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Home My WebLink About000267.tiff G Gallagher Public Entity & Scholastic Division Arthur I, Gallagher Rick Management Services, Inc. April 25, 2006 Don Warden Weld County, Colorado P.O. Box 758 Greeley, CO 80632 RE: Excess Workers'Compensation Policy#EWC005661 Policy Period: December 31, 2005 to December 31, 2006 Dear Don: Enclosed is your insurance policy as referenced above. Please review and let us know if you have any questions. Don, we appreciate the opportunity to place this important insurance coverage for you. Sincerely, Arthur J. Gallagher Risk Management Services, Inc. 9.t[-c.-e,..Jt-Lfr e Tully, CISR Account Manager Enclosure 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 267 www.ajg.com r! !4A Midwest Employers Casualty Company PRIVACY NOTICE Midwest Employers 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 regulations. This notice refers to the Company by using the terms "us," "we," or "our." This 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. 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 offer 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. i 1 14755 North Outer Forty Drive • Suite 300 • Chesterfield, MO 63017 • Phone: 636-449.7000 • Fax: 636.449-7195 Ad \\.s.....) A BERKLEY COMPANY"' L7 To Whom VVe Disclose information We may, as permitted or required by applicable law, disclose your Information to nonaffiliated third parties, such as (1) 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 acid 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 marketing companies. How We Protect information We:requir-.e your 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 lhem,iifrequired 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-usat1Midwest Employers..Casuaity;Company, 14755 North Outer Forty.Drive, Suite 300, :Chesterfield," tD'63017:(Attn: Peter:Shaw, CFO), we will, generally, -makeavailable information for your review. If you believe the Information we have about,you is incorrept.or inaccurate, you:may request .that we make any necessary corrections, additions:ordeletions:.,.;Iffwe agree with your-belief,,we will correct our.records if required by ,applicable'law. 'If we do not.agr:ee,.you:maysubm:it to us..a short statement of d€spute, 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 estate laws :and .regulations establishing new privacy..standards and requires us ;to provide this;privacy po€icy. For additional information regarding our privacy policy, please write.to.us at:Midwest Employers . Casualty. Company, 14755 North Outer Forty :Drive, Suite 300, Chesterfield, :MO:63017.(Attn: Peter•Shaw, CFO). • Adopted: July 1, 2001 - • 2 PsA'1 V4%'j Vii V4%A1 V4'IAI Fs% i ,iYs1 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: 12/31/2005 (b) To: 12/31/2006 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: $450,000 (b) Each Employee for Disease: $450,000 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 (1-04) Page 1 of 2 A Member Company of the W. R. Berkley Corporation • k V PAVI IVI rvi kVA PAVI PAVI 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: .1200 (b) Policy Minimum Premium: $52,270 (c) Total Estimated Policy Premium: $58,078 (d) Deposit Premium: $58,078 Premium Payable as follows: Amount Due $58,078.00 02/01/2006 10. Classification of Operations: See Endorsement 11. Endorsement Serial Numbers: See Endorsement Schedule 12. Service Company: County Technical Services, Inc. 800 Grant Street, Suite 400 Denver, CO 80203- Countersigned MIDWEST EMPLOYERS CASUALTY� � COMPANY Licensed Resident Agent Date Authorized Representative SO-SCH (1-04) Page 2 of 2 A Member Company of the W. R. Berkley Corporation Midwest Employers Casualty Company Endorsement Schedule Insured: Weld County, Colorado Policy Term: 12/31/2005 to 12/31/2006 Policy No.: EWC005661 Endorsement Code Effective Date Expiration Date Date Created SO-10 12/31/2005 01/03/2006 1O-31 12/31/2005 01/03/2006 1O-32 12/31/2005 01/03/2006 1O-39C 12/31/2005 01/03/2006 SO-43 12/31/2005 01/03/2006 SO-44 12/31/2005 01/03/2006 1O-60 12/31/2005 01/03/2006 1O-100 12/31/2005 01/03/2006 1O-100 12/31/2005 01/03/2006 1O-CO 12/31/2005 01/03/2006 Page 1 of 1 Print Date: 01/03/2006 Page 1 of 1 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 $4,879,331 8.67 $423,038 CO 7382 BUS COMPANY $370,771 7.50 $27,808 CO 7720 POLICE OFFICERS &DRIVERS $13,700,088 4.33 $593,214 CO 8742 SALESPERSONS $3,262,868 .66 $21,535 CO 8810 CLERICAL OFFICE OR LIBRARIES $14,650,880 .37 $54,208 CO 8820 ATTORNEY $2,892,027 .59 $17,063 CO 8832 PHYSICIAN&CLERICAL $2,684,214 .68 $18,253 CO 8868 SCHOOLS-PROFESSIONAL $1,424,943 .74 $10,545 CO 9014 BUILDINGS $169,509 4.97 $8,425 CO 9015 BUILDINGS $900,156 4.88 $43,928 CO 9101 SCHOOLS-ALL OTHER $882,737 6.22 $54,906 CO 9410 MUNICIPAL EMPLOYEE NOC $2,580,809 1.76 $45,422 Total Payroll: $48,398,333 Total Manual Premium: $1,318,345 Total Manual Premium: $1,318,345 (a) Experience Modification Factor: 1.000000000 (b) Other Modification Factor: 1.000000000 Normal Premium: $1,318,345 Endorsement Effective: 12/31/2005 Policy No.: EWC005661 Named Insured: Weld County,Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY ,D X. k ?la ✓, fuk„ .-- Authorized Representative Secretary President This endorsement forms part of the policy to which attached,effective on the inception date of the policy unless otherwise stated herein. SO-10 (1-93) EWC005661 Date Printed: 01/03/2006 Voluntary Compensation Endorsement Part One of the policy shall also apply to payments you gratuitously make to any employee included within the group described below (or to the employee's dependent) for benefits indicated in the workers compensation law of the state where the employee is normally employed, but only if that state is named in Schedule Item 3. All officers and employees not subject to the Workers' Compensation Law of the state of their normal employment. This endorsement does not apply: (a) unless the gratuitous benefits are paid as a result of an accident or disease exposure occurring during the policy period and in the course of employment; (b) if the employee (or dependent) is entitled to benefits under any workers compensation law. Endorsement Effective: 12/31/2005 Policy No.: EWC005661 Named Insured: Weld County,Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY 44nref ?la ,17 Authorized Representative Secretary President This endorsement forms part of the policy to which attached,effective on the inception date of the policy unless otherwise stated herein. 1O-31 (1-93) Date Printed: 01/03/2006 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: 12/31/2005 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-32 (1-93) Date Printed: 01/03/2006 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 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: 12/31/2005 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. IO-39C (11-04) Date Printed: 01/03/2006 Deletion of Commutation Clause Paragraph G of Part Three of the policy is deleted. Endorsement Effective: 12/31/2005 Policy No.: EWC005661 Named Insured: Weld County,Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY ,N."v" X. kna.7 s�`. ✓, �1CcNnral4.�— 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: 01/03/2006 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: 12/31/2005 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: 01/03/2006 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: 12/31/2005 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: 01/03/2006 • Aircraft Coverage Endorsement Part A The policy does not apply to loss arising out of the ownership, maintenance, operation or use of any aircraft that is owned or leased by the insured. This exclusion does not apply to regularly scheduled commercial airlines, chartered flights and scheduled aircraft in Part B below. Part B It is hereby understood and agreed that coverage is provided under this policy for losses sustained in, upon, entering or alighting form those employer owned or leased aircraft scheduled below. Coverage provided hereunder is limited to a N/A maximum benefit any one life and is further subject to a N/A limit per accident. Endorsement Effective: 12/3112005 Policy No.: EWC005661 Named Insured: Weld County Colorado Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY �.w•� X. k, ,�.� 741-641€1 ✓, f .,4._— 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-100 (1.93) Print Date: 1/3/2006 • Policyholder Disclosure Notice of Terrorism Insurance Coverage Coverage for acts of terrorism,as defined in the Terrorism Risk Insurance Act of 2002(the "Act"), is included in your policy. You should know that,effective November 26,2002, any losses caused by certified acts of terrorism, as defined in the Act,would be partially reimbursed by the United States under a formula established by federal law. Under this formula,the United States pays 90%of covered terrorism losses exceeding the statutorily established deductible paid by the insurance company providing the coverage. A. The portion of your annual premium that is attributable to coverage for acts of terrorism, as defined in the Act through 12/31/05 is $5 B. The portion of your annual premium that is attributable to coverage for acts of terrorism,as defined in the Act,for the period beyond 12/31/05 is estimated to be $1,737 (refer to the paragraph below). Possibility of Additional or Return Premium. The premium for certified acts of terrorism coverage is calculated based in part on the federal participation in payment of terrorism losses as set forth in the Act. The federal program established by the Act is scheduled to terminate at the end of 12/31/05 unless extended by the federal government If the federal program terminates or if the level or terms of federal participation change,the estimated premium shown in(B)of above may not be appropriate. If this policy contains a Conditional Exclusion, continuation of the coverage for certified acts of terrorism,or termination of such coverage,will be determined upon disposition of the federal program, subject to the terms and conditions of the Conditional Exclusion. If this policy does not contain a Conditional Exclusion,coverage for certified acts of terrorism will continue. In either case,when disposition of the federal program is determined,we will recalculate the premium shown in(B)above and will charge additional premium or refund excess premium, if indicated. If we notify you of an additional premium charge,the additional premium will be due as specified in such notice. The additional premium, if any,shall not exceed the amount shown below. The maximum additional premium if any,will be $434 Name of Insurer: Midwest Employers Casualty Company Policy Number: EWC005661 Endorsement Effective, 12/31/2005 Policy No.: EWC005661 Named Insured. Weld County,Colorado Countersigned n MIDWEST EMPLOYERS CASUALTY COMPANY Ank X. e' t.,G-'12 - 3. Steat. des.— Authorized Representative Secretary President This endorsement forms pad of the policy to which attached,effective on the inception dale of the policy unless otherwise stated herein. 10-100 Weld County TRIA 05.xls Date Printed: 1/3/2006 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: 12/31/2005 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-CO (3-95) Date Printed: 01/03/2006 MIDWEST EMPLOYERS CASUALTY COMPANY Specific Excess Workers' Compensation and Employers Liability Indemnity Policy In return for the payment of the premium and subject to all terms of this policy,we agree with you as follows: GENERAL SECTION A. Self-Insurance. Your acceptance of this policy indicates that you are now and will remain until the end of the policy period a duly qualified self-insurer in each state named in Schedule Item 3. If you are not a duly qualified self-insurer with respect to any loss covered by this policy,this policy will apply as if you were. B. Inured. 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 Applies. 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. I ate Hennaing Penalty. As respects each accident or each employee for disease: 1. If you do not give us written notice within one year of when required by Part Three,our indemnity will be reduced by 15%. 2. If you do not give us written notice within three years of when required by Part Three,our indemnity will be reduced by 40%. F. Loss means the amount actually paid by you for regular benefits provided under the workers'compensation law in effect upon the date the accident or disease exposure occurs. Loss includes: 1. The amount paid by you in settlement of claims for regular benefits under the workers'compensation law; 2. The amount paid by you in satisfaction of awards or judgments for regular benefits under the workers'compensation law; 3. Court costs,interest upon awards and judgments,and allocated investigation,adjustment and legal expenses pertaining to workers' compensation claims.This subparagraph 3 does not include: (i) salaries paid to your employees; (ii) service company tees; (iii) claims administrator fees. G. Fxclusions. Part One does not cover: 1. Loss insured by full coverage workers'compensation or employers liability insurance; 2. Loss payable under the workers'compensation law of any state which is not named in Schedule Item 3,if you are protected from the loss by any other insurance; 3. Any loss arising out of operations for which you have rejected any workers'compensation law; MWE-200(1-93) -t- 4. Punitive or exemplary damages because of bodily injury sustained by any employee; 5. Punitive,exemplary or compensatory damages because of your conduct,or the conduct of anyone acting for you: (a) in the investigation,trial or settlement of any workers'compensation claim; (b) in failing to pay or delay in payment of any workers'compensation claim. 6. Any assessment made upon self-insurers,whether imposed by statute, regulation or otherwise. H. Payments You_Must Make. You are responsible(without reimbursement from us)for any payments in excess of the benefits regularly provided by the workers'compensation law including those required because: 1. Of your serious and willful misconduct; 2. You knowingly employ an employee in violation of law; 3. You fail to comply with a health or safety law or regulation; 4. You discharge,coerce or otherwise discriminate against any employee in violation of the workers'compensation law;or 5. You violate or fail to comply with any workers'compensation law. I. Other Insurance. If,as respects any state named in Schedule Item 3,any other insurance exists protecting you against loss covered by this insurance,this insurance shall apply in excess of the other insurance. J. Recovery From Others. We have your rights,and the rights of persons entitled to compensation benefits from you,to recover our loss from anyone liable for the injury.You will do everything necessary to protect those rights for us and to help us enforce them.The recovered loss will first be used to reduce our loss.Then we will pay the balance,if any,to you. Expenses of all proceedings to recover from anyone liable for injury covered by this policy will be allocated between you and us in the ratio represented by the allocation of any damages which have been recovered. PART TWO - EMPLOYERS LIABILITY A. How This Part Annlies. 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. i ate 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- H: Fxclisions. Part Two does not cover: 1. Liability assumed under a contract; 2. Loss payable under the law of any state which is not named in Schedule Item 3,if you are protected from the loss by any other insurance; 3. Punitive or exemplary damages because of bodily injury sustained by any employee; 4. Punitive,exemplary or compensatory damages because of your conduct,or the conduct of anyone acting for you: (a) in the investigation,trial or settlement of any employers liability claim; (b) in failing to pay or delay in payment of any employers liability claim. 5. Bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers; 6. Any obligation imposed by a workers'compensation,occupational disease,unemployment compensation,or disability benefits law,or any similar law; 7. Bodily injury intentionally caused or aggravated by you.This exclusion does not apply to claim expenses(listed in subparagraph 3 of the definition of loss)related to the injury; 8. Damages arising out of coercion,criticism,demotion,evaluation,reassignment,discipline,defamation, harassment,humiliation, discrimination against or termination of any employee,or any personnel practices,policies,acts or omissions; 9. Bodily injury occurring outside the United States of America.This exclusion does not apply to bodily injury to a citizen or resident of the state(s)listed in Item 3 who is temporarily working outside the United States for the Insured; 10. Damages arising out of operations for which you: (a) have violated or failed to comply with any workers'compensation law,or (b) have rejected any workers'compensation law. I. Other Insurance. If,as respects any state named in Schedule Item 3,any other insurance exists protecting you against loss covered by this insurance,this insurance shall apply in excess of the other insurance. J. Recovery From Others. We have your rights to recover our loss from anyone liable for an injury covered by this insurance.You will do everything necessary to protect those rights for us and to help us enforce them.The recovered loss will first be used to reduce our loss. Then we will pay the balance,if any,to you. Expenses of all proceedings to recover from anyone liable for injury covered by this policy will be allocated between you and us in the ratio represented by the allocation of any damages which have been recovered. PART THREE - CLAIMS A. Your Claims Handling Duties. It is your responsibility to investigate,settle,defend and appeal any claim made against you. It is also your responsibility to investigate,settle,defend and appeal any suit brought or other proceeding instituted against you. B. Your Claims Reporting Duties. It is important for you to understand that"Written Notice"shall contain complete details of the injury,disease or death. Providing loss runs does not constitute notice. 1. You must give us written notice as soon as you learn of any of the following events involving loss which exceeds(or might in the future exceed)50%of your retention: (a) claim; (b) award; (c) verdict; (d) action; (e) suit; (f) proceeding; (g) judgment. 2. You must give us immediate(within 30 days)written notice of any accident involving: (a) fatality; (b) spinal cord injury; (c) a permanent total disability as defined in the workers compensation law; (d) serious burn injury; (e) brain injury; (f) amputation of a major member. 3. You must give us prompt written notice of any claim in which the injured employees disability exceeds 52 weeks,even if the claim is being contested by you; 4. You must give us immediate(within 30 days)written notice of all occurrences involving two or more of your employees. C. Claims Information. You agree to send to us any claim information which we may request. D. Claims Particination By t Is. 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 Los,s. When paid loss exceeds your retention,you must provide us with a payment register listing all payments made on the claim. We will reimburse you the amount you have paid in excess of your retention,within 30 days of receiving in a form acceptable to us,a complete and proper proof of loss. MWE-200 (1-93) -3- • • G. Commutation. Beginning thirty-six(36) months after receipt of notice by us of a claim,we may then,or at any time after,submit the claim for commutation. If we so elect,the claim shall be submitted to an actuary or appraiser to be mutually appointed by us and you.Should we both fail to agree upon an actuary or appraiser,then each party shall select an actuary or appraiser who shall then select an independent actuary or appraiser who shall fix a lump sum amount.We may pay the lump sum amount,which shall constitute a full and final release of our liability for the claim. However,such lump sum payment shall not constitute a full and final release of our liability if,after the lump sum payment,any supplemental award is made increasing the amount of benefits payable to the Employee and his/her dependents.Any additional liability,at our election,may immediately be commuted via the process above and we may discharge such liability by payment of another lump sum. H. Claim Audit. You will let us or our representative examine and audit claim files upon our request.These audits may be conducted during your regular business hours. PART FOUR - PREMIUM A. Deposit and Adiustment Premiums. At the beginning of the policy period you must pay us the deposit premium shown in the Schedule.At the end of the policy period: 1. You will owe us the amount by which the final premium is greater than the deposit premium;or 2. We will owe you the amount by which the deposit premium is greater than the final premium. B. Payroll Report. Within 45 days after the end of the policy period,send us a report showing the amount of payroll earned by your employees during the policy period.The report must show payroll separately for each classification identified in Schedule Item 10. C. Final Premium. The final premium due us for the policy period will be computed as shown in Schedule Item 9(a). Unless this policy is cancelled,final premium will be at least the minimum premium shown in Schedule Item 9(b). If we cancel this policy,final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. If you cancel this policy,final premium will be more than pro rata;it will be based on the time this policy was in force,and increased by the customary short rate table and procedure. Final premium will not be less than the short rate portion of the minimum premium. D. Payroll means the gross pay of your employees for the policy period plus other amounts and items received by your employees as part of their pay for the policy period.We will send you a payroll reporting form describing what is included in payroll. E. Records. You will keep records of information needed to compute premium.You will provide us with copies of those records when we ask for them. F. Audit. You will let us or our representatives examine and audit all your payroll records.The audits may be conducted during your regular business hours. PART FIVE - CONDITIONS A. Agreement(loon Terms. Your acceptance of this policy means that you agree with us upon the terms of this policy. B. Sole Representative. The Insured first named in Schedule Item 1 will act on behalf of all Insureds to change this policy, accept loss payments,receive return premium and give or receive notice of cancellation. C. Bankruptcy or Insolvency. Your bankruptcy or insolvency will not relieve us from the payment of any claim covered by this policy.After the retention shown on the Schedule has been paid,payments will be made by us as if you had not become bankrupt or insolvent but not in excess of the Insurers Limit of Indemnity. Payment will be made to the Trustee in Bankruptcy or as directed by an appropriate court. D. Transfer of Your Rights and Duties. Your rights or duties under this policy may not be transferred without our written consent.This provision does not apply to duties transferred to a service company or a claims administrator. E. ,Service and Administration. This Agreement contemplates the concurrent and continued existence of a separate service agreement between you and the Service Company named in Item 12 of the Schedule.You must notify us within 30 days should you decide to change the service company. F. Cancellatiou. 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: / y � _ , /'r)9'f+ X j"bldb(/rl�-..�s.4 / zG e7 cC.. ,�. i*t,c, (U— (1 . SIGNATURE SIGNATURE Authorized Representative Secretary President MWE-200 (1-93) -4- Hello