HomeMy WebLinkAbout814-Hartford-Excess Workers ComExcess Workers'
Compensation
and Employers'
Liability
Policy
From The Hartford
~Y
FOR OUR EXCESS WORKERS' COMPENSATION CUSTOMERS:
To provide you with better clai~n service, we have ar~tnged for a special coordinator, to
ad~ninister Excess Workers' Co~npensation clai~ns.
Please report any clai~n which you are required to under Pa~ Five of your policy
provisions (WC990112) to:
TED COOPER
EXCESS WORKERS' COMPENSATION CLAIMS UNIT
HARTFORD SPECIALTY COMPANY
HARTFORD PLAZA, T-5-97
HARTFORD, CONNECTICUT 06115
You may also telephone or "Fax" Ted at the following nutnbers:
Telephone: (860) 547-8792
Fax: (860) 547-8782
Thank you
EXCESS WORKERS' COMPENSATION AND EMPLOYERS'
LIABILITY INSURANCE POLICY (SPECIFIC)
QUICK REFERENCE
Beginning
on page
Information Page
General Section 1
A. The Policy 1
B. Who is Insured 1
C. Workers Compensation Law 1
D. Qua!ffled Self-Insurer 1
E. Loss 1
PART ONE - EXCESS WORKERS' COMPENSATION
INSURANCE 1
A. How This Insurance Applies 1
B, WeWiillndemnify 1
C. Payments You Must Make 1
D. Exclusions 2
PART TWO - EXCESS EMPLOYERS' LIABILITY
INSURANCE ~
A. How This Insurance Applies ~
B. We Will Indemnify ~
C- Employers' Liability Loss ~
D. Exclusions - Payments You Must Make ~
PART THREE - OTHER INSURANCF ' 3
PART FOUR - LIMITS OF LIABILITY -
RETAINED LIMIT-~ 3
PART FIVE - YOUR DUTIES IF INJURY OCCURS .... 3
A. Written Notice Requirements 3
B. Notice Should Include 3
C. Claims Information 3
Beginning
on page
D. Settlements
E. Experience Report
PART SIX - INVESTIGATION, DEFENSE,
SETTLEMENT
PART SEVEN - PREMIUM
A. Deposit and Adjustment Premiums
B. Total Remuneration Report
C. Final Premium
D. Total Remuneratiop
E. Records
E Audit
PART EIGHT - CONDITIONS
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L
M.
4
4
Inspection
Bankruptcy or Insolvency
Recovery From Others
Cancellation
Sale Representative
Appea|s
Assessments
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
6
Responsibility For Your Self-Insured Retention. ~. 6
Administration of Claim Service 6
Commutation 6
Auditing of Claim 7
Assignment 7
Representation 7
IMPORTANT: This Quick Reference is not part of the Excess Workers' Compensation and Employers' LiabUity
Insurance Policy and does not provide coverage. Refer to the Excess Workers' Compensation and
Employers' Liablty Insurance Policy itself for actual contractual provisions.
PLEASE READ THE EXCESS WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE
POLICY CAREFULLY.
Form WC 99 01 19 A Printed in U.S.A. (NS)
IMPORTANT STATE INFORMATION
Applicable In Arkansas
Any person who knowingly presents a false or fraudulent claim for payment of a loss or beneffi or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in pdson.
Applicable in California
Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may
be subject to fines and confinement In state pdson.
Applicable in Florida and Idaho
Any person who Knowingly and with the Intent to injure, Defraud, or Deceive any Insurance Company Files a
Statement of Claim Containing any False, Incomplete or Misleading information is Guilty of a Felony.*
*In Rorida - Third Degree Felony
Applicable in Indiana
A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false,
incomplete, or misleading information commits a felony.
Applicable in Kentucky and New Jersey
Any person who knowingly and with intent to defraud any insurance company or other persons, files a statement
of claim containing any materially false information, or conceals for the purpose of misleading, information
conceming any fact, material thereto, commits a fraudulent insurance act, which is a crime, subject to criminal
prosecution and civil penalties.
Applicable in Michigan
Any person who knowingly and with intent to injure or defraud any insurer submits a claim containing any false,
incomplete, or misleading information shall, upon conviction, be subject to imprisonment for up to one year for a
misdemeanor conviction or up to ten years for a felony conviction and payment of a line of up to $5,000.00.
Applicable in Minnesota
A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a cdme.
Applicable in Nevada
Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any
false, Incomplete or misleading Information concemlng a material fact is guilty of a felony.
Applicable in New Hampshlre
Any.person who with purpose to injure, defraud or deceive any insurance company, files a statement of claim
containing any false, Incomplete or misleading information is subject to prosecution and punishment for Insurance
fraud, as provided In RSA 638:20.
Form GN 99 48 14 (ED. 05/98)
(c) 1998 The Hartford
Page I of 2
EXCESS WORKERS' COMPENSATION AND EMPLOYERS'
LIABILITY INSURANCE POLICY (SPECIFIC)
INFORMATION PAGE
Insurer: HARTFORD CASUALTY INS CO
HARTFORD, CT 06115
DECLARATIONS ~ Previous Policy No.
Items 21 XST QX0130
1. Named Insured and Mailing Address . ·
The Named Insured is: [] Individual [] Partnership [] Joint Venture
[] Corporation [] Other
2. Policy Period
12:01 A.M. standard time at the address of the
Named Insured as stated herein.
Policy No. 2 1 XST
CITY OF SANFORD
300 N. PARK AVENUE
P.O. BOX 1788
SANFORD, FL 32771
10/01/99
Inception Date
QX0130
(Co. Use Only)
Best L R RPR
Ind C of C F I
SUFFIX
Co. Code
3
lo/ol/2ooo
Expiration Date
Producer'sNameandAddrsss
PENCO
1180 SPRINGS CENTRE S.
SUITE#125
ALTAMONTE SPRINGS, FL
BOULEVARD
32714
CodeNo.
223566
3. A. This insurance applies to the Workers' Compensation and Occupational Disease Laws of the following state(s):
4. Your Specific Retention
A. ·Each Accident
150,000.
B. Each Employee for Disease
$ 150,000.
5. Our Limit of Uability
A. Each Accident (Part One)
STATUTORY
B. Each Accident (Part Two)
$ 1,000,000.
C. Each Employee for Disease (Part One)
D. Each Employee for Disease (Part Two)
E. Aggregate (Part One and Part Two combined)
.... STATUTORY
.$ 1,000,000.
SEE ENDT. #4
6. Deposit and 'Minimum Premium $
88,707, See EXCESS WORKERS' COMPENSATION PREMIUM SCHEDULE
7. Premium Schedule: See EXCESS WORKERS' COMPENSATION PREMIUM SCHEDULE
8. Claim Service Company: INSURANCE SERVICE ADJUSTING CO.
9. Form Numbers of Policy Provisions and Endorsement forming a part of this policy:
See LISTING OF POLICY PROVISIONS AND ENDORSEMENTS FORMING A PART OF THE POLICY AT ISSUE.
This policy will not be valid unless countersigned by our duly authorized representative,
NG 10/13/9'9
Form WC 99 01 10 D
Pdnted in U.S.A. (NS)
Authorized Representative
Policy Number: 2 1 XST
Named Insured and Address:
QX0130
Effective Date
CITY OF SANFORD
300 N. PARK AVENUE
P.O. BOX 1788
SANFORD, FL 32771
10/01/99
LISTING OF POLICY PROVISIONS AND ENDORSEMENTS
FORMING A PART OF THE POLICY AT ISSUE
This Ljsting forms a part of the following:
WORKERS ' COMPENSATION EXCESS POLICY
ThefollowingisalistingofpolicyprovisionsandendorsementsbyForm NumberandTitlethatformapartofthe
pdicy~i~ue.
FORM NUMBER TITLE OF ENDORSEMENT
1 WC990112 EXCESS.WORKERS' COMPENSATION AND
EMPLOYE~S' 'LIABILITY POLICY PROVISIONS (SPECIFIC)
2 WC990120 EXCESS WORKERS' COMPENSATION
PREMIUM SCHEDULE
3 WC990254 (01-95) AMENDMENT OF RETAINED LIMITS
4 WC990257 (01-95) EXCESS STATUTORY WORKERS' COMPENSATION
INSURANCE ENDORSEMENT (SPECIFIC)
5 WC990258 (01-95) OTHER STATES 'INSURANCE ENDORSEMENT
6 WC990159B (11-97)
y wc99o4o~ (o3-9s)
AMENDMENT OF CONDITIONS
POLICY CHANGES ·.
- FLORIDA
Form L-5015-3 (Ed.11/88)
Printed in U.S.A. (NS)
Copyright Hartford Rrb Insurance Company. 1987
EXCESS WORKERS' COMPENSATION AND
EMPLOYERS' LIABILITY POLICY PROVISIONS (SPECIFIC)
THE HARTFORD
The insurer shown on the Information Page is a stock
insurer.
In return for the payment of the premium and subject
to all terms of this policy, we agree with you as
follows. ..
GENERAL SECTION
Ae
The Policy
This policy includes at its effective date the
Information Page and all endorsements and
schedules listed thereon. It is a contract of
insurance between you (the insured named in
Item 1. of the Information Page) and us (the
insurer named on the Information Page). The'
only agreements relating to this insurance are
stated in this policy. The terms of this policy may
not be changed or waived except by endorse-'
ment issued by us to be part of this policy.
B. Who Is Insured
Ce
You are insured if you are an employer named in
Item 1. of the Information Page. If that employer.
is a partnership, and if you are one of its partners,
you are insured, but only in your capacity as an
employer of the partnership's employees.
Workers Compensation Law
Workers' Compensation Law means the Workers,
or Workmens' Compensation Law and Occupa-.
tional Disease Law of the states named in Item
3.A. of the Information Page. It includes any
amendments to that law which are in effect during
the policy period stated in the Information Page.
It does not include provisions of any law that
provides non-occupational disability benefits.
State means any state of the United States of
America and the Distdct of Columbia.
D. Qualified Self-Insurer
Your acceptance of this policy indicates that you
are now and will remain until the end of the policy
period a duly qualified self-insurer in each sta~e
named in Schedule Item 3.A. If you are not a duly
qualified self-insurer with respect to any 'loss
covered by this policy, this policy will apply as'if
you were. ;......:
Form WC 99 01 12 Printed in U.S.A. (NS)
E. Loss
Loss means any benefits actually paid by you
under the Workers' Compensation Law, or dam-
ages actually paid by you adsing out of bodily
injury by accident or bodily injury by disease
covered by Part Two of this policy. Loss does not
include claim expense.
PART ONE - EXCESS WORKERS' COMPENSA-
TION INSURANCE
,, *
A. How This Insurance Applies
This excess workers' compensation insurance
applies to bodily injury by accident or bodily
..injury by disease. The bodily injury must adse out
of and in the course of the injured employee's
employment by you. Bodily injury includes
resulting death.
Bodily injury by accident must occur during the
policy period. A disease is not bodily injury by
accident unless it results directly from bodily
injury by accident.
Bodily injury by disease must be caused or
aggravated by the conditions of your employ-
ment. The employee's last day of last exposure in
your employment to the conditions causing or
aggravating such bodily injury by disease must
occur dudng the policy period. Bodily injury by
disease does not include disease that results
directly from bodily injury by accident.
B. We Will Indemnify
You are responsible for all benefit payments
required by the Workers' Compensation Law. We
will indemnify you for that amount of loss under
the Workers' Compensation Law that is in excess
of your specffic retention stated in Item 4.A. and
4.B. of the Information Page, but not more than
our limit of liability stated in Item 5.A., 5.C. and
5.E. of the Information Page.
C. Payments You Must Make
You are responsible (without reimbursement from
us) for any payments in excess of any benefits or
award regularly provided by the Workers' Com-
pensation Law including those required because:
Page I of 7
1. Of your serious and willful misconduct;
2. You knowingly employ an employee in viola-
tion of law;
3. You fail to comply with a health or safety law or
regulation; or
4. You discharge, coerce or otherwise discrimi-
nate against any employee in violation of the
Workers' Compensation Law.
D. Exclusions
This insurance does not cover and your retained
limits will not be satisfied by any payments arising
out of operations:
1. For which you have formally rejected any
Workers' Compensation Law; or
2. Which are considered to be domestic, farm or
agricultural employments unless required by
the Workers' Compensation Law.
PART TWO - EXCESS EMPLOYERS' LIABILITY'
INSURANCE · .'-.
A. How This Insurance Applies
This Excess Employers' Liability Insurance ap-
plies to bodily injury by accident or bodily injury
by disease not covered by the Workers'
Compensation Law. The bodily injury must arise
out of and in the course of the injured employee's
employment by you. Bodily injury includes
resulting death. It also includes injury arising out
of assault and battery unless committed by you or
at your direction.
1. The employment must be necessary or
incidental to your work in a state or territory
listed in Item 3.A. of the Information Page: '"
2. Bodily injury by accident must occur dudng
the policy period.
Bodily injury by disease must be caused or
aggravated by the conditions of your employ-
ment. The employee's last day of last
exposure in your employment to the conditions
causing or aggravating such' bodily injury by
disease must occur during the policy pedod.
If you are sued, the original suit and any related
legal actions for damages for bodily injury by
accident or by disease must be brought in the
United States of America, its territories or pOs-
sessions, or Canada.
B. We Will Indemnify
You are responsible for all loss payments covered
under Part Two of the policy. We will indemnify
you for that amount of loss that is in excess of
your specific retention as stated in Item 4.A. and
4.B. of the Information Page, but not more than
the limits of liability stated in Item 5.B., 5.D. and
5.E. of the Information Page.
C. Employera' Liability Loss
The damages we will indemnify you for, where
recovery is permitted by law, include damages:
1. Which you have paid to a third party by reason
of a claim or suit against you by that third party
to recover the damages claimed against such
third party as a result of injury to your
employee;
2. For care and loss of services; and
3. For consequential bodily injury to a spouse,
-child, parent, brother or sister of the injured
'employee;
provided that these damages are the direct
consequence of bodily injury that arises out of
and in the course of the injured employee's
employment by you; and
4. Because of bodily injury to your employee that
arises out of and in the course of employment,
claimed against you in a capacity other than as
employer.
D. Exclusions - Payments You Must Make
This 'insurance does not cover and your retained
limits will not be satisfied by payments stated
below. You are responsible for loss payments
adsing out of:
1. Liability assumed under a contract. This ex-
clusion does not apply to a warranty that your
work will be done in a workmanlike manner.
2. Fines or punitive or exemplary damages be-
cause of bodily injury to an. employee em-
ployed in violation of law;
3. Punitive, exemplary or compensatory dam-
ages because of your conduct, or the conduct
of anyone acting for you:
a. In the investigation, trial or settlement of any
workers' compensation claim;
Form WC 99 01 12 Pdnted in U.S.A, (NS) Page 2 of 7
b. In failing to pay or delay in payment of any
Workers' Compensation claim;
Bodily injury to an employee while employed in
violation of law with your actual knowledge .or
the actual knowledge of any of your executive
officers;
Any obligation imposed by Workers' Compen-
sation, occupational disease, unemployment
compensation, or disability benefits law, or any
similar law;
Bodily injury intentionally caused or aggrav-
ated by you;
7. Bodily injury occuring outside the United
States of America, its territories or posses-
sions, and Canada. This exclusion does not
apply to bodily injury to a citizen or resident of
the United States of America or Canada who is
temporarily outside these countries~ ':-
8. The termination of employment; or
9. The coercion, demotion, reassignment, disci-
pline, defamation, harassment, humiliation, or
discrimination against any employee.
PART THREE - OTHER INSURANCE
If you have other insurance, reinsurance, indemnity,
or reimbursement coverage, covering loss also
covered by this policy (other than insurance that is
purchased to. apply in excess of your retention and
our limit of liability, or policies of co-insurance within
the limits of this policy), this coverage shall be excess
of and shall not contribute with such other coverage. -
PART FOUR - LIMITS OF LIABILITY - RETAINED
LIMITS
Our liability to pay for loss is limited. Our limits of
liability are shown in Item 5. of the Information Page.
They apply as explained below.
Regardless of the number of insureds covered by this
policy, the number of people who sustain injury or the
number of claims made or suits brought, our limit of
liability shall be for loss in excess of your retention as
stated in Item 4.A. and 4. B. of the Information'* Page
and then only up to and not exceeding our limit of
liability as stated in Item 5.A., 5.B., 5.C. and 5.D. ofthe
Information Page. : '* '
Your specific retention for each accident (Informantion
Page Item 4.A.) and our limit of liability for each
accident (Infor. mation Page 5.A. and 5.B.) apply to.
Form WC 99 01 12 Pdnted in U.S.A. (NS)
each accident for injuries including death resulting
therefrom, other than disease. A disease is not bodily
injury by accident unless it results directly from bodily
injury by accident.
Your specific retention for disease, each employee
(Information Page Item 4. B.) and our limit of liability
for disease, each employee (Information Page Items
5.C. and 5.D.) apply to each employee for injuries
arising out of disease including death. Bodily injury
by disease does not include disease that results
directly from a bodily injury by accident.
The retained limits and our limit of liability as stated
above apply separately to Part One & Part Two of this
policy.
The maximum amount we will indemnify under Part
One and Part Two above for all losses is as stated in
Item 5.E. of the Information Page.
PART FIVE - YOUR DUTIES IF INJURY OCCURS
A. *Written Notice Requirements
You must give us written notice as soon as
possible:
1. If an injury to your employee occurs involving;
a. Quadriplegia;
b. Paraplegia;
c. A major extremity or multiple minor extrem-
ity amputation~
d. Second or third degree burns over 25 per-
cent or more of the body;
e.' Brain or brain stem injury;
· f. Partial or total blindness;
g. Death.
2. Any injury wherein the potential loss payable
may exceed 50 percent of the retained limit
shown on the Information Page.
3. Any accident which causes injury to two or
more employees.
B. Notice Should Include
Notice should include all notices of injury you
'receive, as well as the demand, and legal papers
related to the injury, claim proceeding or suit.
C. Claims Information
You agree to send to us any claim information
which we may request.
Page 3 of 7
D. Settlements
You agree not to make any voluntary settlement
involving loss to us without our written consent:
E. Experience Report
Within 30 days after written request by us you
agree to send us an experience report (in a form!
satisfactory to us) detailing the claims paid by you
during the period and your current reserves for
unpaid claims.
PARTSIX-INVESTIGATION, DEFENSE, SETI'LE-
MENT
We shall not be obligated to assume charge of the
investigation, defense or settlement of any claim or
suit against the insured, but we shall have the right
and shall be given the opportunity to associate'with
the insured or its claim servicing agency or both, in
the investigation, defense or settlement of any claim
or suit that, in our opinion, involves or appears
reasonably likely to involve us.
If we elect to associate, the insured, its claim servicing
agency, and we shall cooperate in such matters so as
to effect final determination thereof. The insured shall
not make or agree to any settlement for an amount in
excess of the applicable retained limit without our
approval.
Each insured will pay all its own claim expenses
relative to any claim settled or adjudicated for a sum
less than the .applicable retained limit. Claim
expenses does not include salaries of the insured's
regular employees, or our regular employees, expend.
ses incurred by the insured for the first aid or. claim
fees paid to the insured's claims service agency.
Payments of claim expenses shall not reduce the
applicable retained limit.
If a claim is settled or adjudicated for a sum greater
than the applicable retained limit, we will pay claim
expenses in the ratio that our liability for the judgment
rendered or settlement made bears to the whole
amount of such judgment or settlement. We will pay
our share of the claim expenses in addition tO .the
applicable limits of liability stated in the Information
Page.
When we have used up the applicable limit of liability
in the payment of loss, we shall no longer .be
obligated to pay any loss or to pay any share of claim
expenses. This applies both to claims and' suits
pending at that time and those filed thereafter.
PART SEVEN - PREMIUM
A. Deposit and Adjustment Premiums
At the beginning of the policy period you must
pay us the deposit premium shown in Item 6. of
the Information Page. At the end of the policy
period:
1. you will owe us the amount by which the final
premium is greater than the deposit premium;
or
2. we will owe you the amount by which the
deposit premium is greater than the final
premium.
B. Total Remuneration
Total Remuneration means the gross pay of your
employees for the policy pedod plus other
amounts and items received by your employees
as part of their pay for the policy pedod. We will
send you a reporting form describing what is to
be included in remuneration.
C. Total Remuneration Report
Within 45 days after the end of the policy period,
you will send us a report showing the amount of
total remuneration earned by your employees
during the policy period. The report must show
total remuneration separately for each classifica-
tion' identified in Item 7.A. shown in the Excess
Workers' Compensation Premium Schedule.
D. Final Premium
The final premium due us for this policy will be
computed as follows: The total remuneration for
the policy period divided by $100 multiplied by
the rate(s) shown in 7.D. of the Excess Workers'
Compensation Premium Schedule.
Unless this policy is cancelled, final premium will
be at least the minimum and deposit premium
shown in 7.F. of the Excess Workers'
Compensation Premium Schedule.
If we cancel this policy, final premium will be
calculated pro rata based on the time this policy
was in fome. The final premium will not be less
than the pro rata share of the minimum and
deposit premium.
If you cancel this policy, return premium will be
calculated at 90% of the pro rata unearned
premium. The final premium will not be less than
the minimum and deposit premium.
Form WC 99 01 12 Pdnted in U.S.A. (NS) Page 4 of 7
E. Records
You will keep records of information needed to
compute premium. You will provide us with cop-
ies of those records when we ask for them.
F. Audit
You will let us or our representatives examine and
audit all your remuneration records. The audits
may be conducted during your regular business
hours.
PART EIGHT- CONDITIONS
A. Inspection
We have the dght, but are not obligated to inspect
your workplaces at any time. Our inspections are
not safety inspections. They relate only. to the
insurability of the workplaces and the premium' to
be charged. We may give you reports on the
conditions we find. We may also recommend
changes. While they may help reduce losses, we
do not undertake to perform the duty of any
person to provide for the health or safety'of ydur
employees or the public. We do not warrant that
your workplaces are safe or healthful or that they
comply with laws, regulations, codes or stan-
dards. Insurance rate service organizations have
the same rights we have under this provision.
B. Bankruptcy or Insolvency
Your bankruptcy or insolvency will not relieve US
of the duties and liabilities under this policy. After
your retention has been reached, payments due
under this policy will be made as if you. had not
become bankrupt or insolvent but not in excess· of
our limit of liability. Such payments will be made
to the trustee in bankruptcy or as a court of
competent judediction may ultimately direct.
C. Recovery From Others
If you have rights to recover all or part of 'any
indemnification we have made under this policy,
those rights are transferred to us. You must do
nothing after loss to impair them. At our request,
you will bring suit or transfer those rights to .us
and help us enforce them.
Recoveries shall be applied to reimburse:
1. First, any interests (including your interest) that
may have paid any amounts in excess of our
liability under the policy;
2. Then, us for all amounts paid under the policy;
and
3. Finally, all other interests (including your
interest) with respect to the residue, if any.
When we have elected to participate in the
exercise of your dght of recovery. reasonable
expenses resulting therefrom will be apportioned
among all interests in the ratio of their respective
recoveries.
If there should be no recovery as a result of
proceedings instituted solely at our request, we
will bear all expenses of such proceedings.
D. Cancellation
Fe
1. You may cancel this policy. You must mail or
deliver advance notice to us stating when the
cancellation is to take effect.
We may cancel this policy. We must mail or
deliver to you not less than ten days advance
written notice stating when the cancellation is
to take effect. Mailing that notice to you at
your mailing address shown in item 1 of the
Information Page will be sufficient to prove
notice.
The policy period will end on the day and hour
stated in the cancellation notice.
4. Any of these provisions that conflicts with a law
that controls the cancellation of the insurance
in this policy is changed by this statement to
comply with that law.
Sole Representative
The'insured first named in Item 1. of the
Information Page is authorized to act on behalf of
all insureds with respect to giving or receiving
notice of cancellation, receiving refunds, and
agreeing to any changes in this policy.
Appeals
If you or any other insurer elects to appeal a
judgment or award, we will not pay any costs or
interest incidental to the appeal. If you or any
other insurer do not so elect, we may do so.
When we elect to appeal a judgment or award we
will pay the cost and interest incidental to the
appeal. Regardless of who elects to appeal, any
amounts recovered will be applied as follows:
1. First, to our costs and expenses in pursuing
the appeal;
Form WC 99 01 12 Pdnted in U.S.A. (NS) Page 5 of 7
2. Second, to reimburse any interest (including
your interest) that may have paid any amounts
in excess of our liability under the policy;
3. Then, to reimburse us for all amounts paid un-
derthe policy; and
4. Finally, to reimburse all other interest (includ-'
ing. your interest) with respect to the residue, if
any.
G. Assessments
You agree to indemnify us for that portion of any
assessment attributable to the premium we
collect for this policy or the losses we pay pursu-
ant to this policy and arising out of:
1. Our participation in any residual market plan;
2. Our participation in any guarantee fund,
guarantee association or other facility protect-
ing claimants against the uncollectibility of
insurance proceeds; or
3. Your status as a self-insured employer.
You also agree to indemnify us for all reasonable
costs and expenses, including reasonable attor-
ney's fees, in connection with our collection of
such indemnification.
As used in this policy:
"Assessment" means any assessment, tax or
other charge whether payment is required bylaw
or required as a condition of continued opportun-.
ity to transact wokers' compensation insurance in
the applicable state; ....
"Residual market plan" means any plan, pro-.
gram or facility (whether voluntary or required by
law) by which substantially all workers' compen-
sation insurers in a state share in the risk of
providing such insurance for eligible employers.
H. Responsibility for Your Self-insured Retention
This insurance will not take the place of your ob-
ligation to pay any amount within the self-insured
retention or any applicable coinsurance, whether
or not such obligation becomes invalid, suspen-
ded, unenforceable or uncollectible for. any
reason, including bankruptcy or insolvency. ·.
The entire risk of such invalidity, suspension,
unenforceability or uncollectibility is retained by
all insureds and their obligees, not by us.
I. Administration of Claim Service
We shall have the right to approve any claim
service company engaged by you. The Claim
Service Company shall be named in Item 8 of the
Information Page or in an endorsement to this
policy.
You shall notify us in writing of your intention to
engage any other service company at least thirty
days prior to such change. If we object to such
change, we shall notify you in writing of such
disapproval within ten days of receipt of your
notification of change.
J. Commutation
Beginning twenty-four months after receipt by us
or your Claim Service Company of notice of a
claim, we may then, or at any time thereafter,
submit such claim for commutation. We may, at
our election, submit such claim to an actuary or
appraiser of our choice and pay you a lump sum
fixed by such actuary or appraiser.
If you do not agree to the lump sum so fixed, you
may make a written demand for arbitration. You
must make any such demand within sixty days of
your receipt of our notice concerning payment of
the lump sum.
When a demand is made, each party will choose
an arbitrator. The two arbitrators, so chosen,
then will select a third. If this selection is not
completed within thirty days, either or both of the
two arbitrators may request that such selection be
made by a court having jurisdiction. Each party
will:'
1. Pay .the expenses it incurs; and
2. Bear the expenses of the third arbitrator equally.
Unless both parties agree otherwise, arbitration
will take place in the county or parish in which the
address shown in the Information Page is located.
Local rules of law as to procedure and evidence
will apply. A decision agreed to by two of the
arbitrators will be binding.
If subsequent to such lump'sum payment, a
supplemental award is made increasing the
amount of benefits payable to the employee
and/or his or her dependents, any additional
liability, at our election, may immediately be
commuted following the process cited above.
Form WC 99 01 12 Pdnted in U.S.A. (NS)
Page 6 of 7
L.
Auditing of Claims
We have the right but are not obligated to auglit
your claim files.
Assignment
Your dghts or duties under this policy may not be
transferred without our written consent.
Representation
By accepting this policy, you agree:
1. The statements on the Information Page are
accurate and complete;
2. Those statements are based upon represen-
tations you made to us; and
3. We have issued this policy in reliance upon
your representations.
Form WC 99 01 12 Pdnted in U.S.A. (NS) Page 7 of 7
Policy Number: 21 XST QX0130
Effective Date: 10 / 01 / 99
Named Insured and Address:
Endt. No.
CITY OF SANFORD
300 N. PARK AVENUE
P.O. BOX 1788
SANFORD, FL 32771
EXCESS WORKERS' COMPENSATION
PREMIUM SCHEDULE
2
The estimated annual premium (E.) for this policy will be determined by: Total Estimated Annual Remunera-
tion (C.) divided by $100 multiplied by rate (D.).
ALL
All information required below is subject to verification and change by audit.
A. Classifications
· C. Premium Basis D. Rate Per E. Estimated
B. Code Total Estimated $100. of Annual
Number Annual RemuneraUon Remuneration Premium
OPERATIONS OF THE INSURED 0388
12,639,866. .7018
88,707.
F, Minimum and Deposit Premium
88,707.
WC 99 01 20 Primed in U.S.A. (NS)
Policy Number: 2 1 XST
Named Insured end Address:
Endt. No. 3
QX0130
Effective Date:
CITY OF SANFORD,
300 N. PARK AVENUE
P.O. BOX 1788
SANFORD, FL 32771
lo/ol/99
AMENDMENT OF RETAINED LIMITS
(Self Insured Retention - Combining Loss and Claim Expense)
It is agreed that PART FOUR - LIMITS OF LIABIUTY -!RETAINED LIMITS is amended to include the following
additional .paragraph: . .
Your specific retention include loss and claim expense b~ not our limit of liability.
It is further agreed that PART SIX - INVESTIGATION, DEFENSE, SETTLEMENT is replaced by the following:
PART SIX - INVESTIGATION, DEFENSE, SETTLEMENT
We shall not be obligated to assume charge of the investigation, defense or settlement of any claim or suit against
the insured, but we shall have the right and shall be given the opportunity to associate with the insured or its claim
servicing agency or both, in the investigation, defense 'or settlement of any claim or suit that, in our opinion,
involves or appears reasonably likely to involve us.
If we elect to associate, the insured, its claim servicing agency, and we shall cooperate in such matters so as to
effect final determination thereof. The insured shall :'not make or agree to any settlement for an amount in excess
of the applicable retained limit without our approval.
Each insured will pay claim expense for each accident for a sum no greater than the retained limit. The retained
limit includes loss and claim expense. Claim expense does not include salaries of the insured's regular
employees, or our regular employees, expenses incurred by the insured for the first aid or claim fees paid to the
insured's claims service agency. Payments of claim ·expenses shall reduce the applicable retained limit.
When we have used up the applicable limit of liability in the payment of loss, we shall no longer be obligated to pay
any loss. This applies both to claims and suits pending at that time and those filed thereafter.
Form WC 09 02 54 (ED. 01/95) Printed in U.S.A. (NS)
Copyright, Hartford Cas'ualty Insurance Company, 1994
Policy Number: 21 XST QX0130 Effective Date:
Named Insured and Address: CITY OF SANFORD
300 N. PARK AVENUE
P.O. BOX 1788
Endt. No. 4 SANFORD, FL 32771
10/01/99
EXCESS STATUTORY WORKERS' COMPENSATION
INSURANCE ENDORSEMENT (SPECIFIC)
(Self Insured Retention - Combining Part One & Part Two)
This endorsement replaces B. We Will Indemnify under PART ONE - EXCESS WORKERS' COMPENSATION
INSURANCE with the following:
B. We Will Indemnify
You are responsible for all benefits required by the Workers' Compensation Law. We will indemnify you for that
amount of benefits actually paid or required by law to be paid by you as a qualified self-insurer under the
Workers' Compensation Law that is in excess of. your .retained limits stated in Item 4.A. and 4.B. of the
Information Page.
This endorsement replaces PART FOUR - LIMITS OF LIABILITY - RETAINED LIMITS with the following:
PART FOUR - LIMITS OF LIABILITY - RETAINED LIMITS
YOUR SPECIFIC RETENTION
Your Specific Retention as stated in Item 4.A. and '4.BL'Of the Information Page apply on a combined basis to PART
ONE - EXCESS WORKERS' COMPENSATION INSURANCE and PART TWO - EXCESS EMPLOYERS' LIABILITY
INSURANCE.
OUR LIMITS OF LIABILITY
PART ONE
Our liability to pay for loss in excess of your self;insured retention under PART ONE - EXCESS WORKERS'
COMPENSATION INSURANCE is unlimited.
PART TWO
Our liability to pay for loss under PART TWO- EXCESS: EMPLOYERS' LIABILITY INSURANCE is limited. Our limit
of liability is as stated below in this endorsement.
Regardless of the number of insureds covered by this policy, the number of people who sustain injury or the
number of claims made or suits brought, our limit of liability shall be for loss in excess of your retention as stated in
Item 4.A. and 4.B. of the Information Page and then only up to and not exceeding our limit of liability for loss under
Part Two as stated in Items 5.B. and 5.D. of the Information Page.
Your self insured retention for each accident (Information Page Item 4.A.) and our limit of liability for each accident
(Information Page item 5. B.) apply to each accident for injuries including death resulting therefrom, other than
disease. A disease is not bodily injury by accident unless it results directly from bodily injury by accident.
Form WC 99 02 57 (ED. 01/95)
Printed in U.S.A. (NS)
Page I of 2
Your self insured retention for disease, each employee (Information Page Item 4. B.) and our limit of liability for
disease, each employee (Information Page item 5.D~) apply to each employee for injuries arising out of disease
including death. Bodily injury by disease does not include disease that results directly from a bodily injury by
accident.
Item 5.E. of the Information Page is amended to apply to PART TWO - EXCESS EMPLOYERS' LIABILITY
INSURANCE only. The maximum amount we will indemnify under Part Two for all loss payable under this Policy is
stated below:
5.E. Aggregate (Part Two only) $ 1,000,000.
Form WC 99 02 57 (ED. 01/95) Pdnted in U.S.A. (NS) Page 2 of 2
Excess Workers Compensation and Employers Uability Policy
OTHER STATES INSURANCE ENDORSEMENT
This endorsement changes the policy effective on the
inception date of the policy unless another date is indicated
below.
Effective Date Effective hour is the same as stated
10 / 0 1 / 9 9 in the Information Page of the policy.
Endt. No. ~
5
Named Insured and Address
CITY OF SANFORD
300 N. PARK AVENUE
P.O. BOX 1788
SANFORD, FL 32771
SCHEDULE
This endorsement applies in the following additional stmes not listed in Item 3 A of the Information Page:
ALL STATES
A. How This Insurance Applies
1. The other states insurance applies only if the injured employee's state of hire is listed in Item 3 A of the
Information Page.
2. If you have employees working temporarily in any one of the state(s) listed in the SCHEDULE of this
endorsement and are not self-insured for such work, all terms and conditions of this policy will apply as
though that state were listed in item 3. A. of the Information Page.
3. We will reimburse you for the benefits required by the worker's compensation law of the state of hire or state
of injury for amounts in excess of your self-insured retention. -
B. Notice
Tell us at once if you begin work in any state listed in the SCHEDULE of this endorsement.
Form WC 99 02 58 (Ed. 01/95) Printed in U.S.A.
Copyright, Hartford Fire Insurance Company, 1995
Policy Number: 21 XST QXO130 Effective Date:
Named Insured and Address: CITY OF SANFORD
300 N. PARK AVENUE
P.O. BOX 1788
SANFORD, FL 32771
Endt. No. 6
10/01/99
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
AMENDMENT OF CONDITIONS - FLORIDA
This endorsement modifies insurance provided under the following:
EXCESS WORKERS' COMPENSATION AND EXCESS EMPLOYERS' LIABILITY COVERAGE FORM
It is agreed that:
A. The Cancellation Condition is replaced by the
following:
CANCELLATION
1. You may cancel this policy.
advance written notice to:
a.
b.
You must mail
Us; and
The Florida Department of Labor and
Employment Security.
Division of Workers' Compensation
Self-Insurance Section
P.O. Box 5497
Ta!lahassee, FL 32314-5497
by certified mail at least 60 days before the
effective date of cancellation.
We may cancel this policy by mailing advance
written notice to:
a. The Named Insured shown in Item 1. of
the Information Page; and
b. The Florida Department of Labor and
Employment Security.
Division of Workers' Compensation
Self-Insurance Section
P.O. Box 5497
Tallahasseeo FL 32314-5497
,
by certified mail at least 60 days before the
effective date of cancellation.
The policy pedod will end on the day .and hour
stated in the cancellation notice.
B. The following Condition is added to the policy:
NON-RENEWAL
1. If we decide not to renew this policy. we will
mail by certified mail. written notice of non-
renewal with reasons for the non-renewal to:
a. The Named Insured shown in Item 1. of
the Information Page; and
b. The Flodda Department of Labor and
Employment Security.
Division of Workers' Compensation
Self-Insurance Section
P.O. Box 5497
Tallahassee. FL 32314-5497
at least 60 days before the end of the policy
period.
2. If we offer to renew this policy and you do not
accept our offer dudrig the current policy
period. this policy will expire at the end of such
policy period.
Page I of 2
Form WC 99 01 59 B (ED. tl/97)
O 1997 The Hartford
D,
Condition '13. 8anlcruptcy or Insolvency is amended
to include the following additional paragraph:
In the event of insolvency of a member of the
Florida Guaranty Association, Inc. (FSIGA), the
policy wile reimburse ~e FSIGA for any monies
expended on behalf of the member. Any
reimbursement wile be subject to the terms of the
policy to which this endorsement is attached.
Condition J. Commutation is amended to include
the following:
Any commutation effected hereunder shall not
relieve us of further liability in respect to:
1. Claims and claim expenses unknown at the
time of such commutation; or
2. Claims apparently closed, but which may be
subsequently reopened by or through a
competent authority.
Any proposed commutation must first be approved
by the Florida Department of Labor and
Employment Security, Division of Workers
Compensation, Self-Insurance Section for Flodda
employees. Wdtten notice of such commutation
shall be mailed by us certified mail not less than 60
days prior to such commutation.
E. Section 8. We Will Indemnify under beth Part One
and Part Two is amended to include the following:
In the event any commutation is effected, the
Flodda Department of Labor and Employment
Security, Division of Workers Compensation, Self-
Insurance Section shall have the right to direct that
such sum either:
1. Be placed in trust for the benefit of the injured
employee or employees entitled to such future
payments of compensation; or
2. Be invested in approved securities and
deposited with the Florida Department of
Labor and Employment Security, Division of
Workers Compensation, Self-Insurance
Section to assure such future payments of
compensation to the employee of employees
entitled thereto.
The Flodda Department of Labor and Employment
Security, Division of Workers Compensation, Self-
Insurance Section may order the payment of
obligations due under the terms of the policy shall
be made to a party other than the employer. where'
such action is necessary to insure the prompt
payment of benefits to injured employees.
The following Condition is added to the policy:
We agree to be subject to the claims handling
standards established by the Florida Dei:rartment
of Labor and Employment Security, Division of
Workers Compensation. Self-Insurance Section for
carriers and self-insurers in accordance with
Section 440.20(16)(c), Flodda Statutes.
All other terms and conditions of this policy remain unchanged.
FormWC 99 01 59 B (ED, 11/97) Page 2of2
Policy Number: 21 XST QX0130
Effective Date:
Named Insured and Address:
Endt. No. 7
CITY OF SANFORD
300 N. PARK AVENUE
P.O. BOX 1788
SANFORD, FL 32771
10/01/99
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
POLICY CHANGES
This endorsement modifies insurance provided under the following:
EXCESS WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY
This endorsement changes the Policy effective on the Inception Date of the Policy unless another date is indicated
below:
Policy Change Effective Date:
This endorsement is applicable in all states listed in Item 3.A. of the Information Page, except for the following
states:
Minnesota
Nebraska
Virginia
Wisconsin
It is agreed the following "in Witness' provision is added to the policy:
In Witness Whereof, the Company has caused this policy to be signed by its President and Secretary, but the
same shall not be binding unless countersigned on the Information Page by a duly authorized representative of the
Company.
This endorsement does not change the Policy except as shown.
Form WC 99 04 01 (ED. 03/98)
O 1998 The Hartford
~HE
HARTFORD
Form WC 99 02 94 (ED. 03/98)