 3 FREDRICK 80631 1616 WELD 4TH&MAPLE-SOUTHWEST COMPLEX 2 OF 3 FREDRICK 80631 ._M., 0. _M _.. . J ..�..3 1617 WELD 4TH&MAPLE-SOUTHWEST COMPLEX 3 OF 3 FREDRICK . 80631 _ 1618 WELD 1311 17TH AVE-HOUSEHOLD HAZMAT BLDG GREELEY 80634 r -..- ....._._,_...3&',_,t) .. .._ 1619 WELD 900 9TH ST-COURTHOUSE ANNEX/UPS GREELEY 80631 _ _ _ y Y_ _.._-.. Q • 1620 WELD 9009TH ST-COURTHOUSE ANNEX/PROBATION GREELEY 80831-_ • • IV (.0uNTY 6MtL� ._. _ 0 pp 1621 WELD 915 10TH ST-COURTHOUSE GREELEY 80631 -39/� y<'3 1822 WELD 104 11Th AVENUE-FOOD WAREHOUSE GREELEY $4631 1623 WELD 915 10TH ST-ADMINISTRATION/JAIL :^y • to.Yz-j—1 F=1c�G ._ _.__..,._,___0____.___Alai-. .-cQ41/1IY.��of l�10%_C e __ _. O. .__, C3REELEY 80891 J57 ,�__•._,_ .r . .- 4 t fd �S 1624 WELD 315 NO 11TH AVE-SOCIAL SERVICES BLDG STatitY-/'`/)GREELEY 80631 b,77,1).O 1625 WELD 933 NO 11TH-R&B HEADQUARTERS#1 GREELEY 80631 . ._...._ /0 ./O _. ._.,...._._,,...... r9 / / .2., 1628 WELD SH 52/WCR11-SO COUNTY HAZMAT BLDG DACONO 80514 .. oo 1629 WELD 1399 17TH AVE-MOTOR VEHICLE SERVICE CENTER GREELEY 84631 -- Q _A/O.T__.__cJ14(AY _P( yye$ 1630 WELD 1551 NO 17TH AVE-HUMAN RESOURCE BI.DG GREELEY 80631 _.. .....- _ ._. ___ -_- .S ......,... ....-. Zit,Yh 1632 WELD 330 PARK-SOUTH COUNTY SERVICE CENTER FT LUPTON ._ 80631..,. . ./2.--. .. ., ----4 .--,- --- - - .1-d 4 7-3. •-• 1633 WELD ISLAND GROVE PARK-STORAGE BLDG#1 GREELEY 8pR1,�L _ •- 1634 WELD ISLAND GROVE PARK-STORAGE#2 GREELEY 80631 J ... ..._./1.$79 `_3 .- .- 1835 WELD ISLAND GROVE PARK-LIVESTOCK BARN GREELEY 80631 1638 WELD ISLAND GROVE PARK-4 H BUILDING GREELEY 80631_____ 1637 WELD ISLAND GROVE PARK-COUNTY EXHIBITION BLDG GREELEY 80631 1639 WELL) SH 14-AULT BLADE STATION AULT 80610 ~ - 1641 WELD WCR 44&SH 34-PECKHAM BLADE STATION PECKHAM 80831 . ..... _._--..,7�.5 4 1642 WELD FT LUPTON-BLADE STATION FT LUPTON 80621. «Z.�.,.,....._. .. ..:_.._ ,..._. . .. _. .. . _._- . ...:44..4....4.._-..._..-... ._ .:...,... _,__ ._..._.. . ._......,... �V b 1643 WELD GALE TON-BLADE STATION GALE TON 80622 1644 WELD GROVER-BLADE STATION GROVER .....80729 .. ' - __._. 7U 5 5y .... . .............. . 1645 WELD MEAD-MEAD BLADE STATION MEAD 80542 1046 WELD KERSEY KERSEY BLADE STATION KERSEY eon /... • f_ ___...,.__..3Sa 7 1647 WELD KIOWA-KIOWA BLADE STATION/OLD KIOWA 801{!' . _ 1648 WELD KIOWA-KIOWA BLADE STATION/NEW KIOWA 80117 ._1. _1 __.._ ........ . . ._. �' 1649 WELD NUNN-NUNN BLADE STATION NUNN 80843 _...._.__ .._--_ ___..� ...,_:...... ._ 1650 WELD GILL-GILL BLADE STATION#1 GILL_ 80624_,,.•__,�_,se's _ _ l. 1651 WELD. KEOTA-KEOTA BLADE STATION KEOTA 80631 1 -T � _._ __.Y,--_.V.. .. ... �- _...w - ._.3 .. . 7g.... .•M.�. 1653 WELD LUCERNE-LUCERNE BLADE STATION LUCERNE 80846 _ . ._.,__L•_,_. ..__....._.__,,_... __._ 3_.'Z ,...,. 1654 WELD ROCKPORT-ROCKPORT BLADE STATION ROCKPORT 8 31,..,.._......,.._1.:..-.__..,.. / ir,-27(....... 1655 WELD SERVERANCE-SERVERANCE BLADE STATION SEVERANCE 80546 A • --- _.•.___7(1SS .-... 1656 WELD NEW RAYMER-NEW RAYMER BLADE STATION NEW RAYMER 80742 1 1 33c27,. 1657 WELD VIM-VIM BLADE STATION VIM 8901.---___,,l____-..________ _i. . _ 7.k 1868 WELD 1316 4TH AVE-HEADSTART JEFFERSON SCHOOL GREELEY 80631 ,fa /d U .2 Ci az.)y ":_a liar Colorado Counties Casualty&Property Pool T�} r Building Values as of July 9,2002 "O-4aS - ) cf PpG- •1in1� �A iii .. 1�tvp S rt, F P, ! ____—_. Est. # County Address City Zip /.4lot). 1659 WELD 1400 37TH STREET-HEADSTART CENTENNIAL SCHOOL EVANS iUU 1660 WELD 341 14TH AVE-HEADSTART MARTINEE SCHOOL GREELEY VOL__..__.�_..__. - " "f �o...� 1661 WELD 2201 34TH STREET-HEADSTART DOS BIOS SCHOOL EVANS • 8ip$ p_ .._�__ _--- __ ,_---4 _.._.....l log /vim 1662 WELD 24TH AVE&6TH STREET•HEADSTART MADISON SCHOOL GREELEY fl4F3a___, ._ .__ /,7��/u u 1863 WELD 300 BEECH STREET-HEADSTART HUDSON HUDSON a 642 _ lj .- /„241 /90 1664 WELD 614 E 20TH STREET-HEADSTART EAST MEMORIAL GREELEY 80631 !-- - ---____,,a6,1,100 1665 WELD IHWY 392&HWY 34-BRIGGSDALE BLADE STATION BRIGGSDALE 60611_•__...J 1666 WELD STONEHAM-STONEHAM BLADE STATION 2 SIONEHAM 8-0764-________7117_................_ • f ----------... J"57..24 1667 WELD KEENESBURG-KEENESBURGE BLADE STATION KEENESBURG 80643•�_�_.._.. ,-_-_- 1155 G- - 1668 WELD 1121 M STREET NORTH AMBULANCE GREELEY 8083}._,.._._ _ ---. --- • 1669 WELD 1400 77TH AVE-ADMIN/ASSR/TREAS GREELEY 80631 __ 3 ._.___ ' .6---_,3__.._.._�.__ ..._ l'14/7A/,s....._ .. 16/0 WELD CRNR OF 11TH&34TH STS-SOUTH AMBULANCE EVANS 80620 • _,_ - .....2=4-f-- 5-4 1671 WELD 1402 17TH AVE-ADMIWGO CLERK GREELEY 80831 3 •_ Jr r - f� f�/U 1672 WELD 222 HAP COURT-HEADSTART CLASSROOM OLATHA 81452 - •--T� 1673 WELD 3093 EAST 1/4 ROAD,HEADSTART SCHOOL GRAND JUNCTION _ /uV_81504,._.,_...,...__. _.... .. __ ,... ...4, __ 426.42!149... 1674 WELD 415 S SPRUCE ST-PIONEER ELEM/HEADSTART FT MORGAN 80701 _ 1675 WELD 2110 O St-NORTH JAIL GREELEY . 80631 ,-, ..,._• '0 .. -'Z CXJ1 1863 WELD 315. 11TH AVENUE-SOCIAL SERVICES ADDITION GREELEY 8Q63L - .41Z_ --- ----_-- , -7--7/..? - 1865 WELD 35TH AND HIGHWAY 34-COMMUNICATIONS BACK UP BLDG/ GREELEY 1891 WELD 2666 N.17TH AVENUE-PUBLIC HEALTH BLDG GREELEY'? o1`';i 80631 //1/ _� �-._.._ .-_-____..._____.-/.f- - 1921 WELD 1111 -H STREET-PUBLIC WORKS ADMINISTRATION OFF. GREELEY 8nRs1_ ._.._..._ —.-.__-- 1922 WELD 111 -H STREET-PUBLIC WORKS-DIV.BLDG WAREHOUSE GREELEY 8061 jp` 1923 WELD 1111-H STREET-WELDING SHOP GREELEY 60631. _ 1924 WELD 1111 -H STREET-PUBLIC WORKS-VEH.STOR#1 WARE GREELEY 80631 -----• --.-- ---- •-- •-__. • •- - .. ......" 1925 WELD 1111 -HST.- PUBLIC WORKS-VEH STORAGE#2 WARE GREELEY • 50631 �_____.__.,__..,......_.._.--_.. ... _.:...w.._...... .._._ 2012 WELD PUBLIC WORKS DE-ICER STORAGE,1111 H ST. GREELEY 80631 -w - 2023 WELD FT LUPTON BLADE STATION,7625 WCR80621 31 FT LUPTON _._,_._. -��S�� 2024 WELD FT LUPTON DE-ICER STRG,7626 WCR 31 FT LUPTON 6_0B21 D. y - -- ` 2025 WELD TRAINING CENTER, 1104 H STREET GREELEY ADAM, 80631--- -- — �ls�!'. 2087 WELD BLDRS RISK,SW WELD CTY ADM ,WCR 24 1/2&1.25 LONGMONT <1.2 -- •2113 WELD 901 10TH AVE..OFFICE-WEST ANNEX GREELEY A0R31 f -- t----- ---- 2114 WELD 903-909 10TH AVE.,OFFICE-JUVENILE DA GREELEY 8Qfa1__r,.. !1__ ._ _._ _ �. ..-.-_... .._-. _..._ _ 1� 3. 2167 WELD 2110-0 STREET,BLDRS RISK,NORTH JAIL GREELEY 80631 c9 w D eun 5 T zaz'n 1� (,2- (`un'S 7721-ke Tr .- o .... 2168 WELD 2110-O ST.,PUBLIC SAFETY BLDG,BLOBS RISK GREELEY ,80631 O,r -, Will) _, 2169 WELD 3093 EAST 1/4 ROAD,BLDRS RISK,HEADSTART CLASS.--, GRAND JUNCTION 1' 41 -Lad , DON Warden -Vehicle Supplement.xis Page 1 Midwest Employers Casualty Company VEHICLE SUPPLEMENTAL APPLICATION kilIILLET COMPANY- 1. Name of applicant: Weld County, Colorado 2. Number of employee drivers: y0 3. Number of owned or leased vehicles: Passenger Cars: 'U Va s/T,rucks: 1,5.3 Tractors: ,2o Trailers: 026 icic3 4. Number of owner/operators: 6) u Is applicant responsible for workers'compensation coverage on owner/operators? Yes Jo , If yes,what percentage of the payroll represents these drivers? �� If no, are certificates of workers' compensation insurance obtained? te 5. Does applicant provide any transportation of employees to or from the workplace? Yes No If yes,describe frequency of trips, mode of transportation and number of employees: }li , j1a i,t 1 6. Describe applicant's use of trucks: G g A- X .u. l r� 4 tt i ill c rL 1 a atn cNLCA �y 2 - a. Type of goods hauled: Ai el S�hr.� b. Is there any transportation of azardous materials? Yes • If yes, describe: 0 7. What is the average radius of travel?l 02-O -,,Z.c Ai S a. Primary states: Ike Id 0013-411/41-y, .()'(u-0-r-l-civ cN1 17 b. Frequency of trips: ,1"-- / wee K Z00.4 rna 6ti'1 ", 4-- c. Number of employees in each unit: / f 8. What is the maximum radius of travel? .) fYt i le s a. Primary states: [ (1kii/ o b. Frequency of trips: S� dal s/ we_e t _ 2,,,A Y►'1 U i A zec—a— c. Number of employees in each unit: I 9. Does applicant hold intrastate and/or interstate licenses to haul for others? Yes No 10. Does applicant backhaul goods for others? Yes No a. If yes, give frequency of trips: DON Warden -Vehicle Supplement.xls Page 10. b. Type of goods most commonly backhauled: A/'/A- 11. Describe vehic a maintenance program: r��$ C/L LI ci e4 IcJe. /Y1 at 41 V.41/1/1111_1 ffIl o to e--7=L WI C-tY1 u a_r,5 . 12. Provide(if available)any written procedures on driver training, DOT certification, MVR checks, disciplinary programs, etc. r (� f G�-�1 n 1,C 1- � . b e`fiPinS i +� (2 a 1 ti r ii 0-/I& s S-e S 41. � d_1'L(+/ S il at d-1,,,e14-7 '-� 14 i c ca r ct a_ el '--i cu.( fl 1 d 4� . 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A Stk Y'�'N1 art`*'4.+ CY.,,i'p�T"b' R i� 4_ i �Fv. l ^!�t �N i � k3' f��r ��P^ P . DON Warden - 12/31/02-03 Request for Renewal Information Page From: <Ty_Pixler@ajg.com> To: <dwarden@co.weld.co.us> Date: 9/10/02 3:34PM Subject: 12/31/02-03 Request for Renewal Information Don: As discussed, the following items are attached for the upcoming renewal of your Excess Workers Compensation and Self Insurer Bond. In order to obtain renewal terms in a timely manner please provide the items requested and return them to my attention on or before October 1, 2002. Please e-mail me copies of the completed applications and put the signed original in the mail. If you have any Questions or need additional information please call me at 720-528-3909. Request for Renewal Information: (See attached file: Pre-renewal Agendal.doc) Renewal Application: (See attached file: MECC App.xls) Vehicle Supplement: (See attached file: Vehicle Supplement.xls) Ty Pixler Senior Account Manager Arthur J. Gallagher& Co. - Denver 7900 East Union Avenue, Suite 200 Denver, CO 80237 Direct: (720) 528-3609 Fax: (303) 773-9776 CC: <KarenGraham@ajg.com> DON Warden - Pre renewal Agendal.doc Page • Weld County, Colorado Request for Renewal Information September 10, 2002 Policy Term: 12/31/02-03 Current Coverage: • Excess Workers' Compensation is currently with Midwest Employers Casualty Corporation. Because the policy is coming out of a three-year rate guarantee and excess workers compensation reinsurers are excluding terrorism (excess workers compensation carriers are not allowed to pass on this exclusion to insureds), an expectation of anywhere between a 50% - 500% increase is expected. Terms in the policy changing such as availability of statutory limits as well as requirements of higher retentions may also be issues. Therefore, in addition to receiving renewal terms from Midwest, we recommend a full marketing effort to Safety National, Republic Western and Employers Re. • Self Insured Workers Compensation Bond: The bond market is extremely volatile in this market place and we expect to see between a 10% to 15% increase in rate. Request for Renewal Underwriting Information: • Excess Workers Compensation Application Completed, Signed, Dated o Include: • 2003 Estimated and 2002 Estimated Payroll and Number of Employees by Class Code (Question#25) • Employee Concentration (Question #29)—Please note, a location name, zip code and complete address is required for all locations. For locations with 100 or more employees please provide number of stories of building and building construction. • Five Years Loss Runs (1997 through current date, including open/closed, paid, reserved, total incurred, summary and detail of losses over $50,000) • Vehicle Supplement, Completed, Signed, Dated • Most Recent Annual Financial Report (For Self Insured Bond) Renewal application is partially completed;a copy of the 1999 application is available for reference upon request. Renewal Time Line Item Due Date Receipt of Underwriting Information from Weld On or Before October 1, 2002 County Submission to Markets October 7, 2002 Receipt of Quotes from Carriers November 1, 2002 Proposal to Insured November 18, 2002 DON Warden - MECC Appxis Page • Midwest Employers Casualty Company INDIVIDUAL 13801 Riverport Drive, Suite 200 SELF-INSURANCE Maryland Heights, MO 63043-4810 APPLICATION FOR EXCESS WORKERS'COMPENSATION COVERAGE New Application Effective Date: 12/31/02 Renewal of Policy Number: 2392 SO CO To Be Quoted By: 11/1/02 1. Name of Applicant (as shown on self-insurance permit): Weld County,Colorado 2. Address: P.O. Box 758,Greeley,CO Zip: 80632 3. Applicant Phone Number: 970-356-4000 4. Federal Employers Identification Number: 5. Describe operations to be covered;subsidiaries to be covered if any. (Attach copy of current and comprehensive engineering inspection reports,annual report,or 10k report and products brochure.) County Government 6. Describe any substantial or unusual changes in operations that are planned or have taken place in the past five years: 7. Date qualified as a self-insured: 1978 8. States to be self-insured: Colorado 9. Are there other states or jurisdictions included for self-insurance that would not be covered by the insurance requested by this application? Yes No If yes,list: 10. Do any employees receive supplemental benefits in addition to workers'compensation benefits? Yes No 11. Provide details of any OSHA or State OSHA violation within the past 5 years: 12. Does the applicant have any employees who may be subject to the Longshoremen and Harbor Workers Act,Jones Act or Federal Employee's Liability Act? (Unless endorsed,our policy does NOT include federal acts coverage.) Yes No If yes,describe: 13. Do the operations of the applicant include volunteer or donated labor? Yes No If yes,describe: 14. Does applicant have any foreign operations or employees who travel to foreign countries? Yes No If yes,describe: 15. Is applicant engaged in the manufacture,production,refining,storage,distribution,or transportation of gases,gasoline or flammables? Yes No If yes,describe: DON Warden - MECC App.xls Page 16. .Are there any occupational disease exposures involved in the applicant's operations? (asbestos; silica;dusts;toxic,injurious or hazardous chemicals;caustics,fumes,radiation,communicable diseases and any other O.D.exposures) If yes,describe steps taken to control: Yes No 17. Does applicant perform any underground,subaqueous,or tunneling operations? Yes No If yes,describe: 18. Do the operations of the applicant include wrecking or demolition of structures? Yes No If yes,describe: 19. Do the operations of the applicant involve exposure to heights? Yes No If yes,describe: 20. Does applicant now(or have future plans to)own,lease or charter watercraft? Yes No If yes,describe watercraft,use,number of crew members,passenger capacity and whether craft is owned,leased,or chartered. 21. Does applicant own,lease,or charter aircraft? Jlf yes,Aircraft Questionnaire must be completed.) Yes No 22. Complete the following information on owned or leased vehicles: a. Number of: passenger cars trucks tractors b. Number of commerical vehicles owned by: applicant owner-operator c. Is applicant responsible for W.C.coverage on owner-operators? Yes No If no,does applicant obtain certificate of W.C.insurance from such operators? Yes No d. With respect to commercial vehicles: 1. States in which vehicles operate: 2. Average number of persons in each unit: 3. Does applicant transport chemicals,hazardous materials,explosives,explosive material,flammable material,or any petroleum products? Yes No If yes,provide full details: 23. Does applicant provide any transportation for employees to or from the workplace? Yes No If yes,describe the type of conveyance,frequency of trips and number of employees (total number and number per conveyance involved): 24. Policy Coverages and Limits. Current Carrier: Present Program: YFRS INSIIR flATF QATF T _ M SPECIFIC LIABILI ED RATE EXCES LOSS ESTIMAT TERM EXCESS IY RE IEN S FUND ED LOSS LOSS LIMIT Statutory 1,000,000 300,000 0.0576 Coverage DesiredFR5 INCUR RATF BATE SPECIFIC LIABILI ED EXCES LOSS EXCESS IY REIN S FUNU LIMIT Statutory 1,000,000300,000 DON Warden - MECC App.xls, Page 25. .Gross Payroll Distribution by Classification Code. • a. Projected payroll. Provide the following information regarding each state or jurisdiction: (If more space is needed,use a separate page.) 12/31/ 12/31/ 00-0I 99-00 98-99 9r-98 POLICY PERIOD: 02-03 01-02 Audite udite Audite udite Est. Est. pRCnAP STATE CMF CLA 5IFICA1 ION ECTIVE 1st PRIOR 2nd PRIOR PRIOR PRIOF PRIOR YEAR treet CO 5506 nd 4,029,734 3, 13,762.. 3, 06,488 3, 81,605 it CO 7382 uthortt 250,876 43,908 21,540 22,047 Jolicem CO 7720 an/ 10,1127,608 9, 39,706 9, 87,574 8, 04,592 ealbvla _ CO 8742 Outside 2,292,428 2, 00,114 1, 31,748 1, 71,525 ClericaV CO 8810 Office/EI 12,'29,640 12, 80,283 10, 41,444 10, 20,056 Cebdrey 8820 0 1, 99,824 1, 59,210 1, 16,990 Animal CO 8831 Control 52,151 52,870 55,863 53,691 Health CO 8832 Dept., 2,031,003 1, 67,990 1, 28,884 1, 39,879 Belfoesi CO 8868 Prof/Libr 1,037,636 1, 56,198 1, 88,399 1, 17,846 erytepri CO 9014 Examin 78,000 67,020 59,221 58,725 Stirring CO 9015 Operati 1,028,921 1, 05,520 79,986 03,001 8odool CO 9101 -other 491,872 79,928 10,602 18,795 unicip CO 9410 I 1,059,400 1, 03,468 1, 1,471 1, 13.229 employ Totals: 0 0 36'09,269 36, 10,591 33, 12,430 31, 21,981 b. Is there any significant change to the payroll distribution by classification code in the last five years? Yes No c. If yes,describe reason for change(s): 26. Loss Experience and Historical Activity. The following loss information maybe provided via an electronic data dump*or loss runs: INDFM ❑V' OTAI a. STATE ICYPEF NITY .REFER 1.L ?FERN ICUR CAT; ON ^ PAID RED Attach Loss Runs * Electronic file detailing the insured's loss experience by policy period. Data elements should include all claims,open/closed status,payment activity including paid/reserved/total incurred amounts split by medical and indemnity,and a state or location code with a related definition for that code. ** Include allocated claims expenses as part of indemnity ""' Valuation date must be within the past six months DON Warden - MECC App.xls Page z . b. STATE PERIO PAYRO ED FCIF�S r�AIMS, WITH LL 'Rt-F IQ- AYMCN * CNPs are defined as claims reported and closed without any payment being made. c. Are CNP claims included in the totals for open and closed claims? Yes No Don't Know d. if yes,indicate the approximate percentage of total claims that are CNPs: % Don't Know 27. Individual claims in excess of$50,000 incurred(past 5 years). (The following information may be provided via an electronic data dump or loss runs. If more space is needed,use a separate page.) ❑ATF JPTI(]N TATAI TCrrAI NA rw STATE OF OF IUTAL DenRESER INCUR EMPLO LOSS ACCID VE RED PEES 28. Total number of employees: 29. Concentration of Risk. Give the following information regarding each location. (If more space is needed,use a separate page.) TOTAL NUMBER TOTAL NUMBER LOCAT ON/ADDRESS STATE ZIP EMPLOYEES IN EMPLOYEES IN TOTAL CODE ALL SHIFTS MAX SHIFT PAYROLL 30. Loss Prevention. DON Warden MECC App.xis Page E a. Loss Prevention Service Company Information: 1. Name of service company 2. Address of service company b. Do you have dedicated safety professionals on staff which are not human resources personnel? Yes No c. Do you have safety committees? Yes No d. If yes,do they have management participation? Yes No e. Do you provide new hire safety training? Yes No f. Do you provide job specific safety training thereafter? Yes No g. Do you have a cost allocation system in place which links workers'compensation costs to the department or facility? No h. Do you have any incentive plans in place linking individual and department workplace safety to a rewards system? Yes No 31. Claims Handling. (If no service company.MECC Self-Administration Questionnaire must be completed.) a. Service Company Information: 1. Name of service company 2. Address of service company 3. Phone number 4. Contact name for this account: b. Are claims handled to conclusion? If no,give details. Yes No c. What is normal length of service contract? d. Does applicant agree to let the excess carrier know about any changes in the service company or in the kind or amount of services to be performed by the service company? Yes No e. Do you have an alternative duty return to work program in place for all departments? Yes No f. Do you provide in-house medical attention for first aid injuries? Yes No g. If so,who provides the treatment? h. Do you have a process in place in which all injuries are internally investigated and reported to your claim servicing company within 24 hours? Yes No i. Do you conduct regular or quarterly claim reviews with your claim servicing company? Yes No j. Check the following managed care programs that apply to your program: PPO contracted pricing other fee scheduling nurse case management Florid Any person who knowingly and with intent to injure, defraud,or deceive any insurer files a statement of claim or an application containing any false,incomplete,or misleading information is guilty of a felony of the third degree. New Jersey Any person who i< 2 ncludes any false or misleading information on an application for an insurance p is subject to criminal and civil penalties. New York Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information,or conceals ' DON Warden - MECC App.xls Page( for the purpose of misleading,information concerning any fact material thereto,commits a fraudulent insurance act,which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Other States Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing false or deceptive statement is guilty of insurance fraud. Date Applicants Signature Title Print Applicant's Name Print Applicant's Title DON Warden -Vehicle Supplement xls Page Midwest Employers Casualty Company VEHICLE SUPPLEMENTAL APPLICATION A ERKLLY COMPANY. 1. Name of applicant: Weld County, Colorado 2. Number of employee drivers: 3. Number of owned or leased vehicles: Passenger Cars: Vans/Trucks: Tractors: Trailers: 4. Number of owner/operators: Is applicant responsible for workers'compensation coverage on owner/operators? Yes No If yes, what percentage of the payroll represents these drivers? If no, are certificates of workers'compensation insurance obtained? 5. Does applicant provide any transportation of employees to or from the workplace? Yes No If yes,describe frequency of trips, mode of transportation and number of employees: 6. Describe applicant's use of trucks: a. Type of goods hauled: b. Is there any transportation of hazardous materials? Yes No If yes, describe: 7. What is the average radius of travel? a. Primary states: b. Frequency of trips: c. Number of employees in each unit: 8. What is the maximum radius of travel? a. Primary states: b. Frequency of trips: c. Number of employees in each unit: 9. Does applicant hold intrastate and/or interstate licenses to haul for others? Yes No 10. Does applicant backhaul goods for others? Yes No a. If yes, give frequency of trips: UUN waroen - venicle supplement.xis r aye , 10. b. Type of goods most commonly backhauled: 11. Describe vehicle maintenance program: 12. Provide (if available) any written procedures on driver training, DOT certification, MVR checks, disciplinary programs, etc. DON Warden - Mime.822 Page Received:from mail1.gallagheronline.com by AD01;Tue, 10 Sep 2002 15:34:06-0600 To: dwarden@co.weld.co.us Cc: KarenGraham@ajg.com X-Mailer: Lotus Notes Release 5.0.5 September 22,2000 Message-ID:<OFADD24BEA.1BE4F523-ON86256C30.00757B0B@gallagheronline.com> From:Ty_Pixler@ajg.com Date:Tue, 10 Sep 2002 16:32:12-0500 Subject: 12/31/02-03 Request for Renewal Information X-MIMETrack: Serialize by Router on AJGSMTP01/AJG(Release 5.0.10 'March 22,2002)at 09/10/2002 04:21:09 PM MIME-Version: 1.0 Content-type: multipart/mixed; Boundary="0=09BBE6A3DFE6FD9B8f9e8a93df938690918c09BBE6A3DFE6FD9B" Content-Disposition: inline --0 Content-type:text/plain; charset=us-ascii Don: As discussed,the following items are attached for the upcoming renewal of your Excess Workers Compensation and Self Insurer Bond. In order to obtain renewal terms in a timely manner please provide the items requested and return them to my attention on or before October 1, 2002. Please e-mail me copies of the completed applications and put the signed original in the mail. If you have any Questions or need additional information please call me at 720-528-3909. Request for Renewal Information: (See attached file: Pre-renewal Agendal.doc) Renewal Application: (See attached file: MECC App.xls) Vehicle Supplement: (See attached file:Vehicle Supplement.xls) Ty Pixler Senior Account Manager Arthur J. Gallagher&Co.- Denver 7900 East Union Avenue, Suite 200 Denver, CO 80237 Direct: (720)528-3609 Fax: (303)773-9776 --0 =09BBE6A3DFE6FD9B8f9e8a93df938690918c09BBE6A3DFE6FD9B Content-type:application/msword; name="Pre-renewal Agendal.doc" Content-Disposition:attachment;filename="Pre-renewal Agendal.doc" Content-transfer-encoding: base64 Hello