Excess Workers Compensation Agreement (2010-2011)
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MidwesfEmployer~ Casualty Company
SPECIFIC EXCESS
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: 05/01/2010
(b) To: 05/0112011
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) Po.licy Part Two, Employers Liability: .
STATUTORY
$1,000,000
SO-SCH (12-05) .
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A M e m b ere 0 m pan y 0 f the W. R. B e r k. ley
Corporation
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Midwest Employers Casualty 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:
.1972
$43,503
$48,337
(d) Deposit Premium:
(e) Deposit Flat Charges:
(f) Total Deposit Premium and Flat Charges Payable as Follows:
$48,337
nla
Amount Due
$48,337.00 06/19/2010
10. Classification of Operations:
See Endorsement
11. Endorsement Serial Numbers:
See Endorsement Schedule
12. Service Company:
CCMSI
10740 Nail
Suite 380
Overland Park, KS 66211-
Countersigned
MIDWEST EMPLOYERS CASUALTY COMPANY
-
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. Licensed ReSident Agent
Date
AuthOrized Representative
SO-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 I e. yea r par a t ion