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814-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)