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~.
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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.