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Home My WebLink About000264 b�.� Arthur J. Gallagher & Co. - Denver December 24, 2003 Don Warden Weld County, Colorado P.O. Box 758 Greeley, CO 80632 Re: Excess Workers Compensation & Excess Workers Compensation SIR Bond Policy#EWC005661 #19S100729968BCA 12/31/03 - 12/31/04 12/31/03 - 12/31/04 Dear Don: Enclosed please find Insurance Binder for the renewal of your Excess Workers' Compensation coverage, along with an invoice for the renewal premium of$45,414. This Binder is considered a legal document, and as such, will keep your coverage in place until you receive your policy. The Excess Workers Compensation SIR Bond is continuous until cancelled, so a new policy will not be issued. However, this coverage has generated a premium in the amount of$11,520 as evidenced by the enclosed invoice. Please remit payment payment for both by returning in the self addressed envelope provided. A Certificate of Insurance has been mailed out to the Department of Labor and Employment showing that coverage has been renewed. A copy of the Certificate is enclosed for your records. If you have any questions, ore require anything further; please contact either Ty Pixler or myself. Thank you for the opportunity to place this important coverage for you. incerely, a vp enise M Ferrill Account Manager cc: Ty Pixler, Senior Account Manager 6399 South Fiddler's Green Circle, Suite 200 Greenwood Village,CO 80111-4949 303.773.9999 Fax 303.773.9776 Toll Free 800.333.3231 264 www.ajg.com This persedes and—_-- THIS INSURANCE BINDER BinderuB03122309137 corrects 12/24/2003 THIS r7DER IS A TEMPORARY INSURANCE CONTRACT,SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. PRODUCER PHONE (303) (303)773-9776 773_9999 COMPANY BINDER# No,Eat): Midwest Employers Casualty Co B03122409146 FAX EFFECTIVE EXPIRATION Arthur J. Gallagher & Co. - Denver DATE TIME DATE TIME 6399 S. Fiddlers Green Circle 12/31/2003 12:01 X AM 02/28/2004 X 12:o1A Suite 200 PM NOON Greenwood Village, CO 80111 THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY PER EXPIRING POLICY#: CODE: SUB CODE: AGENCY 00003012 DESCRIPTION OF OPERATIONSNEHICLESIPROPERTY(Including Location) CUSTOMER IO. INSURED Weld County, Colorado Policy #EWC005661 - P.O. Box 758 Greeley, CO 80632 I COVERAGES LIMITS TYPE OF INSURANCE COVERAGE/FORMS DEDUCTIBLE COINS% AMOUNT PROPERTY CAUSES OF LOSS BASIC BROAD ri SPEC GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one fire) $ CLAIMS MADE n OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ RETRO DATE FOR CLAIMS MADE: PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS MEDICAL PAYMENTS $ NON-OWNED AUTOS PERSONAL INJURY PROT $ UNINSURED MOTORIST $ $ AUTO PHYSICAL DAMAGE DEDUCTIBLE ALL VEHICLES I I SCHEDULED VEHICLES ACTUAL CASH VALUE COLLISION: 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 $ OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: SELF-INSURED RETENTION $ WC STATUTORY LIMITS WORKER'S COMPENSATION E.L.EACH ACCIDENT $ AND EMPLOYERS LIABILITY EL.DISEASE-EA EMPLOYEE $ E.L.DISEASE-POLICY LIMIT $ SPECIAL Excess Workers Compensation. See attached for limits, terms, FEES $ OTHERIONSI and conditions. Policy Period 12/31/03 - 12/31/04. TAXES $ COVERAGES Premium: $45,414 ESTIMATED TOTAL PREMIUM $ NAME 8 ADDRESS MORTGAGEE ADDITIONAL INSURED LOSS PAYEE LOAN# AUTHORIZED REPRESENTATIVE Karen Graham/DMF Y-.0-.,--- —. .A -(-01,-- _o I ACORD 75-5(1/98) NOTE: IMPORTANT STATE INFORMATION ON REVERSE SIDE ©ACORD CORPORATION 19 • 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. ACORD 75-S(1/98) 13/3c/u3 14:26 (21314298043 MIDWEST EMPLOYER flub) 7 ,,. i-,-4,- y Midwest Employers Casualty Company Excess Workers Compensation • I^41113M,• -ZYCCC.IIM NY. BINDER i;, ured: Weld County,Colorado (icy Number. EWC005661 Effective Date: 12/31/2003 '�_ot:, dumber: 0067065 Expiration Date: 12/31/2004 �rifes Covered: Colorado E•_avic,o Company: County Technical Services,Inc.(Ctsi) 1700 Broadway#1512 Denver, CO 80290 Ik._�Iuci�s the following Endorsements: E3-10-Amending Item 10 Classification of Operations IC-31 -Voluntary Compensation 10-32-Longshoremen and Harbor Workers'Coverage-Limited to State Act 80-43-Deletion of Commutation Clause S0-43-Deletion of Commutation Clause I0-39B-Communicable Disease ID-S1 -Aircraft Exclusion 10-30-Cancellation Notice Changed-Both Parties 10-CO-Colorado rPECIFIC: Specific Limit: STATUTORY Specific Retention: $350,000 Ev1P LIABILITY: Employers Liability Limit: $1,000,000 Employers Liability Retention: $350,000 .i3GREGATE: Aggregate Limit: N/A Aggregate Retention(N/A): N/A Minimum Aggregate Retention: N/A Aggregate Loss Lifnitation: N/A PREMIUM: Policy Period Estimated Payroll $45,143,126 Policy Period Normal Premium: $1,317,549 Rate per$100 of Payroll: .1006 Policy Period Minimum Premium: $40,883 Deposit Premium: $45,414 Terrorism Risk Insurance Act of 2002: $1,362 (included in Deposit Premium above) I 12/24/2003 , Midwest Employers Casualty Company Date Page 1 oft I I ACORD CERTIFICATE OF LIABILITY INSURANCE 12/24/z o PRODUCER (303)773-9999 FAX (303)773-9776 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Arthur J. Gallagher & Co. - Denver ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 7900 E. Union Suite 200 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Denver, CO 80237 INSURERS AFFORDING COVERAGE NAIC# INSURED Weld County, Colorado INSURER A: Midwest Employers Casualty Co P.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. NOTWITHSTANDI 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 SUC POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYpE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSR[ DATE IMM/DO/WI DATE IMM/DD/YYI GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES(Fa nrrurenrel CLAIMS MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY n PRO- ri 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/UMBRELLA LIABILITY EACH OCCURRENCE $ IOCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND EWC005661 12/31/2003 12/31/2004 X I WCSTATU- I 10TH- EMPLOYERS'LIABILITY TORY I IMITS FR A ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000, OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 1,000, If yes,describe under SPECIAL�1F�t PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1,000, OTHERInsurer's W/C 19S100729968BCA 12/31/2003 12/31/2004 Penal Sum: $1,200,000 Self-B Bond DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Self-Insured Retention: $350,000 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE State of Colorado Department of Labor EXPIRATION DATE THEREOF,THE ISSUING INSURER 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 Street OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Denver, CO 80202-2117 AUTHORIZED REPRESENTATIVE Karen Graham/DMF ACORD 25(2001/08) ©ACORD CORPORATION 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. ACORD 25(2001/08) 2004 CURRENT SUMMARY OF INSURANCE PREPARED FOR WELD COUNTY, COLORADO . ---� 4;4 h � 4�, 3 EFFECTIVE DATE: DECEMBER 31, 2003 PRESENTED BY: KAREN L. GRAHAM, CIC, ARM-P Tv PIXLER AREA VICE PRESIDENT SENIOR ACCOUNT MANAGER Public Entity and Scholastic Division ARTHUR J. GALLAGHER & CO. 6399 S. FIDDLERS GREEN CIRCLE, SUITE 200 GREENWOOD VILLAGE, CO 80111 (303) 773-9999 KAREN@GRAHAM@AJG.COM http://www.ajg.com Meeting your needs . . . . . . Exceeding your expectations m\cliencdodWeld CounMWC 04 EXWC 6Ldoc Copyright`Arthur J.Gallagher&Co.2003 WELD COUNTY, COLORADO y SPECIFIC EXCESS WORKERS COMPENSATION CURRENT CARRIER: MIDWEST EMPLOYERS CASUALTY CO. RATE I .1006 per $100 Payroll AUDITABLE BASIS 1 12/31/2003-04 Estimated Payroll - $45,143,126 LIMITS WORKERS COMPENSATION 1 Statutory EMPLOYERS LIABILITY I $ 1,000,000 Occurrence/Aggregate SPECIFIC RETENTIONS WORKERS COMPENSATION I $ 350,000 Each Accident I $ 350,000 Each Employee for Disease EMPLOYERS LIABILITY I $ 350,000 Each Accident I $ 350,000 Each Employee for Disease TERMS/ CONDITIONS I Allocated claims expenses included in SIR and limits I USL&H — Limited to State Act / All States 1 Voluntary Compensation Endorsement I Communicable Disease Endorsement 1 Commutation Clause deleted I Non-Compensated Board Members included I Aircraft Exclusion I 90-day Notice of Cancellation / Non-renewal Auditable - Annually I Deletion of Late Reporting Penalty EXCESS WORKERS COMPENSATION SIR BOND CURRENT CARRIER: TRAVELERS CASUALTY AND SURETY CO. RATE I $ 9.60 LIMIT I $ 1,200,000 Penal Sum RETENTION I $ 350,000 M:\Client.dodWeld County\WC 04 EXWC CSI.doc Page 2 Public Entity and Scholastic Division ,c)O ..)27---; I Weld County, Colorado ua> I \ CO f u:o,, - lIENr n - � � � 3012 pp� a 12/23/2003 IrXiErri�, , Ty Pixler 4PAtE . ' 1 of 1 Weld County, Colorado RM1ShtRR'4R54Fi' # Y P.O. Box 758 - . ' ri Greeley, CO 80632 31ryUSATOE≥SI1MMARWA' a 11,520.00 PAYMENT FOP Invoice#72484 100729968 F'Er.3_L)ET Y P D H5TURRN WITH PAYMENT Client: Weld County,Colorado ,g Ir y N temp N P :: '� . �F,�iT11� ,� ''c'�Q't �lf�" # � f<��%. �i �L'�d .#n 'x. 0 � ,.,. �Y' e.�i;d...yn. Policy #100729968 12/31/2003-12/31/2004 Travelers Insurance Company 72484 12/31/2003 Renew policy Bonds - Renew policy 11,520.00 r _..__. I __Ip OG 1.�.,ztou 6.570 • /41 11,520.O Arthur J. Gallagher & Co. - Denver (303)773-9999 I 12/23/2003 (76)0 �.t.t•1 Hk.i'. Win[ S fY:.....E.�Y. ...> C:. :�F�. .. _l�:Lf.�... S ....__.�.--..._.....• c SOS; _ E-ICE J•. _..4;.,,. Weld County, Colorado 1' DEN VEF: ". =ENT ""�. P. . (33 773-99Y.--, • s 3012 - A' ,,,V 12/23/2003 A Ty Pixley •. • 1 of 1 Weld County,Colorado F.O. Box 758 f•�t�x s# '� �_" �r�Seeast!k�rP �ri�i3xa-.+-. '-• Greeley, CO 80632 =u1i.daid.. 45,414.00 PAYMEW FOR: Invoice#72482 ! 2392 SO CO EAST:DE-ACFI AND RETURN WITH PAYMEN1 Client: Weld County, Colorado ,IIE'SCi4ffW „, . :�� Policy #2392 SO CO 12/31/2003-12/31/2004 Midwest Employers Casualty Co 72482 12/31/2003 Renew policy Workers Compensation - Renew policy 45,414.00 nthe 45,414.00 : Arthur J. Gallagher & Co. - Denver (303)773-9999 1 12/23/2003 Hello