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Home My WebLink About000278.tiff SAFETY NATIONAL CASUALTY CORPORATION EXCESS WORKERS COMPENSATION INSURANCE BINDER NAME INSURED EMPLOYER: WELD COUNTY COLORADO ADDRESS: P.O. BOX 758, GREELEY, CO 80632 POLICY NUMBER: SP 4041255 TYPE OF INSURANCE: Specific Excess Workers'Compensation and Employers'Liability Insurance LOCATION(S): COLORADO POLICY LIABILITY PERIOD: December 31,2009 through December 31, 2011 POLICY PAYROLL REPORTING PERIOD: December 31,2009 through December 31, 2010 This is to certify that the above named Insured Employer is covered by Specific Excess Workers' Compensation and Employers' Liability Insurance by the CORPORATION. Self-Insured Retention Per Occurrence $600,000 Maximum Limit of Indemnity Per Occurrence Statutory Employers' Liability Maximum Limit of Indemnity Per Occurrence $ 1,000,000 Premium Rate $ 0.152 per$100 of Payroll Minimum Premium for the Liability Period $ 175,689 Deposit Premium for the Payroll Reporting Period $97,605 This binder is effective December 31, 2009 to policy issuance and is subject to all the terms and conditions of, and shall be automatically terminated and superseded by, the Excess Workers' Compensation Agreement and Employers' Liability Insurance Agreement when issued. Issued at St. Louis, Missouri,on December 15,2009. SAFETY NATIONAL CASUALTY CORPORATION at, it / By: Gene R. Maier, Senior Vice President of Workers'Compensation Underwriting 1832 Schuetz Road St. Louis MO 63146-3540 314-995-5300 fax 314-995-3843 M0D?�8 SAFETY NATIONAL Casualty Corporation a DELPHI company CERTIFICATE OF INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY LISTED BELOW. NAME AND ADDRESS OF CERTIFICATE HOLDER: State of Colorado Department of Labor and Employment Div of WC Ins Compliance Unite(or) Div of WC Self Ins Unit 633 17th Street, Suite 400 Denver, Colorado 80202-3660 This is to certify that the policy of insurance listed below has been issued to the insured named below and is in force at this time. Notwithstanding any requirement, term or condition of any contract or any other document with respect to which this certificate may be issued or may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions and conditions of such policy. Should any of the policy described herein be canceled before expiration date thereof the CORPORATION will endeavor to mail ninety (90) days written notice to the above named certificate holder, but failure to mail such notice shall impose no obligation or liability of any kind upon the CORPORATION. NAME INSURED EMPLOYER: WELD COUNTY COLORADO ADDRESS: P.O. BOX 758, GREELEY,CO 80632 POLICY NUMBER: SP 4041255 TYPE OF INSURANCE: Specific Excess Workers'Compensation and Employers' Liability Insurance LOCATION(S): COLORADO POLICY LIABILITY PERIOD: December 31, 2009 through December 31, 2011 POLICY PAYROLL REPORTING PERIOD: December 31, 2009 through December 31, 2010 Self-Insured Retention Per Occurrence $600,000 Maximum Limit of Indemnity Per Occurrence Statutory Employers' Liability Maximum Limit of Indemnity Per Occurrence $ 1,000,000 SAFETY NATIONAL CASUALTY CORPORATION 4 . By: Gene R. Maier, Senior Vice President of Workers' Compensation Underwriting Date: December 15, 2009 1832 Schuetz Road St. Louis MO 63146-3540 314-995-5300 fax 314-995-3843 XWC 0003 00 1206 COLORADO NOTICE ENDORSEMENT 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 4041255, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD COUNTY COLORADO, dated December 31, 2009. SAFETY NATIONAL CASUALTY CORPORATION President Secretary II XWC 1004 00 1101 Endorsement Schedule RE: WELD COUNTY COLORADO Policy No: SP 4041255 Effective Date: 12:01 A.M. December 31, 2009 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 0908 SAME COMMUNICABLE DISEASE-SPECIFIC EXCESS XWC 1061 10 1207 POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE Ann Coriano TRAVELERS I 6060 S Willow Dr GREENWOOD VILLAGE,CO 80111 October 13,2009 Phone:(720)200-8409 Fax:(720)-200-8398 Email:ACORIANO@travelers.com Julie Ann Vierra GALLAGHERW ARMS(0HE558) 6399 S FIDDLERS GREEN CIR STE 200 GREENWOOD VILLAGE,CO 80111 This is an Agency Billed Policy. This is the Renewal for: WELD COUNTY,COLORADO 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 8201 Obligee City,State&Zip: DENVER,CO 80202-3660 USA Transaction Effective Date: December 31,2009 Premium Effective Date: December 31,2009 Premium Expiry Date: December 31,2010 Bond Limit: $2,365,085.00 Bond Premium: $22,705.00 Commission-Percentage: 15% Special Commission: $0.00 Countersignature Branch: Countersignature Commission: $0.00 State Tax: $0.00 State Surcharge: $0.00 TOTAL PREMIUM: $22,705.00 Comments: • Thank you for placing your business with u . s Producer Name: BARNES,ROBERT F S.4123 (9/96)Premium Evidence SAFETY NATIONAL CASUALTY CORPORATION 1832 SCHUETZ ROAD ST. LOUIS,MO 83146 DECLARATIONS-SPECIFIC EXCESS SP 4041255 Item 1. Employer: WELD COUNTY COLORADO Address: P.O.BOX 758, GREELEY,CO 80632 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 31,2009 Item 4. Anniversary Date: 12:01 A.M. December 31,2011 Item 5. The Service Company shall be COUNTY TECHNICAL SERVICES Item 6. CLASSIFICATIONS Code Estimated Total Annual Rate Per$100 OF OPERATIONS Number Remuneration/Manhours Remuneration/Manhours See Attached Total Estimated Manual Premium N/A 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 $ 175,689 Item 11. Deposit Premium for the Payroll Reporting Period $97,605 Item 12. Payroll Reporting Period Annually as of December 31 kern 13. Endorsements See Endorsement Schedule dkely 6U t Signed at St.Louis,Missouri on January 06, 2010 Secretary Countersigned this day of By: N/A DSP-O196 XWC 1005 001101 ITEM 6 RE:WELD COUNTY COLORADO Policy No:SP 4041255 Effective Date:12:01 A.M. December 31,2009 peclaratione: 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 $8,085,482 NIA N/A Drivers Limousine Co.:Al Other Employees&Drivers 7382 S 198,732 Poke Officers&Drivers 7720 $19,409,356 Salesperson,Collectors or Messengers-Outside 8742 $5,182,632 Clerical Office Employees NOC 8810 $19,102,862 Attorney-NI Employees&Clerical,Messengers,Drivers 8820 3 4,114,490 Physician&Clerical 8832 $3,938,558 Colege:Professional Employees&Clerical 8888 $1,287,418 Buildings-Operation by Contractors 9014 3199,818 Building-Operation by Owner or Lessee 9015 $986,252 Colege or School: Al Other Employees 9101 $584,836 Municipal,Township,County or State Employee NOC 9410 $3,125,800 $84,214,034 Total Payroll $84,214,034 • • XWC 1004 00 1101 Endorsement Schedule RE: WELD COUNTY COLORADO U Policy No: SP 4041255 • Effective Date: 12:01 A m December 31,2009 Number Title XWC 0003 001206 COLORADO NOTICE ENDORSEMENT XWC 0241 001291 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 001291 90-DAYS NOTICE OF CANCELLATION XWC 0339 01 0908 SAME COMMUNICABLE DISEASE-SPECIFIC EXCESS XWC 1061 101207 POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE • XWC 0003 001206 ENDORSEMENT COLORADO NOTICE ENDORSEMENT Effective 12:01 A.M.. Local Time.December 31.2009 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 4041255, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD COUNTY COLORADO, dated December 31,2009. SAFETY NATIONAL CASUALTY CORPORATION w -- a.., President Secretary • XWC 0241 00 1291 ENDORSEMENT INCIDENTAL LONGSHOREMEN'S AND HARBOR WORKERS'COMPENSATION ACT COVERAGE ENDORSEMENT Effective 12:01 A.M.,Local Time, December 31, 2009 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 that Act 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 4041255, Issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD COUNTY COLORADO,dated December 31,2009. SAFETY NATIONAL CASUALTY CORPORATION „44..9., (z... WC w A -- President Secretary II XWC 0276 02 0408 ENDORSEMENT BROAD FORM ALL STATES FOR EMPLOYEE TRAVEL Effective 12:01 A.M.,Local Time, December 31,2009 • 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: 1. 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 tiros 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. j I 2. Should an Employee, at the direction of the EMPLOYER, travel to or be temporarily assigned to any State or States not designated in kern 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 State. 4. Any Loss covered by this Endorsement shall be subject to all the Imitations 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. 8. 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 4041255, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD COUNTY COLORADO,dated December 31,2009. SAFETY NATIONAL CASUALTY CORPORATION YV'" y `U, !/�W I "�^ President / Secretary • • XWC 029100 0708 ENDORSEMENT VOLUNTARY COMPENSATION ENDORSEMENT-PREMIUM DELINEATION Effective 12:01 A.M., Local Time, December 31,2009 In consideration of the payment of premium and adherence by both parties to the terns 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. B. 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. 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 O3 XWC 0291 00 0708 ENDORSEMENT(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. 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 CORPORATIONS duty to indemnify the EMPLOYER is immediately terminated. E. Recovery From Others If the CORPORATION makes a recovery from others, the CORPORATION will keep an amount 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. G. Premium 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$7.25 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 $7.25 per hour wage, in which event the wage reported for the unpaid voluntary Employee wilt be the same as the wage reported for the paid Employee. 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 Page 2 of 3 XWC 0291 00 0708 ENDORSEMENT(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 4041255, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD COUNTY COLORADO, dated December 31, 2009. SAFETY NATIONAL CASUALTY CORPORATION it, President Secretary • Page 3 of 3 • XWC 0293 00 0906 ENDORSEMENT FOREIGN VOLUNTARY WORKERS'COMPENSATION AND EMPLOYERS'LIABILITY Effective 12:01 A.M.. Local Time. December 31,2009 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 foNowing country or countries: anywhere in the world outside the United States or United States possessions and territories, except Afghanistan, Algeria, Balkans, Belarus, Burma, Burundi, Chad, Central African Republic, Colombia, Cote d'hroire, Cuba, Democratic Republic of Congo, Eritma, 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 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$25,000 with respect to any one Employee and as otherwise subject to the CORPORATION'S Foreign Voluntary Endorsement Limit of Liability for Coverage B—Employer's Liability. D. The CORPORATION'S Foreign Voluntary Endorsement Limit of Liability for Coverage B —Employer's Liability is'linked to$ 100,000 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 or 2 XWC 0293 00 0906 ENDORSEMENT(CONTINUED) i. All other temu,conditions,agreements and stipulations remain unchanged. Attached to and forming a part of Excess Workers' Compensation and Employers'Liability Insurance Agreement No. SP 4041255, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD COUNTY COLORADO,dated December 31,2009. SAFETY NATIONAL CASUALTY CORPORATION kilt/�,_ i/ / President ( 7 i Secretary Page 2 of 2 XWC 0322 001291 ENDORSEMENT 90-DAYS NOTICE OF CANCELLATION Effective 12:01 A.M., Local Time,December 31,2009 • In consideration cf the payment of premium and adherence by both parties to the terms of this Agreement, it is hereby understood and agreed as follows: The portion of the first paragraph of the Section entitled Cancellation which reads, "... not less than sixty (00) 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 No. SP 4041255, Issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD COUNTY COLORADO,dated December 31,2009. • SAFETY NATIONAL CASUALTY CORPORATION btnAiliekP President Secretary • li XWC 0339 01 0908 ENDORSEMENT SAME COMMUNICABLE DISEASE-SPECIFIC EXCESS Effective 12:01 A.M.. Local Time. December 31,2009 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. 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 4041255, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD COUNTY COLORADO dated December 31,2009. SAFETY NNA_TION.AeL,CASUALTY CORPORATION • bPresident Secretary II XWC 1081 10 1207 ENDORSEMENT POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE Effective 12:01 A.M.. Local Time. December 31_ 2009 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 Ad. 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 bNlion,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 terns,conditions,agreements and stipulations remain unchanged. • Attached to and forming a part of Excess Workers'Compensation and Employers' Liability Insurance Agreement No. SP 4041255, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD COUNTY COLORADO, dated December 31,2009. SAFETY NATIONAL CASUALTY CORPORATION ,t4 President Secretary c 2007 National Association of Insurance Commlssionars SAFETY NATIONAL CASUALTY CORPORATION PRIVACY STATEMENT 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 producto and cervices to its CustCxtlers kW over 50 cusiurnms, 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 apply • Parties who perform a business or insurance When you 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 information. Our employees are also advised of application,policy or claim. the importance of maintaining the confidentiality of your information. • Insurance regulatory u to or statistical reporting a ortin e9 NP 9 agencies. Types Of Information We Collect • LLaw enforcement or govammental 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 most 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 nt disclose any non-public, personal We may obtain information from third parties, such information about you to non-affiliated companies as other insurance or reinsurance companies, for marketing purposes or for any other purpose medical providers, government agencies, except those specifically allowed by law and information clearinghouses and other public described above. • • 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'). Whet We Do With Your Information Your Sales Agent may have gathered information F Information that has been collected about you will about you. The use and protection of information be retained In our files. We will review your obtained by your Sales Agent is their information in evaluating your request for responsibility, not Safety National's. If you have insurance coverage, determining your rates or questions about r your Sales Agent uses m discloses your information, please contact them underwriting risk, servicing your policy or adjusting directly. claims. We may retain information about our former customers and would disclose that information only to affiliates and to nonaffillates as described in this notice or as otherwise permitted by law. WC 99 99 28 No.SP 4041255 SPECIFIC EXCESS WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE AGREEMENT SAFETY NATIONAL CASUALTY CORPORATION ST. LOUIS, MISSOURI • (Hereinafter called the CORPORATION) 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 I Per Occurrence shall not operate, in any case, to increase the total amount the CORPORATION agrees to reimburse the This Agreement applies only to Loss sustained by the EMPLOYER for Loss per any one occurrence as per Item 8(a) EMPLOYER because of liability imposed upon the EM- of the Declarations. PLOYER by the Workers' Compensation or Employers' Liability Laws of: C. Definitions (1) the State(s)designated in the Declarations,or 1 "Loss" — shall mean actual( ) payments, less recoveries, (2) other State(s), provided that the Loss shall not be legally made by the EMPLOYER to Employees and their greater than it would have been had liability been dependents in satisfaction of: (a) statutory benefits, (b) imposed by the State(s)specified in the Declarations, settlements of suits and claims, and (c) awards and judgments. Loss shall also include Claim Expenses, paid on account of bodily injury by accident or bodily injury by by the EMPLOYER, as defined in Paragraph (2) of this occupational disease due to Occurrences taking place within Section. The term Loss shall not include the items the Liability Period to Employees of the EMPLOYER specifically excluded engaged in the business operations specified in the P Y b Y Paragraph(3)of this Section. Declarations and all other operations necessary, incidental,or (2) "Claim Expenses"—shall mean court costs, interest upon appurtenant thereto. Bodily injury includes resulting death. awards and judgments and the reasonable allocated costs of investigation, adjustment, defense, and appeal, The inclusion of more than one EMPLOYER in the including pension or appeal bond costs(provided that the Declarations shall not increase the EMPLOYER's Self- prosecution of such appeal and/or the posting of such Insured Retention nor the CORPORATION's Maximum pension or appeal bond is approved by the Limit of Indemnity. CORPORATION)of claims,suits or proceedings brought The insurance afforded by this Agreement applies to against the EMPLOYER under the Workers' operations in the State(s) specified in the Declarations, Compensation or Employers' Liability Laws of the including, however, incidental operations conducted by State(s)designated in the Declarations, or other State(s), Employees who are regularly engaged in operations in the as provided in Section A, even though such claims, suits, specified State(s), but who may be temporarily outside the proceedings or demands are wholly groundless, false or specified State(s). fraudulent. Claim Expenses shall not include fees to the EMPLOYER's Service Company. B. Insurance Under This Agreement (3) "Exclusions from Loss" — shall refer to the following amounts paid by the EMPLOYER, and specifically (1) Speeifle Excess Insurance excluded from the term Loss: (a) Salaries, wages, and remuneration provided to With respect to each Occurrence taking place within a Employees; Liability Period, the EMPLOYER shall retain as its own Loss,as defined below, the amount specified in Item 7 of the (b) Fees to the EMPLOYER's Service Company and/or Declarations, and the CORPORATION agrees to reimburse costs of self-administration ofclaims; the EMPLOYER only for such Loss in excess of such Self- (c) Punitive or exemplary damages as they relate to Insured Retention, subject to the Maximum Limit of claims made under the Employers' Liability coverage Indemnity Per Occurrence, or the Employers' Liability provided by this Agreement; Maximum Limit of Indemnity Per Occurrence, whichever is (d) Fines or penalties assessed against the EMPLOYER annlirahle ar cnerifieMt in item R of the tlerlaratinne The fnr aria vinlorinn by 'ha PhAPI f1VPR nr ;to separate Employers' Liability Maximum Limit of Indemnity I representative(s),of any statute or regulation,unless SPWCLPPt.AI Pta,I of the fines or penalties result from reasonable dispute (6) "State"—shall mean any state, territory, or possession of as to Workers' Compensation benefits owed by the the United States of America and the District of EMPLOYER; Columbia. (e) Assessments and taxes made upon the EMPLOYER as self-insurer whether imposed by statute, D. Reimbursement regulation,or otherwise; If the EMPLOYER pays any Loss incurred in any (t) Any amounts required to be paid by the Liability Period in excess of the Self-Insured Retention Per EMPLOYER because of: Occurrence, the CORPORATION shall reimburse the (1) Serious and willful misconduct of the EMPLOYER upon receipt of a formal proof of loss and other evidence acceptable to the CORPORATION of such payment. EMPLOYER, including intentional torts and Within a reasonable period of time, reimbursement payments intentional acts or omissions resulting in injury, shall be made by the CORPORATION. acts or omissions taken with reckless disregard of the possible occurrence of an injury or acts or The CORPORATION shall have,and may exercise at any omissions taken that are substantially certain to time,and from time to time,the right to offset any balance or result in injury,regardless of whether or not said balances, whether on account of premiums, Losses or actions may be classified in the State(s) as otherwise,due from the EMPLOYER to the CORPORATION intentional torts, against any balance or balances, due from the (2) Coercion, criticism, demotion, evaluation, CORPORATION to the EMPLOYER under this Agreement. reassignment, discipline, defamation, harassment, humiliation, discrimination against E. Liability Period or termination of any Employee and/or related personnel practices, policies, acts or omissions The liability of the CORPORATION for Loss hereunder by the EMPLOYER, shall be determined separately for each Liability Period. The (3) Knowingly employing an Employee in violation initial Liability Period shall commence at 12:01 A.M. on the of law, Effective Date and end at 12:01 A.M. on the Anniversary (4) Rejection by the EMPLOYER of any Workers' Date, designated in Items 3 and 4 respectively, of the Compensation Law, Declarations. Each succeeding Liability Period shall begin (5) Failure with any health, safety, or concurrently with the end of the previous Liability Period and notification to law comply regulation, continue for the same number of consecutive months as the initial Liability Period. All time is stated in local time for the (g) Loss voluntarily assumed by the EMPLOYER under State(s)designated in the Declarations. any contract or agreement, whether expressed or implied; In the event the Employer fails to give express written intent to continue coverage at the end of a given Liability (h) Loss for which the EMPLOYER carries a full Period, the Agreement shall be deemed terminated, and the coverage Workers' Compensation and Employers' Anniversary Date shall serve as the termination date of the Liability policy;and Agreement. (i) Any amount owed by the EMPLOYER pursuant to any provision of any law that provides non- p, premium occupational disability benefits. (4) "Occurrence"—shall mean accident. In addition, bodily Upon acceptance of the Agreement and at the beginning injury by occupational disease must be caused or of each Payroll Reporting Period, as specified in Item 12 of aggravated by the conditions of employment and shall be the Declarations, the EMPLOYER shall pay to the deemed to have occurred on the last day of the last CORPORATION the amount of the Deposit Premium exposure to those conditions of employment causing or specified in Item I I of the Declarations. The EMPLOYER aggravating such injury by occupational disease,or such shall pay premiums when due. The Deposit Premium shall be dates as is otherwise established b the Workers' held by the CORPORATION until the expiration of the yCompensation and Employers' Liability Laws of the Payroll Reporting Period. Within thirty (30) days after the appropriate State(s). Bodily injury by occupational close of each Payroll Reporting Period,the EMPLOYER shall disease sustained by each Employee shall be deemed to render to the CORPORATION a report upon a form be a separate Occurrence unless such disease results satisfactory to the CORPORATION, exhibiting by directly from an accident. classification, the amount of such remuneration earned by 1 Employees during such reporting period,and the EMPLOYER (5) "Employee" — as respects liability imposed upon the shall therewith pay to the CORPORATION the excess of the EMPLOYER by the Workers' Compensation Law of any Earned Premium over the Deposit Premium previously paid. Stale, the won! Ewpleyec shall lucml any persuu in case the Deposit Premium paid exceeds the Earned performing work which renders the EMPLOYER liable Premium, the CORPORATION shall return to the under the Workers' Compensation Law of a State named EMPLOYER the amount of such excess or give appropriate in Item 2 of the Declarations, which is the State of the credit,subject to the proportion of Minimum Premium for the ! injuries or occupational disease sustained by such person. Liability Period in the case of multi-year Liability Periods. • SPY/C-0901-AI Pen_d5 Upon expiration of a Liability Period, a summary of H. Service and Administration voluntary payroll reports for such Liability Period shall be made to determine the Earned Premium under this This Agreement contemplates the concurrent and Agreement. In no event, however, shall the Earned Premium continued existence of a separate service agreement between in respect of any Liability Period be less than the Minimum the EMPLOYER and the Service Company, its designated Premium specified in the Declarations. representative,named in Item 5 of the Declarations,providing For each Payroll Reporting Period, the COR- services approved by the CORPORATION. The PORATION shall compute the Earned Premium as follows: EMPLOYER agrees that its Service Company shall furnish the CORPORATION with quarterly loss runs concurrent with (I) Remuneration—The remuneration earned, or man- each Liability Period of this Agreement. The provision of loss hn,irc accumulated, during such period by all runs alone does not relieve the FMPr.OYER of its reporting Employees, including volunteers, engaged in each obligations as set forth in Section I of this Agreement. In classification covered by this Agreement shall be addition, the electronic transfer of loss information by a computed in accordance with the rules set forth in Service Company of the EMPLOYER shall not constitute the appropriate Manual of Workers'Compensation notice of a claim. and Employers'Liability Insurance. Cancellation of the service agreement between the (2) Manual and Standard Premium — The Service Company and the EMPLOYER shall operate as a remuneration, or man-hours, so computed for notice of cancellation of this Agreement by the EMPLOYER, Employees engaged in each such classification subject to the additional terms of the Cancellation Section of shall be multiplied by the Manual Rate per$100 of this Agreement. Any change in service companies must be remuneration/man-hour, in effect at the inception immediately communicated to and approved by the of each Payroll Reporting Period,and the products CORPORATION, and this obligation shall survive the so obtained shall be added together to determine termination or non-renewal of this Agreement. the Manual Premium. An Experience Modification Factor may be applied to the Manual I. Prompt Reporting of Claims Premium to determine a Standard Premium. Such Experience Modification Factor shall be As soon as the EMPLOYER becomes aware, the determined at the inception of this Agreement and EMPLOYER must provide COR- is subject to annual review and possible revision. prompt A Standard Premium takes precedence over any PORATION of: (a) any claim or action commenced against EMPLOYER which exceeds, or is likely to exceed, fifty Manual Premium. the percent (50%) of the Self-Insured Retention Per Occurrence (3) Earned Premium—Against the Manual or Standard specified in Item 7 of the Declarations and(b) the reopening Premiutn shall be applied the Premium Rate, as of any claim in which a further award might involve liability specified in Item 9 of the Declarations, to of the CORPORATION under this Agreement. determine the appropriate Earned Premium. In addition, the following categories of claims shall be This Agreement is issued by the CORPORATION and reported to the CORPORATION immediately, regardless of accepted by the EMPLOYER subject to the agreement that, any question of potential involvement of the COR- in the event of any change in the Rates per $100 PORATION: remuneration/man-hour, as stated in Item 6 of the (I) Fatalities; Declarations, because of any general rate increase or any legislative amendment affecting the benefits under the (2) Paraplegics and quadriplegics; Workers'Compensation Law of any State(s)named in Item 2 (3) Serious bums, defined as 2n° or 3`d degree burns of the Declarations, such change, upon the effective date involving 25%or more of the body; thereof, shall be, without endorsement, made a part of this injury;(4) Brain inj Agreement (5) Spinal cord injury; G. Self-Insurer (6) Amputation of a major extremity;and The EMPLOYER, by acceptance of this Agreement, (7) Any Occurrence which results in a serious injury to P two or more Employees. warrants that it is a duly qualified Self-Insurer in the State(s) designated in the Declarations, and will continue to maintain If the CORPORATION is prejudiced by the such qualifications during the currency of this Agreement In EMPLOYER's failure to provide prompt notice of a claim in accordance with the requirements set forth above and/or as the event the EMPLOYER should at any time while this Agreement is in force terminate such qualifications or if they otherwise provided by the Law of any State(s), the should be cancelled or revoked, such loss of qualifications CORPORATION may elect to deny coverage for Loss arising shall uperele as twtice of cancellation of this Agreement by from such claim. To constitute prompt, sufficient notice, the the EMPLOYER, subject to the additional terms of the EMPLOYER must provide complete information as to the Cancellation Section of this Agreement. details of the injury,disease,or death. • SPWc-090LAI aw3 f5 J. Defense of Claims N. Recovery from Others The EMPLOYER shall investigate and settle or defend The EMPLOYER agrees to prosecute any and all valid all claims and shall conduct the defense and appeal of all claims the EMPLOYER may have against any other party or actions, suits, and proceedings commenced against it. The source that may mitigate any Loss under this Agreement and EMPLOYER shall forward promptly to the CORPORATION return to the CORPORATION any amount so recovered, less copies of any pleadings or reports as may be requested. The the reasonable expense of collecting such amounts. CORPORATION shall not be obliged to assume charge of The CORPORATION shall have the EMPLOYER's • the investigation, defense, appeal or settlement of any claim, rights toprosecute any and all valid claims suit,or proceeding brought against the EMPLOYER,but the against any other CORPORATION shall be eiven the opportunity to party or source that may mitigate any Loss under this investigate,defend or participate with the EMPLOYER in the Agreement. True EMPLOYER agrees that it will assist the investigation and defense of any claim, if, in the opinion of CORPORATION in any prosecution of any and all valid the CORPORATION, its liability under this Agreement claims against any other party or source that may mitigate any might be involved. Loss under this Agreement. Any amounts recovered by the EMPLOYER or the CORPORATION from any party or K. Good Faith Claims Administration source that may mitigate any Loss under this Agreement shall • first be used to pay the expenses of collection and to reimburse The EMPLOYER shall use diligence, prudence, and the CORPORATION for any amount it may have paid the good faith in the investigation, defense, pursuit of recovery EMPLOYER for the Liability Period concerned, and all from others and settlement of all claims. The EMPLOYER remaining amounts collected shall be paid to the shall not unreasonably refuse to settle any claim which,in the EMPLOYER. exercise of sound judgment with respect to the entire claim, should be settled, provided, however, that the EMPLOYER shall not make any payment or agree to any settlement for O. Change in Agreement any sum which would involve the limits of the No condition,provision,or declaration of this Agreement CORPORATION's liability hereunder without the approval shall be waived or altered at any time, except as specified in of the COR-PORATION. Section F,except by endorsement signed by the President or a If the CORPORATION is prejudiced by the EM- Senior Vice President and the Secretary or an Assistant PLOYER's failure to exercise diligence, prudence, and good Secretary of the CORPORATION. faith, the CORPORATION may elect to disclaim coverage This Agreement hereby terminates, supersedes, and re- for Loss from such claim. places all previously issued Workers'Compensation Insurance or Reinsurance Agreements, as amended, between the L. Inspection and Audit EMPLOYER and the CORPORATION. If terms of this Agreement are in conflict with any law The CORPORATION shall have the right, but not the applicable to this Agreement, this statement amends this obligation, to inspect the premises and equipment and/or to Agreement to conform to such law. In addition, in the event audit the books and records of the EMPLOYER and of its any terms are in conflict with applicable laws, the remaining agents and representatives, including all records relating to terms of the Agreement shall be enforceable. payroll and claims matters, at any reasonable time during the period of this Agreement and within three(3)years after final settlement of all claims due to Occurrences happening during the term of this Agreement. An audit to determine Manual or P. Cancellation Standard Premium shall supersede any and all prior voluntary payroll reports by the EMPLOYER, and will be used to This Agreement may be cancelled by either party giving determine the final adjustment of premiums due to the the other party written notice not less than sixty (60) days CORPORATION. Should a determination be made that prior to the date of cancellation, except, that if the COR- additional audit premium is due to the CORPORATION,the PORATION cancels for non-payment of any premium, the due date for payment of such audit premium shall be thirty cancellation shall become effective ten (10) days after (30)days after the date of billing. dispatch of notice by the CORPORATION. The date of cancellation then becomes the termination date of the final Liability Period. This Agreement does not apply to Loss as a M. Other Insurance result of Occurrences taking place after the effective date of such cancellation. If the EMPLOYER carries other valid and collectible insurance,reinsurance,or indemnity with any other insurer or If cancellation is effected by the EMPLOYER, the reinsurer covering a Loss also covered by this Agreement Manual or Standard Premium shall be determined by the short (other than insurance or reinsurance that is purchased to apply rate tables used for casualty insurance, and the Earned in excess of the sum of the Self-Insured Retention and the Premium shall be the product of the Premium Rate (Item 9) Maximum Limits of Indemnity hereunder), the insurance times the Manual or Standard Premium (or the Total Annual afforded by this Agreement shall apply in excess of and shall Remuneration) so arrived at, but not less than the Minimum not contribute with such other insurance Premium specified in the Declarations. n ranee or reinsurance. spwc-09e,.AI ry,i e% If cancellation is effected by the CORPORATION for S. Sole Representative non-payment of premium, the EMPLOYER shall pay the CORPORATION Earned Premium for the period up to the If more than one EMPLOYER is named in Item 1 of the date of cancellation. Declarations,or an endorsement related thereto,the If the CORPORA710N cancels for any other reason,the EMPLOYER first named in Item 1,or a related endorsement, Manual or Standard Premium (or the Total Annual notice otl act on behalf of all EMPLOYERS to give or receive Remuneration)shall be determined upon a pro rata basis and o ca orltotreq, to receive return et. or the Earned Premium adjusted in accordance therewith. reimbursement,or to request changes in this Agreement. T. Acceptance Q. Assignment By acceptance of this Agreement, the EMPLOYER • An assignment of interest under this Agreement will not agrees that the statements in this Agreement, in the bind the CORPORATION unless an endorsement signed by Declarations, and in the application are the EMPLOYER's the President or a Senior Vice President and the Secretary or representations;that this Agreement is issued in reliance upon an Assistant Secretary of the CORPORATION assigning such representations; that this Agreement embodies all interest under this Agreement is issued by the agreements existing between the EMPLOYER and the CORPORATION. CORPORATION, or any of its agents, relating to this excess insurance, and that full compliance by the EMPLOYER with R. Bankruptcy or Insolvency of Employer all terms of this Agreement is a condition precedent to the CORPORATION's liability hereunder. The bankruptcy or insolvency of the EMPLOYER will not relieve the COROPRATION or the EMPLOYER of its duties and liabilities under this Agreement. After payments IN WITNESS WHEREOF, SAFETY NATIONAL have been made by or on behalf of the EMPLOYER, CASUALTY CORPORATION has caused this Agreement due under this Agreement will be made by to the CORPORATION as if the EMPLOYER had not become be executed by printing below the facsimile signatures of its bankrupt or insolvent, but not in excess of the COR- President and Secretary and by the actual signature of its PORATION's limit of indemnity. Secretary on the Declarations. de" hi tit— a—istitetk Secretary President SPWC-0908-At Para Of Hello