HomeMy WebLinkAbout000306.tiff Cheryl Hoffman
From: Michelle Raimer
Sent: Monday, April 30, 2018 2:27 PM
To: Cheryl Hoffman
Cc: Don Warden
Subject: FW:Weld: 2018 Excess Work Comp Policy
Attachments: C:\Users\tmpaladino\AppData\Local\Temp
\WeldCounty,Colorado_POLCLNT_WRKCOMP_01162018.pdf
Hello Cheryl,
Attached is Weld County's excess work comp policy for 2018 thru 2019.
Michelle Raimer
HR Analyst- Risk Programs
Human Resources
P O Box 758
Greeley CO 80632
tel: 970-400-4233
cell: 970-302-2423
fax: 970-400-4024
"Bringing out the best in our employees through sustained service and support."
f' Sri
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.
From:Tracy Paladino [mailto:Tracy_Paladino@AJG.com]
Sent: Friday, April 27, 2018 5:57 PM
To: Michelle Raimer<mraimer@weldgov.com>
Subject:Weld: 2018 Excess Work Comp Policy
Hi Michelle—
Attached please find your 2018 Excess Work Comp policy. We have completed our review and found the
policy was issued correctly.
If you have any questions or need any additional information, please do not hesitate to contact me!
Respectfully,
1 00 oZ
Tracy Paladino, CISR, CLCS, CIC, CRM
Senior Client Service Manager/ Professional Standards Coordinator
Public Sector I Higher Education
Erb
. Gallagher
Insurance I Risk Management I Consulting
P: 303-889-2614 1800.333.3231 Ext 2614 I F: 303-889-2615
tracy paladino cr.aiq.com
www.aiq.com
6300 S. Syracuse Way, Suite 700 Centennial,CO 80111
This email and any files transmitted with it are intended only for the person or entity to which it is addressed and may contain confidential material and/or material that is
protected by law. Any retransmission or use of this information may be a violation of that law. If you received this in error,please contact the sender and delete the material
from any computer.
2
SAFETY NATIONAL CASUALTY CORPORATION
1832 SCHUETZ ROAD
ST. LOUIS, MO 63146
DECLARATIONS-SPECIFIC EXCESS SP 4058215
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, 2017
Item 4. Anniversary Date: 12:01 A.M. December 31, 2019
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 $ 0.165 per$100 of Payroll
Item 10. Minimum Premium for the Liability Period $ 278,824
Item 11. Deposit Premium for the Payroll Reporting Period $ 154,902
Item 12. Payroll Reporting Period December 31, 2017 through December 31, 2018
Item 13. Endorsements See Endorsement Schedule
W.
Signed at St. Louis, Missouri on January 02, 2018
Secretary
Countersigned this day of
By: N/A
DSP-0195
1005 00 1101 (XWC)
ITEM 6
RE: WELD COUNTY, COLORADO
Policy No: SP 4058215
Effective Date: 12:01 A.M. December 31, 2017
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 $8,793,977 N/A N/A
Limousine Co.:All Other Employees&Drivers 7382 If Any
Police Officers&Drivers 7720 $23,652,362
Salesperson,Collectors or Messengers-Outside 8742 $8,385,106
Clerical Office Employees NOC 8810 $37,114,522
Attorney-All Employees&Clerical,Messengers,Drivers 8820 $5,116,963
Physician&Clerical 8832 $4,328,580
Buildings-Operation by Contractors 9014 $269,335
Building-Operation by Owner or Lessee 9015 $1,404,544
Municipal,Township,County or State Employee NOC 9410 $4,814,503
$93,879,892
Total Payroll $93,879,892
1004 00 1101 (XWC)
Endorsement Schedule
RE: WELD COUNTY, COLORADO
Policy No: SP 4058215
Effective Date: 12:01 A.M. December 31, 2017
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
No. SP 4058215
SPECIFIC EXCESS
WORKERS' COMPENSATION AND
EMPLOYERS' LIABILITY INSURANCE AGREEMENT
SAFETY NATIONAL CASUALTY CORPORATION
ST. LOUIS, MISSOURI
(Hereinafier 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. prosecution of such appeal and/or the posting of such
Bodily injury includes resulting death. pension or appeal bond is approved by the
The inclusion of more than one EMPLOYER in the CORPORATION) of claims, suits or proceedings brought
Declarations shall not increase the EMPLOYER's Self-Insured against the EMPLOYER under the Workers'
Retention nor the CORPORATION's Maximum Limit of Compensation or Employers' Liability Laws of the State(s)
Indemnity. designated in the Declarations, or other State(s), as
provided in Section A, even though such claims, suits,
proceedings or demands are wholly groundless, false or
The insurance afforded by this Agreement applies to
operations in the State(s) specified in the Declarations, fraudulent. Claim Expenses shall not include fees to the
including, however, incidental operations conducted by EMPLOYER's Service Company.
Employees who are regularly engaged in operations in the (3) "Exclusions from Loss" — shall refer to the following
specified State(s), but who may be temporarily outside the amounts paid by the EMPLOYER, and specifically
specified State(s). excluded from the term Loss:
(a) Salaries, wages, and remuneration provided to
B. Insurance Under This Agreement Employees;
(1) Specific Excess Insurance (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.
S PR(-O'fR-.-A I
(f) Any amounts required to be paid by the EMPLOYER period of time, reimbursement payments shall be made by the
because of: CORPORATION.
1) Serious and willful misconduct of the
EMPLOYER, including intentional torts and The CORPORATION shall have, and may exercise at any
intentional acts or omissions resulting in injury, time, and from time to time, the right to offset any balance or
acts or omissions taken with reckless disregard of balances, whether on account of premiums, Losses or
the possible occurrence of an injury or acts or otherwise, due from the EMPLOYER to the CORPORATION
omissions taken that are substantially certain to against any balance or balances due from the CORPORATION
result in injury, regardless of whether or not said to the EMPLOYER under this Agreement.
actions may be classified in the State(s) as
intentional torts, E. Liability Period
2) Coercion, criticism, demotion, evaluation, The liability of the CORPORATION for Loss hereunder shall
reassignment, discipline, defamation, harassment, be determined separately for each Liability Period. The initial
humiliation, discrimination against or termination 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
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 be deemed terminated, and the
(h) 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
(i) Any amount owed by the EMPLOYER pursuant to F. Premium
provision of any law that provides non-occupational Upon 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 be caused or CORPORATION the amount of the Deposit Premium
aggravated by the conditions of employment and shall be specified in Item 11 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 be
exposure to those conditions of employment causing or held by the CORPORATION until the expiration of the Payroll
aggravating such injury by occupational disease, or such Reporting Period. Within thirty (30) days after the close of
dates as is otherwise established by the Workers' each Payroll Reporting Period, the EMPLOYER shall render
Compensation and Employers' Liability Laws of the to the CORPORATION 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 reporting period, and the EMPLOYER shall therewith pay to
from an accident. the CORPORATION the excess of the Earned Premium over
(5) "Employee" — as respects liability imposed upon the the Deposit Premium previously paid. In case the Deposit
EMPLOYER by the Workers' Compensation Law of any premium paid exceeds the Earned Premium, the
State, the word Employee shall mean any person CORPORATION shall return to the EMPLOYER the amount
performing work which renders the EMPLOYER liable of such excess or give appropriate credit, subject to the
under the Workers' Compensation Law of a State named in proportion of Minimum Premium for the Liability Period in
Item 2 of the Declarations, which is the State of the
injured Employee's normal employment, for bodily the case of multi-year Liability Periods.
injuries or occupational disease sustained by such person.
(6) "State" — shall mean any state, territory, or possession of Upon expiration of a Liability Period, a summary of voluntary
the United States of America and the District of Columbia. payroll reports for such Liability Period shall be made to
determine the Earned Premium under this Agreement. In no
D. Reimbursement event, however, shall the Earned Premium in respect of any
If the EMPLOYER pays any Loss incurred in any Liability Liability Period be less than the Minimum Premium specified
Period in excess of the Self-Insured Retention Per Occurrence, in the Declarations.
the CORPORATION shall reimburse the EMPLOYER upon
receipt of a formal proof of loss and other evidence acceptable For each Payroll Reporting Period, the CORPORATION shall
to the CORPORATION of such payment. Within a reasonable compute the Earned Premium as follows:
SPWGOUOR-4I
(I) Remuneration — The remuneration earned, or man hours addition, the electronic transfer of loss information by a
accumulated during such period by all Employees, Service Company of the EMPLOYER shall not constitute
including volunteers, engaged in each classification notice of a claim.
covered by this Agreement shall be computed in
accordance with the rules set forth in the 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
Liability Insurance. cancellation of this Agreement by the EMPLOYER, subject to
(2) Manual and Standard Premium — The remuneration, or the additional terms of the Cancellation Section of this
man-hours, so computed for Employees engaged in each Agreement. Any change in service companies must be
such classification shall be multiplied by the Manual Rate immediately communicated to and approved by the
per $100 of remuneration/man-hour, in effect at the CORPORATION, and this obligation shall survive the
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-
may be applied to the Manual Premium to determine a As soon as the EMPLOYER 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 of this Agreement and claim or action commenced against the EMPLOYER which
is subject to annual review and possible revision. A exceeds, or is likely to exceed, fifty percent (50%) of the Self-
Standard Premium takes precedence over any Manual Insured Retention Per Occurrence specified in Item 7 of the
Premium. Declarations and (b) the reopening of any claim in which a
(3) Earned Premium — Against the Manual or Standard further award might involve liability of the CORPORATION
Premium shall be applied the Premium Rate, as specified under this Agreement.
in Item 9 of the Declarations, to determine the appropriate
Earned Premium. In addition, the following categories of claims shall be
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 1. 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 burns
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.
G. Self-Insurer If the CORPORATION is prejudiced by the EMPLOYER's
The EMPLOYER, by acceptance of this Agreement, warrants failure to provide prompt notice of a claim in accordance with
that it is a duly qualified Self-Insurer in the State(s) designated the requirements set forth above and/or as otherwise provided
in the Declarations, and will continue to maintain such by the Law of any State(s), the CORPORATION may elect to
qualifications during the currency of this Agreement. In the deny coverage for Loss arising from such claim. To constitute
event the EMPLOYER should at any time while this prompt, sufficient notice, the EMPLOYER must provide
Agreement is in force terminate such qualifications or if they complete information as to the details of the injury, disease, or
should be 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,
H. Service and Administration suits, and proceedings commenced against it. The
This Agreement contemplates the concurrent and continued EMPLOYER shall forward promptly to the CORPORATION
existence of a separate service agreement between the copies of any pleadings or reports as may be requested. The
EMPLOYER and the Service Company, its designated CORPORATION shall not be obliged to assume charge of the
representative, named in Item 5 of the Declarations, providing investigation, defense, appeal or settlement of any claim, suit,
services approved by the CORPORATION. The EMPLOYER or proceeding brought against the EMPLOYER, but the
agrees that its Service Company shall furnish the CORPORATION shall be given the opportunity to investigate,
CORPORATION with quarterly loss runs concurrent with
each Liability Period of this Agreement. The provision of loss defend, or participate with the EMPLOYER in the
runs alone does not relieve the EMPLOYER of its reporting investigation and defense of any claim, if, in the opinion of the
[of this Agreement. In CORPORATION, its liability under this Agreement might be
obligations as set forth in Section
involved.
SPW C-09UR-A I
K. Good Faith Claims Administration mitigate any Loss under this Agreement shall first by used to
The EMPLOYER shall use diligence, prudence,and good faith pay the expenses of collection and to reimburse the
in the investigation, defense, pursuit of recovery from others CORPORATION for any amount it may have paid the
and settlement of all claims. The EMPLOYER shall not EMPLOYER for the Liability Period concerned, and all
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 No condition, provision, or declaration of this Agreement shall
which would involve the limits of the CORPORATION's be waived or altered at any time, except as specified in Section
liability hereunder without the approval of the F, except by endorsement signed by the President or a Senior
CORPORATION. Vice President and the Secretary or an Assistant Secretary of
the CORPORATION.
If the CORPORATION is prejudiced by the EMPLOYER's
failure to exercise diligence, prudence, and good faith, the This Agreement hereby terminates, supersedes, and replaces
CORPORATION may elect to disclaim coverage for Loss all previously issued Workers' Compensation Insurance or
from such claim. Reinsurance Agreements, as amended, between the
EMPLOYER and the CORPORATION.
L. Inspection and Audit
The CORPORATION shall have the right, but not the If terms of this Agreement are in conflict with any law
obligation, to inspect the premises and equipment and/or to applicable to this Agreement, this statement amends this
audit the books and records of the EMPLOYER and of its Agreement to conform to such law. In addition, in the event
agents and representatives, including all records relating to any terms are in conflict with applicable laws, the remaining
payroll and claims matters, at any reasonable time during the terms of the Agreement shall be enforceable.
period of this Agreement and within three (3) years after final P. Cancellation
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 tell (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.
M. Other Insurance If cancellation is effected by the EMPLOYER, the Manual or
If the EMPLOYER carries other valid and collectible Standard Premium shall be determined by the short rate tables
insurance, reinsurance, or indemnity with any other insurer or used for casualty insurance, and the Earned Premium shall be
reinsurer covering a Loss also covered by this Agreement the product of the Premium Rate (Item 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 than the Minimum Premium specified in
Maximum Limits of Indemnity hereunder), the insurance the Declarations.
afforded by this 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 pay the
N. Recovery from Others CORPORATION Earned Premium for the period up to the
The EMPLOYER agrees to prosecute any and all valid claims date of cancellation.
the EMPLOYER may 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 Manual or Standard Premium (or the Total Annual
reasonable expense of collecting such amounts. Remuneration) shall be determined upon a pro rata basis and
the Earned Premium adjusted in accordance therewith.
The CORPORATION shall have the EMPLOYER's rights to
prosecute any and all valid claims against any other party or Q Assignment
source that may mitigate any Loss under this Agreement. The An assignment of interest under this Agreement will not bind
EMPLOYER agrees that it will assist the CORPORATION in the CORPORATION unless an endorsement signed by the
any prosecution of any and all valid claims against any other President or a Senior Vice President and the Secretary or an
party or source that may mitigate any Loss under this Assistant Secretary of the CORPORATION assigning interest
Agreement. Any amounts recovered by the EMPLOYER or under this Agreement is issued by the CORPORATION.
the CORPORATION from any party or source that may
SPW C-U90R-A I
R. Bankruptcy or Insolvency of Employer in the application are the EMPLOYER's representations; that
The bankruptcy or insolvency of the EMPLOYER will not this Agreement is issued in reliance upon such representations;
relieve the CORPORATION or the EMPLOYER of its duties that this Agreement embodies all agreements existing between
and liabilities under this Agreement. After payments have the EMPLOYER and the CORPORATION, or any of its
been made by or on behalf of the EMPLOYER, agents, relating to this excess insurance, and that full
reimbursements due under this Agreement will be made by compliance by the EMPLOYER with all terms of this
the CORPORATION as if the EMPLOYER had not become Agreement is a condition precedent to the CORPORATION's
bankrupt or insolvent, but not in excess of the liability hereunder.
CORPORATION's limit of indemnity.
S. Sole Representative
If more than one EMPLOYER is named in Item I of the
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
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.
President
Secretary
SPW( ,))OR-AI
0003 00 1206 (XWC)
ENDORSEMENT
COLORADO NOTICE ENDORSEMENT
Effective 12:01 A.M., Local Time, December 31, 2017
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 4058215, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY, COLORADO, dated December 31, 2017.
SAFETY NATIONAL CASUALTY CORPORATION
A‘1 k hlji.A.e.t.
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, 2017
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 4058215, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY, COLORADO, dated December 31, 2017.
SAFETY NATIONAL CASUALTY CORPORATION
21f411/,
President
Secretary
0276 02 0408 (XWC)
ENDORSEMENT
BROAD FORM ALL STATES FOR EMPLOYEE TRAVEL
Effective 12:01 A.M., Local Time, December 31, 2017
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 4058215, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY, COLORADO, dated December 31, 2017.
SAFETY NATIONAL CASUALTY CORPORATION
elijus.e.„„LL____
24,f,
President
Secretary
0291 00 0708 (XWC)
ENDORSEMENT
VOLUNTARY COMPENSATION ENDORSEMENT-PREMIUM DELINEATION
Effective 12:01 A.M., Local Time, December 31, 2017
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:
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
(Meted WOtttaftt
l: ees Std"of Employment Compen4tkiq L
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 4058215, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY, COLORADO, dated December 31, 2017.
SAFETY NATIONAL CASUALTY CORPORATION
244 ,
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, 2017
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, Burkina Faso, Burma, Burundi, Cameroon, Central
African Republic, Chad, Colombia, Cote dIvoire, Cuba, Democratic Republic of Congo, Djiboutr; El
Salvador, Eritrea, Honduras, Iran, Iraq, Israel, Kenya, Lebanon, Libya, Mali, Mauritania, Niger,
Nigeria, North Korea, Pakistan, Philippines, Republic of South Sudan, Saudi Arabia, Somalia,
Sudan, Syria, Turkey, Ukraine, Venezuela, West Bank and Gaza, 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 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 4058215, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY, COLORADO, dated December 31, 2017.
SAFETY NATIONAL CASUALTY CORPORATION
Ak,
President
Secretary
Page 2 of 2
0322 00 1291 (XWC)
ENDORSEMENT
90-DAYS NOTICE OF CANCELLATION
Effective 12:01 A.M., Local Time, December 31, 2017
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 4058215, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY, COLORADO, dated December 31, 2017.
SAFETY NATIONAL CASUALTY CORPORATION
ziklk
President
•
Secretary
0339 01 0908 (XWC)
ENDORSEMENT
SAME COMMUNICABLE DISEASE-SPECIFIC EXCESS
• Effective 12:01 A.M., Local Time, December 31, 2017
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 sectionof 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 4058215, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY, COLORADO, dated December 31, 2017.
SAFETY NATIONAL CASUALTY CORPORATION
„I"
President
Secretary
1061 11 0115 (XWC)
ENDORSEMENT
POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE
Effective 12:01 A.M., Local Time, December 31, 2017
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 and extended by the
Terrorism Risk Insurance Program Reauthorization Act of 2015 (collectively, "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 within certification time frames
prescribed in the Act; 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 between 80% to 85% of covered
terrorism losses exceeding a deductible paid by the CORPORATION. The Act contains a $100 million
annual program trigger for 2015 and an increasing trigger amount each year of up to a $200 million annual
program trigger for 2020 and limits on the reimbursement from the U.S. Government as well as from all
insurers. If aggregate insured losses for all insurers exceed program caps, 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 4058215, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD
COUNTY, COLORADO, dated December 31, 2017.
SAFETY NATIONAL CASUALTY CORPORATION
74.izziose.„
241(
President
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 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 and
understand our commitment to your privacy. subsidiaries of the Tokio Marine Holdings, Inc.
group of companies).
W
• Your agent or broker.
We Respect Your Privacy
When you apply to Safety National for any type of • Parties who perform a business or insurance
insurance, you disclose information about you to function for Safety National, including
us. The collection, use and disclosure of such reinsurance, underwriting, claims
information is regulated by law. Safety National administration or adjusting, investigation, loss
and its affiliates maintain physical, electronic and control and computer systems companies.
procedural safeguards that comply with state and
federal regulations to guard your personal • Other insurance companies or agents as
information. Our employees are also advised of reasonably necessary concerning your
the importance of maintaining the confidentiality of application, policy or claim.
your information.
• Insurance regulatory or statistical reporting
agencies.
Types Of Information We Collect •
Safety National obtains most of our information • Law enforcement or governmental authorities
directly from you, your agent or broker. The in connection with suspected fraud or illegal
application you complete, as well as any additional activities.
information you provide, generally gives us most of
the details we need to know. Depending on the • Authorized persons as ordered by subpoena,
nature of your insurance transaction, we may need warrant or court order, or as required by law.
further details about you.
We may obtain information from third parties, such We do not disclose any non-public, personal
as other insurance or reinsurance companies,
information about you to non-affiliated companies
medical providers, government agencies, for marketing purposes or for any other purpose
information clearinghouses and other public except those specifically allowed by law and
records. We may also obtain information about you described above.
from your other transactions with us, our affiliates
or others. Independent Sales Agents or Brokers
Your policy may have been placed with us through
What We Do With Your Information an independent agent or broker ("Sales Agent").
Information that has been collected about you will Your Sales Agent may have gathered information
be retained in our files. We will review your
about you. The use and protection of information
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 non-affiliates as
described in this notice or as otherwise permitted
by law.
WC 99 99 28
C R 1 S I S SAFET NATIONAL I
PROTECTION
- BENEFIT INFORMATION -
Available Exclusively to Safety National's Excess and Large Deductible
Workers'Compensation Policyholders
rt ,
SAFETY RA110,44.CRISIS PRj�O�V�E' 24-HOt t
88 �
DEFINITIONS
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 direct employees of Your Company that are directly involved
in a qualifying event. It specifically excludes any contractors. 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 3
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 BENEFITS UNDER SAFETYNA TIONAL 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.
2 of 3
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:
crisisorotectionesafetynational.cont. 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
Hello