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Excess Workers Compensation Agreement (2009-2010) . 'i','~ "','~ l','~ "','~ "','~ "','~ "','~ Midwest Employers Casualty Company SPECIFIC IiEXCESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY INDEMNITY POLICY Policy No.: EWC006379 SCHEDULE 1. Insured: City of Salina, KS 2. Mailing Address: 300 West Ash, Room 200 Salina, KS 67401- 3. Named States: Kansas 4. Excluded States: None 5. Policy Period: (a) From: 05/01/2009 (b) To: 05/01/2010 Both days at 12:01 A.M. standard time at the Insured's address shown in Item 2 of this schedule. 6. Retention: (a) Each Accident: (b) Each Employee for Disease: $300,000 $300,000 7. Limit Each Accident: (a) Policy Part One, Workers' Compensation: (b) Policy Part Two, Employers Liability: STATUTORY $1,000,000 8. Limit Each Employee for Disease: (a) Policy Part One, Workers' Compensation: (b) Policy Part Two, Employers Liability: STATUTORY $1,000,000 SQ-SCH (12-05) Page 1 of 2 A M e m b ere 0 m pan y 0 f the W. R. B e r k ley Cor p 0 rat ion l','~ "','~ "",~ "','~ "",~ "','~ "",~ Midwest Employers q:asualty Company SPECIFIC EXCESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY INDEMNITY POLICY Policy No.: EWC006379 SCHEDULE 9. Premium: (a) Rate per $100 of Payroll: (b) Policy Minimum Premium: (c) Total Estimated Policy Premium: .1915 $40,764 $45,294 (d) Deposit Premium: $45,294 (e) Deposit Flat Charges: nla (f) Total Deposit Premium and Flat Charges Payable as Follows: Amount Due $45,294.00 06/16/2009 10. Classification of Operations: See Endorsement 11. Endorsement Serial. Numbers: See Endorsement Schedule 12. Service Company: CCMSI 10740 Nail Ste. 380 Overland Park, KS 66211- Countersigned MIDWEST EMPLOYERS CASUAL TV COMPANY Licensed Resident Agent Date f}~ X.~ Authonzed Representative SQ-SCH (12-05) Page 2 of 2 A M e m b ere 0 m pan y 0 f the W. R. B e r k ley Cor p 0 rat ion I Midwest Employers Casualty Company Endorsement Schedule Insured: Policy Term: Policy No.: City of Salina, KS 05/01/2009 to 05/01/2010 EWC006379 Endorsement Code Effective Date Expiration Date Date Created Description SO-lO 05/0112009 OS/20/2009 10-66 05/01/2009 OS/20/2009 10-74A 05/01/2009 OS/20/2009 10-85 05/01/2009 OS/20/2009 10-86 05/01/2009 OS/20/2009 10-KS 05/01/2009 OS/20/2009 10-KSA 05/01/2009 OS/20/2009 IO-KSB 05101/2009 OS/20/2009 Page 1 of 1 Print Date: OS/20/2009 I Page 1 of2 Schedule Item 10 is amended to read as follows: 10. Classification of Operations: State Code Classification Estimated Payroll Rate per Estimated $100 of Manual Payroll Premium KS 5403 CARPENTRY NOC $98,685 8.49 $8,378 KS 5506 STREET OR ROAD CONSTRUCTION $1,259,423 5.74 $72,291 KS 6217 EXCAVATION AND DRIVERS $381,378 4.89 $18,649 KS 7370 TAXICAB COMPANY $0 7.68 $0 KS 7520 WATERWORKS OPERATION $1,315,764 4.05 $53,288 KS 7580 SEWAGE DISPOSAL PLANT OPER $979,894 2.72 $26,653 KS 7710 FIREFIGHTERS & DRIVERS $5,266,704 5.36 $282,295 KS 7720 POLICE OFFICERS & DRIVERS $4,167,164 3.47 $144,601 KS 8380 AUTO SERVICE OR REPAIR CENTER $281,477 3.34 $9,401 KS 8742 SALESPERSONS $55,578 .47 $261 KS 8810 CLERICAL OFFICE OR LIBRARIES $4,622,705 .28 $12,944 KS 8820 ATTORNEY $88,824 .30 $266 KS 9015 BUILDINGS $319,228 4.70 $15,004 KS 9060 CLUBS - COUNTRY GOLF/FISHING $365,799 1.53 $5,597 KS 9063 YMCA INSTITUTIONS $700,545 1.17 $8,196 KS 9102 PARK-ALL EMPLOYEES & DRIVERS $922,206 3.63 $33,476 KS 9154 THEATER-ALL OTHER EMPLOYEES $871,404 2.48 $21,611 KS 9220 CEMETERY OPERATION & DRIVERS $90,563 4.09 $3,704 KS 9402 STREET OR SEWER CLEANING $125,262 5.91 $7,403 KS 9403 GARBAGElREFUSElDEBRIS REMOVAL $645,663 9.30 $60,047 KS 9410 MUNICIPAL EMPLOYEE NOe $1,093,708 4.73 $51,732 Total Payroll: $23,651,974 Total Manual Premium: $835,797 Total Manual Premium: I! (a) Experience Modification Factor: (b) Other Modification Factor: II Normal Premium: ;1 I' i! " $835,797 1.000000000 1.000000000 $835,797 50-10 (1-93) EWC006379 Date Printed: OS/20/2009 Endorsement Effective: Policy No.: Named Insured: Countersigned 05/01/2009 EWC006379 City of Salina, KS Authorized Representative Page 2 of 2 MIDWEST EMPLOYERS CASUAL TV COMPANY f}~ X.~ Secretary ~ J: f~1e1 President This endorsement forms part of the policy to which attached, effective on the inception date of the policy unless otherwise stated herein. SO-10 (1-93) EWC006379 Date Printed: OS/20/2009 !I I' Definition of Pavroll Pertainina to Volunteer Workers Payroll pertaining to volunteer workers (except vOlun~eer firefighters and volunteer police officers) means the federal minimum hourly wage multiplied b~ the hours worked by the volunteers, unless the work performed by the volunteers is similar to wqrk performed by a paid employee who is receiving more than the federal minimum hourly wag~, in which event the wage reported for the volunteer worker will be the same as the wage reporttd for the paid employee. The greater of $12,500 per year or the same wage as teported for a paid employee performing similar work, shall be included in payroll for each vOI~nteer firefighter or volunteer police officer. Ii I' Duties performed by volunteer workers will be assig~ed to the classification which the duties would be assigned to if performed by regular employees. " No amount is included in payroll pertaining to any volunteer worker who is not covered under the workers compensation law because Part One of the ~olicy does not apply with respect to that worker. Endorsement Effective: Policy No.: Named Insured: 05/01/2009 EWC006379 City of Salina, KS Countersigned !: ii II MIDWEST EMPLOYERS CASUAL TV COMPANY Ii ,I fJ..- :l. t-9 ~ J. f_J. Authorized Representative Secretary President This endorsement forms part of the policy to which attached, effective on the inpeption date of the policy unless otherwise stated herein. II I' " i: 10-66 (1-93) Date Printed: OS/20/2009 Aircraft Coveraae Endorsement Part A The policy does not apply to loss arising out of the ownership, maintenance, operation or use of any aircraft that is owned or leased by the insured. This exclusion does not apply to regularly scheduled commercial airlines, chartered flights, and scheduled aircraft in Part B below. Part B It is hereby understood and agreed that coverage is provided under this policy for losses sustained in, upon, entering or alighting from those employer owned or leased aircraft scheduled below. Coverage provided hereunder is limited to a N/A maximum benefit anyone life and is further subject to a N/A policy limit. In consideration for coverage provided under Part B of this endorsement, a surcharge will apply as computed in the schedule below. The terms and conditions contained in this Aircraft Coverage Endorsement do not apply in the states of Connecticut, Massachusetts, New Mexico, New York and Oregon. Endorsement Effective: Policy No.: Named Insured: 05/0112009 EWC006379 City of Salina, KS Countersigned MIDWEST EMPLOYERS CASUAL TV COMPANY f}~ x. ~ ~ 7: f~le. Authorized Representative Secretary President This endorsement forms part of the policy to which attached, effective on the inception date of the policy unless otherwise stated herein. IO-74A (12-05) Page 1 of 1 Date Printed: OS/20/2009 1___ Policvholder Disclosure Notice of Terrorism Insurance Coveraae Coverage for acts of terrorism, as defined in the Terrorism Risk Insurance Act, as amended, (the "Act"), is included in your policy. You are hereby notified that under the Act the definition of act of terrorism has changed. As defined in Section 102(1) of the Act: The term "act of terrorism" means any act that is certified by the Secretary of the Treasury-in concurrence with the Secretary of State, and the Attorney General of the United States-to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of certain air carriers or vessels or the premises of a United States mission; and to have been committed by an individual or individuals as part of an.effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. Under your coverage, any losses resulting from certified acts of terrorism may be partially reimbursed by the United States Government under a formula established by the Act. However, your policy may contain other exclusions which might affect your coverage, such as an exclusion for nuclear events. Under the formula, the United States Government generally reimburses 85% of covered terrorism losses exceeding the statutorily established deductible paid by the insurance company providing the coverage. The Act contains a $100 billion cap that limits U.S. Government reimbursement as well as insurers' liability for losses resulting from certified acts of terrorism when the amount of such losses exceeds $100 billion in anyone calendar year. If the aggregate insured losses for all insurers exceed $100 billion, your coverage may be reduced. The portion of your annual premium that is attributable to coverage for acts of terrorism as defined in the Act, is $1.359, and does not include any charges for the portion of losses covered by the United States .Government under the Act. Name of Insurer: Midwest Employers Casualty Company Policy Number: EWC006379 Endorsement Effective: Policy No.: Named Insured: 05/01/2009 EWC006379 City of Salina, KS Countersigned MIDWEST EMPLOYERS CASUAL TV COMPANY f}~ X.~ ~ 7: f~,i Authorized Representative Secretary President This endorsement forms part of the policy to which attached, effective on the inception date of the policy unless otherwise stated herein. 10-85 (12-07) Date Printed: OS/20/2009 L. Claims Information Endorsement In consideration of the premium charged, it is understood and agreed that the following portion of the policy: PART THREE - CLAIMS C. Claims Information. You agree to send us any claim information that we may request. is amended to include the following: PART THREE - CLAIMS C. Claims Information. You agree to send us any claim information that we may request. "Claim information" means any information collected, maintained, analyzed or generated by you, your third-party administrator (TPA), claims consultant, pharmacy benefits manager, bill reviewer and any other outside vendors or entities retained on your behalf, that relates to any claim or loss occurring during the policy period. In the event that you do not possess or have access to the requested claim information, you authorize the release and disclosure of the requested claim information directly to us. Endorsement Effective: Policy No.: Named Insured: 05/01/2009 EWC006379 City of Salina, KS Countersigned MIDWEST EMPLOYERS CASUAL TV COMPANY f}~ X.~ ~ 7: f~J. Authorized Representative Secretary President This endorsement fomis part of the pOlicy to which attached, effective on the inception date of the policy unless otherwise stated herein. 10-86 (10-08) Date Printed: OS/20/2009 Amendatory Endorsement to Workers Compensation Excess Insurance Policv - Kansas It is agreed and understood that in the event excess insurance policy EWC006379 is cancelled or non-renewed by either the insurance carrier or self-insured employer, the approved self- . insured status of City of Salina, KS in the state of Kansas is automatically revoked and terminated as of the date of cancellation or non-renewal. No change to the self-insured retention, aggregate limits of liability or upper limits of the policy shall be made unless prior approval is obtained from the Department of Human Resources, Division of Workers Compensation. Pursuant to KAR 51-14-4. Self-Insurance, the Department of Human Resources, Division of Workers Compensation shall be notified by the self-insured and insurance carrier at least 20 days prior to the cancellation or non-renewal of any excess insurance policy. Endorsement Effective: Policy No.: Named Insured: Countersigned 05/0112009 EWC006379 City of Salina, KS MIDWEST EMPLOYERS CASUAL TV COMPANY f}~ X. ~ ~:J: f~ri. Authorized Representative Secretary President This endorsement forms part of the policy to which attached, effective on the inception date of the policy unless otherwise stated herein. IO-KS (1-93) Date Printed: OS/20/2009 Page 1 of 2 Kansas Cancellation and Nonrenewal Endorsement This endorsement applies only to the insurance provided by the policy because Kansas is shown in Item 3 of the Schedule Page. Paragraph F of Part Five of the policy is amended to read as follows: F. Cancellation. 1. You may cancel this policy. You will mail or deliver advance written notice to us stating when the cancellation is to take effect 2. We may cancel this policy. If we cancel because you fail to pay all premium when due, we will mail or deliver to you not less than 10 days advance written notice stating when the cancellation is to take effect. If we cancel for any other reason, we will mail or deliver to you not less than 30 days advance written notice stating when the cancellation is to take effect Mailing notice to you at your last known address will be sufficient to prove notice. 3. If this policy has been in effect for 90 days or more, we may cancel only for one of the following reasons: a. Nonpayment of premium b. The policy was issued because of a material misrepresentation c. You violated any of the material terms and conditions of the policy d. There are unfavorable underwriting factors, specific to you, that were not present when the policy took effect e. The commissioner has determined that our continuation of coverage could place us in a hazardous financial condition or in violation of the laws of Kansas f. The commissioner has determined that we no longer have adequate reinsurance to meet our needs 4. Our notice of cancellation will state our reasons for canceling. 5. The policy period will end on the day and hour stated in the cancellation notice. Part Five of the policy is amended to add the following: G. Non-renewal. 1. We may elect not to renew the policy. We will mail to you not less than 60 days advance written notice when the non-renewal will take effect. Mailing that notice to you at your mailing address shown in Item 2 of the Schedule Page will be sufficient to prove notice. IO-KSA (1-93) EWC006379 Date Printed: OS/20/2009 Kansas Cancellation and Nonrenewal Endorsement 2. Our notice of non-renewal will state our reasons for not renewing. Endorsement Effective: Policy No.: Named Insured: Countersigned 05/01/2009 EWC006379 City of Salina, KS MIDWEST EMPLOYERS CASUAL TV COMPANY f)~:L.~ Authorized Representative Secretary ~ 7: .f~J~ President This endorsement forms part of the policy to which attached effective on the inception date of the policy unless otherwise stated herein. IO-KSA (1-.93) EWC006379 Date Printed: Page 2 of 2 05120/2009 I Kansas Endorsement I. You acknowledge that, in the event you cancel or non-renew this policy or in the event we cancel or non-renew this policy, the authority shown below will automatically revoke and terminate your status as an approved self-insured in the State of Kansas, to become effective upon the same date that cancellation or non-renewal of this policy becomes effective: Division of Workers Compensation Department of Labor 800 SW Jackson St., Ste. 600 Topeka, KS 66612-1227 II. Neither the retention(s) nor the Iimit(s) of this policy may be changed without obtaining prior approval from the authority shown above. III. You may not cancel or non-renew this policy without giving the authority shown above at least 20 days notice prior to the date that cancellation or non-renewal becomes effective. We may not cancel or non-renew this policy without giving the authority shown above at least 20 days notice prior to the date that the cancellation or non- renewal becomes effective. K-WC 1511 (8-05) Endorsement Effective: Policy No.: Named Insured: Countersigned 05/0112009 EWC006379 City of Salina, KS MIDWEST EMPLOYERS CASUALTY COMPANY f}~ x.~ ~ 7: f~Jt Authorized Representative Secretary President This endorsement forms part of the policy to which attached, effective on the inception date of the policy unless otherwise stated herein. IO-KSB (8-05) Date Printed: OS/20/2009 MIDWEST EMPLOYERS CASUAL TV COMPANY Specific Excess Workers' Compensation and Employers Liability Indemnity Policy I ' In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows: GENERAL SECTION A. Self-Insurance. 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 state named in Schedule Item 3. 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. B. .I.ns.umd. The Insured is named in Item 1 of the Schedule. If the Insured is a partnership or joint venture, each partner or member of the joint venture is insured only in the capacity as employer of employees of the partnership or joint venture. C. The Policy. This policy includes the Schedule and any attached endorsements. It is a contract of insurance between you (the Insured named in Schedule Item 1) and us (the Insurer named on the. Schedule). 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 endorsement issued by us to be a part of this policy. Endorsements amending Schedule Items 1, 3, 4, 6, 7 or 8 apply with respect to accidents and disease exposures occurring at or after 12:01 A.M. on the endorsements' effective date. D. Policv Period means the period of time covered by this policy as shown in Schedule Item 5. If this policy is cancelled, the policy period will . end at 12:01 A.M. on the cancellation date. E. Workers' Compensation Law includes occupational disease law. It does not include the provisions of any law that provides non-occupational disabnity benefits. F. Stillil means any state of the United States of America and the District of Columbia. PART ONE. WORKERS' COMPENSATION A. How This Part Applies. Part One applies to loss paid by you because of liability imposed upon you by the workers' compensation law of any state named in Schedule Item 3. Part One also applies to loss paid by you because of liability imposed upon you by the workers' compensa- tion law of any other state which is not shown in Schedule Item 4. LIABILITY MUST RESULT FROM BODILY INJURY BY ACCIDENT OR BODILY INJURY BY DISEASE SUSTAINED BY AN EMPLOYEE YOU NORMALLY EMPLOY IN A STATE NAMED IN SCHEDULE ITEM 3. 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 employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. Bodily injury by disease does not include disease that results directly from bodily injury by accident. Bodily iniury by disease includes cumulative trauma. B. Your Retention. You must retain loss as shown in Schedule Item 6. This retention applies to Part One loss and to Part Two loss together. IT IS IMPORTANT FOR YOU TO UNDERSTAND THAT YOUR RETENTION FOR DISEASE APPLIES SEPARATELY TO EACH EM- PLOYEE. Naming more than one Insured in Schedule Item 1 does not increase your retention. C. Our Indemnity. We will indemnify you for loss paid by you in excess of your retention. This indemnity may be reduced by a late reporting penalty. D. Our Limit. The most loss we will reimburse you for with respect to each accident is shown in Schedule Item 7(a). The most loss we will reimburse you for with respect to each employee for disease is shown in Schedule Item 8(a). Naming more than one Insured in Schedule Item 1 does not increase our limit. E. Late Reporting Penalty. As respects each accident or each employee for disease: 1. If you do not give us written notice within one year of when required by Part Three, our indemnity will be reduced by 15%. 2. If you do not give us written notice within three years of when required by Part Three, our indemnity will be reduced by 40%. F. ~ means the amount actually paid by you for regular benefits provided under the workers' compensation law in effect upon the date the accident or disease exposure occurs. Loss includes: 1. The amount paid by you in settlement of claims for regular benefits under the workers' compensation law; 2. The amount paid by you in satisfaction of awards or judgments for regular benefits under the workers' compensation law; 3. Court cos~, inter~st upo~ awards and judgments, and allocated investigation, adjustment and legal expenses pertaining to workers' compensatron claims. ThiS subparagraph 3 does not include: (i) salaries paid to your employees; (ii) service company fees; (iii) claims administrator fees. G. Exclusions. Part One does not cover: 1. Loss insured by full coverage workers' compensation or employers liability insurance; 2. Loss payable und~r the workers' compensation law of any state which is not named in Schedule Item 3, if you are protected from the loss by any other Insurance; 3. Any loss arising out of operations for which you have rejected any workers' compensation law; MWE-ZOO (1-93) -1- -----~ G. Commutation. Beginning thirty-six (36) months after receipt of notice by us of a claim, we may then, or at any time after, submit the claim for commutation. If we so elect, the claim shall be submitted to an actuary or appraiser to be mutually appointed by us and you. Should we both fail to agree upon an actuary or appraiser, then each party shall select an actuary or appraiser who shall then select an independent actuary or appraiser who shall fix a lump sum amount. We may pay the lump sum amount, which shall constitute a full and final release of our liability for the claim. However, such lump sum payment shall not constitute a full and final release of our liability if, after the lump sum payment, any supplemental award is made increasing the amount of benefits payable to the Employee and his/her dependents. Any additional liability, at our election, may immediately be commuted via the process above and we may discharge such liability by payment of another lump sum. H. Claim Audit. You will let us or our representative examine and audit claim files upon our request. These audits may be conducted during your regular business hours. PART FOUR - PREMIUM A. Deposit and Adiustment Premiums. At the beginning of the policy period you must pay us the deposit premium shown in the Schedule. 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. Payroll Report. Within 45 days after the end of the pOlicy period, send us a report showing the amount of payroll earned by your employees during the policy period. The report must show payroll separately for each classification identified in Schedule Item 10. C. Final Premium. The final premium due us for the policy period will be computed as shown in Schedule Item 9(a). Unless this policy is cancelled, final premium will be at least the minimum premium shown in Schedule Item 9(b). If we cancel this policy, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. If you cancel this policy, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by the customary short rate table and procedure. Final premium will not be less than the short rate portion of the minimum premium. D. fmalill means the gross pay of your employees for the policy period plus other amounts and items received by your employees as part of their pay for the policy period. We will send you a payroll reporting form describing what is included in payroll. E. Records. You will keep records of information needed to compute premium. You will provide us with copies of those records when we ask for them. F. Audit. You will let us or our representatives examine and audit all your payroll records. The audits may be conducted during your regular business hours. PART FIVE - CONDITIONS A. Agreemem Upon Terms. Your acceptance of this policy means that you agree with us upon the terms of this policy. B. Sole Representative. The Insured first named in Schedule Item 1 will act on behalf of all Insureds to change this policy, accept loss payments, receive return premium and give or receive notice of cancellation. C. Bankruptcy or Insolvency. Your bankruptcy or insolvency will not relieve us from the payment of any claim covered by this policy. After the retention shown on the Schedule has been paid, payments will be made by us as if you had not become bankrupt or insolvent but not in excess of the Insurers Limit of Indemnity. Payment will be made to the Trustee in Bankruptcy or as directed by an appropriate court. D. Transfer of Your RiQhts and Duties. Your rights or duties under this policy may not be transferred without our written consent. This provision does not apply to duties transferred to a service company or a claims administrator. E. Service and Administration. This Agreement contemplates the concurrent and continued existence of a separate service agreement between you and the Service Company named in Item 12 of the Schedule. You must notify us within 30 days should you decide to change the service company. F. Cancellation. You may cancel this policy by giving us at least thirty (30) days advance notice by registered mail stating the cancellation date. We may cancel this policy by giving you at least thirty (30) days advance notice by registered mail stating the cancellation date. Our mailing of registered notice to your address shown in Schedule Item 2 will be sufficient proof that we cancelled this policy. If you fail to pay premium, we may cancel with 10 days written notice to you. We have executed this policy by printing below the facsimile signatures of our President and Secretary and by the actual signature of our authorized representative on the Schedule. MIDWEST EMPLOYERS CASUALTY COMPANY Countersigned: ~~X~~J:J~L Authorized Representative MWE-200 (1-93) SIGNA TURE Secretary SIGNA TURE President -4- ~ KANSAS DEPARTMENT OF LABOR DATE: 05106/2009 TO: DIVISION OF WORKERS COMPENSATION DEPARTMENT OF LABOR 800 SW JACKSON STE 600 TOPEKA KS 66612-1227 CERTIFICATE OF EXCESS INSURANCE This certifies that a Workers Compensation Excess Insurance Policy has been issued and delivered to the employer named below, and that by issuance and delivery of said policy and the filing of this certificate of insurance, it is admitted that said excess policy was effective on the date stated below and that the coverage provided therein is applicable to benefits under the Workers Compensation Act of the state of Kansas and that said policy shall remain in full force and effect until 20 days after receipt by the Division of Workers Compensation of notice of its cancellation or expiration and/or non-renewal. Name of Employer Insured: Address: City of Salina, KS 300 West Ash, Room 200 Salina, KS 67401- Name of Insurer: Midwest Employers Casualty Company Address: 14755 North Outer Forty Drive, Suite 300 Chesterfield, Missouri 63017 Policy Number: Expiration Date: EWC006379 05/01/2010 Effective Date: 05/01/2009 FORM OF COVERAGE *Specific Excess * Aggregate Excess Policy Umit: STATUTORY (Per occurrence) $300,000 (Per occurrence) 05/01/2009 to 05/01/2010 Policy Umit: Loss Fund Percentage: Minimum Loss Fund: Estimated Loss Fund: Policy Term: N/A N/A N/A N/A 05/01/2009 to 05/01/2010 Retention: Policy Term: If more than one insurer is providing coverage, you must provide separate certificates for each insurer. * No changes shall be made to the Self-insured Specific Retention Amount or other limits of the policy upon renewal until approval is granted by the Division of Workers Compensation. Insurer: Midwest Employers Casualty Company ~~;(.~ Authorized Representative Signature: Address: 14755 North Outer Forty Drive, Suite 300 Chesterfield, Missouri 63017 I K-WC 129 (Rev. 9-05) ~ ~,- . ~ \- ".,--.. , , " "', ':"'- ,'- ',^ ';,'\r:' , .J', ;-': " ~~\\r:, ,J.-:' , ~, '''. '. , . ,- -<' -" ,.' 'I _U "'c -., "',' 1 <' '", '. f "; , " 'PRIVACYNQTJ~E ~.. ' ' , , >",;1,' , ' ,.,. ",'; ,..~: '" \, ", , .,;': ',' /", <. '-. ,< ,'. . - , ":. . > Midwest, E01ployersGasualtyCoinpahYv:ttti~ '"CQmpany"): ;i>mernoer company 'of the W,"R ' " ' ' '~erkley,Oorporation C'B~r\(ley~').group,"of;'coinpahies'an~' each other member ofth~'B,erKley ",' ,'\ , gtbup,of GC)mpanies · (" Affiliates~')U1ic:JefStcmps ,.'out 'custQmers':roncern, ,about' ~ir-ivacy of t~eir " ': 'iqformation "eoll~ctea by ',the'~ 'Com8~,9y.:;04L Comp~~y\isdedi~ted . Jojjrotectin:g" the . . ".,G6nfjder1.tialifYano'sectirityofnoDPul?lic.'Re~~()'laHnformati,on:we-colleqtapout. ou(custornefsh; \ , .~ ,accordance',wittr applica~leJaws:an~r~gvl~tioris.'ThisnotiCerefersto the CompanyJ;>y using ., " · the 'terms ~us," "We;" 'or "our."; This; r;1crtifie, ;de~cribesp.urpriv~cypolicyand, d~scribes hoW We. ." , " treCJt: the lJonpublic 'personal inf6fma'tlb~. about, our customers that' we ,receiye,fr6in tt;u~m' " ("Information"). ... ,,~,' , ' ' , , .."".'~),~" ..',i--', ~, .,' ( ~""{~ " WhYV'feC911~ct and HO~'\l\IeUsel~fotmatipn~ ':, ','; " c ',' , Weccillect and use fnfor~'atio~ fo; busides~ purposes ~ith(espe~t 'to;our~~iris~t8nce .,t:m:>ducts ' and'~erVi~c:!~\a:nd<oth~r !>usiness Te!~tiqr;i~~in"olving our' customers.. ,We' g~athet this Inform,atioA, , ", ,'tq' ~valu~t~'your;"requestf6r,ins.uran(;e;~:~o;ev~luate ,your;Jn~i.Jra'~ce" claims:, to ,:ad.m,ini$t~~; " ' . " maintainor' review ,your ins!,iranGeP'ciliGy;,and tOprOQ8SSyqUr ,ihsOraDpe tr,ans~ctions. 'W ~:also !3ccu'rhulate:certain. inf()rrnationabout'you~ ~s'r:nay be required:br ,per:mitfed 'bylaw~ ," '" .., . '" '- , .: . (" ',. - -:. \ "f ',' ; - r.- -."'" ~ ^ ' (, J ~ .,." r "'. >-:, . . t -< ,.. " \ v ~ . , ~. ~ J r,'" ,) ~ Yciu~, ins,:france agent or broker also'pollects',tl1i~,; Infol1J1ation and may ,wse,'iUp help \vith your overall ,insuranc~ p~ograrri 'or to marKet- aqditibnal, products and, services, ,to y()u. We may also use Information to offer'you other products Of services that we, or our Affiliates provide. ". , ~~' ...." I ,cJ~: ' ~ ~ "_' ,'-: ~' , '~'" \ . 1,'" ~ "'. " , ~ ! . " . I' , .~~ " ! . ~ ' ' , '..r ". " )'. -." , ," ~. , ' We ,disclose" ani Information w~ichW~'be:lieve.: :1~',nece~$arY to. COh(Juct,our ',business as '.' pe,rmitted by.app,licable law or wherEf,feqUir~p~ oy .applicable' law: : This disclosure m'ayinclud~ (i) ), In(ot01atibhwe, ,receive from 'you on,appl(cations, or other. forms:prQvidedlo 'US'8f1d oUr'Affiliate~; Isti9.h asn~mes{ addresse~,spcial ,:se~urttY;,numbers, :~sse!s, 'employetinfotma.t!Q[l;,salaFi~S;: etc~ ", , (ii}^lnfor;lnati6if.about~our trans~ctiQd~'With;~s and qur ~ffiliates,such ~as; policy pOV,erag~5;' ",.,' prerTliums;:p~Y.ITlenr histQry; ,,' etc~'i'an~:' (iJi~ .:Informatior;: we 'receive from' a. oonl?umer fEiportirig' "~Q~ocy;.such a.s'cr~ditWdrthin'essanq:cr~dithistory. ., , ", , . ., -. _ ,~. c I '. i I I, " ~" ,I.- /' : ~' ..... ".I..rjl.,~'}1~lidw~tEme~~~ts ,r_)'\II,G~i~lnPanyf ........... ,. .' '" ;.. ':', -". - l . ," -{ ,'. 'f ;.,7 "y,' ' ',"\'" ,. CCMSI ,." Attn: Claims Manager. . ',:10740Nall,;Suite380, '.' " lOvenancj' Park',; Ks': 662l.'1' ~ ; ~" ,~ . '"' .' r .' ;:<.-'::" ',' - , \, '. I'~ . I' \~, , , , .1'. . ,I , \~ . . ~', " " < ,r " ';; I .. , . ,~ ~, " ' ,', ';>, : -1 i ':: j:. - . . - ~ r~ 'He:. " 'Clal~ pa~ket'For~:' ~, ,- ", . ..'; . , '.' ,..PolicyNumber:', ,~',PolicyPeriod:'.: '. . ....r , ,c_ ') .,,_ , , -,CityofSalina,kS. " , .,' ':"'_:,'1. EWC00637'9<'l' t !~, ' '".:> " ", . "05/P1/:i609toQ'q/Oll~P1.0'." . - '. \'. , " -t,_ . ,/. , e ,^ .'~ "~.:>':_.:",". '....~,',...:_,,' 'r,o, . ",",' ~,",'.";."':'...,":>-.-.>_ -.' "',:"",,:j~.,....,-<\'- .: '.., ',~~,r,'>, -.'".,' '..~,~:.;::,:,._~.., "_ ,"; ,",". . " . '. MidwEistEmpioyers c~s'uajtY Company h,as ~eensele9tedto'PI6vid~the'~~Gess workers'cQmpensatipncoverage,for . ; the abo'v,e:aCcount."W et1ave',cor:J1rnitt~d sigrijficantteSl:>urces~q support your.. effqrts to make.this self~Asured:pr6gram ,:' a continued:succes.s: ." '." ',;:',." . ..... , '; ,;'. ." ; , ...... '.' .:'> ,;,,',' ". ". ,,;... , . Th~atta,l;;hedclaim~packet 'contain~variou!)fctrmsandinfQrrnatiQnpertainin~ito theexcessc~\{~rage.., 'The 'Claim Packet' Contelitssheet. explains' each, item 'enClosed; ,/ Please. review it' carefully and advise should .y'oilhave :any .questi9I1s::',. "",' ; ,:.<,,~ :, "" :::. '".' " ':1, '. , .,.... ""',':- .,....., Ma~k.F~en6h'; {Claim Analy-sJ:is r~~pbn$it,.,~for',~upp6rtrhgy~~r'~fforts,on fl1i~acc~uht. ..' ,c". ,. ,"';:. "... '" ',",',>,".' ~ ........'.,v ,'h: ", "" ,'f ~: ,,'. .....,. . ,', fIIIaintaining a good relationship,.\vifh'your' org~niZ1:!~iQn is'yeryimportanfto us. 'Jfwecan"be' of helpo,it any claim ot'. : shbuldyoQhave'anysuggestiQns for now wec~rJ'assisf.you b~ttel',.p!e~sedo;not tH:~sitafet,o'Goritact us.: ,".~.' ,",,1,,_" d- <' ',',"'.' ",_:;. - . ''>J-:'-',': ,_~. " . ': -, "-"~'I' ',' -', .:. ~; ~.....\ H . ~. :' .-. , . > '.. :'," _' ,'-'::' l-:-' ',~. '- ,..' . ,,\ -}; ., ,". -. . ~incerely; . . , {~~- . . -'/: , , ,-; , . -. ~< -. _, J ,-. ~;' , . -. ,,~: _' , MIDWEST EM'PLOYERS CASUALT,YCOMPANY \, .' , ,"" / r}, '" ~ ", .",'_".'.' : :" ' ~~ , ..", '~J, ,< " , " , / '.," " .; ".' T~; ,"," 'Clairmonte'Cappelle '...... .', .',,'. Vice PresidenfofClaims . ;:" . " '. . '> ., " ',' .'. ,_' " -\ -.../' ,'. ,::' I ., -'(',". . : ~,~ t' J '\ , ,1/ " . , " . , .~ i " , - '-. - ,. 'cc: .,.' .:... ,', ,', ' ,( '~_ t', , '-T ,{ ~ - , ": \ , .,} " \.