HomeMy WebLinkAbout000333.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 4064135
TYPE OF INSURANCE: Specific Excess Workers' Compensation and Employer's' Liability Insurance
LOCATION(S): COLORADO
POLICY LIABILITY PERIOD: December 31, 2020 through December 31, 2021
POLICY PAYROLL
REPORTING PERIOD: December 31, 2020 through December 31, 2021
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 $ 0.1912 per$100 of Payroll
Minimum Premium for the Liability Period $ 198,356
Deposit Premium for the Payroll Reporting Period $220,396
This binder is effective December 31, 2020 and is subject to all the forms, terms and conditions of bound
quote number 9274488564, and shall be automatically terminated and superseded by the Excess Workers'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 14, 2020.
SAFETY NATIONAL CASUALTY CORPORATION
By: Seth A. Smith
Executive Vice President Underwriting
1832 Schuetz Road St. Louis MO 63146-3540 314-995-5300 fax 314-995-3843
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