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Home My WebLink About20230030.tiffPolicy number: 4234402 Name of Insured: Weld County endorsement effective 01/01/2023 12:01 A.M. standard time (The information above is required only when this endorsement is issued subsequent to preparation of the policy) THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY This endorsement modifies insurance provided under the following: WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY DEDUCTIBLE ENDORSEMENT (ALLOCATED EXPENSE INCLUDED WITHIN THE DEDUCTIBLE LIMIT) This deductible endorsement applies between you and us. It does not affect or alter the rights of others under the policy. A. Now this deductible Applies 1. Each Occurrence; Each Claim; Loss Conversion Factor In consideration of a reduced premium, 'You agree to reimburse us, up to the deductible amount shown below, for the total of all sums we pay for: a. all benefits required of you by the workers compensation or occupational disease law of the states listed in the schedule of premium factors; plus b. all sums you legally must pay as damages; plus c. all "allocated loss adjustment expense" which arises out of any claim or suit we defend; because of (1) bodily injury by accident to your employees arising out of any one "occurrence"; (2) bodily injury by disease to your employee arising out of any one "claim". In addition to the deductible amount, you agree to pay us for the cost of claim handling produced by the application of the "loss conversion factor," if one is shown in the schedule of deductibles below. 2. Policy Period Aggregate If an amount is shown in the schedule of deductibles below as aggregate, the most you must reimburse us for is the sum of all benefits, damages and "allocated loss adjustment expense" because of bodily injury by accident and bodily injury by disease for each policy period, limited to the amount of the aggregate, plus the cost of claim handling produced by the application of the "loss conversion factor", if one is shown in the schedule of deductibles. You are obligated to reimburse us for losses and expenses equal to the full amount of the aggregate even if: (a) this endorsement is issued for a term of less than one (1) year or (b) the policy, or this endorsement, is canceled for any reason by you or by us before the end of the policy period. SCHEDULE OF DEDUCTIBLES Coverage Deductible Amount Bodily Injury By Accident: $750,000 Bodily Injury By Disease: $750,000 All Covered Bodily Injury Aggregate: * Unlimited Loss Conversion Factor: 1.10 Co marilicr d69- 01/oLi/Z3 Basis Per Occurrence Per Occurrence No aggregate Limitation *Unlimited unless a percentage is entered in the blank space Page 1 of 3 GC : F"(RR2P), PE(MR) 04/05/2 3 2023-0030 PEoo35 The premium you must pay for this endorsement will be determined by multiplying the premium factor for each state in which this deductible applies by the "standard premium" you would be required to pay in each such state if this endorsement did not apply. The premium factors and states to which the deductible applies appear in the schedule of premium factors below. SCHEDULE OF PREMIUM FACTORS State Colorado Premium Factor .236 B. Effect of the Deductible on Limits of Liability With respect to the Employers Liability Insurance provided by this policy, the applicable "each employee", "each accident", "policy, or other similar limits of liability are reduced by the sum of all damages (other than "allocated loss adjustment expense") within the applicable deductible amount shown in the schedule of deductibles. The limits of liability shown in item 3.B. of the Information Page of this policy include and are not in addition to the deductible amount. This provision applies whether the Employers Liability Insurance is provided by PART TWO or by an endorsement to this policy. C. Definitions 1. Allocated loss adjustment expense for losses means: a. fees of attorneys or other authorized representatives where permitted for legal services, whether outside or staff representative, b. Court, alternative dispute resolution and other specific items of expense such as: medical examinations of 3 claimant to determine the extent of the carriers liability, degree of permanency or length of disability, expert medical or other testimony. autopsy, witnesses and summonses, copies of documents such as birth and death certificates, Medical or other treatment records; arbitration fees; surveillance: appeal bond costs and appeal filing fees. c. Medical cost containment expenses incurred with respect to a particular claim, whether by an outside vendor or done internally by an employee for the purposes of controlling losses, to ensure that only reasonable and necessary costs or services are paid. The expenses include: bill auditing expenses for any medical or vocational services rendered, including hospital bills inpatient or outpatient), nursing home bills, physician bills, chiropractic bills, medical equipment charges, pharmacy charges, physical therapy bills, medical or vocational rehabilitation vendor bills, hospital and other treatment utilization reviews, including pre -certification / pre- admission, concurrent or retrospective reviews. Preferred provider network / organization expenses, medical fee review panel expenses. d. Expenses which are not defined as losses and are directly related to and directly allocated to the handling of a particular claim for services which are required to be performed by statute or regulation. 2. "Claim" means a demand you receive for: a) Benefits required of you by the workers compensation law; or b) damages covered by this policy; including a filing by your employee for such benefits with an agency authorized by law, or a suit or other proceeding brought by your employee for such benefits or damages, "By your employee" includes such action taken by others legally entitled to do so on his or her behalf. All claims for benefits or damages because of bodily injury by the same or related diseases to any one person will be considered as one claim when determining how the deductible amounts apply. 3. "Occurrence" means a single accident, which results in bodily injury to one or more of your employees. 4. "Loss conversion factor" means a factor applied to all amounts included within the deductible, to compensate us for those costs of handling claims which are not included in "allocated loss adjustment expense." The loss conversion factor shall not be applied to any amounts of benefits, damages or " loss adjustment expense" that are not included within the deductible. Page 2 of 3 WC 99 06 25A (9-2005) 5. "Standard premium" means the premium calculated in accordance with Part Five -Premium of this policy, but it does not include the expense constant charge or the premium discount credit. However, if you or we cancel the policy or this endorsement before the end of the policy period, the calculation of the aggregate which is based on "standard premium" shall be calculated in accordance with Part Five -Premium, extended to the amount that would have been charged for the original policy period. D. Conditions 1. Recovery from Others We have your rights and the rights of persons entitled to the benefits of this insurance to recover all advances and payments, including those within the deductible amount from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. If we recover any advance or payment made under this policy from anyone liable for the injury, the amount we recover, less expenses to recover against third parties, will first be applied to any payments made by us in excess of the deductible amount; then the remainder of that recovery, if any will be applied to reduce the deductible amount paid by you. 2 Cancellation If you fail to comply with the terms of this endorsement, we will apply the same cancellation terms of this policy as apply to non-payment of the policy premium. If we cancel In accordance with the prior paragraph, your obligation to reimburse us as required by other terms of this endorsement is not waived, and we will retain our right to enforce such deductible if necessary. 3. Your Duties a. The first Named Insured shown In the Declarations agrees and is obligated on behalf of all Named Insured(s) to reimburse us for any deductible amounts that we expend. b. Each named Insured is jointly and severally liable for all deductible amounts under this policy. 4. Other Rights and Duties (Ours and Yours) a. All other terms of this policy, not in conflict with this endorsement, apply irrespective of the application of this endorsement. b. Failure by you to reimburse us for deductible amounts due us will not affect coverage for an eligible employee under this policy. 5. Payment of Benefits Pinnacol Assurance is liable to pay workers' compensation benefits directly to the employee or the employee's dependents, in the event of death. THIS WORKERS COMPENSATION POLICY CONTAINS A DEDUCTIBLE OPTION, UNDER WHICH YOU, THE EMPLOYER, ARE REQUIRED TO REIMBURSE CERTAIN LOSSES. PLEASE READ THIS POLICY CAREFULLY AND UNDERSTAND ITS CONDITIONS THOROUGHLY PRIOR TO PURCHASING COVERAGE. Nothing herein contained shall be held to vary, waive or extend any of the terms, conditions, agreements or limitations of this policy other than as stated above. I hereby declare that I have read, understand, and agree with all the terms, conditions and obligations of this, Large Deductible Endorsement, attached to and made a part of this policy, and the multiple billings of the deductible claim payments made until all claims are closed. Name of the Insured: WELD COUNTY GOVERNMENT By: - . Scott K. James Chair Title: Board of Weld County Commissioners Date: o02 /2a,w. Nothing herein contained shall be held to vary, waive or extend any of the terms, conditions, agreements or limitations of this policy other than as stated above. Page 3 of 3 WC 99 06 25A (9-2005) PINNAICOL ASSURANCE 7501 E. Lowry Blvd. Denver, CO 80230-7006 www.pinnacol.com December 14, 2022 Weld County Attn: Risk Management Subject: $750,000 Large Deductible Collateral Requirements Policy number: 4234402 The financial collateral required to issue the policy for the deductible you have selected for policy number 4234402 is currently Two Hundred and Fifty Thousand Dollars ($250,000). The above -mentioned collateral has been agreed upon in the form of a Bond issued by an °A" rated carrier, a copy of which is attached. The Bond is subject to review at twelve months, and at least annually thereafter, and according to statutory requirements maybe adjusted if indicated. If at any time the carrier that issued the Bond provides notice of cancellation to Pinnacol Assurance, Weld County will be required to secure a replacement bond in the then required amount, in a form acceptable to Pinnacol Assurance, within 30 days, or the workers' compensation insurance policy will be cancelled on 10 days' notice for failure to meet the financial requirements of the policy. These collateral requirements extend to the renewal of any policy. In addition to the above requirements, failure to provide any required collateral by a renewal date shall also result in issuance of a 30 -day notice of cancellation of the policy for failure to meet the financial requirements of the deductible policy. "Obligations," as referred to in the Bond shall be defined as Weld County obligations under the applicable workers' compensation application, policy, relevant statutes and regulations, or any other obligation of any kind or nature that is owed by Weld County to Pinnacol Assurance. Weld County agrees that Pinnacol Assurance may draw on the bond at any time(s) to satisfy any and all Obligations (in addition to its other remedies and without prejudice to its other rights against Weld County) and if so, substitute collateral in the prescribed form must be immediately provided to, at all times, maintain the collateral amounts required by this agreement. This agreement must be signed by an officer of Weld County capable of making such financial agreement. Officer Name/Title — Scott K. James, Michael Smith Weld County BOCC Chair Sr. Underwriter, Pinnacol Assurance CC: James Sumner, Pinnacol Assurance Matt Liebgott, Business Director, Pinnacol Assurance Gallagher !CORE 360 Client Authorization to Bind Coverage After careful consideration of Gallagher's proposal dated December 15, 2022 we accept the following coverage(s). Please check the desired coverage(s) and note any coverage amendments below: Workers Compensation - CO NJ Accept ❑ Reject Carrier: Pinnacol Assurance Deposit Premium: $467,723 Deductible: $750,000 Workers Compensation — Other States %1 Accept O Reject Carrier: Zurich American Deposit Premium: $655 Deductible: $0 Plnnnacol Collateral Bond 1 Accept O Reject Carrier: Travelers Casualty & Surety Company of America Deposit Premium: $2,400 Penal Sum: $250,000 Self -Insurer Workers Compensation Bond .R[ Accept O Reject Carrier: Travelers Casualty & Surety Company of America Deposit Premium: $14,400 Penal Sum: $1,500,000 Additional Recommended Coverages Gallagher recommends that you purchase the following additional coverages for which you have exposure. By checking the box(es) below, you are requesting that Gallagher provide you with a Proposal for this coverage. By not requesting a Proposal for this coverage, you assume the risk of any uncovered loss. Other Coverages to Consider ❑ Standalone Cyber Liability ❑ Foreign Liability The above coverage(s) does not necessarily represent the entirety of available insurance products. If you are interested in pursuing additional coverages other than those listed in the Additional Recommended Coverages, please list below: Weld County, CO ©2019 Artl,r.1. Gallagher 8 Co. All r,htr; re,er,. Gallagher e CORE 36O iatIa Exposures and Values You confirm the payroll, values, schedules, and any other information pertaining to your operations, and submitted to the underwriters, were compiled from information provided by you. If no updates were provided to Gallagher, the values, exposures and operations used were based on the expiring policies. You acknowledge it is your responsibility to notify Gallagher of any material change in your operations or exposures. Additional Terms and Disclosures Gallagher is not an expert in all aspects of your business. Gallagher's Proposals for insurance are based upon the information concerning your business that was provided to Gallagher by you. Gallagher expects the information you provide is true, correct and complete in all material respects. Gallagher assumes no responsibility to independently investigate the risks that may be facing your business, but rather have relied upon the information you provide to Gallagher in making our insurance Proposals. Gallagher has established security controls to protect Client confidential information from unauthorized use or disclosure. For additional information, please review Gallagher's Privacy Policy located at https://www.aio.com/privacy-colicv/. You have read, understand and agree that the information contained in the Proposal and all documents attached to and incorporated into the Proposal, is correct and has been disclosed to you prior to authorizing Gallagher to bind coverage and/or provide services to you. By signing below, or authorizing Gallagher to bind your insurance coverage through email when allowed, you acknowledge you have reviewed and agree with terms, conditions and disclosures contained in the Proposal. Scott K. James, Chair Board of Weld County Commissioners By: Date: Print Name (Specify Title) Weld County Government Company Signature /00/2942 r2,2,72 Weld County, CO O2019 Arthur J. Gallagher Et Co. All ryhts reserved 22 Cheryl Hoffman From: Sent: To: soccerjon77@yahoo.com Thursday, December 29, 2022 12:39 PM Cheryl Hoffman Caution: This email originated from outside of Weld County Government. Do not click links or open attachments unless you recognize the sender and know the content is safe. 2fl4 „f /�• _w1 athispr Waits dr.p .rr S I Chace teary litPerot Smart bum PO OS dame tUOff C,ae+you caese ro do se s.irlt ' Sat a la? 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