HomeMy WebLinkAbout000277.tiff Ann Coriano
TRAVELERS J 6060 S Willow Dr
GREENWOOD VILLAGE,CO 80111
April 30,2009 Phone:(720)200-8409
Fax:(720)-200-8398
Email:ACORIANO@travelers.com
Julie Ann Vierra
GALLAGHER\A ARMS(0HE558)
6399 S FIDDLERS GREEN CIR
STE 200
GREENWOOD VILLAGE,CO 80111
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This is an Agency Billed Policy.
This is the Policy Change WELD COUNTY,COLORADO
for: P.O.BOX 758
GREELEY,CO 80632
Bond Number: 100729968
Type of Bond: SIWC
Obligee Name: COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT/DIVISION OF WORKER'COMPENSATION
Obligee Address: 633 17TH STREET#201
Obligee City,State&Zip: DENVER,CO 80202-3660 USA
Transaction Effective Date: December 31,2008
Premium Effective Date: December 31,2008
Premium Expiry Date: December 31,2009
Bond Limit: $2,365,085.00
Bond Premium: $0.00
Commission-Percentage: 15%
Special Commission: $0.00
Countersignature Branch:
Countersignature Commission: $0.00 •
State Tax: $0.00
State Surcharge: $0.00
TOTAL PREMIUM: $0.00
Comments:
Thank you for placing your business with us.
Producer Name: BARNES,ROBERT F
S-4123 (9/96)Premium Evidence
SAFETY NATIONAL CASUALTY CORPORATION
1832 SCHUETZ ROAD
ST. LOUIS, MO 63146
AMENDED
DECLARATIONS-SPECIFIC EXCESS SP-2T94-CO
Item 1. Employer WELD COUNTY COLORADO
Address: 915 10TH STREET, GREELEY, CO 80631
Item 2. This Agreement covers all business operations of the EMPLOYER as a Self-Insurer in the following
State(s): COLORADO
Item 3. Effective Date:12:01 A.M. December 31,2008
Item 4. Anniversary Date: 12:01 A.M. December 31,2009
Item 5. The Service Company shall be COUNTY TECHNICAL SERVICES OF DENVER, COLORADO
Item 6. CLASSIFICATIONS Code Estimated Total Annual Rate Per$100
OF OPERATIONS Number RemuneratlonlManhours Remuneration/Manhours
See Attached
Total Estimated Manual Premium $ N/A
SNCC Experience Modification Factor N/A
Total Estimated Standard Premiu
m
$ NIA
Item 7. Self-Insured Retention Per Occurrence $ 600,000
Item 8. (a)Maximum Limit of Indemnity Per Occurrence $ STATUTORY
(b)Employers'Liability Maximum Limit of Indemnity Per Occurrence $ 1,000,000
Item 9. Premium Rate$0.152 per$100.of Payroll
Item 10. Minimum Premium for the Liability Period $ 85,525
Item 11. Deposit Premium for the Payroll Reporting Period $ 95,028
Item 12. Payroll Reporting Period Annually as of December 31st A,
Item 13. Endorsements See Endorsement Schedule 44 /[t-
Signed at St.Louis,Missouri on February 25,2009
Secretary
Countersigned this day of
By: N/A
DSP-0195
XWC 1005 00 1101
ITEM 6
RE: WELD COUNTY COLORADO
Policy No:SP-2T94-CO
Effective Date: 12:01 A.M.December 31,2008
Declarations:
Item B. AMENDED
Estimated
Total Annual Rate per$100 I
Code Remuneration/ Remuneration/ Estimated
St Classifications of Operations No. Manhours Manhours Premium
CO Street or Road Construction:Paving or Repaving& 5505 $6,106,655 N/A NIA
Drivers •
Limousine Co.:Al Other Employees&Drivers 7382 244,489 •
Police Officers&Drivers 7720X 18,649,284
Salesperson,Collectors or Messengers-Outside 8742 4,828,485 i.
Clerical Office Employees NOC 8810 18,243,118 �.
Attorney-All Employees&Clerical,Messengers,Drivers 8820 3,938,207
Physician&Clerical 8832 3,765,835
College:Professional Employees&Clerical 8868 1,595,787
Buildings-Operation by Contractors 9014 242,038
Building-Operation by Owner or Lessee 9015 904,045
College or School: Al Other Employees 9101 925.976
Municipal,Township,County or State Employee NOC 9410 3,074,736
$62,518,655
Total Payroll $82,518,855
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No SP-2T94-0D
SPECIFIC EXCESS
WORKERS' COMPENSATION AND
EMPLOYERS' LIABILITY INSURANCE AGREEMENT
SAFETY NATIONAL CASUALTY CORPORATION
ST. LOUIS, MISSOURI
(Hereinafter called the CORPORATION)
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In consideration of the payment of premium and subject to all the terms of this Agreement,hereby agrees with the EMPLOYER
named in the Declarations(hereinafter called the EMPLOYER),as follows:
A. Coverage of Agreement C. Definitions
This Agreement applies only to Loss sustained by the (1) "Loss"—shall mean actual payments, less recoveries, •
EMPLOYER because of liability imposed upon the EM- legally made by the EMPLOYER to Employees and
PLOYER by the Workers' Compensation or Employers' their dependents in satisfaction of: (a) statutory bene-
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Liability Laws of fits,(b)settlements of suits and claims,and(c)awards
(1) the State(s)designated in the Declarations,or and judgments. Loss shall also include Claim Expen •
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(2) other State(s), provided that the Loss shall not be ses,paid by the EMPLOYER,as defined in Paragraph
greater than it would have been had liability been (2)of this Section. The term Loss shall not include the
imposed by the State(s)specified in the Declarations, items specifically excluded by Paragraph (3) of this
on account of bodily injury by accident or bodily injury by Section.
occupational disease due to Occurrences taking place within (2) -Claim Expenses" —shall mean court costs, interest
the Liability Period to Employees of the EMPLOYER engaged upon awards and judgments and the reasonable alloc-
in the business operations specified in the Declarations and all ated costs of investigation, adjustment, defense, and
other operations necessary,incidental,or appurtenant thereto. appeal, including pension or appeal bond costs
Bodily injury includes resulting death. (provided that the prosecution of such appeal and/or the
The inclusion of more than one EMPLOYER in the Dec- posting of such pension or appeal bond is approved by
lararions shall not increase the EMPLOYER's Self-Insured the CORPORATION)of claims, suits or proceedings
Retention nor the CORPORATION's Maximum Limit of brought against the EMPLOYER under the Workers'
Indemnity. Compensation or Employers' Liability Laws of the
The insurance afforded by this Agreement applies to State(s) designated in the Declarations, or other
operations in the State(s) specified in the Declarations, State(s), as providedin Section A; even though such
including, however, incidental operations conducted by claims, suits, proceedings or demands are wholly
Employees who are regularly engaged in operations in the groundless,false or fraudulent. Claim Expenses shall
specified State(s), but who may be temporarily outside the not include fees to the EMPLOYER's Service
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specified State(s). Company. •
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(3) "Exclusions from Loss"—shall refer S the following
B. Insurance Under This Agreement amounts paid by the EMPLOYER, and specifically
excluded from the term Loss:
(1) Specific Excess Insurance (a) Salaries, wages, and remuneration provided to
Employees;
With respect to each Occurrence taking place within a (b) Fees to the EMPLOYER's Service Company
Liability Period,the EMPLOYER shall retain as its own Loss, and/or costs of self-administration of claims;
. as defined below, the amount specified in Item 7 of the (c) Punitive or exemplary damages as they relate to
Declarations,and the CORPORATION agrees to reimburse the claims made under the Employers' Liability
EMPLOYER only for such Loss in excess of such Self-Insured coverage provided by this Agreement; .
Retention, subject to the Maximum Limit of Indemnity Per (d) Fines or penalties assessed against the EM-
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Occurrence, or the Employers' Liability Maximum Limit of PI.OYF.R for nnv violation by the FMPI.OYFR
Indemnity Per Occurrence, whichever is applicable, as or its representative(s), of any statute or
specified in Item 8 of the Declarations. The separate regulation, unless the fines or penalties result
Employers' Liability Maximum Limit of Indemnity Per from a reasonable dispute as to Workers'
Occurrence shall not operate,in any case,to increase the total Compensation benefits owed by the EMPLOYER;
amount the CORPORATION agrees to reimburse the (e) Assessments and taxes made upon the EM- •
tawrau' tae for Loss per any one occurrence as per Item s(a) PLOVER as self-insurer whether imposed by sta-
of the Declarations. tute,regulation;or otherwise;
SPA t'.enn•AI -
(0 Any amounts required to he paid by the EMPLOYER D. Reimbursement
because of:
I) Serious and willful misconduct of the If the EMPLOYER pays any Loss incurred in any
EMPLOYER, including intentional torts and Liability Period in excess of the Self-Insured Retention Per
intentional acts or omissions resulting in injury, Occurrence, the CORPORATION shall reimburse the EM-
acts or omissions taken with reckless disregard of PLOYER upon receipt of a formal proof of loss and other
the possible occurrence of an injury or acts or evidence acceptable to the CORPORATION of such
omissions taken that are substantially certain to payment. Within a reasonable period of time,
result in injury,regardless of whether or not said reimbursement payments shall be made by the
actions may be classified in the State(s) as CORPORATION.
intentional torts, The CORPORATION shall have,and may exercise at any .
2) Coercion, criticism, demotion, evaluation, time, and from time to time,the right to offset any balance
reassignment, discipline, defamation,harassment, or balances, whether on account of premiums, Losses or
humiliation,discrimination against or termination otherwise, due from the EMPLOYER to the
of any Employee and/or related personnel . CORPORATION against any balance or balances,due from
practices, policies, acts or omissions by the the CORPORATION to the EMPLOYER under this
EMPLOYER, Agreement.
3) Knowingly employing an Employee in violation of
law, E. Liability Period
4) Rejection by the EMPLOYER of any Workers'
Compensation Law, The liability of the CORPORATION for Loss hereunder •
5) Failure to comply with any health, safety, or shall be determined separately for each Liability Period.
notification law or regulation, The initial Liability Period shall commence at 12:01 A.M.
(g) Loss voluntarily assumed by the EMPLOYER under
on the Effective Date and end at 12:01 A.M. on the
any contract or agreement,whether express or implied; Anniversary Date,designated in Items 3 and 4 respectively, .
(h) Loss for which the EMPLOYER carries a full coverage of the Declarations. Each succeeding Liability Period shall
• Workers' Compensation and Employers' Liability begin concurrently with the end of the previous Liability
policy;and Period and continue for the same number of consecutive
(i) Any amount owed by the EMPLOYER pursuant to any months as the initial Liability Period. All time is stated in
provision of any law that provides non-occupational local time for the State(s)designated in the Declarations.
disability benefits. In the event the Employer fails to give express written
(4) "Occurrence" — shalt mean accident. In addition, intent to continue coverage at the end of a given Liability
bodily injury by occupational disease must be caused or Period,the Agreement shall be deemed terminated, and the I
aggravated by the conditions of employment and shall Anniversary Date shall serve as the termination date of the
. be deemed to have occurred on the last day of the last Agreement.
exposure to those conditions of employment causing or
aggravating such injury by occupational disease, or F. Premium
such dates as is otherwise established by the Workers'
Compensation and Employers' Liability Laws of the - Upon acceptance of the Agreement and at the beginning
of each Payroll Reporting specified in Item 14 of Period,as
appropriate State(s). Bodily injury by occupational Y F b
disease sustained by each Employee shall be deemed to the Declarations,the EMPLOYER shall pay to the CORP-
be a separate Occurrence unless such disease results ORATION the amount of the Deposit Premium specified in
directly from an accident. Item 13 of the Declarations. The EMPLOYER shall pay
(5) "Employee"—as respects liability imposed upon the premiums when due. The Deposit Premium shall he held by
EMPLOYER by the Workers' Compensation Law of the CORPORATION until the expiration of the Payroll
any State, the word Employee shall mean any person Reporting Period. Within thirty(30)days after the close of
performing work which renders the EMPI.OYER liable each Payroll Reporting Period,the EMPLOYER shall render
under the Workers' Compensation Law of a State to the CORPORATION a report,upon a form satisfactory to
named in Item 2 of the Declarations,which is the State the CORPORATION, exhibiting, by classification, the
of the injured Employee's normal employment, for amount of such remuneration earned by Employees during .•
bodily injuries or occupational disease sustained by such reporting period,and the EMPLOYER shall therewith
such person. pay to the CORPORATION the excess of the Earned
IAN «ctate"_ct, 11?,Pa„a^y't?te r>,=trn,, .. -P .__ ..f Premium over the Deposit Premium previously paid. In •
the United States of America and the District of case the Deposit Premium paid exceeds the Earned
Columbia. Premium, the CORPORATION shall return to the
EMPLOYER the amount of such excess or give appropriate
• credit, subject to the proportion of Minimum Premium for
the Liability Period in the ease of multi-year Liability
Periods.
Upon expiration of a Liability Period,a summary of
voluntary payroll reports for such Liability Period shall be services approved by the CORPORATION. The •
made to determine the Earned Premium under this Agreement. EMPLOYER agrees that its Service Company shall furnish
in no event,however,shall the Earned Premium in respect of the CORPORATION with quarterly loss runs concurrent
any Liability Period be less than the Minimum Premium with each Liability Period of this Agreement. The pro-
specified in the Declarations. vision of loss runs alone does not relieve the EMPLOYER
For each Payroll!Reporting Period,the CORPORATION of its reporting obligations as set forth in Section I of this
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shall cuntpute the Earned Premium as follows: Agreement. In addition, the electronic transfer of loss
(1) Remuneration — The remuneration earned, or man- information by a Service Company of the EMPLOYER shall
hours accumulated, during such period by all not constitute notice ofa claim.
Employees, including volunteers, engaged in each Cancellation of the service agreement between the Service
classification covered by this Agreement shall he Company and the EMPLOYER shall operate as a notice of
computed in accordance with the rules set forth in the cancellation of this Agreement by the EMPLOYER,subject
appropriate Manual of Workers' Compensation and to the additional terms of the Cancellation Section of this
Employers'Liability Insurance. Agreement. Any change in service companies must be
(2) Manual and Standard Premium—The remuneration,or immediately communicated to and•approved by the
man-hours, so computed for Employees engaged in CORPORATION, and this obligation shall survive the
each such classification shall be multiplied by the termination or non-renewal of this Agreement.
Manual Rate per$100 of remuneration/man-hour, in
effect at the inception of each Payroll Reporting Period, 1. Prompt Reporting of Claims
and the products so obtained shall be added together to
determine the Manual Premium. An Experience As soon as the EMPLOYER becomes aware, the
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Modification Factor may be applied to the Manual EMPLOYER must provide prompt notice to the CORP-
Premium to determine a Standard Premium. Such ORATION of: (a)any claim or action commenced against
Experience Modification Factor shall be determined at the EMPLOYER which exceeds,or is likely to exceed,fifty
the inception of this Agreement and is subject to annual percent(50%)of the Self-Insured Retention Per Occurrence
review and possible revision. A Standard Premium specified in Item 7 of the Declarations and(b)the reopening
takes precedence over any Manual Premium, of any claim in which a further award might involve liability
(3) Earned Premium — Against the Manual or Standard of the CORPORATION under this Agreement.
Premium shall be applied the Premium Rate,as sped- In addition, the following categories of claims shall be
lied in Item 9 of the Declarations, to determine the reported to the CORPORATION immediately,regardless of
appropriate Earned Premium. any question of potential involvement of the CORPOR-
This Agreement is issued by the CORPORATION and ATION:
accepted by the EMPLOYER subject to the agreement that,in I. Fatalities;
the event of any change in the Rates per $100 remun- 2. Paraplegics and quadriplegics;
erationiman-hour, as stated in Item 6 of the Declarations, 3. Serious burns,defined as 2nd or 3rd degree burns
because of any general rate increase or any legislative involving 25%or more of the body; •
amendment affecting the benefits under the Workers' 4. Brain injury;
Compensation Law of any State(s)named in Item 2 of the 5. Spinal cord injury;
Declarations, such change, upon the effective date thereof, 6. Amputation of a major extremity;and
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shall be,without endorsement,made a part of this Agreement. 7. Any Occurrence which results in a serious injury : .
to two or more Employees.
G. Self-Insurer If the CORPORATION is prejudiced by the EMPLOY-
ER's failure to provide prompt notice of a claim in
The EMPLOYER, by acceptance of this Agreement, war- accordance with the requirements set forth above and/or as
rants that it is a duly qualified Self-Insurer in the State(s) otherwise provided by the Law of any State(s), the
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designated in the Declarations,and will continue to maintain CORPORATION may elect to deny coverage for Loss
such qualifications during the currency of this Agreement. In arising from such claim. To constitute prompt, sufficient
the event the EMPLOYER should at any time while this notice,the EMPLOYER must provide complete information
Agreement is in force terminate such qualifications or if they as to the details of the injury,disease,or death.
should be cancelled or revoked, such loss of qualifications
shall operate as notice of cancellation of this Agreement by the .L Defense of Claims
EMPLOYER, subject to the additional terms of the
Cancellation Section of this Agreement. The EMPLOYER shall investigate and settle or defend all
claims and shall conduct the defense and appeal of all
H. Service and Administration actions, suits, and proceedings commenced against it. The
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EMPLOYER shall forward promptly to the CORPOR-
This Agreement contemplates the concurrent and continued ATION copies of any pleadings or reports as may be
existence of a separate service agreement between the requested. The CORPORATION shall nut be obliged to
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EMPLOYER and the Service Company, its designated assume charge of the investigation,defense,appeal or settle-r epresentailve,namea in item 3 or the Declarations,providing i meat of any claim,suit,or proceeding brought against the
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EMPLOYER,, but the CORPORATION shall be given the to prosecute any and all valid claims against any other party
opportunity to investigate, defend or participate with the or source that may mitigate any Loss under this Agreement.
EMPLOYER in the investigation and defense of any claim.if, The EMPLOYER agrees that it will assist the
" in the opinion of the CORPORATION, its liability under this CORPORATION in any prosecution of any and all valid
Agreement might be involved. claims against any other party or source that may mitigate
any Loss under this Agreement. Any amounts recovered by
K. Good Faith Claims Administration the EMPLOYER or the CORPORATION from any party or j.
source that may mitigate any Loss under this Agreement
The EMPLOYER shall use diligence,prudence, and good shall first be used to pay the expenses of collection and to
faith in the investigation, defense, pursuit of recovery from reimburse the CORPORATION for any amount it may have
others and settlement of all claims.The EMPLOYER shall not paid the EMPLOYER for the Liability Period concerned, i.
unreasonably refuse to settle any claim which, in the exercise and all remaining amounts collected shall be paid to the
of sound judgment with respect to the entire claim,should be EMPLOYER. •
settled, provided, however, that the EMPLOYER shall not
make any payment or agree to any settlement for any sum O. Change in Agreement
which would involve the limits of the CORPORATION's
liability hereunder without the approval of the No condition,provision,or declaration of this Agreement
CORPORATION. shall be waived or altered at any time,except as specified in
If the CORPORATION is prejudiced by the EMPLOYER's Section F,except by endorsement signed by the President or
failure to exercise diligence, prudence., and good faith, the a Senior Vice President and the Secretary or an Assistant
CORPORATION may elect to disclaim coverage for Loss Secretary of the CORPORATION.
from such claim. • • This Agreement hereby terminates, supersedes, and re-
places
all previously issued Workers' Compensation
L. Inspection and Audit Insurance or Reinsurance Agreements,as amended,between
the EMPLOYER and the CORPORATION.
The CORPORATION shall have the right, but not the If terms of this Agreement are in conflict with any law
obligation, to inspect the premises and equipment and/or to applicable to this Agreement,this statement amends this
audit tfie books and records of the EMPLOYER and of its Agreement to conform to such law. In addition,in the event
agents and representatives, including all records relating to any terms are in conflict with applicable laws,the remaining
payroll and claims matters, at any reasonable time during the terms of the Agreement shall be enforceable.
period of this Agreement and within three(3)years after final
settlement of all claims due to Occurrences happening during P. Cancellation
the term of this Agreement. An audit to determine Manual or
Standard Premium shall supersede any and all prior voluntary This Agreement may be cancelled by either party giving
payroll reports by the EMPLOYER, and will be used to the other party written notice not less than sixty(60)days
determine the final adjustment of premiums due to the prior to the date of cancellation,except,that if the COR-
CORPORATION. Should a determination be made that PORATION cancels for non-payment of any premium, the
additional audit premium is"due to the CORPORATION,the cancellation shall become effective ten (10) days after
due date for payment of such audit premium shall be thirty dispatch of notice by the CORPORATION. The date of
(30)days after the date of billing. cancellation then becomes the termination date of the final •
Liability Period. This Agreement does not apply to Loss as •
• M. Other Insurance a result of Occurrences taking place after the effective date
of such cancellation.
If the EMPLOYER carries other valid amid collectible If cancellation is effected by the EMPLOYER, the
insurance,reinsurance,or indemnity with any other insurer or Manual or Standard Premium shall be determined by the a�
reinsurer covering a Loss also covered by this Agreement short rate tables used for casualty insurance,and the Earned
(other than insurance or reinsurance that is purchased to apply Premium shall be the product of the Premium Rate(Item 9)
in excess of the sum of the Self-Insured Retention and the times the Manual or Standard Premium(or the Total Annual
Maximum Limits of Indemnity hereunder), the insurance Remuneration) so arrived at, but not less than Minimum
afforded by this Agreement shall apply in excess of and shall Premium specified in the Declarations.
not contribute with such other insurance or reinsurance. if cancellation is effected by the CORPORATION for •
non-payment of premium, the EMPLOYER shall pay the
N. Recovery From Others CORPORATION Earned Premium for the period up to the
date of cancellation.
The EMPLOYER agrees to prosecute any and all valid If the CORPORATION cancels for any other reason,the ! •
claims the EMPLOYER may have against any other party or Manual or Standard Premium (or the Total Annual
source that may mitigate any Loss under this Agreement and Remuneration)shall be determined upon a pro rata basis and
return to the CORPORATION any amount so recovered, less the Earned Premium adjusted in accordance therewith.
the reasonable expense of collecting such amounts.
The CORPORATION shall have the EMPLOYER's rights 1 •
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Q. Assignment behalf of all EMPLOYERS to give or receive notice of
cancellation,to receive return premium or reimbursement,or
An assignment of interest under this Agreement will not to request changes in this Agreement
bind the CORPORATION unless an endorsement signed by •
the President or a Senior Vice President and the Secretary or T. Acceptance
an Assistant Secretary of the CORPORATION assigning
interest under this Agreement is issued by the By acceptance of this Agreement, the EMPLOYER
CORPORATION. - agrees that the statements in this Agreement, in the
Declarations, and in the application are the EMPLOYER's
It Bankruptcy or Insolvency of Employer representations; that this Agreement is issued..in reliance
The bankruptcy or insolvency of the EMPLOYER will not upon such representations;that this Agreement embodies all
relieve the CORPORATION or the EMPLOYER of its duties agreements existing between the EMPLOYER and the
CORPORATION,or any of its agents,relating to this excess and liabilities under this Agreement. After payments have
been made by or on behalf of the EMPLOYER, insurance,and that full compliance by the EMPLOYER with
reimbursements due under this Agreement will be made by the all terms of this Agreement is a condition precedent to the
CORPORATION as if the EMPLOYER had not become CORPORATION's liability hereunder.
bankrupt or insolvent, but not in excess of the
CORPORATION's limit of indemnity. IN WITNESS WHEREOF, the SAFETY NATIONAL
CASUALTY CORPORATION has caused this Agreement
S. Sole Representative to be executed by printing below the facsimile signatures of
If more than one EMPLOYER is named in item I of the its President and Secretary and by the actual signature of its
Declarations,or an endorsement related thereto,the EMPLOY- Secretary on the Declarations.
ER first named in Item I,or a related endorsement,will act on
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Secretary President
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SAFETY NATIONAL CASUALTY CORPORATION
PRIVACY STATEMENT
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Our Commitment To Our Customers To Whom Do We Disclose Your Information
Safety National Casualty Corporation ("Safety We will not disclose any non-public, personal
National") is proud to have provided quality information about our customers or former •
products and services to its customers far over 50 customers, except as permitted by law. That •
years. We greatly appreciate the trust that you means we may disclose information we have
and all of our customers place in us. We protect collected about you to the following types of third
that trust by respecting the privacy of all of our parties:
customers, both present and past. The following
will explain our privacy practices so that you will • Our affiliated companies (members of the
understand our commitment to your privacy. Delphi Financial group of companies).
• Your agent or broker.
We Respect Your Privacy • Parties who perform a business or insurance
When you apply to Safety National for any type of function for Safety National, including
insurance, you disclose information about you to reinsurance, underwriting, claims
us. The collection, use and disclosure of such administration or adjusting, investigation, loss
information is regulated by law. Safety National control and computer systems companies. '•
and its affiliates maintain physical, electronic and
procedural safeguards that comply with state and • Other insurance companies or agents as
federal regulations to guard your personal reasonably necessary concerning your i.
information. Our employees are also advised of application,policy or claim.
the importance of maintaining the confidentiality of
your information. Insurance regulatory or statistical reporting
agencies.
Types Of Information We Collect • Law enforcement or governmental authorities
Safety National obtains most of our information in connection with suspected fraud or illegal
directly from you, your agent or broker. The activities.
application you complete, as well as any additional
information you provide,generally gives us mast of • Authorized persons as ordered by subpoena,
the details we need to know. Depending on the warrant or court order,or as required by law.
nature of your insurance transaction,we may need •
further details about you. We do not disclose any non-public, personal •
information about you to non-affiliated companies
We may obtain information from third parties,such for marketing purposes or for any other purpose
as other insurance or reinsurance companies, except those specifically allowed by law and
medical providers, government agencies, described above.
information clearinghouses and other public
records. We may also obtain information about you
from your other transactions with us,our affiliates •
Independent Sales Agents or Brokers
or others. Your policy may have been placed with us through
an independent agent or broker("Sales Agent").
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Your Sales Agent may have gathered information •
What We Do With Your Information
Information that has been collected about you will about you. The use and protection of information
obtained by your Sales Agent is their
be retained in our files. We will review your
responsibility, not Safety National's. If you have
information in evaluating your request for
insurance coverage, determining your rates or questions about how your Sales Agent uses or
discloses your information, please contact them
underwriting risk, servicing your policy or adjusting
ciaims. We may retain iniounaiiuri auvui vui
directly. •
former customers and would disclose that
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information only to affiliates and to nonaffiliates as
described in this notice or as otherwise permitted
by law. •
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WC 99 99 28 •
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Ii
SAFETY NATIONAL CASUALTY CORPORATION
1832 SCHUETZ ROAD
ST.LOUIS,MO 63146
_ DECLARATIONS-SPECIFIC EXCESS SP-2T94-CO
Item 1. Employer: WELD COUNTY COLORADO
Address: 915 10TH STREET, GREELEY,CO 80631
Item 2. This Agreement covers all business operations of the EMPLOYER as a Self-Insurer in the following
State(s): COLORADO
Item 3. Effective Date: 12:01 A.M. December 31, 2008
Item 4. Anniversary Date: 12:01 A.M. December 31,2009
Item 5. The Service Company shall be COUNTY TECHNICAL SERVICES OF DENVER,COLORADO
Item 6. CLASSIFICATIONS Code Estimated Total Annual Rate Per$100
OF OPERATIONS Number RemunerationlManhours Remuneration/Manhours
See Attached
Total Estimated Manual Premium $ NIA
SNCC Experience Modification Factor N/A
Total Estimated Standard Premium $ N/A
Item 7. Self-Insured Retention Per Occurrence $ 600,000
Item 8. (a)Maximum Limit of Indemnity Per Occurrence $ STATUTORY
(b)Employers'Liability Maximum Limit of Indemnity Per Occurrence $ 1,000,000
Item 9. Premium Rate$0.152 per$100.of Payroll
Item 10. Minimum Premium for the Liability Period
� 82,911
Item 11. Deposit Premium for the Payroll Reporting Period $ 92,123
Item 12. Payroll Reporting Period Annually as of December 31st .
Item 13. Endorsements See Endorsement Schedule jilt/ /1•4 l�
Signed at St. Louis,Missouri on January 14,2009
Secretary
Countersigned this day of
By: N/A
DSP-0195 {�
I`•
XWC 1005 00 1101
ITEM 6
RE: WELD COUNTY COLORADO
Policy No: SP-2T94-CO
Effective Date: 12:01 A.M. December 31,2008
Declarations:
Item 6.
Estimated
Total Annual Rate per$100
Code Remuneration/ Remuneration/ Estimated
St Classifications of Operations No. Manhours Manhours Premium
CO Street or Road Construction:Paving or Repaving& 5506 - $6,800,228 N/A NIA
Drivers
Limousine Co.:All Other Employees&Drivers 7382 276,895
Police Officers&Drivers 7720 17,659,488
Salesperson,Collectors or Messengers-Outside 8742 4,408,479
Clerical Office Employees NOC 8810 16,649,923
Attorney-All Employees&Clerical,Messengers,Drivers 8820 3,904,271
•
Physician&Clerical 8832 3,857,276
College:Professional Employees&Clerical 8868 1,699,178 •
Buildings-Operation by Contractors 9014 297,014
Building-Operation by Owner or Lessee 9015 1,019,480
College or School: All Other Employees 9101 914,676
Municipal,Township,County or Stale Employee NOC 9410 3,120,025
$60,606,833
Total Payroll $60,606,933
•
•
XWC 1004 00 1101
Endorsement Schedule
RE: WELD COUNTY COLORADO
Policy No: SP-2T94-CO
Effective Date: 12:01 A.M. December 31, 2008
Number Title
XWC 0003 00 1206 COLORADO NOTICE ENDORSEMENT
XWC 0241 00 1291 INCIDENTAL LONGSHOREMEN'S AND HARBOR WORKERS'COMPENSATION ACT COVERAGE
ENDORSEMENT
XWC 0276 02 0408 BROAD FORM ALL STATES FOR EMPLOYEE TRAVEL
XWC 0291 00 0708 VOLUNTARY COMPENSATION ENDORSEMENT-PREMIUM DELINEATION
XWC 0293 00 0906 FOREIGN VOLUNTARY WORKERS'COMPENSATION AND EMPLOYERS' LIABILITY
XWC 0322 00 1291 90-DAYS NOTICE OF CANCELLATION
XWC 0339 01 0906 SAME COMMUNICABLE DISEASE-SPECIFIC EXCESS
XWC 1061 10 1207 POLICYHOLDER DISCLOSURE
NOTICE OF TERRORISM INSURANCE COVERAGE
•
•
XWC 0003 00 1206
ENDORSEMENT#1
COLORADO NOTICE ENDORSEMENT
Effective 12:01 A.M.,Local Time, December 31,2008
In consideration of the payment of premium and adherence by both parties to the terms of this Agreement, it is
hereby understood and agreed as follows:
NOTICE OF CANCELLATION
If either the EMPLOYER or the CORPORATION intends to cancel this Agreement, ninety(90)
days written notice must be given to the Colorado Division of Workers' Compensation, Self-
Insurance Coverage Enforcement Unit,633 17th Street, Suite 400, Denver,CO 80202-3660.
•
All other terms, conditions, agreements and stipulations remain unchanged.
Attached to and forming a part of Excess Workers'Compensation and Employers' Liability Insurance Agreement
No. SP-2T94-CO, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY COLORADO, dated December 31,2008.
SAFETY NATIONAL CASUALTY
CORPORATION
jet7 tilet—
President
Secretary
•
•
•
XWC 0241 001291
ENDORSEMENT#2
INCIDENTAL LONGSHOREMEN'S AND HARBOR WORKERS'COMPENSATION ACT COVERAGE
ENDORSEMENT
Effective 12:01 A.M.,Local Time, December 31,2008
•
In consideration of the payment of premium and adherence by both parties to the terms of this Agreement, it is
hereby understood and agreed as follows:
This Agreement also applies to Loss sustained by the EMPLOYER because of liability
imposed upon the EMPLOYER by the U. S. Longshoremen's and Harbor Workers'
Compensation Act due to Occurrences taking place within the Liability Period as a result
of incidental work, subject to that Act, performed by Employees in the State(s) listed in
the Declarations. Incidental work means incidental to an Employee's normal duties. To
that end, the term "Workers' Compensation Law" includes the Longshoremen's and
Harbor Workers'Compensation Act(33 USC Sections 901-950)and any amendment to
thatAct that is in effect during the Liability Period.
Any incidental Longshoremen's and Harbor Workers'Compensation Loss, so covered,
is, of course, subject to the Maximum Limit(s) of Indemnity and the appropriate Self-
Insured Retention Per Occurrence as specified in the Declarations.
All other terms,conditions, agreements and stipulations remain unchanged.
•
•
Attached to and forming a part of Excess Workers'Compensation and Employers' Liability Insurance Agreement •
No. SP-2T94-CO, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY COLORADO,dated December 31,2008.
RR
SAFETY NATIONAL CASUALTY CORPOAT N
T
•
President
Secretary
•
XWC 0276 02 0408
ENDORSEMENT#3
BROAD FORM ALL STATES FOR EMPLOYEE TRAVEL
Effective 12:01 A.M.,Local Time,December 31,2008
In consideration of the payment of premium and adherence by both parties to the terms of this Agreement,it
is hereby understood and agreed that this Agreement shall include the following: •
'L If the EMPLOYER undertakes operations in or, at the request of the EMPLOYER, an Employee •
travels to or is temporarily assigned to, any State not designated in Item 2 of the Declarations,this
Agreement applies to such operations, travel or temporary assignment. Should EMPLOYER
undertake operations in a state not designated in Item 2 of the Declarations, the EMPLOYER
shall give notice to the CORPORATION before or within a reasonable time after the
•
commencement of such operations. The EMPLOYER shall take whatever action is necessary to
come within the Workers'Compensation and occupational disease laws of such State. •
•
2. Should an Employee,at the direction of the EMPLOYER, travel to or be temporarily assigned to •
any State or States not designated in Item 2 of the Declarations,this Agreement shall provide
coverage for Loss sustained by the EMPLOYER because of liability imposed upon the
EMPLOYER by the Workers'Compensation or Employers'Liability Laws of such non-designated.
State.
3. This Agreement also applies to Loss sustained by the EMPLOYER because of liability imposed
upon the EMPLOYER by the Workers'Compensation and Employers'Liability Laws of such non-
designated Slate.
4. Any Loss covered by this Endorsement shall be subject to all the limitations of this Agreement
including but not limited to the Self-Insured Retention Per Occurrence or the Limitation Per
Occurrence and the Maximum Limit(s)of Indemnity of the CORPORATION for the Liability Period.
5. The word "State" as used in this Endorsement shall mean any State of the United States of
America and the District of Columbia.
6. The insurance afforded by this Endorsement does not cover fines or penalties imposed on the
EMPLOYER for failure to comply with the requirements of any Workers'Compensation Law.
7. All of the provisions of this Agreement,insofar as such provisions are not inconsistent herewith,
are applicable to the insurance afforded by the Agreement by virtue of this Endorsement.
•
All other terms,conditions,agreements and stipulations remain unchanged.
Attached to and forming a part of Excess Workers'Compensation and Employers'Liability Insurance Agreement
. No. SP-2T94-CO, issued by SAFETY NATIONAL CASUALTY CORPORATION of St.Louis,Missouri to WELD
COUNTY COLORADO,dated December 31, 2008.
SAFETY NATIONAL CASUALTY CORPORATION •
•
A/ow,e. // 1 President
Secretary
•
XWC 0291 00 0708
ENDORSEMENT#4
VOLUNTARY COMPENSATION ENDORSEMENT-PREMIUM DELINEATION
Effective 12.01 A , Local Time. December 31,2008
In consideration of the payment of premium and adherence by both parties to the terms of this Agreement, it is
hereby understood and agreed that this Endorsement adds voluntary compensation insurance to this Agreement
as follows:
•
A. Coverage
It is the intent of this endorsement to extend the coverage provided by this Agreement to non-
compensated volunteer Employees, operating at the direction of the EMPLOYER, as if the
volunteer Employees were subject to the Workers'Compensation and Employers' Liability Laws
stipulated in the Schedule below, even though these laws may not require payment of benefits to
such volunteer Employees.
This insurance applies to Loss sustained by the EMPLOYER because of bodily injury and
occupational disease, including death resulting therefrom, due to Occurrences taking place within
the Liability Period of this Agreement.
1. The bodily injury or occupational disease must be sustained by an Employee included in the
group of Employees described in the Schedule.
•
•
2. The bodily injury or occupational disease must occur in the course of employment necessary
or incidental to work in a State listed in the Schedule.
3. The bodily injury or occupational disease must occur in the United States of America, its
territories or possessions or Canada and may occur elsewhere if the Employee is an
American or Canadian citizen temporarily away from their home country.
S. Indemnification
The CORPORATION will indemnify the EMPLOYER for Loss in satisfaction of statutory benefits
that would be imposed if the EMPLOYER and Employees described in the Schedule were subject
to the Workers'Compensation Law shown in the Schedule. Naturally,indemnification for any such
Loss is subject to the Self-Insured Retention Per Occurrence, Loss Fund(s)and Maximum Limit(s)
of Liability as specified in the Declarations.
I .
C. Exclusions
This insurance does not cover:
1. Any obligation imposed by a workers' compensation or occupational disease law, or any
similar law.
2. Bodily injury intentionally caused or aggravated by the EMPLOYER_
Page 1 of
- - i
XWC 0291 00 0708
ENDORSEMENT#4 (CONTINUED)
D. - Before Indemnification
•
Before the CORPORATION indemnifies the EMPLOYER, the injured Employee, or his legal
representative in the case of his incapacity or death, must:
1. Release the EMPLOYER and the CORPORATION,in writing,of all responsibility for the injury
or death. f .
•
2. Transfer to the EMPLOYER and the CORPORATION their right to recover from others who
may be responsible for the injury or disease.
3. Cooperate and do everything necessary to enable the EMPLOYER and the CORPORATION
to enforce the right to recover from others.
If the injured Employee, or his legal representative(s),fails to perform as required above, or if they
claim damages from the EMPLOYER or the CORPORATION for the injury or disease, the
CORPORATION'S duty to indemnify the EMPLOYER is immediately terminated. Ii .
E. Recovery From Others
' •
If the CORPORATION makes a recovery from others, the CORPORATION will keep an amount f'
equal to its expenses of recovery and the Loss paid by the CORPORATION. The CORPORATION
will pay the balance to the parties entitled to payment. If the parties entitled to the benefits of this
insurance make a recovery from others, they must reimburse the CORPORATION for the Loss
previously paid by the CORPORATION to such parties.
•
F. Employers'Liability Insurance
Employers'Liability Insurance applies to Loss covered by this endorsement as though the State of •
employment shown in the Schedule were shown in Item 2 of the Declarations. 1.
G. Premium i•
It is agreed that all persons who donate their services to the EMPLOYER will be reported for .
•
purposes of premium computation at an hourly wage of$6.55 per hour minimum, unless the work . .
they do is similar to the work being done by a paid Employee who is receiving more than a $6-55
per hour wage, in which event the wage reported for the unpaid voluntary Employee will be the
same as the wage reported for the paid Employee.
r•
•
•
SCHEDULE
Designated Workers
Employees State of Employment Compensation Law
Authorized volunteers, student COLORADO State(s)of COLORADO •
workers,etc,while not subject to
any Workers'Compensation Law
i•
! .
I •
Page 2 of 3 .
i• .
XWC 0291 00 0708
ENDORSEMENT#4(CONTINUED)
All other terms,conditions,agreements and stipulations remain unchanged. _
Attached to and forming a part of Excess Workers'Compensation and Employers'Liability Insurance Agreement
No. SP-2T94-CO, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY COLORADO,dated December 31,2008.
SAFETY NArfO P TI
President
Secretary
•
•
•
Page 3 of 3
•
XWC 0293 00 0906
ENDORSEMENT#5
FOREIGN VOLUNTARY WORKERS'COMPENSATION AND EMPLOYERS'LIABILITY
Effective 12:01 A.M., Local Time,December 31,2008
SECTION 1. SCOPE OF INSURANCE
A. The insurance afforded by this Agreement also applies to Employees, as defined in Section 2 of this
. Endorsement,who are employed to work at locations within the following country or countries:
anywhere in the world outside the United States or United States possessions and territories, except:
Afghanistan, Algeria, Balkans, Belarus, Bolivia, Burma, Burundi, Chad, Central African Republic,
Colombia, Cote d'Ivoire, Cuba, Democratic Republic of Congo, Eritrea, Georgia, Haiti, Iran, Iraq, Israel,
Kenya, Lebanon, Nepal, Nigeria, North Korea, Pakistan, Philippines, Saudi Arabia, Sri Lanka, Somalia,
Sudan, Syria, Uzbekistan, the West Bank and Gaza, Yemen or Zimbabwe. .
B. Benefits payable under this Endorsement are the same as those that would be payable if the Employees i.-
in question were subject to the Worker's Compensation Law of the following State or States:
COLORADO
C. Benefits payable under this Endorsement shall include repatriation expense in an amount up to$25,000
with respect to any one Employee and as otherwise subject to the CORPORATION'S Foreign Voluntary
Endorsement Limit of Liability for Coverage B—Employer's Liability_
D. The CORPORATION'S Foreign Voluntary Endorsement Limit of Liability for Coverage B—Employer's
Liability is limited to$I00,000 and applies in excess of the Self-Insured Retention Per Occurrence.
SECTION 2. EMPLOYEES COVERED
A. It is agreed that the insurance provided by this Agreement also applies to those Employees of the
EMPLOYER who are hired or assigned by the EMPLOYER to work at locations within the country or
countries not excluded in this Endorsement.
B. This insurance, with respect to any such Employee, shall attach from the moment such Employee is
hired or assigned for such work and shall cease from the moment the employment or assignment for
such work is terminated_ If the Employee has been hired in the United States of America, coverage
continues after termination of employment until the Employee returns to the United States of America or
for a reasonable period of time for the opportunity to return to the United States of America, unless
termination of employment is due to the Employee's resignation.
C. This insurance shall not apply to persons other than citizens or residents of the United States of America
within the country or countries stated in this Endorsement except as stated herein:.NONE.
Page 1 012
XWC 0293 00 0908
ENDORSEMENT#5(CONTINUED)
•
All other terms,conditions,agreements and stipulations remain unchanged. •
Attached to and forming a part of Excess Workers'Compensation and Employers'Liability Insurance Agreement
No. SP-2T94-CO,issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY COLORADO,dated December 31,2008.
SAFETY NATIONAL CASUALTY CORPQRATION
President
Secretary
•
•
Page 2 of 2
•
XWC 0322 00 1291 .
ENDORSEMENT#6
90-DAYS NOTICE OF CANCELLATION f•
Effective 12101 A.M.,Local Time,December 31, 2008
In consideration of the payment of premium and adherence by both parties to the terms of this Agreement, it is F
hereby understood and agreed as follows:
The portion of the first paragraph of the Section entitled Cancellation, which
reads, "... not less than sixty (60) days prior to the date of cancellation..." is
amended to read, "...not less than ninety (90) days prior to the date of
cancellation...".
All other terms,conditions,agreements and stipulations remain unchanged.
Attached to and forming a part of Excess Workers'Compensation and Employers'Liability Insurance Agreement l•
No. SP-2T94-CO,issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD •!
COUNTY COLORADO, dated December 31,2008. •
SAFETY NATIONAL CASUALTY CORPO TION 1 .
President(41,1/7
Secretary
i•
•
XWC 0339 01 0908 •
ENDORSEMENT#7
SAME COMMUNICABLE DISEASE-SPECIFIC EXCESS
Effective 12:01 A.M.,Local Time, December 31,2008
In consideration of the payment of premium and adherence by both parties to the terms of this Agreement, it is
hereby understood and agreed that the Definitions of this Agreement shall be revised as follows:
1. Paragraph(4)shall be revised to include the following:
With respect to bodily injury caused by the Same Communicable Disease, Occurrence
shall mean,an accident or a series of related events having a detectable common source of
causation at the workplace, that results in bodily injury to two or more Employees who are
infected with the Same Communicable Disease, which infection is manifested during the
Liability Period of this Agreement.
2. Paragraph (7)shall be added and shall read as follows:
(7) "Same Communicable Disease" - shall mean specifically diagnosed infectious disease
caused by an infectious organism which is transmitted from one source to another, directly
or indirectly,which is the same proximate cause of bodily injury to each infected Employee.
Ali other terms,conditions,agreements and stipulations remain unchanged.
Attached to and forming a part of Excess Workers'Compensation and Employers'Liability Insurance Agreement
No. SP-2T94-CO, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY COLORADO,dated December 31,2008.
SAFETY NATIONAL��CASUALTY CORPORATION•I. /jam._ President
4
Secretary
•
•
•
XWC 1061 10 1207
ENDORSEMENT#8
POLICYHOLDER DISCLOSURE
NOTICE OF TERRORISM INSURANCE COVERAGE
Effective 12:01 A.M.,Local Time, December 31,2008 •
In consideration of the payment of premium and adherence by both parties to the terms of this Agreement,it is •
hereby understood and agreed as follows:
Coverage for workers'compensation losses caused by certified acts of terrorism is included in this
Agreement as set forth under the Terrorism Risk Insurance Act of 2002 as amended("the Act").
For purposes of this Endorsement,a"certified act of terrorism"is defined as any act:
a. That is certified by the Secretary of the Treasury in concurrence with the Secretary of State and
the Attorney General of the United States,to be an act of terrorism;and,
b. That is violent or dangerous to human life, property or infrastructure;and,
c. That results in damage within the United States,or outside the United States in the case of certain
air carriers or vessels or the premises of a United States mission;and,
d. • That has been committed by an individual or individuals 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.
Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your
Agreement,and any applicable federal and/or state laws, rules, or regulations. Under the Act,terrorism
losses would be partially reimbursed by the U.S. Government under a formula established by the Act.
Under this formula, the U.S. Government would generally reimburse 85% of covered terrorism losses
exceeding a deductible paid by the CORPORATION. The Act contains a $100 billion cap that limits the •
reimbursement from the U.S. Government as well as from all insurers. If aggregate insured losses for all
insurers exceed$100 billion,the EMPLOYER's coverage may be reduced.
The portion of the EMPLOYER'S annual premium that is attributable to coverage for losses caused by a
certified act of terrorism is: 0.5%.
All other terms,conditions,agreements and stipulations remain unchanged. •
Attached to and forming a part of Excess Workers'Compensation and Employers' Liability Insurance Agreement
No. SP -2T94-CO, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY COLORADO,dated December 31,2008.
SAFETY NATIONAL CASUALTY CORPORATION
President . •
(4,/-47
Secretary
c 2007 National Association of Insurance Commissioners
Hello