Loading...
669-Hilb Rogal...-Workers Comp CERTIFICATE OF LIABILITY INSURANCE,.?; :::" " ... ~'~ 10/22/97 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORNIATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HRH Of 0rtando HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P .0. Box 871 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 0rtando FL 32802-0S71 COMPANIES AFFORDING COVERAGE COMPANY Phone So. 407-841-2250 Fax No. 407-841-9904 A ITT Hartford Insurance INSURED COMPANY B City of Sanford, EL. COMPANY Tim McCautey, PersonneI. Dir. C P. 0. Box 1788 COMPANY Sanford Ft. 32772-1788 D THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMBD ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE pOLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BERN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EF/a~CTIVE POLICY EXPIRATION LTR DATE (MM/DD/YY) DATE (MM/DD/YY) LI~IIT$ GENERAL LIABILITY GENERAL AGGREGATE COMMERCIAL GENERAL LiABILiTY PRODUCTS - COMPIOP AGG ::::::~ MA PERSONAL & ADV INJURY OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE FIRE DAMAGE (Any one fire) AUTOMOBILE LIABILITY ~ COMBINED SINGLE LIMIT $ ANY AUTO __ ALL OWNED AUTOS BODILY 1NJURY $ SCHEDULED AUTOS (Per person) __ HIRED AUTOS BODILY INJURY $ NON4}WNED AUTOS (Per accic~ent) -- PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ EACH ACCIDENT $ EXCEFgS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ EMPLOYEES' LIABILITY EL EACH ACCIDENT $ A THEPROPRILerOR/ ~ INCL 21XSTQX0150 10/01/97 10/01/98 ELDISEASE-POL[CYLIMrr $ 1,000,000. PARTNERS/EXECUTIVE OFFICERS ARE: EXCL EL DISEASE- EA EMPLOYEE $ ~t000,000. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS Specific Retention: A. each accident $150,000 B. each employee for disease $150,000 Box 44204 (FL0122) A~NT~ SOREP~S~A~. PJOJ-:JJeFI eql LUOJ-I Xo!lod AZl!l!.qeFI ,s~ZoIdttr~ pu~ uo.qi3su~dtuo3 _~ " ,s~l~oA~ ssaoxEI b~,~_NQ,0 - FOR OUR EXCESS WORKERS' COMPENSATION CUSTOMERS: :/ To provide you with better claim service, we have arranged for a special coordinator, to administer Excess Workers' Compensation claims. :. ' Please report any claim which you are required to under Part Five of your policy provisions (WC990112) to: "' TED COOPER EXCESS WORKERS' COMPENSATION CLAIMS UNIT HARTFORD SPECIALTY COMPANY HARTFORD PLAZA, T-5-97 HARTFORD, CONNECTICUT 0611S You may also telephone or "Fax" Ted at the following numbers: Telephone: (203) f47-8792 Fax: (203) 547-8782 Thank you EXCESS WORKERS' .COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY (SPECIFIC) QUICK REFERENCE Beginning Beginning on page on page Information Page .~- General Section I D. Settlements · 4 A. The Policy I E. Experience Report 4 B. Who is Insured 1 PART SIX - INVESTIGATION, DEFENSE, SETTLEMENT 4 C. Workers Compensation Law I ..... D. Qualffied Serf-Insurer I PART SEVEN - PREMIUM 4 E. Loss I A. Deposit and Adjustment Premium 4 PART ONE - EXCESS WORKERS' COMPENSATION B. Total RemUneration Report_ 4 INSURANCE I C. Rna] Premium 4 A. How This Insurance Applies I D. Total Remuneration 4 B. We Wdl Indemnify I E Records 4 C. Payments You Must Make 1 F. Audit 4 D. Exc(usiona 2 PART EIGHT - CONDITIONS' 5 PART TWO - EXCESS EMPLOYERS' LIABILITY A. Inspection 5 INSURANCE 2 B. Bankruptcy or Insolvency 5 A. How This lnsurance Applies 2 C. Recovery From Other~ 5 B. We Will Indemnify ~ D. Cancellation 5 , C. Employers' Liability Lo~s D. Exdusions - Payments You Must Make 2 F. Appeals 5 PART THREE - OTHER INSURANCF 3 G. Assessments 6 PART FOUR ~ UMITS OF LIABILITY - H. Responsibility For Your Self4nsured Retention. 6 RETAINED UMIT~ 3 I. Administration of Claim 8ervic~ 6 PART FIVE-YOUR DUTIES IF INJURY OCCURS .3 J. Commutation 6~ K. Auditing of Claims 7 A. Written Notice Requirements 3 L Assignment 7 B. Notice Should Include 3 M. Representation 7 C. Clalmslnformation 3- IMPORTANT: This Quick Reference is not part of the Excess Workers' Compensation and .Employers' Uat~lity Insurance Palicy and does not provide coverage. Refer to the Excess Workers' Compensation and Employers' Liability Insurance Policy itseft for actual contractuaJ provisions. PLEASE READ THE EXCESS WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POUCY CAREFULLY. Form WC 99 01 19 A Pdnted in U,S.A. (NS) EXCESS WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY (SPECIFIC) INFORMATION PAGE ,~""~surer: HARTFORD CASUALTY INS CO (Co. UseOnly) HARTFORD, CT 06115 BI-~st L R R P R] d CofCF] Policy No. 2:]. XST QX0130 Items CITY OF SANFORD ROOM 241 1. Named Insured and Mailing Address - 300 N. PARK AVENUE The Nam~ Insur~ is: ~ Individual Q Pa~nership Q Joint Venture SANFORD, FL 32771 co. Code 3 ~ Corporation ~ Other From ~0/0!/97 To ~0/0~/98 2. Policy Period Incep~on Date ~pira~on Date 12:01 A.M. standard time at the address of the Named Insured as stated heroin. Producer's Name and Address Code No. ~S~CO 221908 ll80 S~GS C~ S. ~O~V~D S~I~ 125 3. A, This insurance applies to the Workers' Compen~tion and Occupational Disease ~ws of the following state(s): Your Specific Retention A. EachAccident $ 150,000. B, Each Employee for Disease $ 150,000. 5. dur Um~ of Liability A. Each Accidem (Pa~ One) S~A~O~ B. Each Accidem (Pa~ Two) $ ~, 00 O, 000. C. Each Employee for Disease (Pa~ One) S~O~ b. Each Employee for Disease (Pa~ T~o) $ 1,000,000. E. Aggregate (Pa~ One and Pa~Two combined) S~ ~D~. 6. Deposit and Minimum Premium $ 78,691. See ~CESS WORKERS' COMPENSATION PREMIUM SCHEDULE 7. Premium Schedule: See ~CESS WORKERS' COMPENSATION PREMIUM SCHEDULE 8. Claim Se~iceCompany: I~S~C~ S~VIC~ ~S~I~G CO~ 9. Form Numbers of Policy Provisions and Endorsement forming a pa~ of this policy: See LISTING OF POLICY PROVISIONS AND ENDORSEME~S FORMING A PART OF THE POLICY AT ISSUE. ~s policy will not be valid unless countersig~ed by our duly a~horized representatNe. ~C~ ( 09 / 08 / 9 ? ) Countersign~ bV · Authorized Representative Form WC 99 01 10 D Pdm~ in U.S.A. (NS) Policy Number: 21 XST QX0130 EffectiveDate 10/01/97 ~ ~ . CITY OF SANFORD Named Insured and Ad~lress: ROOM 241 300 N. PARK AVENUE SANFORD, FL 32771 LISTING OF POLICY PROVISIONS AND ENDORSEMENTS FORMING A PART OF THE POLICY AT ISSUE This Listing forms a part of the following: WORKERS' COMPENSATION EXCESS POLICY Thefollowingisali~ing ~ poli~ provisionsandendomememsbyForm NumberandTMeth~form apart ~the poli~ ~issue. FORM NUMBER TITLE OF ENDORSEMENT WC990112 EXCESS WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY POLICY PROVISIONS (SPECIFIC) WC990120 EXCESS WORKERS' COMPENSATION PREMIUM SCHEDULE 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 WC990149 AMENDATORY ENDORSEMENT 7 WC990159 AMENDMENT OF CONDITIONS - FLORIDA Form L-5015-3 (Ed.11/88) Printed in U.S.A. (NS) Copyright Hartford Fire Insurance Company, 1987 EXCESS WORKERS' COMPENSATION AND ,~ EMPLOYERS' LIABILITY POLICY PROVISIONS (SPECIFIC) THE HARTFORD The insurer shown on the information Page is a stock E. Loss insurer. Loss means any benefits actually paid by you In return for the payment of the premium and subject under the Workers' Compensation Law, or dam- to all terms of this policy, we agree with you as ages actually paid by you arising out of bodily follows. injury by accident or bodily injury by disease covered by Part Two of this policy. Loss does not GENERAL SECTION include claim expense. A, The Policy PART ONE -EXCESS WORKERS' COMPENSA- This policy includes at its effective date the TION INSURANCE Information Page and all endorsements and A. How ThislnsuranceApplies schedules listed thereon. It is a contract of insurance between you (the insured named in This excess workers' compensation insurance Item 1. of the Information Page) and us (the applies to bodily injury by accident or bodily insurer named on the Information Page). The injury by disease. The bodily injury must arise out only agreements relating to this insurance are of and in the course of the injured employee's stated in this policy. The terms of this policy may employment by you. Bodily injury includes not be changed or waived except by endorse- resulting death. ment issued by us to be part of this policy. Bodily injury by accident must occur during the policy period. A disease is not bodily injury by B. Who Is Insured accident unless it results directly from bodily You are insured if you are an employer named in injury by accident. Item 1, of the Information Page. If that employer Bodily injury by disease must be caused or is a partnership, and if you are one of its partners, aggravated by the conditions of your employ- you are insured, but only in your capacity as an ment. The employee's last day of last exposure in employer of the partnership's employees. your employment to the conditions causing or aggravating such bodily injury by disease must C. Workers Compensation Law occur during the policy period. Bodily injury by Workers' Compensation Law means the Workers' disease does not include disease that results orWorkmens' Compensation Law and Occupa- directlyfrom bodily injury by accident. tional Disease Law of the states named in Item B. We Will Indemnify 3.A. of the Information Page. It includes any amendments to that law which are in effect during You are responsible for all benefit payments the policy period stated in the Information Page. required by the Workers' Compensation Law. We It does not include provisions of any law that will indemnify you for that amount of loss under provides non-occupational disability benefits. the Workers' Compensation Law that is in excess State means any state of the United States of of your specific retention stated in Item 4.A. and America and the District of Columbia. 4.B, of the Information Page, but not more than D. Qualified Self-Insurer our limit of liability stated in Item 5.A., 5,C. and 5.E, of the Information Page. Your acceptance of this policy indicates that you are now and will remain until the end of the policy C. Payments You Must Make period a duly qualified self-insurer in each state You are responsible (without reimbursement from named in Schedule Item 3.A. If you are not a duly us) for any payments in excess of any benefits or qualified self-insurer with respect to any loss award regularly provided by the Workers' Corn- covered by this policy, this policy will apply as if you were. pensation Law including those required because: Form WC 99 01 12 Printed in U.S.A. iNS) Page 1 of 7 1. Of your serious and willful misconduct; B. We Will Indemnify 2. You knowingly employ an employee in viola- You are responsible for all loss payments covered tion of law; under Part Two of the policy. We will indemnify 3. You fail to comply with a health or safety law or you for that amount of loss that is in excess of regulation; or your specific retention as stated in Item 4.A. and 4.B. of the Information Page, but not more than 4. You discharge, coerce or otherwise discrimi- the limits of liability stated in Item 5.B., 5.D. and nate against any employee in violation of the 5.E. of the Information Page. Workers' Compensation Law. D. Exclusions C. Employers' Liability Loss This insurance does not cover and your retained The damages we will indemnify you for, where limits will not be satisfied by any payments arising recovery is permitted by law, include damages: out of operations: 1. Which you have paid to a third party by reason 1. For which you have formally rejected any of a claim or suit against you by that third party Workers' Compensation Law; or to recover the damages claimed against such third party as a result of injury to your 2. Which are considered to be domestic, farm or employee; agricultural employments unless required by the Workers' Compensation Law. 2. For care and loss of services; and PART TWO - EXCESS EMPLOYERS' LIABILITY 3. For consequential bodily injury to a spouse, child, parent, brother or sister of the injured INSURANCE employee; A. How ThislnsuranceApplies provided that these damages are the direct This Excess Employers' Liability Insurance ap- consequence of bodily injury that arises out of and in the course of the injured employee's plies to bodily injury by accident or bodily injury by disease not covered by the Workers' employment byyou;and Compensation Law. The bodily injury must arise 4. Because of bodily injury to your employee that out of and in the course of the injured employee's arises out of and in the course of employment, employment by you. Bodily injury includes claimed against you in a capacity other than as resulting death, it also includes injury arising out employer. of assault and battery unless committed by you or at your direction. D. Exclusions-PaymentsYouMustMake 1. The employment must be necessary or This insurance does not cover and your retained incidental to your work in a state or territory limits will not be satisfied by payments stated listed in item 3.A. of the Information Page. below. You are responsible for loss payments 2. Bodily injury by accident must occur during arising out of: the policy period. 1. Liability assumed under a contract. This ex- 3. Bodily injury by disease must be caused or clusion does not apply to a warranty that your aggravated by the conditions of your employ- work will be done in a workmanlike manner. ment. The employee's last day of last 2. Fines or punitive or exemplary damages be- exposure in your employment to the conditions cause of bodily injury to an employee em- causing or aggravating such bodily injury by ployed in violation of law; disease must occur during the policy period. 3. Punitive, exemplary or compensatory dam- If you are sued, the original suit and any related ages because of your conduct, or the conduct legal actions for damages for bodily injury by of anyone acting for you: accident or by disease must be brought in the United States of America, its territories or pos- a. In the investigation, trial or settlement of any sessions, or Canada. workers' compensation claim; Form WC 99 01 12 Printed in U.S,A. (NS) Page 2 of 7 b. In failing to pay or delay in payment of any each accident for injuries including death resulting Workers' Compensation claim; therefrom, other than disease. A disease is not bodily injury by accident unless it results directly from bodily 4. Bodily injury to an employee while employed in injury by accident. violation of law with your actual knowledge or the actual knowledge of any of your executive Your specific retention for disease, each employee officers; (Information Page Item 4.B.) and our limit of liability for disease, each employee (Information Page Items 5. Any obligation imposed by Workers' Compen- 5.C. and 5,D.) apply to each employee for injuries sation, occupational disease, unemployment arising out of disease including death. Bodily injury compensation, or disability benefits law, or any by disease does not include disease that results similar law; directly from a bodily injury by accident. 6. Bodily injury intentionally caused or aggrav- The retained limits and our limit of liability as stated ated by you; above apply separately to Part One & Part Two of this 7. Bodily injury occuring outside the United policy. States of America, its territories or posses- The maximum amount we will indemnify under Part sions, and Canada. This exclusion does not One and Part Two above for all losses is as stated in apply to bodily iniury to a citizen or resident of Item 5,E, of the Information Page. the United States of America or Canada who is temporarily outside these countries. PART FIVE - YOUR DUTIES IF INJURY OCCURS 8. The termination of employment; or A. Written Notice Requirements 9. The coercion, demotion, reassignment, disci- You must give us written notice as soon as pline, defamation, harassment, humiliation, or possible: discrimination against any employee. I. If an injuryto your employee occurs involving; PART THREE - OTHER INSURANCE a, Quadriplegia; If you have other insurance, reinsurance, indemnity, b. Paraplegia; or reimbursement coverage, covering loss also covered by this policy (other than insurance that is c. A major extremity or multiple minor extrem- purchased to apply in excess of your retention and ity amputation; our limit of liability, or policies of co-insurance within d. Second orthird degree burns over 25 per- the limits of this policy), this coverage shall be excess cent or more of the body; of and shall not contribute with such other coverage. e. Brain or brain stem injury; PART FOUR - LIMITS OF LIABILITY - RETAINED f. Partial ortotal blindness; LIMITS g. Death. Our liability to pay for loss is limited, Our limits of liability are shown in Item 5. of the Information Page. 2. Any injury wherein the potential loss payable They apply as explained below. may exceed 50 percent of the retained limit shown on the Information Page. Regardless of the number of insureds covered by this policy, the number of people who sustain injury or the 3. Any accident which causes injury to two or number of claims made or suits brought, our limit of more employees. liability shall be for loss in excess of your retention as B. Notice Should Include stated in Item 4.A. and 4.B. of the Information Page and then only up to and not exceeding our limit of Notice should include all notices of injury you liability as stated in Item 5.A., 5.B., 5.C. and 5.D. of the receive, as well as the demand, and legal papers Information Page. related to the injury, claim proceeding or suit. Your specific retention for each accident (Information C. Claims Information Page Item 4,A.) and our limit of liability for each accident (Information Page 5.A, and 5.B.) apply to You agree to send to us any claim information which we may request, Form WC 99 01 12 Printed in U.S.A. (NS) Page 3 of 7 D. Settlements PART SEVEN - PREMIUM You agree not to make any voluntary settlement A. Deposit and Adjustment Premiums involving loss to us without our written consent. At the beginning of the policy period you must E. Experience Report pay us the deposit premium shown in Item 6. of the Information Page, At the end of the policy Within 30 days after written request by us you period: agree to send us an experience report (in a form satisfactory to us) detailing the claims paid by you 1. you will owe us the amount by which the final during the period and your current reserves for premium is greater than the deposit premium; unpaid claims, or 2. we will owe you the amount by which the PARTSIX-INVESTIGATION, DEFENSE, SE'FrLE- deposit premium is greater than the final MENT premium. We shall not be obligated to assume charge of the B. Total Remuneration investigation, defense or settlement of any claim or suit against the insured, but we shall have the right Total Remuneration means the gross pay of your and shall be given the opportunity to associate with employees for the policy period plus other the insured or its claim servicing agency or both, in amounts and items received by your employees the investigation, defense or settlement of any claim as part of their pay for the policy period. We will or suit that, in our opinion, involves or appears send you a reporting form describing what is to reasonably likely to involve us. be included in remuneration. if we elect to associate, the insured, its claim servicing C. Total Remuneration Report agency, and we shall cooperate in such matters so as Within 45 days after the end of the policy period, to effect final determination thereof. The insured shall you will send us a report showing the amount of not make or agree to any settlement for an amount in total remuneration earned by your employees excess of the applicable retained limit without our during the policy period. The report must show approval. total remuneration separately for each classifica- tion identified in Item 7.A. shown in the Excess Each insured will pay all its own claim expenses relative to any claim settled or adjudicated for a sum Workers' Compensation Premium Schedule. less than the applicable retained limit. Claim D. FinalPremium expenses does not include salaries of the insured's regular employees, or our regular employees, expen- The final premium due us for this policy will be ses incurred by the insured for the first aid or claim computed as follows: The total remuneration for fees paid to the insured's claims service agency. the policy period divided by $100 multiplied by Payments of claim expenses shall not reduce the the rate(s) shown in 7.D. of the Excess Workers' applicable retained limit. Compensation Premium Schedule. if a claim is settled or adjudicated for a sum greater Unless this policy is cancelled, final premium will than the applicable retained limit, we will pay claim be at least the minimum and deposit premium expenses in the ratio that our liability for the judgment shown in 7.F. of the Excess Workers' rendered or settlement made bears to the whole Compensation Premium Schedule. amount of such judgment or settlement. We will pay our share of the claim expenses in addition to the If we cancel this policy, final premium will be applicable limits of liability stated in the Information calculated pro rata based on the time this policy Page. was in force. The final premium will not be less than the pro rata share of the minimum and When we have used up the applicable limit of liability deposit premium, in the payment of loss, we shall no longer be obligated to pay any loss or to pay any share of claim If you cancel this policy, return premium will be expenses. This applies both to claims and suits calculated at 90% of the pro rata unearned pending at that time and those filed thereafter. premium. The final premium will not be less than the minimum and deposit premium. Form WC 99 01 12 Printed in U.S.A. (NS) Page 4 of 7 E. Records 2. Then, us for all amounts paid under the policy; and You will keep records of information needed to compute premium. You willprovideuswithcop- 3. Finally, all other interests (including your ies of those records when we ask for them. interest) with respect to the residue, if any. F. Audit When we have elected to participate in the exercise of your right of recovery reasonable You will let us or our representatives examine and expenses resulting therefrom will be apportioned audit all your remuneration records. The audits among all interests in the ratio of their respective may be conducted during your regular business recoveries. hours. PART EIGHT-CONDITIONS If there should be no recovery as a result of proceedings instituted solely at our request, we A. Inspection will bear all expenses of such proceedings. D. Cancellation We have the right, but are not obligated to inspect your workplaces at any time. Our inspections are 1. You may cancel this policy. You must mail or not safety inspections. They relate only to the deliver advance notice to us stating when the insurability of the workplaces and the premium to cancellation is to take effect. be charged. We may give you reports on the 2. We may cancel this policy. We must mail or conditions we find. We may also recommend deliver to you not less than ten days advance changes. While they may help reduce losses, we written notice stating when the cancellation is do not undertake to perform the duty of any to take effect. Mailing that notice to you at person to provide for the health or safety of your your mailing address shown in item 1 of the employees or the public. We do not warrant that information Page will be sufficient to prove your workplaces are safe or healthful or that they notice. comply with laws, regulations, codes or stun- dards. Insurenee rate service organizations have 3. The policy period will end on the day and hour the same rights we have under this provision, stated in the cancellation notice. 4. Any of these provisions that conflicts with a law B. Bankruptcy or Insolvency that controls the cancellation of the insurance in this policy is changed by this statement to Your bankruptcy or insolvency will not relieve us of the duties and liabilities under this policy. After comply with that law. your retention has been reached, payments due E. Sole Representative under this policy will be made as if you had not become bankrupt or insolvent but not in excess of The insured first named in Item 1. of the our limit of liability. Such payments will be made Information Page is authorized to act on behalf of to the trustee in bankruptcy or as a court of all insureds with respect to giving or receiving competent jurisdiction may ultimatelydirect. notice of cancellation, receiving refunds, and agreeing to any changes in this policy. C. Recovery From Others F. Appeals If you have rights to recover all or part of any indemnification we have made under this policy, If you or any other insurer elects to appeal a those rights are transferred to us. You must do judgment or award, we will not pay any costs or nothing after loss to impair them. At our request, fnterest incidental to the appeal. if you or any you will bring suit or transfer those rights to us other insurer do not so elect, we may do so. and help us enforce them. When we elect to appeal a judgment or award we will pay the cost and interest incidental to the Recoveries shall be applied to reimburse: appeal. Regardless of who elects to appeal, any amounts recovered will be applied as follows: 1. First, any interests (including your interest) that may have paid any amounts in excess of our 1, First, to our costs and expenses in pursuing liability under the policy; the appeal; Form WC 99 01 12 Printed in U,S.A. (NS) Page 5 of 7 2. Second, to reimburse any interest (including I. Administration of Claim Service your interest) that may have paid any amounts ~ in excess of our liability under the policy; We shall have the right to approve any claim , · service company engaged by you, The Claim 3. Then, to reimburse us for all amounts paid un- Service Company shall be named in Item 8 of the derthe policy; and Information Page or in an endorsement to this 4. Finally, to reimburse all other interest (includ- policy. ing your interest) with respect to the residue, if You shall notify us in writing of your intention to any. engage any other service company at least thirty G. Assessments days prior to such change. If we object to such change, we shall notify you in writing of such You agree to indemnify us for that portion of any disapproval within ten days of receipt of your assessment attributable to the premium we notification of change. collect for this policy or the losses we pay pursu- ant to this policy and arising out of: J. Commutation 1, Our participation in any residual market plan; Beginning twenty-four months after receipt by us 2. Our participation in any guarantee fund, or your Claim Service Company of notice of a guarantee association or other facility protect- claim, we may then, or at any time thereafter, ing claimants against the uncollectibility of submit such claim for commutation. We may, at insurance proceeds; or our election, submit such claim to an actuary or appraiser of our choice and pay you a lump sum 3. Your status as a self-insured employer. fixed by such actuary or appraiser. You also agree to indemnify us for all reasonable If you do not agree to the lump sum so fixed, you costs and expenses, including reasonable attor- may make a written demand for arbitration. You ney's fees, in connection with our collection of must make any such demand within sixty days of such indemnification. your receipt of our notice concerning payment of /---, As used in this policy: the lump sum. When a demand is made, each party will choose "Assessment" means any assessment, tax or other charge whether payment is required by law an arbitrator, The two arbitrators, so chosen, or required as a condition of continued opportun- then will select a third. If this selection is not ity to transact wokors' compensation insurance in completed within thirty days, either or both of the the applicable state; two arbitrators may request that such selection be made by a court having jurisdiction. Each party "Residual market plan" means any plan, pro- will: gram or facility (whether voluntary or required by law) by which substantially all workers' compen- 1. Pay the expenses it incurs; and sation insurers in a state share in the risk of 2. Bear the expenses of the third arbitrator equally. providing such insurance for eligible employers. Unless both parties agree otherwise, arbitration H. Responsibility for Your Self-insured Retention will take place in the county or parish in which the This insurance will not take the place of your ob- address shown in the Information Page is located. ligation to pay any amount within the self-insured Local rules of law as to procedure and evidence will apply. A decision agreed to by two of the retention or any applicable coinsurance, whether arbitrators will be binding. or not such obligation becomes invalid, suspen- ded, unenforceable or uncollectible for any If subsequent to such lump sum payment, a reason, including bankruptcy or insolvency. supplemental award is made increasing the amount of benefits payable to the employee The entire risk of such invalidity, suspension, and/or his or her dependents, any additional unenforceability or uncollectibility is retained by liability, at our election, may immediately be all insureds and their obligees, not by us. commuted following the process cited above. Form WC 99 01 12 Printed in U.S.A. (NS) Page 6 of 7 K. Auditing of Claims We have the right but are not obligated to audit your claim files. L. Assignment Your rights or duties under this policy may not be transferred without our written consent. M. 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 Printed in U.S.A. (NS) Page 7 of 7 Policy Number: 21 XST QX0130 EffectiveDate: 10/01/97 Named insured and Address: CITY OF SANFORD ROOM 241 300 N. PARK AVENUE Endt No. 2 SANFORD, FL 32771 EXCESS WORKERS' COMPENSATION PREMIUM SCHEDULE 7.The estimated annual premium (E.) for this policy will be determined by: Total Estimated Annual Remunera- tion (C.) divided by $100 multiplied by rate (O,). All information required below is subject to verification and change by audit, c. Premium Basis D. Rate Per E. Estimated A. Classifications B. Code Totel Estimated $100. of Annual Number Annual Remuneration Remuneration Premium ALL OPERATIONS OF THE INSURED 0388 11,212,693. ,7018 78,691. F. Minimum and Deposit Premium 78,691. WC 99 01 20 Printed in U,S.A. (NS) Policy Number: 21 XST QXOl30 EffectiveDate: 10/01/97 Named Insured and Address: CITY OF SANFORD ROOM 2~1 300 N. PARK AVENUE Endt. No. 3 SANFORD, FL 32771 AMENDMENT OF RETAINED LIMITS (Self Insured Retention - Combining Loss and Claim Expense) It is agreed that PART FOUR - LIMITS OF UABILITY - RETAINED UMITS is amended to include the following additional paragraph: Your specific retention include loss and claim expense but 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 applicabie 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 99 02 54 lED. 01/95) Printed in U.S.A. (NS) Copyright, Hartford Casualty Insurance Company, 1994 Policy Number: 21 XST QXO130 EffectiveDate: 10/01/97 Named Insured and Address: CITY OF SANFORD ROOM 241 300 N. PARK AVENUE Endt. No. 4 SANFORD, FL 32771 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.B. 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 lED. 01/95) Printed in U.S,A. INS) 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) $ :]' ' 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 Liability Policy ~ ' OTHER STATES INSURANCE ENDORSEMENT Named Insured and Address { C TY This endorsement changes the policy effective on the ROOM 241 inception date of the policy unless another date is indicated 3 0 0 N. PARK AVENUE below. SANFORD, FL 32771 Effective Date Effective hour is the same as stated 10 / 0 1 / 9 7 in the Information Page of the policy. Endt. No. I 5 SCHEDULE This endorsement applies in the following additional states 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 /---I 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 QX0130 EffectiveDate: 10/01/97 Named Insured and Address: CITY OF SANFORD ROOM 241 6 300 N. PARK AVENUE Endt. No. SANFORD, FL 32771 AMENDATORY ENDORSEMENT It is agreed that the "In Witness" provision preceding the signatures of the President and Secretary is deleted and replaced by the following: 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, Form WC 99 01 49 Printed in U.S.A, Policy Number: 21 XST QX0130 EffectiveDate: 10/01/97 Named Insured and Address: C'rT¥ OF S,L~FORD ROOM 2 4 1 7 300 N. PARK AVENUE Endt. No. SANFORD, FL 32771 AMENDMENT OF CONDITIONS - FLORIDA It is agreed that: 1. The Cancellation Condition is replaced by the 2. The following Condition is added to the policy: following: Non-Renewal Cancellation 1. If we decide not to renew this policy, we will 1. You may cancel this policy, You must mail or mail or deliver written notice of non-renewal deliver advance notice to us stating when the with reasons for the non-renewal to you and cancellation is to take effect. the Bureau of Self-insurers, Division of Wor- kers' Compensation at least sixty days before 2. We may cancel this policy. We must mail or the end of the policy period. deliver to you not less than sixty days advance written notice stating when the cancellation is 2. If we mail our notice, it will be mailed to you at /"', to take effect. We must also mail to the Bureau your mailing address shown in item 1. of the of Self-insurers, Division of Workers' Cornpen- information page. Notice to the Bureau of sation sixty days advance written notice. Self-insurers, Division of Workers' Compensa- tion will also be sent registered or certified 3. If we mail our notice, it will be by registered or mail. certified mail. It will be mailed to you at your mailing address shown in item 1. of the 3. If we offer to renew this policy and you do not Information Page. Notice to the Bureau of accept our offer during the current policy Self-insurers, Division of Workers' Compensa- period, this policy will expire at the end of such tion will also be sent registered or certified policy period. mail. 4. The policy period will end on the day and hour stated in the cancellation notice. Form WC 99 01 59 Printed in U.S.A.