HomeMy WebLinkAbout000282.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 4045262
TYPE OF INSURANCE: Specific Excess Workers' Compensation and Employers' Liability Insurance
LOCATION(S): COLORADO
POLICY LIABILITY PERIOD: December 31, 2011 through December 31, 2012
POLICY PAYROLL
REPORTING PERIOD: December 31, 2011 through December 31, 2012
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 $ 750,000
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 $ 86,013
Deposit Premium for the Payroll Reporting Period $ 95,570
This binder is effective December 31, 2011 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conditions of, and shall be automatically terminated and superseded by, the Excess Workers'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 08, 2011.
SAFETY NATIONAL CASUALTY CORPORATION
esat„ ill .
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
aoa8a
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, STATE DEPARTMENT OF INSURANCE
DEPARTMENT OF LABOR AND EMPLOYMENT,
DIV OF W C INS COMPLIANCE UNIT, DIV OF WC SELF INS UNIT
633 17TH STREET, SUITE 400
DENVER, CO 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 4045262
TYPE OF INSURANCE: Specific Excess Workers' Compensation, and Employers' Liability Insurance
LOCATION(S): COLORADO
POLICY LIABILITY PERIOD: December 31, 2011 through December 31, 2012
POLICY PAYROLL
REPORTING PERIOD: December 31, 2011 through December 31, 2012
Self-Insured Retention Per Occurrence $ 750,000
Maximum Limit of Indemnity Per Occurrence Statutory
Employers' Liability Maximum Limit of Indemnity Per Occurrence $ 1,000,000
SAFETY NATIONAL CASUALTY CORPORATION
By: Gene R. Maier,
Senior Vice President of Workers' Compensation Underwriting
Date: December 08, 2011
1832 Schuetz Road St. Louis MO 63146-3540 314-995-5300 fax 314-995-3843
XWC 0003 00 1206
ENDORSEMENT
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 4045262, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY, COLORADO, dated December 31, 2011.
SAFETY NATIONAL CASUALTY CORPORATION
President
Secretary
EXCESS WORKERS' COMPENSATION AND
EMPLOYERS' LIABILITY AGREEMENTS
NOTICE
REGARDING CHANGE
IN SAFETY NATIONAL
ENDORSEMENT FORM NUMBERS
Please be advised that, due to state system limitations regarding endorsement
form numbering, Safety National has revised the form numbering for all its
excess workers' compensation and employers' liability endorsements.
The "XWC" that previously preceded each endorsement form number is now
generated by our system to print at the end of the form number rather than the
beginning. While the endorsement form number appears differently, the content
of your endorsement(s) has not been modified.
All quote or schedule references to endorsement form numbers beginning with
"XWC" shall be construed to be modified by changing the "XWC" to "(XWC)" and
placing it at the end of the endorsement form number.
1004 00 1101 (XWC)
Endorsement Schedule
RE: WELD COUNTY, COLORADO
Policy No: SP 4045262
Effective Date: 12:01 A.M. December 31, 2011
Number Title
0003 00 1206 (XWC) COLORADO NOTICE ENDORSEMENT
0241 00 1291 (XWC) INCIDENTAL LONGSHOREMEN'S AND HARBOR WORKERS' COMPENSATION ACT COVERAGE
ENDORSEMENT
0276 02 0408 (XWC) BROAD FORM ALL STATES FOR EMPLOYEE TRAVEL
0291 00 0708 (XWC) VOLUNTARY COMPENSATION ENDORSEMENT-PREMIUM DELINEATION
0293 00 0906 (XWC) FOREIGN VOLUNTARY WORKERS'COMPENSATION AND EMPLOYERS'LIABILITY
0322 00 1291 (XWC) 90-DAYS NOTICE OF CANCELLATION
0339 01 0908 (XWC) SAME COMMUNICABLE DISEASE-SPECIFIC EXCESS
1061 10 1207 (XWC) POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE
SAFETY NATIONAL CASUALTY CORPORATION
1832 SCHUETZ ROAD
ST. LOUIS, MO 63146
DECLARATIONS-SPECIFIC EXCESS SP 4045262
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 31,2011
Item 4. Anniversary Date: 12:01 A.M. December 31, 2012
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/PAanhoum
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 $750,000
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 $86,013
Item 11. Deposit Premium for the Payroll Reporting Period $95,570
Item 12. Payroll Reporting Period Annually as of December 31 —
Item 13. Endorsements See Endorsement Schedule (�
Signed at St.Louis,Missouri on December 30, 2011
Secretary
Countersigned this day of
By: N/A
DSP-O195
1005 001101 (XWC)
ITEM 6
RE: WELD COUNTY, COLORADO
Policy No: SP 4045262
Effective Date: 12:01 A.M. December 31,2011
Declarations:
Item 6.
Estimated
Total Annual Rate per 6100
Code Remuneration/ Remuneration/ Estimated
St Classifications of Operations No. Manhours Manhours Premium
co
Street or Road Construction:Paving or Repaving&Drivers 5506 $6,115,614 N/A N/A
Limousine Co.:All Other Employees&Drivers 7382 $226,587
Police Officers&Drivers 7720 $20,085,081
Salesperson,Collectors or Mecsengers-Outside 8742 $5,264,603
Clerical Office Employees NOC 8910 $19,278,806
Attorney-All Employees&Clerical,Messengers,Drivers 8820 $4,047,361
Physician&Clerical 8832 $3,542,639
College:Professional Employees&Clerical 8868 If My
Buildings-Operation by Contractors 9014 $184,042
Building-Operation by Owner or Lessee 9015 $1,072,249
College or School: All Other Employees 9101 If My
Municipal,Township,County or State Employee NOC 9410 $3,058,226
$62,875,208
Total Payroll $62,875,208
1004 00 1101 (XWC)
Endorsement Schedule
RE: WELD COUNTY, COLORADO
Policy No: SP 4045262
Effective Date: 12.01 A u D8ce;,ber 31, '1011
Number Title
0003 001206(XWC) COLORADO NOTICE ENDORSEMENT
0241 00 1291 (XWC) INCIDENTAL LONGSHOREMEN'S AND HARBOR WORKERS'COMPENSATION ACT COVERAGE
ENDORSEMENT
0276 02 0408(XWC) BROAD FORM ALL STATES FOR EMPLOYEE TRAVEL
0291 00 0708(XWC) VOLUNTARY COMPENSATION ENDORSEMENT-PREMIUM DELINEATION
0293 00 0906(XWC) FOREIGN VOLUNTARY WORKERS'COMPENSATION AND EMPLOYERS'LIABILITY
0322 00 1291 (XWC) 90-DAYS NOTICE OF CANCELLATION
0339 01 0908(XWC) SAME COMMUNICABLE DISEASE-SPECIFIC EXCESS
1061 10 1207(XWC) POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE
0003 00 1206(XWC)
ENDORSEMENT
COLORADO NOTICE ENDORSEMENT
Effective 12:01 A.M., Local Time, December 31,2011
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 4045262, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY, COLORADO,dated December 31,2011.
SAF TY NATIONAL CASUALTY CORPORATION
President
Secretary
0241 001291 (XWC)
ENDORSEMENT
INCIDENTAL LONGSHOREMEN'S AND HARBOR WORKERS'COMPENSATION ACT COVERAGE
ENDORSEMENT
Effective 12:01 A.M., Local Time, December 31,2011
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 4045262, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Mis
souri to WELD
CO
UNTY, COLORADO, dated December 31,2011.
iSAFETY NATIONAL CASUALTY CORPORATION
Y 1�"',z ""l \f� h 1
41
President
Secretary
0276 02 0408(XWC)
ENDORSEMENT
BROAD FORM ALL STATES FOR EMPLOYEE TRAVEL
Effective 12:01 A.M., Local Time, December 31, 2011
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 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 State.
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 4045262, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY, COLORADO,dated December 31,2011.
SAFETY NATIONAL CASUALTY CORPORATION
President
Secretary
0291 00 0708(XWC)
ENDORSEMENT
VOLUNTARY COMPENSATION ENDORSEMENT-PREMIUM DELINEATION
Effective 12:01 A.M., Local Time, December 31,2011
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 p e e must occur in the course of employment necessar
y
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 of 3
0291 00 0708 (XWC)
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
CORPORATION'S 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 will 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
0291 00 0708(XWC)
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 4045262, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY, COLORADO, dated December31,2011.
SAFETY NATIONAL CASUALTY CORPORATION
fr,
Ly-
President
Secretary
Page 3 of 3
0293 00 0906(XWC)
ENDORSEMENT
FOREIGN VOLUNTARY WORKERS'COMPENSATION AND EMPLOYERS'LIABILITY
Effective 12:01 A.M., Local Time, December 31.2011
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, Belarus, Bosnia, Burma, Burundi, Central African Republic, Chad,
Colombia, Cote d'Ivoire, Cuba, Dem. Rep. of Congo, Egypt, Eritrea, Guinea, Haiti, Herzegovina,
Iran, Iraq, Israel, Kenya, Kosovo, Lebanon, Libya, Macedonia, Mali, Mauritania, Nepal, Niger,
Nigeria, North Korea, Pakistan, Philippines, Saudi Arabia, Somalia, Sudan, Syria, Uzbekistan,
Yemen, and 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 limited 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 retums 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 of 2
0293 00 0906(XWC)
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 4045262, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY, COLORADO,dated December 31,2011.
SAFETY ATIONAL CASUALTY CORPORATION
President
t�"Do
Secretary
Page 2 of 2
0322 00 1291 (XWC)
ENDORSEMENT
90-DAYS NOTICE OF CANCELLATION
Effective 12:01 A.M.. Local Time. December 31. 2011
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:
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
No. SP 4045262, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY,COLORADO,dated December 31,2011.
SAFETY NATIONAL CASUALTY CORPORATION
at-
President
Secretary
0339 01 0908(XWC)
ENDORSEMENT
SAME COMMUNICABLE DISEASE-SPECIFIC EXCESS
Effective 12:01 A.M., Local Time, December 31,2011
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 4045262, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY, COLORADO,dated December31,2011.
SAFETY NATIONAL CASUALTY CORPORATION
ifil
President
Secretary
1061 10 1207(XWC)
ENDORSEMENT
POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE
Effective 12:01 A.M., Local Time, December 31. 2011
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 4045262, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY, COLORADO, dated December 31, 2011.
SAFETY ATIONAL CASUALTY CORPORATION
1 President
Secretary
c 2007 National Association of Insurance Commissioners
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
products and services to its customers for over 50 customers, except as permitted by law. Thai
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
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 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 mt.n t disclose any non-public,ublic, 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').
What We Do With Your Information Your Sales Agent may have gathered information
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 how your Sales Agent uses or
underwriting risk, servicing your policy or adjusting discloses your information, please contact them
claims. We may retain information about our directly.
former customers and would disclose that
information only to affiliates and to nonaffiliates as
described in this notice or as otherwise permitted
by law.
WC 99 99 28
No.SP 4045262
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 C. Definitions
This Agreement applies only to Loss sustained by the (I) "Loss" — shall mean actual payments, less recoveries,
EMPLOYER because of liability imposed upon the legally made by the EMPLOYER to Employees and their
EMPLOYER by the Workers' Compensation or Employers dependents in satisfaction of: (a) statutory benefits, (b)
Liability Laws of: settlements of suits and claims, and (c) awards and
(I) the State(s)designated in the Declarations,or judgments. Loss shall also include Claim Expenses, paid
(2) other State(s),provided that the Loss shall not be greater by the EMPLOYER, as defined in Paragraph (2) of this
than it would have been had liability been imposed by Section. The term Loss shall not include the items
the State(s)specified in the Declarations, specifically excluded by Paragraph(3)of this Section.
on account of bodily injury by accident or bodily injury by (2) "Claim Expenses" — shall mean court costs, interest upon
occupational disease due to Occurrences taking place within awards and judgments and the reasonable allocated costs
the Liability Period to Employees of the EMPLOYER engaged of investigation, adjustment, defense, and appeal,
in the business operations specified in the Declarations and all including pension or appeal bond costs (provided that the
other operations necessary, incidental, or appurtenant thereto.
Bodily injury includes resulting death. prosecution of such appeal and/or the posting of such
The inclusion of more than one EMPLOYER in the pension or appeal bond is approved by the
Declarations shall not increase the EMPLOYER's Self-Insured CORPORATION) of claims, suits or proceedings brought
Retention nor the CORPORATION's Maximum Limit of against the EMPLOYER under the Workers'
Indemnity. Compensation or Employers' Liability Laws of the State(s)
The insurance afforded by this Agreement applies to designated in the Declarations, or other State(s), as
operations in the State(s) specified in the Declarations, provided in Section A, even though such claims, suits,
including, however, incidental operations conducted by proceedings or demands are wholly groundless, false or
Employees who are regularly engaged in operations in the fraudulent. Claim Expenses shall not include fees to the
specified State(s), but who may be temporarily outside the EMPLOYER's Service Company.
specified State(s). (3) "Exclusions from Loss" — shall refer to the following
amounts paid by the EMPLOYER, and specifically
B. Insurance Under This Agreement excluded from the term Loss:
1 Specific Excess Insurance (a) Salaries, wages, and remuneration provided to
(I) PEmployees;
(b) Fees to the EMPLOYER's Service Company and/or
With respect to each Occurrence taking place within a costs of self-administration of claims;
Liability Period,the EMPLOYER shall retain as its own Loss, (c) Punitive or exemplary damages as they relate to
as defined below, the amount specified in Item 7 of the claims made under the Employers' Liability coverage
Declarations, and the CORPORATION agrees to reimburse provided by this Agreement;.
the EMPLOYER only for such Loss in excess of such Self- (d) Fines or penalties assessed against the EMPLOYER
Insured Retention, subject to the Maximum Limit of Indemnity for any violation by the EMPLOYER, or its
Per Occurrence, or the Employers' Liability Maximum Limit representative(s), of any statute or regulation, unless
of Indemnity Per Occurrence, whichever is applicable, as the fines or penalties result from a reasonable dispute
specified in Item 8 of the Declarations. The separate as to Workers' Compensation benefits owed by the
Employers' Liability Maximum Limit of Indemnity Per EMPLOYER;
Occurrence shall not operate, in any case, to increase the total (e) Assessments and taxes made upon the EMPLOYER
amount the CORPORATION agrees to reimburse the as self-insurer whether imposed by statute, regulation,
EMPLOYER for Loss per any one Occurrence as per Item 8(a) or otherwise;
of the Declarations.
SPWCUYU8.A1
(f) Any amounts required to be paid by the EMPLOYER period of time, reimbursement payments shall be made by the
because of: CORPORATION.
I) Serious and willful misconduct of the The CORPORATION shall have, and may exercise at any
EMPLOYER, including intentional torts and time, and from time to time, the right to offset any balance or
intentional acts or omissions resulting in injury, balances, whether on account of premiums, Losses or
acts or omissions taken with reckless disregard of otherwise, due from the EMPLOYER to the CORPORATION
the possible occurrence of an injury or acts or against any balance or balances due from the CORPORATION
omissions taken that are substantially certain to to the EMPLOYER wider this Agreement.
result in injury, regardless of whether or not said
actions may be classified in the State(s) as F. L iahility Period
intentional torts,
2) Coercion, criticism, demotion, evaluation, The liability of the CORPORATION for Loss hereunder
reassignment, discipline, defamation, harassment, shall be determined separately for each Liability Period. The
humiliation, discrimination against or termination initial Liability Period shall commence at 12:01 A.M. on the
of any Employee and/or related personnel Effective Date and end at 12:01 A.M. on the Anniversary Date,
practices, policies, acts or omissions by the designated in Items 3 and 4 respectively, of the Declarations.
EMPLOYER, Each succeeding Liability Period shall begin concurrently with
3) Knowingly employing an Employee in violation the end of the previous Liability Period and continue for the
of law, same number of consecutive months as the initial Liability
4) Rejection by the EMPLOYER of any Workers' Period. All time is stated in local time for the State(s)
Compensation Law, designated in the Declarations.
5) Failure to comply with any health, safety, or In the event the EMPLOYER fails to give express written
notification law or regulation, intent to continue coverage at the end of a
(g) Loss voluntarily assumed by the EMPLOYER under g given t Liability
dte
any contract or agreement,whether express or implied; Period, the Agreement atshallshall be deemed inatoated, and the
(h) Loss for which the EMPLOYER carries a full Anniversary Date serve as the termination date of the
coverage Workers' Compensation and Employers Agreement.
Liability policy;and F. Premium
(i) Any amount owed by the EMPLOYER pursuant to
provision of any law that provides non-occupational Upon acceptance of the Agreement and at the beginning of
disability benefits. g g
(4) ""Occurrence" — shall mean accident. In addition, bodily each Payroll Reporting Period, as specified in Item 12 of the
injury by occupational disease must be caused or Declarations, the EMPLOYER shall pay to the
aggravated by the conditions of employment and shall be CORPORATION the amount of the Deposit Premium
deemed to have occurred on the last day of the last specified in Item 11 of the Declarations. The EMPLOYER
shall pay premiums when due. The Deposit Premium shall be
exposure to those conditions of employment causing or
aggravating such injury by occupational disease, or such held by the CORPORATION until the expiration of the Payroll
dates as is otherwise established by the Workers' Reporting Period. Within thirty (30) days after the close of
Compensation and Employers' Liability Laws of the each Payroll Reporting Period, the EMPLOYER shall render
appropriate State(s). Bodily injury by occupational to the CORPORATION a report, upon a form satisfactory to
disease sustained by each Employee shall be deemed to be the CORPORATION, exhibiting, by classification, the amount
a separate Occurrence unless such disease results directly of such remuneration earned by Employees during such
from an accident. reporting period, and the EMPLOYER shall therewith pay to
(5) "Employee" — as respects liability imposed upon the the CORPORATION the excess of the Earned Premium over
EMPLOYER by the Workers' Compensation Law of any the Deposit Premium previously paid. In case the Deposit
State, the word Employee shall mean any person Premium paid exceeds the Earned Premium, the
performing work which renders the EMPLOYER liable CORPORATION shall return to the EMPLOYER the amount
under the Workers' Compensation Law of a State named in of such excess or give appropriate credit, subject to the
Item 2 of the Declarations, which is the State of the proportion of Minimum Premium for the Liability Period in
injured Employee's normal employment, for bodily the case of multi-year Liability Periods.
injuries or occupational disease sustained by such person. Upon expiration of a Liability Period, a summary of
(6) "State"— shall mean any state, territory, or possession of voluntary payroll reports for such Liability Period shall be
the United States of America and the District of Columbia. made to determine the Earned Premium under this Agreement.
In no event, however, shall the Earned Premium in respect of
D. Reimbursement any Liability Period be less than the Minimum Premium
specified in the Declarations.
If the EMPLOYER pays any Loss incurred in any Liability
Period in excess of the Self-Insured Retention Per Occurrence, For each Payroll Reporting mP as f, the CORPORATION
the CORPORATION shall reimburse the EMPLOYER upon shall compute the Earned Premium as follows:
p (I) Remuneration — The remuneration earned, or man-hours
receipt of a formal proof of loss and other evidence acceptable accumulated, during
to the CORPORATION of such payment. Within a reasonable such period by all Employees,
including volunteers engaged in each classification covered ,
t
srwc-090841
by this Agreement shall be computed in accordance with Company and the EMPLOYER shall operate as a notice of
the rules set forth in the appropriate Manual of Workers' cancellation of this Agreement by the EMPLOYER, subject to
Compensation and Employers' Liability Insurance. the additional terms of the Cancellation Section of this
(2) Manual and Standard Premium — The remuneration, or Agreement. Any change in service companies must be
man-hours, so computed for Employees engaged in each immediately communicated to and approved by the
such classification shall be multiplied by the Manual Rate CORPORATION, and this obligation shall survive the
per $100 of remuneration/man-hour, in effect at the termination or non-renewal of this Agreement.
inception of each Payroll Reporting Period, and the
products so obtained shall be added together to determine I. Prompt Reporting of Claims
the Manual Premium. An Experience Modification Factor
may be applied to the Manual Premium to determine a As soon as the EMPLOYER becomes aware, the
Standard Premium. Such Experience Modification Factor EMPLOYER must provide prompt notice to the
shall be determined at the inception of this Agreement and CORPORATION of: (a) any claim or action commenced
is subject to annual review and possible revision. A against the EMPLOYER which exceeds, or is likely to exceed,
Standard Premium takes precedence over any Manual fifty percent (50%) of the Self-Insured Retention Per
Premium. Occurrence specified in Item 7 of the Declarations and (b)the
(3) Earned Premium — Against the Manual or Standard reopening of any claim in which a further award might involve
Premium shall be applied the Premium Rate, as specified liability of the CORPORATION under this Agreement.
in Item 9 of the Declarations,to determine the appropriate In addition, the following categories of claims shall be
Earned Premium. reported to the CORPORATION immediately, regardless of
This Agreement is issued by the CORPORATION and any question of potential involvement of the CORPORATION:
accepted by the EMPLOYER subject to the agreement that, in I. Fatalities;
the event of any change in the Rates per $100 2. Paraplegics and quadriplegics;
remuneration/man-hour, as stated in Item 6 of the 3. Serious burns, defined as 2nd or 3rd degree bums
Declarations, because of any general rate increase or any involving 25%or more of the body;
legislative amendment affecting the benefits under the 4. Brain injury;
Workers' Compensation Law of any State(s) named in Item 2 5. Spinal cord injury;
of the Declarations, such change, upon the effective date 6. Amputation of a major extremity;and
thereof, shall be, without endorsement, made a part of this 7. Any Occurrence which results in a serious injury
Agreement. to two or more Employees.
If the CORPORATION is prejudiced by the EMPLOYER's
G. Self-Insurer failure to provide prompt notice of a claim in accordance with
the requirements set forth above and/or as otherwise provided
The EMPLOYER, by acceptance of this Agreement, warrants by the Law of any State(s), the CORPORATION may elect to
that it is a duly qualified Self-Insurer in the State(s)designated deny coverage for Loss arising from such claim. To constitute
in the Declarations, and will continue to maintain such prompt, sufficient notice, the EMPLOYER must provide
qualifications during the currency of this Agreement. In the complete information as to the details of the injury, disease,or
event the EMPLOYER should at any time while this death.
Agreement is in force terminate such qualifications or if they
should be cancelled or revoked, such loss of qualifications J. Defense of Claims
shall operate as notice of cancellation of this Agreement by the
EMPLOYER, subject to the additional terms of the The EMPLOYER shall investigate and settle or defend all
Cancellation Section of this Agreement. claims and shall conduct the defense and appeal of all actions,
suits, and proceedings commenced against it. The
H. Service and Administration EMPLOYER shall forward promptly to the CORPORATION
copies of any pleadings or reports as may be requested. The
This Agreement contemplates the concurrent and continued CORPORATION shall not be obliged to assume charge of the
existence of a separate service agreement between the investigation, defense, appeal or settlement of any claim, suit,
EMPLOYER and the Service Company, its designated or proceeding brought against the EMPLOYER, but the
representative, named in Item 5 of the Declarations, providing CORPORATION shall be given the opportunity to investigate,
services approved by the CORPORATION. The EM- defend, or participate with the EMPLOYER in the
PLOYER agrees that its Service Company shall furnish the investigation and defense of any claim, if, in the opinion of the
CORPORATION with quarterly loss runs concurrent with CORPORATION, its liability under this Agreement might be
each Liability Period of this Agreement. The provision of loss involved.
runs alone does not relieve the EMPLOYER of its reporting
obligations as set forth in Section I of this Agreement. In K. Good Faith Claims Administration
addition, the electronic transfer of loss information by a
Service Company of the EMPLOYER shall not constitute The EMPLOYER shall use diligence, prudence, and good
notice of a claim. faith in the investigation, defense, pursuit of recovery from
Cancellation of the service agreement between the Sery ice others and settlement of all claims. The EMPLOYER shall not
SPWC-09D&AI
unreasonably refuse to settle any claim which, in the exercise remaining amounts collected shall be paid to the EMPLOYER.
of sound judgment with respect to the entire claim, should be
settled, provided, however, that the EMPLOYER shall not O. Change in Agreement
make any payment or agree to any settlement for any sum
which would involve the limits of the CORPORATION's No condition, provision, or declaration of this Agreement
liability hereunder without the approval of the shall be waived or altered at any time, except as specified in
CORPORATION. Section F, except by endorsement signed by the President or a
If the CORPORATION is prejudiced by the EMPLOYER's Senior Vice President and the Secretary or an Assistant.
failure to exercise diligence, prudence, and good faith, the Secretary of the CORPORATION.
. . This Agreement hereby t..-...:....t,.- supersedes, A -,..J....,.�
CORPORA l ioN may elect to disclaim coverage for Loss "" Agreement^"��� `""'^ .,..re'.,c.....,, a❑.. ..,P�...,.,.,
from such claim. 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[he Agreement shall be enforceable.
payroll and claims matters, at any reasonable time during the P Cancellation
period of this Agreement and within three (3)years after final
settlement of all claims due to Occurrences happening during This Agreement may be cancelled by either party giving the
the term of this Agreement. An audit to determine Manual or other party written notice not less than sixty (60) days prior to
Standard Premium shall supersede any and all prior voluntary the date of cancellation, except, that if the CORPORATION
payroll reports by the EMPLOYER, and will be used to cancels for non-payment of any premium, the cancellation
determine the final adjustment of premiums due to the shall become effective ten(10)days after dispatch of notice by
CORPORATION. Should a determination be made that the CORPORATION. The date of cancellation then becomes
additional audit premium is due to the CORPORATION, the the termination date of the final Liability Period. This
due date for payment of such audit premium shall be thirty Agreement does not apply to Loss as a result of Occurrences
(30)days after the date of billing. taking place after the effective date of such cancellation.
If cancellation is effected by the EMPLOYER, the Manual
M. Other Insurance or Standard Premium shall be determined by the short rate
tables used for casualty insurance, and the Earned Premium
If the EMPLOYER carries other valid and collectible shall be the product of the Premium Rate (Item 9) times the
insurance, reinsurance, or indemnity with any other insurer or Manual or Standard Premium (or the Total Annual
reinsurer covering a Loss also covered by this Agreement Remuneration) so arrived at, but not less than the Minimum
(other than insurance or reinsurance that is purchased to apply Premium specified in the Declarations.
in excess of the sum of the Self-Insured Retention and the If cancellation is effected by the CORPORATION for non-
Maximum Limits of Indemnity hereunder), the insurance payment of premium, the EMPLOYER shall pay the
afforded by this Agreement shall apply in excess of and shall CORPORATION Earned Premium for the period up to the
not contribute with such other insurance or reinsurance. date of cancellation.
N. Recovery from Others If the CORPORATION cancels for any other reason, the
Manual or Standard Premium (or the Total Annual
The EMPLOYER agrees to prosecute any and all valid Remuneration) shall be determined upon a pro rata basis and
claims the EMPLOYER may have against any other party or the Earned Premium adjusted in accordance therewith.
source that may mitigate any Loss under this Agreement and
return to the CORPORATION any amount so recovered, less Q. Assignment
the reasonable expense of collecting such amounts.
The CORPORATION shall have the EMPLOYER's rights to An assignment of interest under this Agreement will not
prosecute any and all valid claims against any other party or bind the CORPORATION unless an endorsement signed by
source that may mitigate any Loss under this Agreement. The the President or a Senior Vice President and the Secretary or
EMPLOYER agrees that it will assist the CORPORATION in an Assistant Secretary of the CORPORATION assigning
any prosecution of any and all valid claims against any other interest under this Agreement is issued by the
party or source that may mitigate any Loss under this CORPORATION.
Agreement. Any amounts recovered by the EMPLOYER or
the CORPORATION from any party or source that may R. Bankruptcy or Insolvency of Employer
mitigate any Loss under this Agreement shall first be used to
pay the expenses of collection and to reimburse the The bankruptcy or insolvency of the EMPLOYER will not
CORPORATION for any amount it may have paid the relieve the CORPORATION or the EMPLOYER of its duties
EMPLOYER for the Liability Period concerned,and all and liabilities under this Agreement. After payments have
SFWCiN08-AI
been made by or on behalf of the EMPLOYER, that the statements in this Agreement, in the Declarations, and
reimbursements due under this Agreement will be made by in the application are the EMPLOYER's representations; that
the CORPORATION as if the EMPLOYER had not become this Agreement is issued in reliance upon such representations;
bankrupt or insolvent, but not in excess of the that this Agreement embodies all agreements existing between
CORPORATION's limit of indemnity. the EMPLOYER and the CORPORATION, or any of its
agents, relating to this excess insurance, and that full
S. Sole Representative compliance by the EMPLOYER with all terms of this
Agreement is a condition precedent to the CORPORATION's
If more than one EMPLOYER is named in Item I of the liability hereunder.
Declarations, or an endorsement related thereto, the EM-
PLOYER first named in Item 1,or a related endorsement,will
act on behalf of all EMPLOYERS to give or receive notice of
cancellation, to receive return premium or reimbursement, or
to request changes in this Agreement. IN WITNESS WHEREOF, SAFETY NATIONAL
CASUALTY CORPORATION has caused this Agreement to
T. Acceptance be executed by printing below the facsimile signatures of its
President and Secretary and by the actual signature of its
By acceptance of this Agreement,the EMPLOYER agrees Secretary on the Declarations.
Secretary President
SPWC-0902AI
EXCESS WORKERS' COMPENSATION AND
EMPLOYERS' LIABILITY AGREEMENTS
NOTICE
REGARDING CHANGE
IN SAFETY NATIONAL
ENDORSEMENT FORM NUMBERS
Please be advised that, due to state system limitations regarding endorsement
form numbering, Safety National has revised the form numbering for all its
excess workers' compensation and employers' liability endorsements.
The "XWC" that previously preceded each endorsement form number is now
generated by our system to print at the end of the form number rather than the
beginning. While the endorsement form number appears differently, the content
of your endorsement(s) has not been modified.
All quote or schedule references to endorsement form numbers beginning with
"XWC" shall be construed to be modified by changing the "XWC" to "(XWC)" and
placing it at the end of the endorsement form number.
No.SP 4045262
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 C. Definitions
This Agreement applies only to Loss sustained by the (I) "Loss" — shall mean actual payments, less recoveries,
EMPLOYER because of liability imposed upon the legally made by the EMPLOYER to Employees and their
EMPLOYER by the Workers' Compensation or Employers dependents in satisfaction of: (a) statutory benefits, (b)
Liability Laws of: settlements - ' ...suits and claims, and (c) awards and
(I) the State(s)designated in the Declarations,or judgments. shall also include Claim Expenses, paid
(2) other State(s),provided that the Loss shall not be greater by th MPL, , as defined in Paragraph (2) of this
than it would have been had liability been imposed by Sectite Loss shall not include the items
the State(s)specified in the Declarations, specifi r y Paragraph(3)of this Section.
on account of bodily injury by accident or bodily injury by (2), Expe 11 mean court costs, interest upon
occupational disease due to Occurrences taking place within - _�—„i d judgni .., d the reasonable allocated costs
the Liability Period to Employees of the EMPLOYER engaged H Iof i a[ion, ent, defense, and appeal,
in the business operations specified in the Declarations and all
other operations necessary, incidental, or appurtenant thereto. : y;, cludi pinion ot. eal bond costs (provided that the
Bodily injury includes resulting death. .e_ a of such'appeal and/or the posting of such
The inclusion of more than one EMPLOYE ""or appeal bond is approved by the
Declarations shall not increase the EMPLOYER's s • CO TION) of claims, suits or proceedings brought
Retention nor the CORPORATION„@; unum`. it o againn _ EMPLOYER under the Workers'
Indemnity. 2,-"t, nor Employers' Liability Laws of the State(s)
The insurance afforded by at greement app designated in the Declarations, or other State(s), as
operations in the State(s) spa' in the Declaraf .-pr, provided in Section A, even though such claims, suits,
including, however, incidental ions co d by proceedings or demands are wholly groundless, false or
Employees who are regularly en ' operati ' the fraudulent. Claim Expenses shall not include fees to the
specified State(s), but who may b ily a the EMPLOYER's Service Company.
specified State(s). may :
.,e' (3) "Exclusions from Loss" — shall refer to the following
amounts paid by the EMPLOYER, and specifically
B. Insurance Under This Agreement excluded from the term Loss:
(I) Specific Excess Insurance (a) Salaries,Employees;wages, and remuneration provided to
(b) Fees to the EMPLOYER's Service Company and/or
With respect to each Occurrence taking place within a
Liability Period,the EMPLOYER shall retain as its own Loss, costs of self-administration of claims; I
as defined below, the amount specified in Item 7 of the (c) Punitive madeor under the exemplary mpldamoyer as they relate ov to
Declarations, and the CORPORATION agrees to reimburse claims under Employers' Liability coverage
provided by this Agreement;
the EMPLOYER only for such Loss in excess of such Self-
(d) Fines or penalties assessed against the EMPLOYER
Insured Retention, subject to the Maximum Limit of Indemnity
Per Occurrence, or the Employers' Liability Maximum Limit for any violation by the EMPLOYER, or its
of Indemnity Per Occurrence, whichever is applicable, as the
representative(s), of any statute or regulation, unless
the fines or penalties result from a reasonable dispute
specified in Item 8 of the Declarations. The separate as to Workers' Compensation benefits owed by the
Employers' Liability Maximum Limit of Indemnity Per EMPLOYER;
Occurrence shall not operate, in any case, to increase the total (e) Assessments and taxes made upon the EMPLOYER
amount the CORPORATION agrees to reimburse the as self-insurer whether imposed by statute. regulation.
EMPLOYER for Loss per any one Occurrence as per Item 8(a) I or otherwise;
of the Declarations.
SPW(WgFAI
t
(t) Any amounts required to be paid by the EMPLOYER period of time, reimbursement payments shall be made by the 1
because of: CORPORATION.
I) Serious and willful misconduct of the The CORPORATION shall have, and may exercise at any
EMPLOYER, including intentional torts and time, and from time to time, the right to offset any balance or
intentional acts or omissions resulting in injury, balances, whether on account of premiums, Losses or
acts or omissions taken with reckless disregard of otherwise, due from the EMPLOYER to the CORPORATION
the possible occurrence of an injury or acts or against any balance or balances due from the CORPORATION
omissions taken that are substantially certain to to the EMPLOYER under this Agreement.
result in injury, regardless of whether or not said
actions may be classified in the State(s) as E. Liability Period
intentional torts,
2) Coercion, criticism, demotion, evaluation, The liability of the CORPORATION for Loss hereunder
reassignment, discipline, defamation, harassment, shall be determined separately for each Liability Period. The
humiliation, discrimination against or termination initial Liability Period shall commence at 12:01 A.M. on the
of any Employee and/or related personnel Effective Date and end at 12:01 A.M. on the Anniversary Date,
practices, policies, acts or omissions by the designated in Items 3 and 4 respectively, of the Declarations.
EMPLOYER, Each succeeding Liability Period shall begin concurrently with
3) Knowingly employing an Employee in violation the end of the previous Liability Period and continue for the
of law, same number of consecutive months as the initial Liability
4) Rejection by the EMPLOYER of any Workers' Period. All time is stated in local time for the State(s)
Compensation Law, designated in the Declarations.
5) Failure to comply with any health, safety, or In the event the:EMPLOYER fails togive express written
notification law or regulation, P
(g) Loss voluntarily assumed by the EMPLOYER under intent to eoAinua-'got shat at the end f a given Liability
any contract or agreement,whether express or implied; Period, the AgreedS*pt shall emer terminated, and the
(h) Loss for which the EMPLOYER carries a full Agreemenrym,pate serve as the termination date of the
Agreement 'a , .
coverage Workers' Compensation and Employers :6,41 ,+ �
Liability policy;and v"
(i) Any amount owed by the EMPLOYER pursuant to F' r_, ::
provision of any law that provides non-occupational ...i..--
:Type—n accept age of the -ement and at the beginning of
disability benefits. a rot - rting as specified in Item 12 of the
(4) "Occurrence" — shall mean accident. In addition, bodily ° Y - ' P�
injury by occupational disease must be c he EMPLOYER shall pay to the
CO ON the amount of the Deposit Premium
aggravated by the conditions of employment an 0O•ON the amount of the Deposit Premium
I [fie Rem I I of the Declarations. The EMPLOYER deemed to have occurred on the last day o
exposure to those conditions o ent or paY s when due. The Deposit Premium shall be
aggravating such injury by disease,' h by the CORPORATION until the expiration of the Payroll
dates as is otherwise e ed by the fling Period. Within thirty (30) days after the close of
Compensation and Employ' iability La of' h Payroll Reporting Period, the EMPLOYER shall render
appropriate State(s). Bodi 'ury by tional to the CORPORATION a report, upon a form satisfactory to
disease sustained by each Empf II be d to be the CORPORATION, exhibiting, by classification, the amount
a separate Occurrence unless suc re • ectly of such remuneration earned by Employees during such
from an accident. "' ',Y" » reporting period, and the EMPLOYER shall therewith pay to
(5) "Employee" — as respects liability itifposearupon the the CORPORATION the excess of the Earned Premium over
EMPLOYER by the Workers' Compensation Law of any the Deposit Premium previously paid. In case the Deposit
State, the word Employee shall mean any person Premium paid exceeds the Earned Premium, the
performing work which renders the EMPLOYER liable CORPORATION shall return to the EMPLOYER the amount
under the Workers' Compensation Law of a State named in of such excess or give appropriate credit, subject to the
Item 2 of the Declarations, which is the State of the proportion of Minimum Premium for the Liability Period in
injured Employee's normal employment, for bodily the case of multi-year Liability Periods.
injuries or occupational disease sustained by such person. Upon expiration of a Liability Period, a summary of
(6) "State" — shall mean any state, territory, or possession of voluntary payroll reports for such Liability Period shall be
the United States of America and the District of Columbia. made to determine the Earned Premium under this Agreement.
In no event, however, shall the Earned Premium in respect of
D. Reimbursement any Liability Period be less than the Minimum Premium
specified in the Declarations.
If the EMPLOYER pays any Loss incurred in any Liability For each Payroll Reporting Period, the CORPORATION
Period in excess of the Self-Insured Retention Per Occurrence, shall compute the Earned Premium as follows:
the CORPORATION shall reimburse the EMPLOYER upon (1) Remuneration — The remuneration earned, or man-hours
receipt of a formal proof of loss and other evidence acceptable accumulated, durine such period by all Employees,to the CORPORATION of such payment. Within a reasonable including volunteers engaged in each classification covered
i
n
SPWC-090B-AI
by this Agreement shall be computed in accordance with Company and the EMPLOYER shall operate as a notice of
the rules set forth in the appropriate Manual of Workers' cancellation of this Agreement by the EMPLOYER, subject to
Compensation and Employers' Liability Insurance. the additional terms of the Cancellation Section of this
(2) Manual and Standard Premium — The remuneration, or Agreement. Any change in service companies must be
man-hours, so computed for Employees engaged in each immediately communicated to and approved by the
such classification shall be multiplied by the Manual Rate CORPORATION, and this obligation shall survive the
per $100 of remuneration/man-hour, in effect at the termination or non-renewal of this Agreement.
inception of each Payroll Reporting Period, and the
products so obtained shall be added together to determine I. Prompt Reporting of Claims
the Manual Premium. An Experience Modification Factor
may be applied to the Manual Premium to determine a As soon as the EMPLOYER becomes aware, the
Standard Premium. Such Experience Modification Factor EMPLOYER must provide prompt notice to the
shall be determined at the inception of this Agreement and CORPORATION of: (a) any claim or action commenced
is subject to annual review and possible revision. A against the EMPLOYER which exceeds, or is likely to exceed,
Standard Premium takes precedence over any Manual fifty percent (50%) of the Self-Insured Retention Per
Premium. Occurrence specified in Item 7 of the Declarations and (b) the
(3) Earned Premium — Against the Manual or Standard reopening of any claim in which a further award might involve
Premium shall be applied the Premium Rate, as specified liability of the CORPORATION under this Agreement.
in Item 9 of the Declarations, to determine the appropriate In addition, the following categories of claims shall be
Earned Premium. reported to the CORPORATION immediately, regardless of
This Agreement is issued by the CORPORATION and any question of potential involvement of the CORPORATION:
accepted by the EMPLOYER subject to the agreement that, in I. Fatalas;
the event of any change in the Rates per $100 2. P s and quadriplegics;
remuneration/man-hour, as stated in Item 6 of the 3. Seri° ,, ns, defined as 2n° or 3b degree burns
Declarations, because of any general rate increase or any a;,.. Iv" - %or more of the body;
legislative amendment affecting the benefits under the 4.
Workers' Compensation Law of any State(s) named in Item 2 e..i=; i._ Spi •
of the Declarations, such change, upon the effective date 3'z"'6 _ putah major extremity;and
thereof, shall be, without endorsement, made a part of this h 7y Occurr which results in a serious injury
Agreement. o or mo ployees.
Ifs CORATION�Iejudiced by the EMPLOYER's
G. Self-Insurer wrr: fatlareap' de prompt notice of a claim in accordance with
Yom, re nts set forth above and/or as otherwise provided
The EMPLOYER, by acceptance of ' eemen is .' e L y State(s), the CORPORATION may elect to
that it is a duly qualified Self-Ins late(s) ted cove Loss arising from such claim. To constitute
in the Declarations, and will u "'to maint pt, sufficient notice, the EMPLOYER must provide
qualifications during the currencyr }his Agreement. d ' plete information as to the details of the injury, disease, or
event the EMPLOYER should-it .any time a this death.
Agreement is in force terminates Itfication 'f they
should be cancelled or revoked, su a of q ' tions J. Defense of Claims
shall operate as notice of cancellation oft Y{p 'by the
EMPLOYER, subject to the additional:-+ r`of the The EMPLOYER shall investigate and settle or defend all
Cancellation Section of this Agreement. claims and shall conduct the defense and appeal of all actions,
suits, and proceedings commenced against it. The
H. Service and Administration EMPLOYER shall forward promptly to the CORPORATION
copies of any pleadings or reports as may be requested. The
This Agreement contemplates the concurrent and continued CORPORATION shall not be obliged to assume charge of the
existence of a separate service agreement between the investigation, defense, appeal or settlement of any claim, suit,
EMPLOYER and the Service Company, its designated or proceeding brought against the EMPLOYER, but the
representative, named in Item 5 of the Declarations, providing CORPORATION shall be given the opportunity to investigate,
services approved by the CORPORATION. The EM- defend, or participate with the EMPLOYER in the
PLOYER agrees that its Service Company shall furnish the investigation and defense of any claim, if, in the opinion of the '
CORPORATION with quarterly loss runs concurrent with CORPORATION, its liability under this Agreement might be
each Liability Period of this Agreement. The provision of loss involved.
runs alone does not relieve the EMPLOYER of its reporting
obligations as set forth in Section I of this Agreement. In K. Good Faith Claims Administration
addition, the electronic transfer of loss information by a
Service Company of the EMPLOYER shall not constitute The EMPLOYER shall use diligence, prudence, and good
II notice of a claim. I faith in the investigation, defense, pursuit of recovery from
Cancellation of the service agreement between the Service others and settlement of all claims. The EMPLOYER shall not
I
l
SPWC-O,0b-A1
unreasonably refuse to settle any claim which, in the exercise remaining amounts collected shall be paid to the EMPLOYER.
of sound judgment with respect to the entire claim, should be
settled, provided, however, that the EMPLOYER shall not O. Change in Agreement
make any payment or agree to any settlement for any sum
which would involve the limits of the CORPORATION's No condition, provision, or declaration of this Agreement
liability hereunder without the approval of the shall be waived or altered at any time, except as specified in
CORPORATION. Section F, except by endorsement signed by the President or a
If the CORPORATION is prejudiced by the EMPLOYER's Senior Vicc President and the Secretary or an Assistant
failure to exercise diligence, prudence, and good faith, the Secretary of the CORPORATION.
ono onP n•r1CN may elect t:. disclaim c__ This Agreement hereby terminates, supersedes and replaces
ay coverage .o. Loss
from such claim. � 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 P. Cancellation
settlement of all claims due to Occurrences happening during
This Agreeme�Rm ay be cancelled by either party giving the
the term of this Agreement. An audit to determine Manual or ew:
Standard Premium shall supersede any and all prior voluntary other party wri tice not less than sixty(60) days prior to
payroll reports by the EMPLOYER, and will be used to the date of copse n, except, that if the CORPORATION
determine the final adjustment of premiums due to the
cancels fort
t of any premium, the cancellation
CORPORATION. Should a determination be made that shall beef; (10)days after dispatch of notice by
the• date of cancellation then becomes
additional audit premium is due to the CORPORATION, the th 'on a final Liability Period. This
due date for payment of such audit premium shall be thirty mettFitoes not app Loss as a result of Occurrences
(30)days after the date of billing. g place"j.j,_ the effe "date of such cancellation.
cellatillik'is eff y the EMPLOYER, the Manual
M. Other Insurance -x--
+ or ium shall be determined by the short rate
:: a g, -tables for casualty insurance, and the Earned Premium
If the EMPLOYER carries other valid and collecteb "- I bealt{pfoduct of the Premium Rate (Item 9) times the
insurance, reinsurance, or indemnity wit1},an other' r or ual dj Standard Premium (or the Total Annual
reinsurer covering a Loss also co, :this A- ent uneratioiivJTio arrived at, but not less than the Minimum
(other than insurance or reinsuran $ hosed ium specified in the Declarations.
in excess of the sum of the Se d Retention an f cancellation is effected by the CORPORATION for non-
Maximum Limits of Indemnity rpunder), the urance
afforded by this Agreement �,^ payment of premium, the EMPLOYER shall pay the
shall app excess ouran shall
�`�.''." CORPORATION Earned Premium for the period up to the
not contribute with such other insu ins
*. date of cancellation.
'a; . ..
N. Recovery from Others " )" If the CORPORATION cancels for any other reason, the
#.-:u-• Manual or Standard Premium (or the Total Annual
The EMPLOYER agrees to prosecute any and all valid Remuneration) shall be determined upon a pro rata basis and
claims the EMPLOYER may have against any other party or the Earned Premium adjusted in accordance therewith.
source that may mitigate any Loss under this Agreement and
return to the CORPORATION any amount so recovered, less Q. Assignment
the reasonable expense of collecting such amounts.
The CORPORATION shall have the EMPLOYER's rights to An assignment of interest under this Agreement will not
prosecute any and all valid claims against any other party or bind the CORPORATION unless an endorsement signed by
source that may mitigate any Loss under this Agreement. The the President or a Senior Vice President and the Secretary or
EMPLOYER agrees that it will assist the CORPORATION in an Assistant Secretary of the CORPORATION assigning
any prosecution of any and all valid claims against any other interest under this Agreement is issued by the
party or source that may mitigate any Loss under this CORPORATION.
Agreement. Any amounts recovered by the EMPLOYER or
the CORPORATION from any party or source that may R. Bankruptcy or Insolvency of Employer
mitigate any Loss under this Agreement shall first be used to
pay the expenses of collection and to reimburse the The bankruptcy or insolvency of the EMPLOYER will not
CORPORATION for any amount it may have paid the relieve the CORPORATION or the EMPLOYER of its duties
EMPLOYER for the Liability Period concerned.and all I and liabilities under this Agreement. After payments have
II
SPWC.0908-A I
been made by or on behalf of the EMPLOYER, that the statements in this Agreement, in the Declarations, and
reimbursements due under this Agreement will be made by in the application are the EMPLOYER's representations; that
the CORPORATION as if the EMPLOYER had not become this Agreement is issued in reliance upon such representations;
bankrupt or insolvent, but not in excess of the that this Agreement embodies all agreements existing between
CORPORATION's limit of indemnity. the EMPLOYER and the CORPORATION, or any of its
agents, relating to this excess insurance, and that full
S. Sole Representative compliance by the EMPLOYER with all terms of this
Agreement is a condition precedent to the CORPORATION's
If more than one EMPLOYER is named in Item I of the liability hereunder.
Declarations; or an endorsement related thereto, the EM-
PLOYER first named in Item I, or a related endorsement,will
act on behalf of all EMPLOYERS to give or receive notice of
cancellation, to receive return premium or reimbursement, or
to request changes in this Agreement. IN WITNESS WHEREOF, SAFETY NATIONAL
CASUALTY CORPORATION has caused this Agreement to
T. Acceptance be executed by printing below the facsimile signatures of its
President and Secretary and by the actual signature of its
By acceptance of this Agreement,the EMPLOYER agrees Secretary on the Declarations.
z
:.:4-4, .
2 _
S
Secretary 4i
at
President
.x :tna .,
NG
i
SPWC-MS-AI
SAFETY NATIONAL CASUALTY CORPORATION
1832 SCHUETZ ROAD
ST. LOUIS, MO 63146
DECLARATIONS-SPECIFIC EXCESS SP 4045262
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, 2011
Item 4. Anniversary Date: 12:01 A.M. December 31, 2012
Item 5. The Service Company shall be COUNTY TECHNICAL SERVICES
Item 6. CLASSIFICATIONS Code Estimated Total Annual Rate Per$ 100
OF OPERATIONS Number RemunerationlManhours Remuneratlon/Manhours
See Attached
Total Estimated Manual Premium 1.'*x N/A
SNCC Experience Modification Factor N/A
Total Estimated Standard Premium; ;„ N/A
Item 7. Self-Insured Retention Per Occurrence $750,000,
Item 8. (a) Maximum Limit of Indemnity Per Occurrence .- , a• Statutory
(b) Employers' Liability Maximum Limit of Indemrffrapr Occ ce $ 1,000,000
Item 9. Premium Rate $0.152 per$100 of Payroll ~�- Ares raZ"
Item 10. Minimum Premium for the Liability Pe $86,013
Item 11. Deposit Premium forth eport rind $ 95,570
Item 12. Payroll Reporting Pe nually as of De
Item 13. Endorsements See End nt Sche
Signed at St. Louis,Missouri on Dec
Secretary
Countersigned this day of
By: N/A
DSP-0195
1005 00 1101 (XWC)
ITEM 6
RE: WELD COUNTY, COLORADO
Policy No: SP 4045262
Effective Date: 12:01 A.M. December 31,2011
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&Drivers 5506 $6,115,614 N/A N/A
Limousine Co.:All Other Employees&Drivers 7382 $226,587
Police Officers&Drivers 7720 $20,085,081
Salesperson.Collectors or Messengers-Outside 8742 $5.264.603
Clerical Office Employees NOC 8810 19.278,806
Attomey-All Employees&Clerical.Messengers,Drivers 8820 4,047.361
Physician&Clerical 8832 , 2.639
L.
College:Professional Employees&Clerical 8868 -of If Any
Buildings-Operation by Contractors 042
Building-Operation by Owner or Lessee
xs
College or School. All Other Employees 9101" `:-£ r
Municipal,Township,County or State Employee NOC " °9410 5 S£:: $3,0
4- .,fir jY
;.
rw 18�th $62,675,208
Ti
Atg
i pay t 14.:W- $62,875,208
WO
'net;
H.
7 tr.
q *it n
1004 00 1101 (XWC)
Endorsement Schedule
RE: WELD COUNTY, COLORADO
Policy No: SP 4045262
Effective Date: 12:01 A.M. December 31. 2011
Number Title
0003 00 1206(XWC) COLORADO NOTICE ENDORSEMENT
0241 00 1291 (XWC) INCIDENTAL LONGSHOREMEN'S AND HARBOR WORKERS'COMPENSATION ACT COVERAGE
ENDORSEMENT
0276 02 0408(XWC) BROAD FORM ALL STATES FOR EMPLOYEE TRAVEL
0291 00 0708(XWC) VOLUNTARY COMPENSATION ENDORSEMENT-PREMIUM DELINEATION
0293 00 0906(XWC) FOREIGN VOLUNTARY WORKERS'COMPENSATION 4LOIEMPLOYERS' LIABILITY
0322 00 1291 (XWC) 90-DAYS NOTICE OF CANCELLATION „ a., ' ;,
1,4m-tra-
0339 01 0908(XWC) SAME COMMUNICABLE DISEASE SPECIF }EXCESS - �QM
z n
rs
1061 10 1207(XWC) POLICYHOLDER DISCLOSURE NOTICE. RORISM INSURANCE COVERAGE
7E #r.
1m1 -
YEL
aal9:trd � $
�y 4
4A d.� V30.vy:VW'?
�,, r 1
0003 00 1206(XWC)
ENDORSEMENT
COLORADO NOTICE ENDORSEMENT
Effective 12:01 A.M., Local Time, December 31, 2011
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:y°
Attached to and forming a part of Excess Workers' Compensation a Liability Insurance Agreement
No. SP 4045262, issued by SAFETY NATIONAL CASUAL ' PO t. Louis, Missouri to WELD
COUNTY, COLORADO, dated December 31,2011.
SAF ,. TIONALOASUALTY CORPORATION
4N
C fi
YN#� J7 �.
a':
m
President
Secretary
� P
0241 001291 (XWC)
ENDORSEMENT
INCIDENTAL LONGSHOREMEN'S AND HARBOR WORKERS'COMPENSATION ACT COVERAGE
ENDORSEMENT
Effective 12:01 A.M., Local lime, December 31,2011
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 E,ttttployee's normal duties. To
that end, the term "Workers' Compensation Law" ind the Longshoremen's and
Harbor Workers' Compensation Act (33 USC Sections 90 ) and any amendment to
. a.
that Act that is in effect during the Liability Period.
Any incidental Longshoremen's and Harbor fkers n Loss, so covered,
is, of course, subject to the Maximum Li - em e appropriate Self-
Insured Retention Per Occurrence as sped arati
All other terms, conditions, agreements and stipule'•ns rem Y
Attached to and forming a part of faccess Co lion ployers' Liability Insurance Agreement
No. SP 4045262, issued by TIO r CASU t :', CORROtATION of St. Louis, Missouri to WELD
COUNTY, COLORADO, dat tier 31 2' k
.-.4(--"l•-.- ...
-trik
tn.
- SAFETY NATIONAL CASUALTY CORPORATION
t'd -
3 �A
-.snu•
• President
Secretary
0276 02 0408(XWC)
ENDORSEMENT
BROAD FORM ALL STATES FOR EMPLOYEE TRAVEL
Effective 12:01 A.M., Local Time, December 31, 2011
h coisidei atior vi he paymeni vi premium and dutnereuce by instil pasties iu lire icons vi tills Agreement, ii
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 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 Declarati this Agreement shall provide
coverage for Loss sustained by the EMPLOYER becaus , lability imposed upon the
EMPLOYER by the Workers' Compensation or Employers'Jjabil' s of such non-designated
State. mu..,- n-._
3. This Agreement also applies to Loss sustained by, PLO se of liability Imposed
upon the EMPLOYER by the Workers'Compensa ploye Laws of such non-
designated State. „ •
�'- asp
4. Any Loss covered by this Endorsement shall be to limiteftons of this Agreement
including but not limited to the Self- etc , ccurrence or the Limitation Per
Occurrence and the Maximum Limit( ' of • RPORATION for the Liability Period.
5. The word "State" as . j this E` Itsemen ll mea State of the United States of
America and the Di CO umbra " ' 17
' f
6. The insurance affa* by this Enq,Qfsem�tkies'not cover fines or penalties imposed on the
EMPLOYER for failure lo comply wit *. requirements of any Workers'Compensation Law.
7. All of the provisions o ;, insofar as such provisions are not inconsistent herewith,
are applicable to the insu by the Agreement by virtue of this Endorsement.
All other terms,conditions,agreements and stipulations remain unchanged. I
Attached to and forming a part of Excess Workers' Compensation and Employers' Liability Insurance Agreement
No. SP 4045262, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY, COLORADO,dated December 31, 2011.
SAFETY NATIONAL CASUALTY CORPORATION
President
Secretary
0291 00 0708(XWC)
ENDORSEMENT
VOLUNTARY COMPENSATION ENDORSEMENT-PREMIUM DELINEATION
Effective 12:01 A.M., Local Time, December 31, 2011
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 vuiuniary 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 EMPLOY use of bodily injury and
occupational disease, including death resulting therefrom, due to • rrences taking place within
the Liability Period of this Agreement.
1. The bodily injury or occupational disease must be suss sEmployee included in the
group of Employees described in the Schedule
2. The bodily injury or occupational disease " •` urVithe course ogfployment necessary
or incidental to work in a State listed in the le.
sat
3. The bodily injury or occupation mu e United States of America, its
territories or possessions or a elsewhere if the Employee is an
American or Canadian citizen t rily m me country.
B. Indemnification �' Y[
The CORPORATI ' I indemnify E R for Loss in satisfaction of statutory benefits
that would be impo e EMPL and Employees described in the Schedule were subject
to the Workers' Corn • Law in the Schedule. Naturally, indemnification for any such
Loss is subject to the ed. 'on Per Occurrence, Loss Fund(s) and Maximum Limit(s)
of Liability as specified in S.
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 3
0291 00 0708(XWC)
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
CORPORATION'S duty to indemnify the EMPLOYER is immediate) ,terminated.
'Ti et
E. Recovery From Others
If the CORPORATION makes a recovery from others the' N will keep an amount
equal to its expenses of recovery and the Loss paid OR The CORPORATION
will pay the balance to the parties entitled to paym _ . arties to the benefits of this
rzr
insurance make a recovery from others, they reimt atathe COR TION for the Loss
previously paid by the CORPORATION to such
F. Employers'Liability Insurance * ^W `z
Employers' Liability Insurance applie - 'Loss by ' dorsement as though the State of
employment shown in rule own 2 of larations.
G. Premium
SPC
It is agreed that a : ns who J ll e their services to the EMPLOYER will be reported for
purposes of premium' bon ourly wage of$7.25 per hour minimum, unless the work
they do is similar to th Dein by a paid Employee who is receiving more than a $7.25
per hour wage, in which' a reported for the unpaid voluntary Employee will be the
same as the wage reported for d Employee.
SCHEDULE
Employees State of Employment .C` om #speletton L.awipd �'•
Authorized volunteers, student COLORADO State(s)of COLORADO
workers,etc,while not subject to
any Workers'Compensation Law
Page 2 of 3
0291 00 0708(XWC)
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 4045262, issued by SAFETY NATIONAL CASUALT i uvr rtni.mi ON 01 St. Louis, Missouri to WELD
COUNTY,COLORADO, dated December 31, 2011.
SAFETY NATIONAL CASUALTY CORPORATION
President
Secretary
ITT
NA9:w
�, Jfv
Page 3 of 3
0293 00 0906(XWC)
ENDORSEMENT
FOREIGN VOLUNTARY WORKERS'COMPENSATION AND EMPLOYERS'LIABILITY
Effective 12:01 A.M., Local Time, December 31,2011
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,
ercept: Afghanistan, Algeria, Belarus, Bosnia, Burma, Burundi, Central African Republic, Chad,
Colombia, Cote d'Ivoire, Cuba, Dent. Rep. of Congo, Egypt, Eritrea, Guinea, Haiti, Herzegovina,
Iran, Iraq, Israel, Kenya, Kosovo, Lebanon, Libya, Macedonia, Mali, Mauritania, Nepal, Niger,
Nigeria, North Korea, Pakistan, Philippines, Saudi Arabia, Somalia, Sudan, Syria, Uzbekistan,
Yemen, and Zimbabwe.
nst
B. Benefits payable under this Endorsement are the same as Owe th Id be payable if the Employees
in question were subject to the Workers Compensation Lawoft tfoa State or States: COLORADO
C. Benefits payable under this Endorsement shall incl anon exptl an amount up to $25,000
with respect to any one Employee and as otherwise= the CORPORATION'S Foreign Voluntary
Endorsement Limit of Liability for Coverage B Ebil6yers Lle$jty.
D. The CORPORATIONS Foreign VoluntaryA ljdorse Liability for Coverage B — Employer's
Liability is limited to$moo and appli$*1tf pss of -inured Retention Per Occurrence.
SECTION 2. EMPLOYEES CO1f� 0x
e_t
µms:
A. It is agreed that thlk' BCe provide reement also applies to those Employees of the
EMPLOYER who red or assigned " PLOYER to work at locations within the country or
countries not exclucdajf*ihis Endo nt.
B. This insurance, with to any , Employee, shall attach from the moment such Employee is
hired or assigned for su - II cease from the moment the employment or assignment for
such work is terminated. yee has been hired in the United States of America, coverage
continues after termination of emp dyment 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 of 2
0293 00 0906(XWC)
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 4045262, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY, COLORADO,dated December 31,2011.
SAFETY NATIONAL CASUALTY CORPORATION
aq President
Secretary
sew-
ire
xr�
4
#N.
Page 2 of 2
0322 00 1291 (XWC)
ENDORSEMENT
90-DAYS NOTICE OF CANCELLATION
Effective 12:01 A.M., Local Time, December 31,2011
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:
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 ' p_ Liability Insurance Agreement
Na SP 4045262, issued by SAFETY NATIONAL CASUALTY ORP�'+ St. Louis, Missouri to WELD
COUNTY, COLORADO, dated December 31, 2011. ;70. "•
t "` a:
nt¢Ysa F TIONAI.CASUALTYCORPORATION
sw i.�ss -:.try`
r {tla
President
;w y ify qtr - 4 £
Secretary
rE- 1/4iCA
7.‘-' r n
0339 01 0908(XWC)
ENDORSEMENT
SAME COMMUNICABLE DISEASE-SPECIFIC EXCESS
Effective 12:01 A.M., Local Time, December 31,2011
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 ly nosed infectious disease
caused by an infectious organism which is transm tt urce to another, directly
or indirectly,which is the same proximate ca odi" h infected Employee.
All other terms,conditions,agreements and stipulations unchaiSd. 4.;r.,,:
Attached to and forming a part of Excess Wo s mployers' Liability Insurance Agreement
No. SP 4045262, issued by SAFETY NATIO CA C RATION of St. Louis, Missouri to WELD
COUNTY, COLORADO,dated Bra 31
'N e� 1rq?,l:
, s„,. SAFETY NATIONAL CASUALTY CORPORATION
President
Secretary
I
1061 10 1207(XWC) i
ENDORSEMENT
POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE j
Effective 12:01 A.M., Local Time, December 31,2011
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. . United States in the case of certain
air carriers or vessels or the premises of a United States ml ;and,
d. That has been committed by an individual or individu as an effort to coerce the civilian
population of the United States or to influence the ff' conduct of the United States
Government by coercion.
Coverage for such losses is still subject to all to " _ s ex , and conditions in your
Agreement, and any applicable federal and/or s rut regulatiotit;Under the Act, terrorism
losses would be partially reimbursed by the U.S. men r a ford established by the Act.
Under this formula, the U.S. Government would ge ,re* e 85 covered terrorism losses
exceeding a deductible paid by the CORPS !N. ins a $100 billion cap that limits the
reimbursement from the U.S. Govemm •m " rers. If aggregate insured losses for all
insurers exceed$100 billion,the EMPL• e?''s co may uced.
The portion of the EM annual 'c, m e attribu e to coverage for losses caused by a
certified act of terroris O.5% * ``
—5-
All other terms, conditions, a' ents and tions remain unchanged.
ry
Attached to and forming a part s, ' Compensation and Employers' Liability Insurance Agreement
No. SP 4045262, issued by SAF - , CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY, COLORADO, dated Decem , , 011.
SAFETY NATIONAL CASUALTY CORPORATION
President
Secretary
c 2007 National Association of Insurance Commissioners
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
products and services to its customers for 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 reinsurae underwriting, claims
us. The collection, use and disclosure of such administration or adjusting, investigation, loss
information is regulated by law. Safety National control ar Eomputer systems companies.
and its affiliates maintain physical, electronic and
procedural safeguards that comply with state and . companies or agents as
federal regulations to guard your personal asp ssary concerning your
information. Our employees are also advised of ication, claim.
the importance of maintaining the confidentiality of
your information. , InsUe regul or statistical reporting
ss •..age ,^
Types Of Information We Collect m,RI •a enforcement or governmental authorities
Safety National obtains most of our info kt 1pnnectton with suspected fraud or illegal
directly from you, your agent roker. a. audits.
application you complete, as add'
information you provide, ge us mo s Authorized persons as ordered by subpoena,
the details we need to k e endin th
p g on warrant or court order, or as required by law.
nature of your insurance tra 'on, we m
further details about you.
We do not disclose any non-public, personal
We may obtain information front information about you to non-affiliated companies
for marketing purposes or for any other purpose
as other insurance or reinsure es,
except those specifically allowed by law and
medical providers, government agencies,
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').
What We Do With Your Information Your Sales Agent may have gathered information
about you. The use and protection of information
Information that has been collected about you will
obtained by your Sales Agent is their
be retained in our files. We will review your
responsibility, not Safe National's. If
information in v
ty a s. you have
evaluating your request for uestrons
insurance coverage, determining your rates or q about how your Sales Agent uses or
underwriting risk, servicing your policy or adjusting discloses your information, please contact them
claims. We may retain information about our directly.
former customers and would disclose that
information only to affiliates and to nonaffiliates as
described in this notice or as otherwise permitted
by law.
WC 99 99 28
Hello