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Home My WebLink About000265 Arthur J. Gallagher & Co. - Denver January 30, 2004 Don Warden Weld County, Colorado P.O. Box 758 Greeley, CO 80632 RE: Policy Description: Excess Workers Compensation Policy Number: EWC005661 Insurance Company: Midwest Employers Casualty Company Policy Period: 12/31/2003 to 12/31/2004 Dear Don: Enclosed please find your renewal policy as referenced above, effective 12/31/03. Please review your renewal policy carefully and if you have any questions or require any assistance, please call either Ty Pixler or myself. As last year, I have sent a copy of this policy to the Department of Labor and Employment, Division of Workers' Compensation for their file. Don, we appreciate the opportunity to place these important insurance coverage's for you. Sincerely, ' A Denise M. FerrilI Account Manager cc: Ty Pixler, Senior Account Manager Enclosure 6399 S. Fiddlers Green Circle Suite 200 Greenwood Village, CO 80111-4949 303.773.9999 Fax 303.773.9776 Toll Free 800.333.3231 265 www.ajg.com rAY V YeYI kVA kVA ViYa!I kVA Fall • Midwest Employers Casualty Company SPECIFIC EXCESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY INDEMNITY POLICY Policy No.: EWC005661 SCHEDULE 1. Insured: Weld County, Colorado 2. Mailing Address: P O Box 758 Greeley, CO 80632-0758 3. Named States: Colorado 4. Excluded States: None • 5. Policy Period: (a) From: 12/31/2003 (b) To: 12/31/2004 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: $350,000 (b) Each Employee for Disease: $350,000 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 SO-SCH(1/93) Page 1 of 2 A Member Company of the WR. Berkley C orpo rati o n VA Is!sI FiVI FiYa!I ,a!JI F1eVI Fail • Midwest Employers Casualty Company SPECIFIC EXCESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY INDEMNITY POLICY Policy No.: EWC005661 SCHEDULE 9. Premium: (a) Rate per$100 of Payroll: .1006 (b) Minimum: $40,883 (c) Deposit: $45,414 Premium Payable as follows: Amount Due $45,414.00 02/15/2004 • 10. Classification of Operations: See Endorsement 11. Endorsement Serial Numbers: See Endorsement Schedule 12. Service Company: County Technical Services, Inc. (Ctsi) 1700 Broadway# 1512 Denver, CO 80290 Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY to X Licensed Resident Agent Date Authorized Representative ) SO-SCH(1193) Page 2 of 2 A Member Company of the W. R. Berkley Corpo rati o n Midwest Employers Casualty Company Endorsement Schedule Insured: Weld County, Colorado Policy Term: 12/31/2003 to 12/31/2004 Policy No.: EWC005661 Endorsement Code Effective Date Expiration Date Date Printed SO-10 12/31/2003 12/31/2004 01/19/2004 1O-31 12/31/2003 12/31/2004 01/19/2004 1O-32 12/31/2003 12/31/2004 01/19/2004 1O-39B 12/31/2003 12/31/2004 01/19/2004 SO-43 12/31/2003 12/31/2004 01/19/2004 SO-44 12/31/2003 12/31/2004 01/19/2004 1O-51 12/31/2003 12/31/2004 01/19/2004 1O-60 12/31/2003 12/31/2004 01/19/2004 1O-77 12/31/2003 12/31/2004 01/19/2004 • 1O-CO 12/31/2003 12/31/2004 01/19/2004 Page 1 of 1 Print Date: 01/22/2004 • Schedule Item 10 is amended to read as follows: 10. Classification of Operations: State Code Classification Estimated Payroll Rate per Estimated $100 of Manual Payroll Premium CO 5506 STREET OR ROAD CONSTRUCTION $4,619,859 10.74 $496,173 CO 7382 BUS COMPANY $357,624 6.97 $24,926 CO 7720 POLICE OFFICERS&DRIVERS $12,733,447 3.91 $497,878 CO 8742 SALESPERSONS $2,690,232 .74 $19,908 CO 8810 CLERICAL OFFICE OR LIBRARIES $14,507,152 .44 $63,831 CO 8820 ATTORNEY $2,027,126 .68 $13,784 CO 8831 HOSPITAL-VETERINARY $58,380 3.33 $1,944 CO 8832 PHYSICIAN &CLERICAL $2,398,569 .79 $18,949 CO 8868 SCHOOLS-PROFESSIONAL $1,294,660 .85 $11,006 CO 9014 BUILDINGS $166,930 6.19 $10,333 CO 9015 BUILDINGS $1,047,868 5.76 $60,357 CO 9101 SCHOOLS-ALL OTHER $757,010 6.64 $50,265 CO 9410 MUNICIPAL EMPLOYEE NOC $2,484,269 1.94 $48,195 Total Payroll: $45,143,126 Total Manual Premium: $1,317,549 • Total Manual Premium: $1,317,549 (a) Experience Modification Factor: 1.000000000 (b) Other Modification Factor: 1.000000000 Normal Premium: $1,317,549 Endorsement Effective: 12/31/2003 Policy No.: EWC005661 Named Insured: Weld County,Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY Dr X. ?tided ✓, f44.-nJ._-- 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. /l SO-10 (1-93) EWC005661 Date Printed: 01/16/2004 • 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. S Endorsement Effective: 12/31/2003 Policy No.: EWC005661 Named Insured: Weld County,Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY Authorized Representative Secretary President C1 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) Date Printed: 01/16/2004 • 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: 12/31/2003 Policy No.: EWC005661 Named Insured: Weld County,Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY .0,.,.-„," X. k ✓, -- 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) Date Printed: 01/16/2004 • 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 "communicable disease" shall mean a disease caused by an infectious organism which is directly transmitted from one source to another, directly or indirectly. It is further agreed that our limit as respects bodily injury arising from same communicable disease is Statutory. • Endorsement Effective: 12/31/2003 Policy No.: EWC005661 Named Insured: Weld County,Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY a 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. lO-39B (12-01) Date Printed: 01/16/2004 • Deletion of Commutation Clause Paragraph G of Part Three of the policy is deleted. • Endorsement Effective: 12/31/2003 Policy No.: EWC005661 Named Insured: Weld County,Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY , . X• ka ?filed, ✓. 144.40L___ 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) Date Printed: 01/16/2004 • 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: 12/31/2003 Policy No.: EWC005661 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) Date Printed: 01/16/2004 • 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: 12/31/2003 Policy No.: EWC005661 Named Insured: Weld County,Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY Dr,..w X. 4.ew-i,a y� ? ✓, fccw„a(c.-- 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) Date Printed: 01/16/2004 • 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: 12/31/2003 Policy No.: EWC005661 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) Date Printed: 01/16/2004 Page 1 of 2 • Terrorism Risk Insurance Act Endorsement This endorsement addresses requirements of the Terrorism Risk Insurance Act of 2002. Definitions: The definitions provided in this endorsement are based on the definitions in the Act and are intended to have the same meaning. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002,which took effect on November 26, 2002, and any amendments. "Act of terrorism" means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property or infrastructure. c. The act resulted in damage within the United States, or outside the United States in the case of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals acting on behalf of any foreign person or foreign interest, as part of an effort to coerce the civilian population • of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured terrorism or war loss" means any loss resulting from an act of terrorism (including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at United States missions or to certain air carriers or vessels. "Insurer deductible" means: a. For the period beginning on November 26, 2002 and ending on December 31, 2002, an amount equal to 1% of our direct earned premiums, as provided in the Act, over the calendar year immediately preceding November 26, 2002. b. For the period beginning on January 1, 2003 and ending on December 31, 2003, an amount equal to 7% of our direct earned premiums, as provided in the Act, over the calendar year immediately preceding January 1, 2003. c. For the period beginning on January 1, 2004 and ending on December 31, 2004, an amount equal to 10% of our direct earned premiums, as provided in the Act, over the calendar year immediately preceding January 1, 2004. d. For the period beginning on January 1, 2005 and ending on December 31, 2005, an amount equal to 15% of our direct earned premiums, as provided in the Act, over the calendar year immediately preceding January 1, 2005. • 1O-77 (2-03) EWC005661 Date Printed: 01/16/2004 Page 2 of 2 • Terrorism Risk Insurance Act Endorsement Item B-1383 Catastrophe Provision — Certified Terrorism Losses (as defined in Terrorism Risk Insurance Act of 2002) Limitation of Liability: The Act may limit our liability to you under this policy. If annual aggregate insured terrorism or war losses of all insurers exceed $100,000,000,000 during the applicable period provided in the Act, and if we have met our insurer deductible, the amount we will pay for insured terrorism or war losses under this policy will be limited by the Act, as determined by the Secretary of the Treasury. Policyholder Disclosure Notice: 1. Insured terrorism or war losses would be partially reimbursed by the United States Government under a formula established by the Act. Under this formula, the United States Government would pay 90% of our insured terrorism or war losses exceeding our insurer deductible. 2. The additional premium charged for the coverage this policy provides for insured terrorism or war losses is shown below: State Terrorism Charge • CO 51,362 Endorsement Effective: 12/31/2003 Policy No.: EWC005661 Named Insured: Weld County,Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY ,Dm.w X. ?fa 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-77 (2-03) EWC005661 Date Printed: 01/16/2004 • 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: 12/31/2003 Policy No.: EWC005661 Named Insured: Weld County,Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY ID Authorized Representative Secretary (QI 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) Date Printed: 01/16/2004 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 it 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 I aw 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 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(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. ) 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. Loa 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 tees; (iii) claims administrator fees. d. 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) -t- 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 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 Renorting 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- 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 Ifs. 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. Deoosit and Adjustment 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. Rer,nrd% 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 Upon Terms. Your acceptance of this policy means that you agree with us upon the terms of this policy. B. Sole Renresentative. 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. Dankruotcy 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 Di ties. 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: /, t Y XJr./2 14144s I Ste,.o SIGNATURE SIGNATURE Authorized Representative Secretary President MWE-200 (1-93) .¢ • • JAIl Midwest Employers Casualty Company . PRIVACY NOTICE Nlidwest bmployers Casualty Company (the "Company") a member company of the W. R. Berkley Corporation ("Berkley") group of companies and each other member of the Berkley group of companies ("Affiliates") understands our customers' concern about privacy of their information collected by the Company. Our Company is dedicated to protecting the confidentiality and security of nonpublic personal information we collect about our customers in accordance with applicable laws and re<gulations. This notice refers to the Company by using the terms "us," we. or ' our." [his notice describes our privacy policy and describes how we treat the nonpublic personal information about our customers that we receive from them (-Information"). Why We Collect and How We Use Information We collect and use Information for business purposes with respect to our insurance products and services and other business relations involving our customers. We gather this Information to evaluate your request for insurance, to evaluate your insurance claims, to administer, maintain or review your insurance policy, and to process your insurance transactions. We also accumulate certain information about you as may be required or permitted by law. 0 Your insurance agent or broker also collects this Information and may use it to help with your overall insurance program or to market additional products and services to you. We may also use Information to otter you other products or services that we or our Affiliates provide. How We Collect Information Most Information collected by us is provided by you or your insurance agent or broker to us. We obtain Information from (i) applications or other forms submitted by you, your insurance agent or broker or your authorized representatives to us and our Affiliates, and (ii) your transactions with us or our Affiliates. We may also obtain Information from other sources such as (i) consumer reporting agencies, (ii) other institutions or information services providers (third party administrators), (iii) employers, (iv) other insurers, or (v) your family members. Information We Disclose We disclose any Information which we believe is necessary to conduct our business as permitted by applicable law or where required by applicable law. This disclosure may include (i) information we receive from you on applications or other forms provided to us and our Affiliates, such as names, addresses, social security numbers, assets, employer information, salaries, etc. (ii) Information about your transactions with us and our Affiliates, such as policy coverages, premiums, payment history, etc., and (iii) Information we receive from a consumer reporting agency, such as credit worthiness and credit history. ' rte,.. icAT ' 13801 Riverport Drive• Suite 200 • Maryland Heights, MO 63043 • Phone: 314-298-7332 • Fax: 314-298-043' Ori A BERKLEY COMPANY. us- • • To Whom We Disclose Information We may, as permitted or required by applicable law, disclose your Information to nonaffiliated third parties. such as (i) your insurance agent or broker, (ii) independent claims adjusters, (iii) insurance support organizations, (iv) processing companies . (v) actuarial organizations. (vi) law firms. (vii) other insurance companies involved in an insurance transaction with you, (viii) law enforcement, regulatory, or governmental agencies. (ix) courts or parties therein pursuant to a subpoena or court order. (x) businesses with whom we have a marketing agreement, or (xi) our Affiliates. We may share Information with our Affiliates so that they may offer you products and services from the Berkley group of companies or to analyze our book of business and to consolidate • necessary information. We do not disclose Information to other companies or organizations not affiliated with us for the purpose of using Information to sell their products or services to you. For example. we do not sell your name to unaffiliated mail order or direct marketng companies. How We Protect Information We require our employees to protect the confidentiality of Information as required by applicable law. Access to Information by- our employees is limited to administering, offering, servicing, processing or maintaining of our products and services, We also maintain physical. electronic and procedural safeguards designed to protect Information. When we share or provide Information to other persons or organizations, we contractually obligate them. if required by law, to treat Information as confidential and conform to our privacy policy and applicable laws and regulations. Correction and Access to Information Upon our receipt of your written request to us at Midwest Employers Casualty Company, 13801 Riverport Drive Suite 200, Maryland Heights. :'1O 63043 (Attn: Peter Shaw, CEO). we will. generally, make available Information for your review. If you believe the Information we have about you is incorrect or inaccurate. you may request that we make any necessary corrections. additions or deletions. If we agree with your belief, we will correct our records if required by applicable law. If we do not agree, you may submit to us a short statement of dispute, which we will include in any future disclosure by us of such Information if required by applicable law. Requirements for Privacy Notice This privacy notice is being provided due to recently enacted federal and state laws and regulations establishing new privacy standards and requires us to provide this privacy policy. For additional information regarding our privacy policy, please write to us at Midwest Employers Casualty Company, 13801 Riverport Drive Suite.200, Maryland Heights, MO 63043 (Attn: Peter Shaw, CFO). Adopted: July 1, 2001 __ Arthur J. Gallagher & Co. - Denver 1/30/2004 Department of Labor & Employment Division of Workers' Compensation Employers Services 1515 Arapahoe Street 2 Park Central, Suite 600 Denver, CO 80202-2117 RE: Weld County, Colorado Policy Description: Excess Workers Compensation Policy Number: EWC00561 Policy Period: 12/31/03- 12/31/04 Dear To Whom It May Concern: Enclosed for your file, please find copy of the current Excess Workers Compensation Policy for Weld County, Colorado as referenced above. If you have questions, please feel free to contact either Ty Pixler or myself. Sincerely, Denise M Ferrill Account Manager cc: Don Warden, Weld County, CO Ty Pixler, Senior Account Manager—Arthur J. Gallagher& Co. Encl. 6399 S. Fiddlers Green Circle Suite 200 Greenwood Village, CO 80111-4949 303.773.9999 Fax 303.773.9776 Toll Free 800.333.3231 www.ajg.corn Hello