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Home My WebLink About000283.tiff Esther Gesick From: Michelle Raimer Sent: Monday, January 27, 2014 12:45 PM To: Esther Gesick Subject: Work Comp Excess Carrier Insurance Name Update Attachments: SIR Bond Rider Carrier Travelers Casualty& Surety Company of America Ja....pdf Hello Esther, Please add the attached correspondence to the work comp insurance file. The work comp excess carrier updated their name...thanks! Michelle Raimer HR Analyst- Risk Programs Human Resources P O Box 758 Greeley CO 80632 tel: 970-336-7220 x4233 cell: 970-302-2423 fax: 970-352-9019 "Bringing out the best in our employees through sustained service and support." Confidentiality Notice:This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication.Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. 1 Arthur J. Gallagher Risk Management Services, Inc. January 24,2014 Weld County,Colorado Attn: Michelle Raimer PO Box 758 Greeley,CO 80632 • RE: WC SIR Bond 100729968 Dear Michelle, Enclosed is a bond rider amending the Carrier name for the above named bond,as follows: • Effective 1-1-2014: Amend Carrier's name from"Travelers Casualty and Surety Company"to"Travelers Casualty and Surety Company of America" 1. This original bond rider was previously sent to the State of Colorado by the carrier on 12-13-2013. 2. Enclosed is a letter from the carrier advising why the name change has occurred. No premium was generated by these changes. If you have any questions or need additional information,please feel free to give me a call at(303)889-2574. Sincerely, A6th $rik1.er Anita Bruner, CSIR Account Representative 6399 South Fiddler's Green Circle,Suite 200 Greenwood Village,CO 80111-4949 Main 303.773.9999 Toll Free 800.333.3231 Fax 303.773.9776 www.ajg.com 6060 South Willow Drive,Suite 200 Richard C.Schultz TRAVELERS J Greenwood Village,CO 80111 Regional Vice President Denver Hub Phone Number (720)200-8423 Fax Number (720)2001398 January 24, 2014 To Whom It May Concern: This is to notify you that as of the renewal date of your bond, Bond Number 100228687 will be amended to reflect a change in surety from Travelers Casualty and Surety Company (NAIL #19038, A.M. Best Rating A+, XV) to Travelers Casualty and Surety Company of America (NAIL #19046, A.M. Best Rating A+, XIV). Both companies are subsidiaries of The Travelers Companies, Inc. Please note that this change is for internal reasons only. It does not impact the suretys financial strength or the coverage under your existing surety bond. Regards, it?1,400(44- TRAVELERS] CHANGE IN SURETY COMPANY RIDER To: Colorado Department of Labor&Employment Division.of Worker's Compensation 630317th Street,Suite 41)Q Denver,,CO 80202-3660 Tote attached to and form part of: Bond Number: 100729968 Former Bond Number; 19 S 100729968 BCA = Bond Limit: $2,365,085 Issued on behalf of Weld County,Colorado PO Box 758' Greeley,CO;80632 Arid iii favor of Colorado Department of Labor&Employment Division of Worker's Compensation: 63317th:Street,Spite 400 Deaver.,CO 802.02-3660 The.purpose of this Rider is ORANGE IN SURETY COMPANY Effective December 31,2013 ,the surety.on the above referenced bond is Travelers Casualty and.Surety Company of America:. Travelers Casualty and Surety Company of America replaces Travelers Casualty And Suretk Company as surety. The termination Of liability under the travellers Casualty and Surety Companyy bond is a.condition precedent to the change of surety. Signed,sealed and dated this: 13th day Of December , 2013_ Travelers Casualty and Surety Company of America n en C.FOX Attorney-In-Fact: I . S-6656(2/091- Obligee Copy WARNING THISPOWER OF ATTORNEMINVALICI.WiTHOlffTHE REFS 60RDER TRAVELERS . POWER OF NJvY• i Farmington Ct smuttyCompany. St.PaiiudeicuTinsuraece Company t I?idefity and Guaranty insurance C �i�Y TraveiersCiuviIt ru�etycompany 1 Fidelity•and t:Yuaranty Insurance 10ndtirwriteis,lue. Travelers Casualt nd:s Y Suixty.Company ofArneriea St.Oust Firer .and Marine int:uramce Company .United.States'Hldelitya$:Guaranty Company iI St.Paul Guardian insure Company ' Atu,etey-In Fact,No. 227065 Certltleate 1Yo.•.005613088 • • I KNOt?Y ALL:MEN BY THESE PRESENTS That F?aimingtim Casualty Company,St.Paul:Fite"and Marine in-swam-v.Ctinipany,St:Paul Guardian Insurance Company,St.'Paul'iTtxtvey Insurance Company.,Travelers'Casualty and Surety.Company„Travelers Casualty and Surety'Coinp'any of Atiterica:and limited States' Fidelity'and Guaranty Company are corpoiati.4as dui},organised°under die Laws of The State of Connect₹cut,that.Fideiity:and.(3uaranty Gvurance Company.is•u co on:duty c ti Y ,under the lain: the Stare'of Iowa';and that fidelity and Guaranty Insurance Undehyrittas,10.,.is.a:rnrpotation duly.organized under the . i laws ofthe'State ofWisetinsin(herein col ectiv.ely called tl:e"Compardes");and dial the Companies.do hereby'make,constitute•.and,appoint Rietiard.C..Schui Lisa D.Selby, es,,Mary�; . Y Mary Athartit r. E.Davis,.:I(risten•C..Fbx,chris E..Case,..loannc Bttriiey,;4tia.Kamaltrakul,:Coiieen•N. I opivood,Michael-P.Pltz,Marva L Jackson,Ronald 1..Bauer,Peter;Romanovsky:Mary Belcher,ICelly'R ayes,.Jared R.Scharton,Stephanie,L. Snook,Timothy J:Wilson,Christian'Gerrnani,Sara Rogers;Erin Singmaster,Aaron Salvuccii Laura Spomer;'Jill Hovey;.Alex:Befus,Ana Ochoa,and Cameron Pritchett af.the bty or Greenwood village- __,.Stara Of Colorado ,.ilieir true and lawful Attotneyrs),M-Fact. each in.their:separate,capacity if more than one is named above,to sign,execute,:seal`and acknowledge any,and•all:bonds,recognizanc.es•:eonditmirni undcirakin,r anti. other•wtithigs..obligatorr in the nature thereof:On :of the Companies in their,.business'ofguaranteeing•the-ftdelity of persons,guatameeing the performance of contracts and executing or guaranteeing bonds and.undertaltingstegttired•orpespitieti.iti;aoy nns ar•proceedings.i llowed by law. ,,' r 1i4.2..' . .1•41"-•'-`'' ' 21st IN WITNESSS t'VREREOF,the Companies:haVe:caused:this instiµl[easittibe t ued:and the.ilasnr'iorate seals to.be•hereto affixed,this_ day or s 4._ _ _ _ ; -;ice--,Q- '� • V - i nv.:�. .,,,-1/41..:�j•kk•r 'z�Y4-.'t , Faratington Casualty Company ..&.,.., .� r St.Paul Mercury Fidelity and.Guaranty nsurance Clo « '` s ally and S'ure.ty Comps �� '11*'avetars:Casbubty and.Surety Ciimgtmy Fidelity andGnarunty ii siu+tuiec isider `t .Inca II-avatars Casualtyand'Sureety Campamy of America St.PuulFire•and Marine Insurance.Company United States Fidelity and Guaranty Company St.Paul Guardian Insurance Company• • pl,, .e ."✓�ufrf.,. . `i:• '*°`a. . 0 �`9. •J¢.u.re,44. ..ysngoe • • —* .• r i L 4�2f'o r �S� g • 4 411,... �f loviol • l.co?eeU}0 , �3. ' l `' i Ya mc,,ar. er X951 *. s f3r� �yi�SEBy�ro° 3$71L.3 �)` �` 7� o°etpJ`4' � - • State ofConneciicut •e. • Ciry ofllurtforcl.ss; sachet-5r,-kancy.. cniotVice:Precident On tltis.the 21St day of. Aitoust 2013 b efgm'mdpetaottally appeared,Ruben L_R.eitpyi:who aeltuOled AiMself to• be thetbeSetilor.Viee•Pnishients of Farmington Casnahy Company;Fidelity and:•Guaranty Inauniace.Cotnpayy,Fidelity and Gouratay Insurance Undetwncers.,lac..?St.Peat.: line end.Mannc.Insurance Company,..Si.Paul Guardian.Insurance Company;St..Pattl.Morcuty:hretuance Compariyt;Thyeh:rs:Casualty and Surety Ccimpany'Ttasalers Casually and.Surety'Cotupany of America,and United States Fidelity and G uaranty Cr many;•and•that he,as such.being ywhori.ed•so to do.exca.uusd the foscgoing• Instrumcntfor:tlie:ptltpo; stherein contafnhd:by.$gning•oo behalf of the corporatitati:by.himelti'is aduly authodkd:bffcer. • ..‘ • . Tn Vatitess'Whereof;i heie=set my hand and official se-al. 'ic-..ikr- .4 SAR ketd C. .. �' My conunissiens axpucs the;30rh day.oflune,2016. * ip� Marti C.'ft:m:ault,Notary Public • 58440-8.12.Printed in U.S.A. ,�__._ ,WA FINING:THIS POWER OFAiTOHfJEY_ISRVVALIt3Winto. TitiE WAHNING::THIS POWER OF ATTORNEY-IS:INVALID WiTH.Ot1TTHE RED BORDER This Powcr.of Attorney is granted under and by the authority of the following'resolutions adopted.by the Boards of Directors of Farntington.Casualty Company;Fidelity end•Guaranty insurance Company,Fideliiyand Guaranty'Instuance Underwriters,Inc,,.St.Paul Fire and Marine.Insurance:Company;St.Paul Guardian Insurance Couipany,,.St.Pant Mcicury-Insurance Company,firavelers CA:orslty and Surety Company,Travelers Casualty and Surety.Company of America,and.?hiited>States •Fidelity.and Guaranty Company,which resolutions:arenow in full force and effect,reading-at follows: RESOLVED,,that the Chairman,the Pres;dent.any Vice Chairman,any Execotiyc Vice President,any Saner Vico.President,any Vice President,.any Second Vice President,the treasurer,any-Assistant Treasurer,the-Corporate Secretary or any.•Assistant Secretary.may appoint.Attorneys:4n Agents to act.fur,and-en-hehalf of the-Company and may give such appointee such authority as his or her certifcate.of authority may prescribe to sign with the Company's nante'and•seal with the . Company's-seal-bonds,recoguizrnecs,contracts of indemnity;and other writings'obligatory in the nature of a bond.recognizance;or conditional undertaking,and any. of said officers or:the oaid of Directors•ar any time.may remove any such appointee and revoke the power given:him'or her;and it is FEATHER RESOLVED,that the lanan,•tbe Pre sident,esident,any Vice Chairman,any Eieethve Vice President;any Senior Vice'Presidentor any Vice•President may delegate•all or any.part of the foregoingauthoiity to one or more officers or employees of this Company provided that each such delegation is in•writing and a copy thereof.is•filed is the calm of the Secretary.;and FURTi ER RESOLVED,that any bond,:recognizance,contract of indemnity,or writing obligatory in the-nature-Of a bond;recognizance,or conditional undertaking: shall be valid and binding upon the Company when(a)signed by.the President,any Vine Chairman,any Executive Vice President;any Senior Vice President or.any Vice • President,any Second Vide President,the Treasurer;any Assistant Treasurer;ine•Ceiporate Searetary or any Assisnint Semetary and duly attested kart sealed with the Company's seat.by:a Secretary.or Assistant Secretary;or(b)duly:.executed(under.seal,,if reguired)by one or more Attorneys in.Fact and Agents prirSuarit to-the power prescribed in his or her certifleate or their.certificates of'authority or by one or morn Company:officers pursuant to a written delegation ofAuthority:-rind FURTii ii.RESOLVED that the signature()leach of the.following offlcex President any Executive Vice President,.any Settler Vice President;any Vice-President, any Assistant Vice President,any Secretary,any Assistant Secretary,•and tire,teal of the:Company may be affixed by facsimile to any Power of Attorney br to any certificate reioting thereto.appointing Resident Vice Presidents Resident Assistant'Secretaries or'Atiorneyt-in-Faet:for purposes only of executing and areatmg•fronds and undertakings.and other writings obligatory in the nature thereof,;and any such.Power•of.ilittorney or certifcate.beating such facsaunile sigratune'or fi esimile seal • . shall be valid and binding upon the Company-and.any stich power so executed and carolled by such facsimile signature and'facsimile seal shall be valid and binding:on the Company in.the future with respect to:any bond or understanding to which it as attached; I,Kevin.E..Fiugbes;the undersigned Assistant Secretary ofFarmiugton Casualty Company;Fidelity atrdGuaranty Insurance Company,FfdelttY..and Guaranty lrsrriance UnderwriterS,:Inc:,St.Paul Fire and Marine Insurance.Company,St.'Paul.Guardian Ynsutanr a Company,St.Paul Mercury Insurance Company,Travclers•Cesualty and • Surety..Company,Travelers Casualty'and StuetvCompaay of America,and hutted States Eidrlrfyand Guaranty Company do hereby certify that'the above and foregoing. is a.true.and correct copy of the Powerof:Attorney executed by said Compa,p,th,,,w)twb is tit bit foiee:ll d'cffecrand has pot.been revoked_ 12.1 IN TESTIMONY WHEREOF.I havc.her untoset my.hand and ethos•titi-Sdalc n{acid graprrnies this i k day t••• ' • :.�t\()eta( ,20 • • v'•:E.;-a •Ke rt Hu 'Assistrn't �, tary • • • Wit• 4 4.0.0)4.!:(0.4,.. ,�°'....&1`94, f 6 r a ��braeast'~a a` : u..t9t12 1977 • 1951 +b 'fn e. a ry 4,7 ot.ef '. t ` " 6:2* Wt To verify the autheorieity•of this Power:of Attorney;.call.l-800-421-3880 or contacttis at•www.tiavelersbond,com.Please refer to.the Attorney-la-Fact number,cute trbove-namcd•individuals and the details of the bond to.which the power is.attached. • ..wee WARNING:.THIS POWER.OF ATTORNEY IS.INVALID WITHOUT THE RED BORDER AC ORE)o® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/20/2013 • THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONT PRODUCER NAMEACT Anita Bruner Arthur J. Gallagher Risk Management Services, Inc. PIGNo,E.n:303-889-2574 FAX (A/C,No): 6399 S. Fiddlers Green Cir EMAIL Greenwood Village CO 80111 ADDREss:anita bruner@atg.com INSURER(S)AFFORDING COVERAGE NAIC INSURERA:Safety National Casualty Corooratio 15105 INSURED INSURER B Travelers Casualty and Surety Compa 19038 Weld County, Colorado INSURER C: PO Box 758 Greeley,CO 80632 INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:841775872 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSR WVO POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ ICLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY accident $ AUTOS AUTOS l HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ OED I RETENTION$ $ A WORKERS COMPENSATION 5P4049841 12/31/2013 12/31/2014 X WCSTATU- I OTH- AND EMPLOYERS'LIABILITY Y/N TORY UMITS I FR ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $1,000,000 B Self Insurer's WC Bond 100729968 12/31/2013 12/31/2014 Penal Sum 2,365,085 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) For WC Coverage-SIR-$750,000 RE: Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN State of Colorado, Department of Labor& ACCORDANCE WITH THE POLICY PROVISIONS. EmploymentSelf Insured Division 633 17th Street,#400 AUTHORIZED REPRESENTATIVE Denver CO 802 80202-362-36 60 USA ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD SAFETY NATIONAL CASUALTY CORPORATION 1832 SCHUETZ ROAD ST. LOUIS, MO 63146 DECLARATIONS-SPECIFIC EXCESS SP 4047371 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 31,2012 Item 4. Anniversary Date: 12:01 A.M. December 31,2013 Item 5. The Service Company shall be COUNTY TECHNICAL SERVICES Item 6. CLASSIFICATIONS Code Estimated Total Annual Rate Per$100 OF OPERATIONS Number Remuneration/Manhours Remuneration/Manhours See Attached Total Estimated Manual Premium N/A SNCC Experience Modification Factor N/A Total Estimated Standard Premium N/A Item 7. Self-Insured Retention Per Occurrence $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 $0.1778 per$100 of Payroll Item 10. Minimum Premium for the Liability Period $ 105,451 Item 11. Deposit Premium for the Payroll Reporting Period $ 117,168 Item 12. Payroll Reporting Period Annually as of December 31 Item 13. Endorsements See Endorsement Schedule Signed at St.Louis, Missouri on November 09,2012 Secretary Countersigned this day of By: N/A DS P-0195 1005 00 1101 (XWC) ITEM 6 RE: WELD COUNTY. COLORADO Policy No: SP 4047371 Effective Date: 12:01 A.M. December 31, 2012 Declarations: Item 6. Estimated Total Annual Rate per 5100 Code Remuneration/ Remuneration/ Estimated St Classifications of Operations_ _ No. Manhours Manhours Premium co Street or Road Construction Paving or Repaving&Drivers 5506 5 6.642 712 N/A N/A Limousine Co. All Other Employees&Drivers 7382 $31,158 Police Officers&Dnvers 7720 $20,332,837 Salesperson.Collectors or Messengers-Outside 8742 5 5.581.308 Clerical Office Employees NOC 8810 $20 593.933 Attorney-All Employees&Clerical.Messengers.Drivers 8820 $4.342.678 Physician&Clerical 8832 $3.630.757 Buildings-Operation by Contractors 9014 $ 169.796 Building-Operation by Owner or Lessee 9015 5 1 094.758 Municipal.Township.County or Slate Employee NOC 9410 5 3.478.589 5 65 898.526 Total Payroll $65.898.526 1004 00 1101 (XWC) Endorsement Schedule RE: WELD COUNTY, COLORADO Policy No: SP 4047371 Effective Date: 12:01 A.M. December 31. 2012 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 0003 00 1206 (XWC) ENDORSEMENT COLORADO NOTICE ENDORSEMENT Effective 12.01 A.M., Local Time, December 31, 2012 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 4047371, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD COUNTY, COLORADO, dated December 31, 2012, SAFETY NATIONAL CASUALTY CORPORATION President Secretary 0241 00 1291 (XWC) ENDORSEMENT INCIDENTAL LONGSHOREMEN'S AND HARBOR WORKERS' COMPENSATION ACT COVERAGE ENDORSEMENT Effective 12:01 A M., Local Time, December 31, 2012 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 4047371, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD COUNTY, COLORADO, dated December 31, 2012. SAFETY NATIONAL CASUALTY CORPORATION v ' W Auk-"aa, Awk---- President Secretary 0276 02 0408 (XWC) ENDORSEMENT BROAD FORM ALL STATES FOR EMPLOYEE TRAVEL Effective 12.01 A.M Local Time, December 31, 2012 In consideration of the payment of premium and adherence by ootn parties to the terms of tnis 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 4047371, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis. Missouri to WELD COUNTY, COLORADO, dated December 31, 2012 SAFETY NATIONAL CASUALTY CORPORATION get W President Secretary 0291 00 0708 (XWC) ENDORSEMENT VOLUNTARY COMPENSATION ENDORSEMENT-PREMIUM DELINEATION Effective 1201 A.M. Local Time. December 31. 2012 In consideration of the payment of premium and adherence by both parties to the terms of this Agreement, it is hereby understood and agreed that this Endorsement adds voluntary compensation insurance to this Agreement as follows: A. Coverage It is the intent of this endorsement to extend the coverage provided by this Agreement to non- compensated volunteer Employees, operating at the direction of the EMPLOYER, as if the volunteer Employees were subject to the Workers' Compensation and Employers' Liability Laws stipulated in the Schedule below, even though these laws may not require payment of benefits to such volunteer Employees. This insurance applies to Loss sustained by the EMPLOYER because of bodily injury and occupational disease, including death resulting therefrom, due to Occurrences taking place within the Liability Period of this Agreement. 1 The bodily injury or occupational disease must be sustained by an Employee included in the group of Employees described in the Schedule. 2. The bodily injury or occupational disease must occur in the course of employment necessary or incidental to work in a State listed in the Schedule. 3. The bodily injury or occupational disease must occur in the United States of America, its territories or possessions or Canada and may occur elsewhere if the Employee is an American or Canadian citizen temporarily away from their home country. 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. i. Release the EMPLOYER and the uuftrunATION, 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 7 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 4047371. issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD COUNTY. COLORADO, dated December 31. 2012. SAFETY NATIONAL CASUALTY CORPORATION k fi, 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. 2012 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. airyulhen, it) 1/u• world outside the. United States or United Stales possessions and territories, except: A/rlhamstan. Alpena, Bela Pus, Burma, Bunauyt, Central A%iiean Republic, Chad. Colombia. Cite 'Moire, Cuba. l)emocratre Republic' of Congo, Eritrea, Guinea, Haiti. Iran. Iraq. Israel. Kent/a. Lebanon. Libya. ltali, Mauritania, .l'iycr. A5peria. A'cnrl/r Korea, Pakistan, Pluhppmes. Republic of South Sudan. Saudi Arabia, Somalia. Siulatt. S do. [Vest Bank and Gaza. }imam, 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 $25000 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 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 4047371. issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD COUNTY, COLORADO. dated December 31, 2012. SAFETY NATIONAL CASUALTY CORPORATION President Secretary Page 2 of 2 0322 00 1291 (XWC) ENDORSEMENT 90-DAYS NOTICE OF CANCELLATION Effective 1201 A M., Local Time December 31. 2012 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 4047371, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD COUNTY, COLORADO, dated December 31. 2012. SAFETY NATIONAL CASUALTY CORPORATION j ' President Secretary 0339 01 0908 (XWC) ENDORSEMENT SAME COMMUNICABLE DISEASE-SPECIFIC EXCESS Effective 1201 A M.. Local Time, December 31. 2012 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 4047371, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD COUNTY, COLORADO, dated December 31, 2012, SAFETY NATIONAL CASUALTY CORPORATION v 1 kerit President Secretary 1061 10 1207 (XWC) ENDORSEMENT POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE Effective 12.01 A.M., Local Time, December 31. 2012 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 5100 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 5100 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 ad 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 4047371, issued by SAFETY NATIONAL CASUALTY CORPORATION of St Louis, Missouri to WELD COUNTY, COLORADO, dated December 31, 2012. SAFETY NATIONAL CASUALTY CORPORATION kPresident Secretary 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 s to its customers for e over 50 customers, except as permuted by law. That years^, We greatly appreciate the trust that you means we may disclose information we have and all of our customers place in us. We protect collected about you to the following types of third that trust by respecting the privacy of all of our parties customers. both present and past. The following will explain our privacy practices so that you will • Our affiliated companies (members of the understand our commitment to your privacy. Delphi Financial group of companies). • Your agent or broker. We Respect Your Privacy • Parties who perform a business or insurance When you apply to Safety National for any type of function for Safety National, including insurance, you disclose information about you to reinsurance, underwriting, claims us. The collection, use and disclosure of such administration or adjusting, investigation, loss information is regulated by law. Safety National control and computer systems companies. and its affiliates maintain physical. electronic and procedural safeguards that comply with state and • Other insurance companies or agents as federal regulations to guard your personal reasonably necessary concerning your 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 not disclose any non-public. personal information about you to non-affiliated companies We may obtain information from third parties, such for marketing purposes or for any other purpose as other insurance or reinsurance companies. except those specifically allowed by law and medical providers. government agencies, described above. information clearinghouses and other public records. We may also obtain information about you from your other transactions with us, our affiliates Independent Sales Agents or Brokers or others. Your policy may have been placed with us through an independent agent or broker ("Sales Agent"). Your Sales Agent may have gathered information What We Do With Your 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 Safety National's. If you have information in evaluating your request for insurance coverage. determining your rates or questions about how your Sales Agent uses or discloses your information, please contact them underwriting risk, servicing your policy or adjusting directly. claims. We may retain information about our former customers and would disclose that information only to affiliates and to non-affiliates as described in this notice or as otherwise permitted by law'. \.',/ti 99 99 28 _ _ — — _ — -- — — —_--..7it No. SP 4047371 SPECIFIC EXCESS WORKERS' COMPENSATION AND I EMPLOYERS' LIABILITY INSURANCE AGREEMENT SAFETY NATIONAL CASUALTY CORPORATION ST. LOUIS, MISSOURI ,//en inn/%'r(.1/IV/he C'OR/'OR:1770 1; In consideration of the pas meni 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 i This Agreement applies only to Loss sustained by the (I I Loss' shall mean actual payments. less recoveries. I EMPLOYER because of liability imposed upon the legally made by the EMPLOYER to Employees and their EMPLOYER by the Workers' Compensation or Fmplo}ers' dependents in satisfaction of: (a) statutory benefits. (h) 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 States) prov ided that the loss shall not he greater by the EMPLOYER, as defined in Paragraph (2) of this than it would have been had liability been imposed M Section The term Loss shall not include the items the States)specified in the Declarations. specifically excluded by Paragraph (3)of this Section. on account of bodily injury by accident or bodily injury bt I2) ..Claim Expenses'' shall mean court costs. interest upon occupational disease due In Occurrences taking place within awards and judgments and the reasonable allocated costs the Liability Period to Employees of the FMPI Ol'13R 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 prosecution of such appeal ardor the posting of such timid) injury includes resulting death. pension or appeal bond is approved by the CORPORATION) of claims, suits or proceedings brought the inclusion of more than one EMPI.O\ER in the against the EMPLOYER under the Workers' Declarations shall not increase the FMPLOA I R s Self-Insured Retention not the COIiPOIZA I ION's Maximum Limit of Compensation or Employers' Liability Laws of the State(sl designated m the Declarations, or other State(s), as Indenumit), provided in Section A. even though such claims, suits. the insurance afforded by this Agreement applies w proceedings or demands are wholly groundless. false or operations in the States) specified in the Declarations. fraudulent Claim Expenses shall not include fees to the including, however, incidental operations conducted by EMI LOY'f-12's Service Company. Employees who ate regularlt engaged in operations in the (3I "Exclusions from loss shall refer to the following specified State(s), but who may he temporarily outside the amounts paid by the Lh1 PLOY FR. and specifically specified State(s I. excluded from the term I.ass: (a) Salaries. wages. and remuneration provided to B. Insurance Under This Agreement Employees: (I) Specific Excess Insurance (h) Fees to the FMPLOYER'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 l.oss. lc) Punitive or eyunplm) damages as they relate to s 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' I lability 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 K of the Declarations tHie separate as to Workers' Compensation benefits owed by the , Employers' Liability Mnxmuun I.inut of Indenmit) Per ' EMPLOYER: Occurrence shall not operate, in any case, to increase the total (c) Assessments and taxes made upon the EMPLOYER amount the C(1RPORA FION agrees to reimburse the as self-insurer whether imposed bt statute, regulation. E:MI'LOYhR for Loss per any one Occurrence as per Item 8(a) or otherwise: of the I lye larauons (I) Any amounts required to be paid hs the EMPLOYER I period of time. reimbursement payments shall he made by the because of: ('ORI'(1RATR I) Set ions and willful misconduct of the ' h.MPLOI'FR, including intentional torts and The CORPORATION shall have, and may exercise at any intentional acts or omissions resulting in injury, true. and from time to lime. the right to offset any balance or acts or omissions taken with reckless disregard of I balances. whether on account of premiums. Losses or II the possible occurrence of an injury or acts ur others',Ise. due from the EMPLOYER to the CORPORA LION omissions taken that are substantially certain to against any balance or balances due from the CORPORA I ION icsult in injun, regardless of shether or not said to the IiMI'LOYER under this Agreement. odium. uses he classified io the Staffs(s) a- intentional torts. F. Liability Period 2) coercion criticism demotion, cs:duation, The liability of the CORPORATION for Loss hereunder shall reassignment. discipline defamation. harassment. he determined separately for each Liability Period. the initial humiliation, discrunm won against or ternunation Liability Period shall commence at 12.01 A.M. on the of am 1-ntplovee and or related personnel Effective Date and end at I2:01 A NI on the Anniversary bate, practices, policies, acts or omissions by the designated in Items 3 and 4 respectively, of the Declarations. I:MI'LOYII IC Each succeeding I.lability Period shall begin concurrently with 3) Knowingly employing an Employee in violation the end of the prey ions Liability Period and continue for the of law, same number of conseetaise 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. 51failure to comply with any health. safety, or notification law or regulation. In the event the EMPLOYER fails to give express written (g) Loss voluntarily assumed by the EMPLOYER under intent to continue coverage at the end of a given Liability. any contract or agreement. whether express or implied: Period. the Agreement shall he deemed terminated. and the I (hl Loss for which the EMPLOYER carries a full ' Anniversary Date shall serve as the termination date of the coverage Workers' Compensation and Employers' Agreement- Liability policy:and ail Any amount owed by the I'Ml'I OVER pursuant to F. Premium pros ision of any law that provides non-occupational t;yon acceptance of the Agreement and at the beginning of disability benefits. each Payroll Reporting Period, as specified in Item 12 of the (4) "Occurrence"' — shall mean accident. In addition, bodily Declarations, the EMPLOYER shall pay to the injury by occupational disease must he caused or CORPORATION the amount of the Deposit Premium aggravated by the conditions of employment and shall be specified in Item I I of the Declarations. The EMPLOYER deemed to have occurred on the last day of the last shall pay premiums when due The Deposit Premium shall he exposure to those conditions of employment causing or held by the CORPORA HON until the expiration of the Payroll aggravating such injury by occupational disease, or such Reporting Period Within thirty (111) days after the dose of ' dates as is otherwise established by the Workers' • each Payroll Reporting Period, the EM F'I.OVER shall render Compensation and Employers' Liability Laws of the to the ('ORPORAI ION a report. upon a form satisfactory to appropriate State(s). Bodily injury by occupational the CORPORATION. exhibiting. by classification, the amount disease sustained by each Employee shall be deemed to be of such remuneration earned by Employees during such , a separate Occurrence unless such disease results directly ieportine period. and the EMPLOYER shall therewith pay to from an aceidr°t the CORPORA PION the excess of the Yarned Premium over (5) "Employee"' as respects liability unposed upon the the Deposit Premium previously paid. In case the Deposit EMPLOYER by the Workers' Compensation Lass of any Premium paid exceeds the Earned Premium, the State. the word Employee shall mean any person CORPORATION shall noun to the EMPLOYER the amount • performing work which renders the EMPLOYER liable - under the Workers' Compensation I.aw of a State named in °f such excess or gtre appropriate credit, subject to the Item 2 of the Declarations. which is the State of the ; proputvun of Minimum Premium for the Liability Period in injured Empioy.ee s normal employment, for bodilythe case of nuthi-year Liability Periods. injuries or occupational disease sustained by such person. (6) "State' shall mean any state, territory. or possession of• lip on expiration of a Liability Period. a summary of voluntary the I Inited States of America and the District of Columbia. payroll reports for such I lability Period shall he made to • determine the Earned Premium under this Agreement, In no ' event. however, shall the Earned Premium in respect of any U. Reimbursement If the EMPLOYER pass any Loss incurred in any Liability Liability Period he less than the Minimum Premium specified Period in excess of the Self-Insured Retention Per Occurrence. in the Declarations. the CORPORA ETON shall reimburse the EMPLOYER upon I _ receipt of a formal proof of loss and other cy mdenee acceptable For each Payroll Reporting Period, the CORPORATION shall to the t()RI'(iRA MCIN of such f aspteitt 1Pdhdn e rat.rm,tb ' nmpnte the harried Premnim as follows' I'I — _ (I) Remuneration -- the remuneration earned. or man hours I addition. the electronic transfer of loss information by a accumulated during such period hs all hmplopees. l Service ( ongran) of the EMPLOYER shall not constitute including volunteers. engaged in each classification notice of a claim. covered by this Agreement shall he computed in accordai e 'sith the rules set forth appropriate Cancellation of the service agreement between the Service - Manual of Workers' Compensation and Employers' Company and the EMPLOYER shall operate as a notice of Liahilit) Insurance. cancellation of this Agreement b) the EMPLOYER, subject to (7) Manual and Standard Premium J !he remuneration. or the additional terns of the Cancellation Section of this ji man-hours. so computed fur F_ntplovees engaged in each Agreement, Any change in sea ice companies must he such classitication shall he multiplied by the Manual Rate immediately communicated to and approved in tire per Sl00 of remuneration man-hour. in effect at the CORPORATION. and this obligation shall survive the I inception of each Payroll Reporting Period, and the termination or non-renewal of this Agreement products so obtained shall be added together to determine the Manual Premium, An Experience Modification Factor I. Prompt Reporting of Claims ma) be applied to the Manual Premium to determine a As soon as the I:MI'LOYER becomes aware. the EMPLOYER Standard Premium. Such Experience Modification Factor must provide prompt notice to the CORPORATION of (a) any shall be determined at the inception or this .Agreement and claint or action commenced against the EMPLOYER which is subject to annual review and possible revision. A exceeds. or is likely to exceed. tiff) percent (50%) of the Self- Standard Premium takes precedence Deer any Manual Insured Retention Per Occurrence specified in Item 7 of the Premium_ Declarations and (h) the reopening of any claim in which a (3) Famed Premium — Against the Manual or Standard further award might invols c Nobility of the CORPORATION • Premium shall he applied the Premium Rate, as specified ; under this Agreement. in Item r) of the Declarations. to determine the appropriate Earned Premium. In addition. the following categories of claims shall he reported to the C'OR I'OR A I ION immediately. regardless of I his Agreement is issued by the CORPORATION and any question of potential involvement of the CORPORATION: accepted En. the EMPLOYER subject to the agreement that. in I. Fatalities: the event of any change in the Rates per Slot) '__ Paraplegics and quadriplegics: remuneration man-hour. as stated in Item 6 of the . . Serious burns. defined nc d^•3 or 3r° degree burns Declaration_, because of any general rate increase or any invuly ing 259 or more of the body: legislative amendment affecting the benefits under the 4, Brain injury: Workers' Compensation Law of any State(s) named in hem 2 5. Spinal cord injury: of the Declarations, such change. upon the effective date 6. Amputation ofa major extremity: and thereof. shall he. without endorsement, made a part of this 7. Any Occurrence which results in a serious injury Agreement, to two or more lintployees. G. Self-Insurer If the CORPORATION is prejudiced by the E:MI'LOYE_R's The HOPI OVER, be acceptance of this Agreement warrants failure to provide prompt notice of a claim in accordance with that it is a duly qualified sell-Insurer in the State(s) designated the requirements set forth above and or as otherwise provided in ncc Declarations, and will "Mimic to maintain such by the l.aw of any State(s). the ('ORPORATION stay elect to qualifications during the currents of this Agreement. In the dens cover ee for Loss arising from such claim. To constitute esent the EMPLOYER should at any lime while this prompt. still'clew notice, the EMPLOYER must provide Agreement is in fixes terminate such qualifications or if the), complete intornlation as to the derails of the injure. disease. or should he cancelled or revoked, such loss of qualifications death shall operate as notice of cancellation of this Agreement by the ' EMPLOYER, subject to the additional terms of the J. Defense of Claims Cancellation Section of this Agreement. The EMPLOYER shall investigate and settle or defend all claims and shall conduct the defense and appeal of all actions. II. Service and Administration suits. and proceed saes commenced against it. The This Agreement contemplates the concurrent and continued EMPLOYER shall forward promptly to the CORPORATION existence of a separate sery ice agreement between the copies of any plcadinus or reports as may he requested. The FNII't_OYFR and the Service Company. its designated CORPORAL ION shall not he obliged to assume charge of the reprcx•mmtice named in Item 5 of the Declarations, providing insestig:uion, defense, appeal or settlement of arm claim. suit. services approved by the CORPORA"! ION. The EMPLOYERor proceeding brought against the EMPLOYER, hot the agrees that its Sans d Compam shall ail-nisi) the ('OILPORA I ION shall he given the opportunity to investigate. CORPORA I ION with quarterly loss runs concurrent with each I.i.iltility Period of this AgreementThe provision of loss defend, or participate with the EMPLOYER in the • utmcsliga runs alone does not relieve the EMPLOYE R of its reporting uon and defense of am claim, if, in the opinion of the obligations as set Ioi1h m Section I nI this :x grxman. In C•ORP(-IR ATION its liandir' ender rhis Agreement might he Iinvolved. �- - - . - ---- .rug , K. Good Faith Claims Administration I mitigate arts Loss under this Agreement shall first bs used to The EMPLOYER shall use diligence, prudence. and good faith pas the expenses of collection and to reimburse the in the insestiunion. defense, pursuit of recosery from others CORPORATION fir ins amount it may have paid the and settlement of all claims. the EMPLOYER shall not EMPLOYER for the Liabilits Period concerned, and all unreasonahls refuse to settle :ms claim which, in the exercise remainim_ antounts collected shall he paid to the EMPLOYER, of sound judgment ss oh respect to the entire claim, should he settled. provided. however. that the EMPLOYER shall not O. Change in Agreement make any payment or agree to any settlement for any sum No condition. provision. or declaration of this Agreement shall which would involve the broils or the CORPORA) iON's he waked or altered at inn time except as specified in Section Iiabilily hereunder without the approsal of the t, except b•y endorsement signed bs tine President or a Seniw, CORPORAA FION. Vice President and the Secretary or an Assistant t Secretary of the CORPORA I ION. If the CORPORA-ION is prejudiced by the [MP!.OYER's failure to exercise diligence, prudence. and good faith, the This Agreement hereby terminates. supersedes. and replaces CURPOR 4TION may elect to disclaim coverage or Loss all previousIs issued Workers. Compensation Insurance or Eteinsurancc Agreements. as amended. hetween the 'row such claim. I.A1PLOYI R and the CORPORA I ION. I.. Inspection and Audit I he CORPORA ION shall base the right. but not the If terms of this Agreement are in conflict with any law obligation, to insprct the premises and equipment and or to applicable to this Agreement, this statement amends this • audit the books and records of the F.MPI.OYI.H and of its Agreement nt conform to such law. In addition, in the event any terms are in conflict with applicable laws. the «mauune agents and representatives. including all records relating to pas roll and claims matters, at any reasonable time during meterms of the Agreement shall he enforceable. period of this Agreement and within three (3) sears after final P. Cancellation settlement of all claims due to Occurrences happening during .Ibis Agreement mas 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 soluntars the date of eancelhnion, except, that if the CORPORATION payroll reports by the EMPLOYER, and will he used to cancels fill non-payment of any premium. the cancellation li determine the final adjustment of premiums due to the shall become effective ten (I(I) days after dispatch of notice by Il CORPORATION_ Should a determination he made that the CORPORA LION. The date of cancellation then becomes additional audit premium is due to the CORPORA PION, 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)doss after the date of billing. taking place after the effective date of such cancellation. AL Other Insurance If cancellation is effected by the EMPLOI ER. the Manual or If the EMPLOYER carries other valid and collectible Standard Premium shall he determined by the short rate tables insurance. reinsurance. or indemnify with any other insurer or used for casualty insurance and the Earned Premium shall be reinsurer covering a Loss also coveted by this Agreement the product of the premium Rate (Rent 9) times the Manual or (other than insurance or reinsurance that is purchased to apply Standard Premium (or the Total Annual Remuneration) so in excess of the sum of the Self-Insured Retention and the arrived at, but not less that the Minimum Premium specified in Maximum Limits of Indemnity hereunder). the insurance the Declarations. afforded by tins Agreement shall apply in excess of and shall not contribute with such other insurance or reinsurance. If cancellation is effected by the CORPORATION for non- payment of premium. the EMPLOYER shall pas the N. Recovery from Others CORI'OItAIION Earned Premium for the period up to the The F_MI't OVER agrees to prosecute ally and all valid claims date of cancellation. the E\fl'LOYER rimy have against any other party or source that may mitigate any Loss under this Agreement and return to If the CORPORATION cancels for any other reason. the the CORPORATION any amount so recovered, less the I Manual or Standard Premium (or the Total Annual reasonable expense of collecting such amouo1i- Remuneration) shall he determined upon a pro rata basis and The CORPORA' ION shall have the EMPLOYER•s rights to the Earned Premium adjusted in accordance therewith. prosecute any and all valid claims against any other parts or Q Assignment source that may mitigate any Loss under this Agreement. The An assignment of interest under this Agreement will not hind EMPLOYER Ili trees that it will assist the CORPORATION in the CORPORA I ION unless an endorsement signed by the any prosecution or any and all valid claims against any other President or a Senior Vice President and the Secrewn_ or an parts or source that man mitigate any Loss under this - - Asystant lecretan of the CORPORA I ION assigning interest Aer'eemem. Any amounts recovered by the EMPLOYER or outlet an, A ceit�em t��o hs Lie C'ORPOR A llON the Ct)RPORAITON from any party or source that may R. Bankruptcy or Insolvency of Employer in the .tpplic ttion are the I.MPLOY'PR's representations; that I. I he bankruptcy or insolvency of the EMPLOYER will not this Agreement is issued in reliance upon such representations. '� relieve the CORPORA ZION or the EMPLOYER of its duties ' that this Agreement embodies all agreements existing between and liabilities under this Agreement. Alter payments have the EMPLOYER and the CORPORATION. or ans of its been made by or on behalf of the EA71'I (IVlR mgaus, relating to this excess msurnnce. and that titll reimbursements due under this Agreement will he made by compliance by the EMPLOYER with all terms of this Ili the CORPORA I ION as if the EMPLOYER had not become Agreement is a condition precedent to the CORPORA IION's bankrupt or insolvent, but not in excess of the liability hereunder. 'CORPORATIONs limit of indemnity- II S. Sole Representative If more than one r-MPI OYER is named in Item I of the Declarations, or an endorsement related thereto_ the EM- PLOYER first named in Item L or a related endorsement, will act on behalf of all [MPI DYERS to give or receive notice of cancellation- to receive return pienuunh or reimbursement. or to request changes in this Agreement. IN WITNESS WHEREOF, S.A Fri lit NATIONAL. ('ASUAI:IY CORPORATION has caused this Agreement to T. Acceptance he executed by printing below the facsimile signatures of its ' By acceptance of this Agreement. the EMPLOYER agrees President and Secretary and by the actual signature of its that the statements in this Agreement. in the Declarations, and Secretary on the Declarations. I I President • Secretary • I �� I 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. Hello