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Home My WebLink About000289.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 4054230 TYPE OF INSURANCE: Specific Excess Workers' Compensation and Employers' Liability Insurance LOCATION(S): COLORADO POLICY LIABILITY PERIOD: December 31, 2015 through December 31, 2017 POLICY PAYROLL REPORTING PERIOD: December 31, 2015 through December 31, 2016 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 $ 0.165 per$100 of Payroll Minimum Premium for the Liability Period $ 239,359 Deposit Premium for the Payroll Reporting Period $ 132,977 For purposes of this Rate Commitment: 2015 Policy Period refers to the policy period of: 12/31/2015-12/31/2016 2016 Policy Period refers to the policy period of: 12/31/2016-12/31/2017 If the below conditions are all met, Safety National agrees that there will be an increase of no more than 0% in the premium rate per payroll/exposure for the 2016 Policy Period over the rates that had been applied to the 2015 Policy Period. The SIR and Limits will remain as expiring per the 2015 Policy Period bound with Safety National. 1) No certified "act of terrorism", as defined under the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization of 2015 ("TRIPRA"), occurs during the 2015 Policy Period. 2) No significant change in exposure as applicable to the type of policy with "significant" being understood to mean a ±20% change in exposure for any of the Policies over that for the 2015 Policy Period bound with Safety National. 3) No significant change in underwriting exposure through development of, or acquisition of, non-core business, with "significant" being understood to be a change that is in excess of 10% for any Policy over that in place for 2015 Policy Period bound with Safety National. 4> No individual incurred loss during the 2015 Policy Period for any of the Policies to exceed 75% of that Policy's applicable SIR/Retention amount with such losses to be valued as of 10/1/2016. The parties understand and agree that, if all the above stated conditions are not met as applicable to a particular policy period renewal, the Premium Rate per payroll/exposure for the 2016 Policy Period shall not be subject to any limitation nor guarantee with respect to rate increases. This binder is effective December 31, 2015 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 16, 2015. SAFETY NATIONAL CASUALTY CORPORATION By: Seth A. Smith Senior Vice President Workers' Compensation Underwriting 1832 Schuetz Road St. Louis MO 63146-3540 314-995-5300 fax 314-995-3843 00oaS1 1004 00 1101 (XWC) Endorsement Schedule RE: WELD COUNTY, COLORADO Policy No: SP 4054230 Effective Date: 12:01 A.M. December 31, 2015 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 11 0115 (XWC) POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE t C R 1 s i s [SAFETYNATIONAL PROTECTION - BENEFIT INFORMATION - Available Exclusively to Safety National's Excess and Large Deductible Workers'Compensation Policyholders SAFETY NATIONAL CRISIS PROTECTION NOTIFICATION EMAIL ADDRESS: crisisprotection@safetynational.com SAFETY NATIONAL CRISIS PROTECTION 24-HOUR HOTLINE: (855)887-3254 DEF/N/T/ONS A. Domestic Crisis Event means a man-made emergency situation limited to an explosion, arson, bombing, workplace violence, structural fire or a vehicular accident occurring entirely in the United States and/or any territories or possessions of the same. Domestic Crisis Event also means a natural disaster at owned, leased or designated workplace locations limited to a tornado, explosion, wildfire, structural fire, earthquake and any resulting tsunami, hurricane or flood occurring entirely in the United States and/or any territories or possessions of the same. In order to qualify as a Domestic Crisis Event, an event must directly involve the death of two (2) or more of Your Employees. Safety National Casualty Corporation ("Safety National") shall solely determine what qualifies as a Domestic Crisis Event for purposes of this benefit. B. International Extraction Crisis Event means an international crisis directly involving Your Employees and resulting in their immediate need of removal from a geographic location to • avoid imminent serious injury or death as the result of an existing emergency situation. An International Extraction Crisis Event is limited to employee extraction from a man-made emergency situation only as the result of an explosion, arson, bombing, riot, or government collapse and political unrest. An International Extraction Crisis Event that necessitates employee extraction as the result of a natural disaster is limited to a tornado, explosion, wildfire, earthquake and any resulting tsunami, cyclone/typhoon/hurricane or flood. Safety National shall solely determine what qualifies as an International Extraction Crisis Event for purposes of this benefit. C. Your Employees means any of Your full-time employees that are direct employees of Your company and directly involved in a qualifying event. It specifically excludes any contractors, temporary or part-time workers. Safety National specifically restricts Safety National Crisis Protection to, and will only provide benefits for, Your Employees who are directly covered by any excess or large deductible workers' compensation insurance policy issued to You by Safety National and who are currently employed at the time of the qualifying event. *Safety National Crisis Protection is a complimentary benefit for Safety National's excess and large deductible workers' compensation customers only and is NOT an insurance coverage or policy of any type. 1 of D. Immediate Family Member means spouse, child or children and parents of Your Employee directly involved in a Domestic Crisis Event. E. You, Your and Yours shall refer to an excess or large deductible workers' compensation policyholder of Safety National who has an active and fully-paid policy at the time of the qualifying event. F. Warning Country shall refer to any country, territory, province or geographical location listed by the United States Department of State at http://travel.state.gov/content/passports/english/alertswarnings.html as a location for which a travel warning has been issued and is currently active. Safety National shall solely determine whether a certain country, territory, province or geographical location is considered a Warning Country at the time of the qualifying event. G. Sanctioned Country shall refer to any country, territory, province or geographical location listed by the United States Department of the Treasury at http://www.treasury.gov/resource-center/sanctions/Programs/Pages/Programs.aspx as the subject of any current Office of Foreign Assets Control ("OFAC") sanctions program. Safety National shall solely determine whether a certain country, territory, province or geographical location is considered a Sanctioned Country at the time of the qualifying event. YOUR BENEF/TS UNDER SAFETY NAT/ONAL CR/S/S PROTECT/ON* As a valued policyholder, Safety National has developed the Safety National Crisis Protection program as a complimentary benefit available to You. If a qualifying Domestic Crisis Event occurs that directly involves You as a Safety National excess or large deductible workers' compensation policyholder, Safety National will pay to cover the cost of either a Safety National approved crisis management firm, crisis response firm, public relations firm and/or for emergency psychological services up to the annual, aggregate limit of the benefit. If You choose to use an unapproved vendor, reimbursement will be made directly to You for services that are approved by Safety National, up to the annual, aggregate limit of this benefit. In the event that a qualifying International Extraction Crisis Event occurs that directly involves You as a Safety National excess or large deductible workers' compensation policyholder, Safety National will reimburse You to cover the cost of expenses approved by Safety National involving an employee extraction firm of Your choice. With respect to any International Extraction Crisis Event, Safety National will provide this benefit for qualifying events anywhere in the world outside the United States or United States possessions and territories, except for events that occur in any country, territory, province or geographical location listed as a Warning Country by the United States Department of State on the initial date that You report the International Extraction Crisis Event to Safety National. Safety National will also not provide this benefit for events that occur in any country, territory, province or geographical location listed by the United States Department of Treasury as the subject of any current Office of Foreign Assets Control ("OFAC") sanctions program on the initial date that You report the International Extraction Crisis Event to Safety National. The total annual, aggregate limit for a Domestic Crisis Event, an International Extraction Crisis Event, or any combination of the two is $50,000 for any active excess or large deductible workers' compensation policy year. In the case of a multi-year excess or large deductible workers' compensation policy, the $50,000 annual, aggregate limit shall renew on the annual anniversary date of such multi-year policy. There is no sublimit for a Domestic Crisis Event or International Extraction Crisis Event but in no instance will Safety National pay an approved vendor and/or reimburse You more than $50,000 in any one-year period. For the sake of clarity, Safety National will only pay up to *Safety National Crisis Protection is a complimentary benefit for Safety National's excess and large deductible workers' compensation customers only and is NOT an insurance coverage or policy of any type. 2of3 the maximum of$50,000 in any one year that coincides with your active and fully-paid excess or large deductible workers' compensation insurance policy with Safety National. The annual, aggregate benefit limit of$50,000 shall apply regardless of the number of policies You have with Safety National. SCOPE OF BENEFITS UNDER SAFETYNA T/ONAL CR/S/S PROTECT/ON* In order to take advantage of this benefit: (1) the Domestic Crisis Event or International Extraction Crisis Event must directly involve Your business and occur within the period of coverage provided by Safety National to You under an active and fully-paid excess or large deductible workers' compensation insurance policy; (2) the facts, circumstances, pre-existing condition(s) or situation(s) that lead up to the Domestic Crisis Event or International Extraction Crisis Event were not known to You in advance; and (3) the Domestic Crisis Event or International Extraction Crisis Event had not affected Your operation in any way before the current policy period began. Since Safety National has approved vendors for Domestic Crisis Events, you can contact them via the following 24-hour hotline as soon as the event occurs: (855) 887-3254. Black Swan Solutions is the Safety National approved vendor for Crisis Management and Counseling and takes all incoming calls regarding Domestic Crisis Events. In the event You need to get in contact with another approved vendor for a Crisis Communication/Public Relations situation, Black Swan Solutions will route Your call to the appropriate vendor. During Your initial call with Black Swan Solutions, You must provide: (1) Your active excess or large deductible workers' compensation account name, (2) Your policy number and (3) the effective date of that policy. If an International Extraction Crisis Event occurs, since there are no approved vendors, You should contact the vendor of Your choice and Safety National will reimburse you for those approved costs up to the above listed annual, aggregate limit. In addition to contacting a vendor, You must notify Safety National within five (51 business days of any Domestic Crisis Event or International Extraction Crisis Event which may result in any benefits under Safety National Crisis Protection at the following email address: crisisnrotection( safetvnational.coal. Failure to do so may void this benefit and any payments or reimbursements by Safety National. This email address is also listed at the beginning of this benefit information packet. Further written notification regarding specifics of the qualifying event must be made as soon as possible after the initial email notification. The written notification must include when, where and how the Domestic Crisis Event or International Extraction Crisis Event occurred, and the nature of the injuries or damages You have experienced to date as well as those You expect to experience as a result of the Domestic Crisis Event or International Extraction Crisis Event. Any notice You provide to Black Swan Solutions and/or Safety National under this Safety National Crisis Protection benefit program shall NOT be considered a notice of loss under any Safety National excess or large deductible workers' compensation insurance policy. All invoices and receipts relating to any request for direct vendor payment and/or reimbursement to You under this benefit must be submitted to Safety National for payment within sixty (60) days from the original date they were generated. Any older invoices or receipts will not be paid by Safety National. Safety National Crisis Protection is a complimentary benefit for Safety National's excess and large deductible workers' compensation customers only and is NOT an insurance coverage or policy of any type. 3 of 3 Esther Gesick From: Michelle Raimer Sent: Monday, December 28, 2015 9:43 AM To: Esther Gesick Cc: Don Warden Subject: Excess Work Comp and Employers' Liability Binder Attachments: Weld County Binder.pdf Good morning Esther, Please find the attached excess work comp and employers' liability coverage binder which I'm forwarding to you to capture in Tyler. Let me know if you need additional information...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." rr 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. Hello