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Excess Workers Compensation Agreement (2017-2019)
IndividualSelf-Insured ExcessWorkers’Compensationand EmployersLiability IndemnityPolicy SchedulePage PolicyNo.:EWC006379 IndemnityCoverageProvided:SpecificExcessWorkers'CompensationandEmployers Liability Indemnity 1. Insured:City ofSalina,KS 2.MailingAddress:300WestAsh, Room 200 Salina,KS67401- 3.NamedStates:Kansas 4.ExcludedStates:None 5.PolicyPeriod: (a)From:05/01/2017 (b)To:05/01/2019 Both daysstartat 12:01A.M.standardtime at theInsured's addressshowninItem 2 of thisschedule. 6.SpecificRetention: (a)EachAccident:$400,000 (b)EachEmployeefor Disease:$400,000 7.SpecificLimitEachAccident: (a)PolicyPartOne,Workers' Compensation:STATUTORY (b)PolicyPartTwo,Employers Liability:$1,000,000 8.SpecificLimitEachEmployeefor Disease: (a)PolicyPartOne,Workers' Compensation:STATUTORY (b)PolicyPartTwo,Employers Liability:$1,000,000 9.Aggregate Retention: (a)(RatingBase):NOTAPPLICABLE (b)Estimated(RatingBase):NOTAPPLICABLE (c)Minimum Retention:NOTAPPLICABLE (d)Aggregate LossLimitation:NOTAPPLICABLE 10.AggregateLimit:NOTAPPLICABLE 11.Classification ofOperations:SeeEndorsement (a)ExperienceModificationFactor: 1.000000000 (b)Other ModificationFactor: 1.000000000 CMB-SCH(8-13)14755North Outer FortyDrive,Suite300Chesterfield, MO 63017Page1of 2 (636)449-7000www.mwecc.com IndividualSelf-Insured ExcessWorkers’Compensationand EmployersLiability IndemnityPolicy SchedulePage 12.Premium: (a)Rateper $100ofPayroll: .3169 (b)PolicyMinimumPremium:SeeBelow (c)TotalEstimatedPolicyPremium:SeeBelow (d)DepositPremium:SeeBelow (e)DepositFlat Charges:SeeBelow (f)Total DepositPremium and FlatChargesPayable asFollows:SeeBelow Payroll ReportingPeriodsDepositDepositFlatTotal DepositPolicy PremiumChargesPremium andMinimum DepositFlatPremium Charges 05/01/17- 05/01/18$80,424$0$80,424$72,381 05/01/18- 05/01/19$80,424$0$80,424$72,381 TotalsforAll$160,848$0$160,848$144,762 Payroll Reporting Periods 13.EndorsementSerialNumbers:SeeEndorsementSchedule 14.ServiceCompany:CCMSI 10740 Nall Suite380 OverlandPark,KS66211- CountersignedMIDWESTEMPLOYERSCASUALTY COMPANY Licensed ResidentAgent DateAuthorized Representative CMB-SCH(8-13)14755North Outer FortyDrive,Suite300Chesterfield, MO 63017Page2of 2 (636)449-7000www.mwecc.com EndorsementSchedule Named Insured:City ofSalina,KS PolicyTerm:05/01/2017to05/01/2019 PolicyNo.:EWC006379 EndorsementEditionDateEffectiveExpirationDateDescription CodeDateDateCreated CMB-11(08-13)05/01/201705/11/2017 CMB-187(08-13)05/01/201705/11/2017 CMB-197(01-15)05/01/201705/11/2017 ISI-254-EXC(08-13)05/01/201705/11/2017 ISI-285(08-13)05/01/201705/11/2017 ISI-KS(08-13)05/01/201705/11/2017 CMB-ES (8-13)Page1of1Date Printed:05/11/2017 Endorsement EndorsementEffective:05/01/2017 PolicyNo.:EWC006379 Named Insured:City ofSalina,KS Amendment toSchedule Item 11 Schedule Item 11 is amended toreadasfollows: 11.Classification ofOperations: Estimated RatePerEstimated Annual $100 ofAnnual StateCodeClassificationPayrollPayrollManualPremium STREETOR ROAD CONSTRUCTION$1,281,3574.64$59,455 KS5506 KS6217EXCAVATIONANDDRIVERS$482,8863.80$18,350 KS7370TAXICAB COMPANY$03.79$0 KS7520WATERWORKSOPERATION$1,526,6112.58$39,387 KS7580SEWAGE DISPOSALPLANTOPER$751,7872.24$16,840 KS7710FIREFIGHTERS& DRIVERS$6,087,6563.98$242,289 KS7720POLICEOFFICERS& DRIVERS$4,758,6412.03$96,600 KS8380AUTOSERVICEORREPAIR CENTER$293,9962.24$6,586 KS8810CLERICALOFFICEOR LIBRARIES$5,352,806.16$8,564 KS8820ATTORNEY$198,584.24$477 KS8831HOSPITAL-VETERINARY$244,2981.43$3,493 KS9015BUILDINGS$524,0783.67$19,234 KS9060CLUBS-COUNTRYGOLF/FISHING$276,9011.13$3,129 KS9063YMCA INSTITUTIONS$555,043.82$4,551 KS9102PARK-ALLEMPLOYEES& DRIVERS$994,4962.47$24,564 KS9154THEATER-ALLOTHEREMPLOYEES$55,5551.38$767 KS9220CEMETERYOPERATION& DRIVERS$91,9894.47$4,112 KS9403GARBAGE/REFUSE/DEBRISREMOVAL$590,5546.34$37,441 KS9410MUNICIPALEMPLOYEENOC$1,310,9568.61$112,873 TotalAnnualPayroll:$25,378,194 TotalAnnualManualPremium:$698,712 Total ManualPremium:$698,712 (a)ExperienceModificationFactor: 1.000000000 (b)OtherModificationFactor: 1.000000000 NormalPremium:$698,712 CMB-11 (8-13)Page1of2Date Printed:05/11/2017 Endorsement EndorsementEffective:05/01/2017 PolicyNo.:EWC006379 Named Insured:City ofSalina,KS CountersignedMIDWESTEMPLOYERS CASUALTY COMPANY Authorized RepresentativeSecretaryPresident Thisendorsement formspartofthe Policytowhichattached,effectiveon theinceptiondateof thePolicyunlessotherwisestatedherein.Allother termsandconditionsofthe Policyremainunchanged. CMB-11 (8-13)Page2of2Date Printed:05/11/2017 Endorsement EndorsementEffective:05/01/2017 PolicyNo.:EWC006379 Named Insured:City ofSalina,KS TwoYearPolicyShort RateTableEndorsement IfyoucancelthisPolicypriortotheexpirationofthetwo-yearPolicyPeriodshowninScheduleItem5,thefollowing shortratetablewillapplyto the TotalEstimatedPolicyPremiumshowninSchedule Item 12(c): MonthWhenShort CancellationRate EffectivePercentage 113% 219% 323% 427% 531% 635% 739% 843% 947% 1051% 1155% 1259% 1363% 1467% 1571% 1675% 1779% 1882% 1985% 2088% 2191% 2294% 2397% 24100% CountersignedMIDWESTEMPLOYERS CASUALTY COMPANY Authorized RepresentativeSecretaryPresident Thisendorsement formspartofthe Policytowhichattached,effectiveon theinceptiondateof thePolicyunlessotherwisestatedherein.Allother termsandconditionsofthe Policyremainunchanged. CMB-187 (8-13)Date Printed:05/11/2017 Endorsement EndorsementEffective:05/01/2017 PolicyNo.:EWC006379 Named Insured:City ofSalina,KS PolicyholderDisclosureNotice ofTerrorism InsuranceEndorsement Coverageforactsofterrorism,asdefinedintheTerrorismRiskInsuranceAct,asamended,(the“Act”),isincludedin yourPolicy. AsdefinedinSection102(1)oftheAct:Theterm“actofterrorism” meansanyactthatiscertifiedbytheSecretaryof theTreasury—inconsultationwiththeSecretaryofHomelandSecurity,andtheAttorneyGeneraloftheUnited States—tobeanactofterrorism;tobeaviolentactoranactthatisdangeroustohumanlife,property,or infrastructure;tohaveresultedindamagewithintheUnitedStates,oroutsidetheUnitedStatesinthecaseofcertain aircarriersorvesselsorthepremisesofaUnitedStatesmission;andtohavebeencommittedbyanindividualor individualsaspartofanefforttocoercethecivilianpopulationoftheUnitedStatesortoinfluencethepolicyoraffect theconductoftheUnitedStatesGovernmentbycoercion.Underyourcoverage,anylossesresultingfromcertified actsofterrorismmay bepartiallyreimbursed bytheUnitedStatesGovernmentundera formulaestablished bytheAct. However,yourpolicy maycontainotherexclusionswhich mightaffectyourcoverage,suchasanexclusionfornuclear events.Undertheformula,theUnitedStatesGovernmentgenerallyreimburses85%through2015;84%beginning January1,2016;83%beginningonJanuary1,2017;82%beginningonJanuary1,2018;81%beginningonJanuary 1,2019and80%beginningonJanuary1,2020ofcoveredterrorismlossesexceedingthestatutorilyestablished deductiblepaidbytheinsurancecompanyprovidingthecoverage.TheActcontainsa$100billioncapthatlimits UnitedStatesGovernmentreimbursementaswellasinsurers’liabilityforlossesresultingfromcertifiedactsof terrorismwhentheamountofsuchlossesexceeds$100billioninanyonecalendaryear.Iftheaggregateinsured lossesfor allinsurers exceed$100billion,yourcoveragemaybereduced. TheportionofyourannualpremiumthatisattributabletocoverageforactsofterrorismasdefinedintheAct,is $2,413,anddoesnotincludeanychargesfortheportionoflossescoveredbytheUnitedStatesGovernmentunder theAct. Name of Insurer:MidwestEmployers CasualtyCompany PolicyNumber:EWC006379 CountersignedMIDWESTEMPLOYERS CASUALTY COMPANY Authorized RepresentativeSecretaryPresident Thisendorsement formspartofthe Policytowhichattached,effectiveon theinceptiondateof thePolicyunlessotherwisestatedherein.Allother termsandconditionsofthe Policyremainunchanged. CMB-197 (1-15)Date Printed:05/11/2017 Endorsement EndorsementEffective:05/01/2017 PolicyNo.:EWC006379 Named Insured:City ofSalina,KS AircraftExclusionEndorsement ThisPolicydoesnotcoveranyLossarisingoutoftheownership,maintenance,operationoruseofanyaircraftthatis leased,owned(inwholeorinpart)oroperatedbyyou,yourexecutiveofficer(s),director(s),Employee(s),parent companyorsubsidiary.This exclusiondoesnotapplytoregularlyscheduledcommercialairlines orchartered aircraft. CountersignedMIDWESTEMPLOYERS CASUALTY COMPANY Authorized RepresentativeSecretaryPresident Thisendorsement formspartofthe Policytowhichattached,effectiveon theinceptiondateof thePolicyunlessotherwisestatedherein.Allother termsandconditionsofthe Policyremainunchanged. ISI-254-EXC (8-13)Date Printed:05/11/2017 Endorsement EndorsementEffective:05/01/2017 PolicyNo.:EWC006379 Named Insured:City ofSalina,KS MoreThanOnePremiumAdjustmentEndorsement PartFive –Premium of the Policyis amendedtoreadasfollows: PARTFIVE - PREMIUM A.DepositandAdjustmentPremiums.AtthebeginningofeachPayrollReportingPeriodset forthinScheduleItem 12,youmust pay us theDepositPremium and anyflatchargesshownin theSchedule. 1.AttheendofeachPayrollReportingPeriodsetforthinScheduleItem12youshalloweustheamountby whichtheFinalPremiumis greaterthan the DepositPremium.; 2.AttheendofthelastPayrollReportingPeriod,ifthesumoftheDepositPremiumsforallPayrollReporting PeriodsisgreaterthanthesumoftheFinalPremiumsforallPayrollReportingPeriods,weshalloweyouthe difference. B.PayrollReport.Withinforty-five(45)daysaftertheendofeachPayrollReportingPeriod,youmustsendusa reportshowingtheamountofPayrollearnedbyyourEmployeesduringthePayrollReportingPeriod.Thereport mustshowPayrollseparatelyfor eachclassificationidentifiedinSchedule Item 11. C.FinalPremium.TheFinalPremiumduetousforeachPayrollReportingPeriodshallbecomputedasshownin Schedule Item 12(a). NormalPremiummeansthesumoftheproductsofyourauditedPayrollwithineachclassificationshownin ScheduleItem11foreachStatenamedinScheduleItem3multipliedbytherateshowninScheduleItem11for therespectiveclassification,theproductofwhichshallbefurthermultipliedbytheExperienceModificationFactor showninSchedule Item 11(a) and/or anyOther ModificationFactorshowninSchedule Item 11(b). Unless thisPolicyiscancelled,FinalPremiumshallbeatleast theMinimumPremiumshownintheSchedule. WhendeterminingFinalPremium,anyflatchargesshownintheSchedulearenotsubjecttoadditional computations ormodificationfactors. IfwecancelthisPolicy,FinalPremiumshallbecalculatedprorata basedonthetimethisPolicywasin force.Final Premiumshallnotbeless than theproratashareof the MinimumPremiumshownin theSchedule. IfyoucancelthisPolicy,youoweustheFinalPremiumdueforallPayrollReportingPeriods.FinalPremiumshall be morethanprorata;itshallbebasedonthetimethisPolicywasinforce,andincreased bythecustomaryshort rate table and procedure.FinalPremiumshallnotbeless than theMinimumPremiumshownin theSchedule. IfthisPolicyisautomaticallycancelledbecauseofthelossofyourdulyqualifiedself-insurerstatusasstatedin SectionA.Self-InsuranceoftheGeneralSectionofthisPolicy,youoweustheFinalPremiumdueforallPayroll ReportingPeriods.FinalPremiumshallbemorethanprorata;itshallbebasedonthetimethisPolicywasin force,andincreasedbythecustomaryshortratetableandprocedure.FinalPremiumshallnotbelessthanthe totalMinimumPremiumshownintheSchedule. TheFinalPremiumduetousshallnotbereduced bytheexistenceofanyotherinsurance,reinsurance,indemnity agreement or otherreimbursement agreement protectingyouagainstLosscoveredby thisPolicy. ISI-285 (8-13)Page1of2Date Printed:05/11/2017 Endorsement EndorsementEffective:05/01/2017 PolicyNo.:EWC006379 Named Insured:City ofSalina,KS D.PayrollmeansthegrosspayofyourEmployeesforeachPayrollReportingPeriodplusotheramountsanditems earnedbyyourEmployeesas part of theirpayforeachPayrollReportingPeriod.Payrollalsoincludes: 1.Gross payplus other amounts anditems earnedbyyour officersifcovered underthisPolicy; 2.ThecontractpriceformaterialsandservicesperformedbyanyindividualdeemedtobeyourEmployeefor liabilitypurposesundertheWorkers’CompensationLaw,ifyoudonothavePayrollrecordsforthisindividual; and 3.AssignedPayrollattributedtovolunteersforwhomyouarelegallyobligatedtoprovidebenefitsunderthe Workers’ CompensationLaw.AssignedPayrollmeans: a.Forvolunteersotherthanvolunteerfirefightersandvolunteerpoliceofficers,thefederalminimumhourly wageasoftheeffectivedateofthisPolicymultipliedbythehoursworkedbythevolunteers,unlessthe workperformedbythevolunteersissimilartoworkperformedbyapaidEmployeewhoisreceivingmore thanthefederal minimumhourlywage,inwhicheventthewagereportedforthevolunteerworkershallbe thesame as thewagereportedfor thepaidEmployee; and b.Forvolunteerfirefightersorvolunteerpoliceofficers,thegreaterof$12,500peryearorthesamewageas reportedforapaidEmployeeperformingsimilarworkshallbeincludedinPayrollforeachsuchvolunteer firefighter orvolunteerpolice officer. Dutiesperformedbyvolunteersshallbeassignedtotheclassificationcodewhichthedutieswouldbe assigned toif performedbyregularEmployees. NoamountisincludedinAssignedPayrollforanyvolunteerworkerwhoisnotcoveredundertheWorkers’ Compensation Law becausePartOneof thisPolicydoes notapplywithrespectto thatworker. E.Records.Youshallkeeprecordsofinformationneededtocomputepremium.Youshallprovideuswithcopiesof thoserecordswhenweaskfor them. F.Audit.Uponourrequest,youshallletusorourrepresentativesexamine andauditallyourPayrollrecords.Payroll recordsinclude,butarenotlimitedto,ledgers,journals,registers,vouchers,contracts,taxreports,Payrolland disbursementrecords,andprogramsforstoringandretrievingdata.Theauditsmaybeconductedduringyour regular business hours. CountersignedMIDWESTEMPLOYERS CASUALTY COMPANY Authorized RepresentativeSecretaryPresident Thisendorsement formspartofthe Policytowhichattached,effectiveon theinceptiondateof thePolicyunlessotherwisestatedherein.Allother termsandconditionsofthe Policyremainunchanged. ISI-285 (8-13)Page2of2Date Printed:05/11/2017 Endorsement EndorsementEffective:05/01/2017 PolicyNo.:EWC006379 Named Insured:City ofSalina,KS KansasEndorsement ThisendorsementappliesonlytocoverageprovidedbythisPolicybecauseKansasisnamedinItem3ofthe SchedulePage. Section I. CancellationofPartSix – Conditions of thisPolicyis amendedtoreadasfollows: I.Cancellation and Non-Renewal. 1.YoumaycancelthisPolicy.Youwillmailordeliveradvancewrittennoticetousstatingwhenthecancellation is to take effect. 2.WemaycancelthisPolicy.Ifwecancelbecauseyoufailtopayallpremiumwhendue,wewillmailordeliver toyounotlessthanten(10)daysadvancewrittennoticestatingwhenthecancellationistotakeeffect.Ifwe cancelforanyotherreason,wewillmailordelivertoyounotlessthanthirty(30)daysadvancewrittennotice statingwhenthecancellationistotakeeffect.Mailingnoticetoyouatyourlastknownaddresswillbe sufficientto provenotice. 3.IfthisPolicyhasbeenineffectforninety(90)daysormore,wemaycancelonlyforoneofthefollowing reasons: a.Nonpayment of premium; b.The policywasissuedbecause of a materialmisrepresentation; c.Youviolatedanyof the material terms and conditionsof the Policy; d.There are unfavorableunderwritingfactors,specific toyou, thatwere not presentwhenthepolicytook effect; e.Thecommissionerhas determined thatourcontinuation ofcoveragecouldplaceusina hazardous financialcondition orinviolation of thelawsofKansas; or f.Thecommissionerhas determined thatwenolongerhaveadequatereinsurance to meet ourneeds. 4.Our notice ofcancellationwillstate ourreasonsforcanceling. 5.IfthisPolicyiscancelled,thePolicyPeriodshallendat12:01A.M.onthecancellationdatestatedinthe notice. 6.ThisPolicydoesnotapplytolossorliabilitywhicharisesoutofbodilyinjurybyaccidentorbodilyinjuryby diseasethat occurs after the effectivedateofsuchcancellation. 7.IntheeventofcancellationofthisPolicy,FinalPremiumshallbecalculatedassetforthinPartFive– Premium,Section C. FinalPremium of thisPolicy. ISI-KS (8-13)Page1of2Date Printed:05/11/2017 Endorsement EndorsementEffective:05/01/2017 PolicyNo.:EWC006379 Named Insured:City ofSalina,KS 8.WemayelectnottorenewthisPolicy.Wewillmailtoyounotlessthansixty(60)daysadvancewrittennotice whenthenon-renewalwill takeeffect.Mailing thatnoticetoyouatyourmailing addressshowninItem2of the SchedulePagewillbesufficientto provenotice. 9.Our notice of non-renewalwillstate ourreasonsfor notrenewing. 10.Youacknowledgethat,intheeventyoucancelornon-renewthisPolicyorintheeventwecancelornon- renewthisPolicy,theDivisionofWorkersCompensationwillautomaticallyrevokeandterminateyourstatus asanapprovedself-insuredintheStateofKansas,tobecomeeffectiveuponthesamedatethatcancellation or non-renewal of thisPolicy becomes effective. 11.Youmaynotcancelornon-renewthisPolicywithoutgivingtheDivisionofWorkersCompensationatthe addressshownbelowatleasttwenty(20)days’noticepriortothedatethatcancellationornon-renewal becomeseffective.Wemaynotcancelornon-renewthisPolicywithoutgivingtheDivisionofWorkers Compensationatleasttwenty(20)days’noticepriortothedatethatthecancellationornon-renewalbecomes effective. Division ofWorkers Compensation Department of Labor 800SWJacksonStreet,Suite600 Topeka,KS 66612-1227 ChangeinRetention orLimits Thefollowingadditionalprovisionapplies to thisPolicy: NeithertheRetention(s)northeSpecificLimitorAggregateLimitshownontheSchedulePageofthisPolicymaybe changedwithoutobtainingpriorapprovalfrom the Division ofWorkers Compensation. CountersignedMIDWESTEMPLOYERS CASUALTY COMPANY Authorized RepresentativeSecretaryPresident Thisendorsement formspartofthe Policytowhichattached,effectiveon theinceptiondateof thePolicyunlessotherwisestatedherein.Allother termsandconditionsofthe Policyremainunchanged. ISI-KS (8-13)Page2of2Date Printed:05/11/2017 IndividualSelf-Insured Excess Workers'Compensation and EmployersLiability IndemnityPolicy InreturnforthepaymentofpremiumandsubjecttoallofthetermsofthisPolicy,we(MidwestEmployersCasualty Company)agreetoprovideyou(theInsuredNamedinScheduleItem1)withtheexcessindemnitycoveragestatedonthe Scheduleand furtheragreewithyouasfollows: GENERALSECTION A.Self-Insurance.OurobligationsunderthisPolicyaresubjecttotheconditionthatyouare,attheinceptionofthisPolicy andshallremainuntiltheendofthePolicyPeriod,adulyqualifiedself-insurerineachStatenamedinScheduleItem3. IfatanytimeduringthePolicyPeriodyourstatusasadulyqualifiedself-insurerissuspended,cancelled,revoked, voluntarilysurrendered,orterminatedinanyoftheStatesnamedinScheduleItem3,thisPolicyshallbeimmediately cancelled.Theeffectivedateofsuchcancellationshallbethedateofsaidlossofyour dulyqualifiedself-insurerstatus. B.Insured.The InsuredisnamedinSchedule Item1.Thewords“you”or“your”asusedinthisPolicy refertothe Insured. Ifthe Insuredisapartnershiporjointventure,eachpartnerormemberofthejointventureisinsuredonlyinthecapacity asemployer ofemployeesofthepartnershiporjointventure. C.Insurer.TheInsurerisMidwestEmployersCasualtyCompany.Thewords“we,”“us,”and“our”asusedinthisPolicy refertothe Insurer. D.The Policy.ThisPolicyincludestheScheduleandanyattachedendorsements. Itisanindemnityagreementbetweenyou andus.TheonlyprovisionsrelatingtothisindemnityagreementarestatedinthisPolicy.ThetermsofthisPolicymay notbechangedorwaivedexceptbyendorsementissuedbyustobeapartofthisPolicy.Endorsementsamending Schedule Items1,3,4,6,7or8applywith respecttobodilyinjurybyaccidentandbodilyinjurybydiseaseoccurringon orafter 12:01 A.M.ontheeffectivedateoftheapplicableendorsement(s). E.PolicyPeriodmeanstheperiodoftimecoveredbythisPolicyasshowninScheduleItem5.IfthisPolicyiscancelled, thePolicyPeriodshallendat12:01 A.M.onthecancellationdate. F.Workers’CompensationLawmeanstheworkers’compensationlaw andoccupationaldiseaselawofaState,including anyamendmentstosuchlawwhichareineffectduringthePolicyPeriod.Thedefinitionof“Workers’Compensation Law”doesnotincludetheprovisionsofanylawthatprovidenonoccupationaldisabilitybenefits.Thedefinitionof “Workers’CompensationLaw”alsodoesnotincludeanyfederalworkers’compensationlaw,federaloccupational diseaselaworanyotherfederallaw. G.StatemeansanystateoftheUnitedStatesofAmericaandtheDistrictofColumbia. H.Employeemeansanindividualthatyouhireandregularlypay,whonormallyperformsworkforyouunderyour directionandcontrolinaStatelistedinScheduleItem3.Thedefinitionof“Employee”doesnotincludeanindependent contractor,subcontractororanagentofathirdparty.IftheWorkers’CompensationLawinastatelistedinSchedule Item3deemsanindividualtobeyouremployeeforliabilitypurposes,thentheindividualshallbeconsideredan EmployeeunderPartOneofthisPolicy. I.ServiceCompanymeanstheentitynamedinScheduleItem14thatisretainedbyyoutoactonyourbehalf,asthethird partyadministratorforClaims. PARTONE – WORKERS’COMPENSATIONEXCESS INDEMNITY A.HowThisPartApplies.PartOneofthisPolicyappliestoLosspaidbyyoubecauseofliabilityimposeduponyouby theWorkers’CompensationLawofanyStatenamedinScheduleItem3,whicharisesoutoforresultsfrombodily injurybyaccidentorbodilyinjurybydiseasesustainedbyyourEmployee.PartOneofthisPolicyalsoappliestoLoss paidbyyoubecauseofliabilityimposeduponyoubytheWorkers’CompensationLawofanyotherStatewhichisnot namedinScheduleItem4,whicharisesoutoforresultsfrombodilyinjurybyaccidentorbodilyinjurybydisease sustainedbyyourEmployee,providedthattheworkgivingrisetothebodilyinjurywastemporaryandincidentaltoyour workinanyStatenamedinSchedule Item3. Bodilyinjurybyaccidentmustoccur duringthePolicyPeriod. Bodilyinjurybydiseasemustbecausedoraggravatedbytheconditionsofyouremployment.Bodilyinjurybydisease includescumulativetrauma.TheEmployee’slastdayoflastexposuretotheconditionsofyouremploymentcausingor EWC-ISI(2013)Page1of10 aggravatingsuchbodilyinjurybydiseasemustoccurduringthePolicyPeriod.Bodilyinjurybydiseasedoesnotinclude diseasethat resultsdirectlyfrombodilyinjurybyaccident. Bodilyinjuryincludes resultingdeath. B.SpecificExcessIndemnityCoverage. THISSECTIONBSHALLNOTAPPLY,ANDTHECOVERAGEAFFORDEDUNDERTHISSECTIONB SHALLNOTBEPROVIDEDTOYOU,IFTHEWORDS“NOTAPPLICABLE”ARESTATEDIN SCHEDULEITEMS7(a)AND8(a). 1.YourSpecificRetention.YoumustretainLossasshowninScheduleItem6.YourSpecificRetentionappliesto PartOneLossandtoPart TwoLosscombined.ITISIMPORTANTFORYOU TOUNDERSTAND THATYOUR SPECIFICRETENTIONFORDISEASEAPPLIESSEPARATELYTOEACHEMPLOYEE.Namingmorethan one InsuredinSchedule Item1doesnotincreaseyourSpecificRetention. 2.OurSpecificIndemnity.WeshallindemnifyyouunderPartOneofthisPolicyonlyforLosspaidbyyouin excess ofyourSpecificRetention. 3.OurSpecificLimit.ThemaximumLossweshallindemnifyyouforunderPartOneofthisPolicywithrespectto eachaccidentisshowninSchedule Item7(a).ThemaximumLossweshallindemnifyyouforunderPartOneofthis PolicywithrespecttoeachEmployeefordiseaseisshowninScheduleItem8(a).NamingmorethanoneInsuredin Schedule Item1doesnotincreaseourSpecificLimitunderPartOneofthisPolicy. C.LossunderPartOneofthisPolicymeanstheamountactuallypaidbyyou,afterdeductionofanyRecovery,forregular benefitsprovidedundertheWorkers’CompensationLawineffectonthedatetheaccidentorexposuretodiseaseoccurs. Lossshallinclude,butislimitedto: 1.TheamountpaidbyyouinreasonablesettlementofclaimsforregularbenefitsundertheWorkers’Compensation Law; 2.TheamountpaidbyyouinsatisfactionofawardsorjudgmentsforregularbenefitsundertheWorkers’ CompensationLaw;and 3.ReimbursableClaimHandling ExpenseasdefinedinPartFour – Claims,SectionL.ofthisPolicy. D.Exclusions FromLoss.PartOneofthisPolicydoesnotcover: 1.AnyServiceCompanyfees,costsandexpenses; 2.Fees,costsandexpenses(includingsalaries,wagesandothercompensationpaidtoyourEmployeesand independentcontractors) ofself-administrationofClaims; 3.Lossinsuredbyanyotherworkers’compensationoremployersliabilityinsurancepolicy; 4.LosspayableundertheWorkers’CompensationLawof anyStatewhichisnotnamedinScheduleItem3,ifyouare insuredforsuchlossbyanyotherinsurance; 5.AnylossarisingoutofoperationsforwhichyouhaverejectedorelectedtooptoutofanyWorkers’Compensation Law; 6.Fines,penalties,sanctions,interest,costs,orattorney’sfeesassessedagainstyouforanyviolationofanyWorkers’ CompensationLaworotherapplicablestatute,ruleorregulation.(Thisexclusiondoesnotapplytoattorney’sfees andcostsyouareorderedtopaytotheprevailingpartyinaClaiminwhichyoucontested,ingoodfaith,your liabilitytopaybenefitsundertheWorkers’Compensation Law); 7.PunitiveorexemplarydamagesbecauseofbodilyinjurysustainedbyanyEmployee; 8.Punitive,exemplaryorcompensatorydamagesbecauseofyourconduct,ortheconductofanyoneactingforyou: a.Intheinvestigation,trialorsettlementofanyclaimundertheWorkers’CompensationLaw;or b.InfailingtopayorindelayingpaymentofbenefitsundertheWorkers’CompensationLaw; 9.Anyassessment,taxorsurchargemadeuponemployersorself-insurers,whetherimposedbystatute,regulationor otherwise;or 10.AnypaymentsinexcessofthebenefitsregularlyprovidedbyanyWorkers’CompensationLaw,includingthose requiredbecause: a.Ofyourserious,grossandwillfulmisconduct; EWC-ISI(2013)Page2of10 b.Youknowinglyemployedan Employeeinviolationofapplicablelaw; c.Youfailedtocomplywithanapplicablehealthorsafetylawor regulation; d.Youdischarged,coercedorotherwisediscriminatedagainstanyEmployeeinviolationoftheWorkers’ CompensationLaw;or e.YouviolatedorfailedtocomplywithanyapplicableWorkers’CompensationLaw. PARTTWO – EMPLOYERSLIABILITYEXCESS INDEMNITY A.HowThis PartApplies.PartTwoofthisPolicyappliestoLosspaidbyyouforDamagesimposeduponyoubythelaws ofanyStateshowninScheduleItem3,whicharisesoutoforresultsfrombodilyinjurybyaccidentorbodilyinjuryby diseasesustainedbyyourEmployee.PartTwoofthisPolicyalsoappliestoLosspaidbyyouforDamagesimposed uponyoubythelawof anyotherStatewhichisnotshowninScheduleItem4,whicharisesoutoforresultsfrombodily injurybyaccidentorbodilyinjurybydiseasesustainedbyyourEmployee,providedthattheworkgivingrisetothe bodilyinjurywastemporaryandincidentaltoyourworkinanyStatenamedinSchedule Item3. Bodilyinjurymustariseoutofandinthecourseoftheinjured Employee’semploymentbyyou. Bodilyinjurybyaccidentmustoccur duringthePolicyPeriod. Bodilyinjurybydiseasemustbecausedoraggravatedbytheconditionsofyouremployment.Bodilyinjurybydisease includescumulativetrauma.TheEmployee’slastdayoflastexposuretotheconditionsofyouremploymentcausingor aggravatingsuchbodilyinjurybydiseasemustoccurduringthePolicyPeriod.Bodilyinjurybydiseasedoesnotinclude diseasethat resultsdirectlyfrombodilyinjurybyaccident. Bodilyinjuryincludes resultingdeath. B.SpecificExcessIndemnityCoverage. THISSECTIONBSHALLNOTAPPLY,ANDTHECOVERAGEAFFORDEDUNDERTHISSECTIONB SHALLNOTBEPROVIDEDTOYOU,IFTHEWORDS“NOTAPPLICABLE”ARESTATEDIN SCHEDULEITEMS7(b)AND8(b). 1.YourSpecificRetention.YoumustretainLossasshowninScheduleItem6.ThisSpecificRetentionappliesto PartOneLossandtoPart TwoLosscombined.ITISIMPORTANTFORYOU TOUNDERSTAND THATYOUR SPECIFICRETENTIONFORDISEASEAPPLIESSEPARATELYTOEACHEMPLOYEE.Namingmorethan one InsuredinSchedule Item1doesnotincreaseyourSpecificRetention. 2.OurSpecificIndemnity.WeshallindemnifyyouunderPartTwoofthisPolicyonlyforLosspaidbyyouinexcess ofyourSpecificRetention. 3.OurSpecificLimit.ThemaximumLossweshallindemnifyyouforunderPartTwoofthisPolicywithrespectto eachaccidentisshowninScheduleItem7(b).ThemaximumLossweshallindemnifyyouforunderPartTwoof thisPolicywithrespecttoeachEmployeefordiseaseisshowninScheduleItem8(b).Namingmorethanone InsuredinSchedule Item1doesnotincreaseourSpecificLimitunderPartTwoofthisPolicy. C.LossunderPartTwoofthisPolicymeanstheamountactuallypaidbyyou,afterdeductionofanyRecovery,for Damagesimposeduponyoubylaw.Lossshallinclude,butislimitedto: 1.Theamountpaidbyyouin reasonablesettlementofclaimsorsuitsforDamages; 2.TheamountpaidbyyouinsatisfactionofawardsorjudgmentsforDamages;and 3.ReimbursableClaimHandling ExpenseasdefinedinPartFour – Claims,SectionL.ofthisPolicy. D.Damagesincludes,andislimitedto: 1.Damagesforwhichyouareliabletoathirdpartybyreasonofaclaimorsuitagainstyoubythatthirdpartyto recoverthedamagesclaimedagainstsuchthird partyasa resultofinjurytoyourEmployee; 2.Damagesforcareandlossofservices; 3.Damagesforconsequentialbodilyinjurytoaspouse,child,parent,brotherorsisteroftheinjuredEmployee; providedthatthesedamagesarethedirectconsequenceofbodilyinjurythatarisesoutofandinthecourseofthe injuredEmployee’semploymentbyyou;and 4.DamagesbecauseofbodilyinjurytoyourEmployeethatariseoutofandinthecourseofemployment,claimed againstyouinacapacityotherthanasemployer. EWC-ISI(2013)Page3of10 E.Exclusions FromLoss.PartTwodoesnotcover: 1.AnyServiceCompanyfees,costsandexpenses; 2.Fees,costsandexpenses(includingsalaries,wagesandothercompensationpaidtoyourEmployeesand independentcontractors) ofself-administrationofClaims; 3.Lossorliabilityassumedunderacontractoragreement; 4.Lossorliabilityvoluntarilyassumedbyyou; 5.LosspayableunderthelawsofanyStatewhichisnotnamedinScheduleItem3,ifyouareprotectedfromtheloss byanyotherinsurance; 6.Punitiveorexemplarydamages; 7.BodilyinjurytoanEmployeewhileemployedinviolationoflawwithyouractualknowledgeortheactual knowledgeofanyofyourexecutiveofficersormanagers; 8.AnyobligationimposedbyanyWorkers’CompensationLaw,unemploymentcompensationlaw,disabilitybenefits law,oranysimilarlaw; 9.Bodilyinjuryintentionallycausedoraggravatedbyyou; 10.Bodilyinjuryresultingfromyourconductwhichisdeterminedtobemalicious,deliberate,willful,withreckless disregard,substantiallycertaintocauseinjury,theequivalenttoanintentionaltort(regardlessofhowthattermis definedorinterpreted),orotherwisetortuous,suchthatyouloseyourimmunityfromcivilliabilityunderany Workers’CompensationLaw; 11.Bodilyinjurytoan Employeewhenyouaredeprivedofcommonlawdefensesoraresubjecttoapenaltybecauseof yourfailuretosecureyourobligationsundertheapplicableWorkers’CompensationLaworotherwisefailto complywiththatlaw; 12.Damagesarisingoutofcoercion,criticism,demotion,evaluation,reassignment,discipline,defamation,harassment, humiliation,discriminationagainstorterminationofanyEmployee,oranypersonnelpractices,policies,actsor omissions; 13.BodilyinjuryoccurringoutsidetheUnitedStatesofAmerica.Thisexclusiondoesnotapplytobodilyinjurytoan EmployeewhoisacitizenorresidentoftheState(s)listedinScheduleItem3whoistemporarilyworkingoutside theUnitedStatesofAmericaforyou; 14.Damagesarisingoutofoperationsforwhichyouhave: (a)ViolatedorfailedtocomplywithanyWorkers’CompensationLaw;or (b)RejectedorelectedtooptoutofanyWorkers’CompensationLaw; 15.BodilyinjurytoanyEmployeeinworksubjecttotheLongshoreandHarborWorkers’CompensationAct(33USC Sections901–950),theNon-appropriatedFundInstrumentalitiesAct(5USCSections8171–8173),theOuter ContinentalShelfLandsAct(43USCSections1331–1356a),theDefenseBaseAct(42USCSections1651–1654), theFederalMineHealthandSafetyActof1969(30USCSections801–945),theFederalEmployers’LiabilityAct (45USCSections51–60),theMigrantandSeasonalAgriculturalWorkerProtectionAct(29USCSections1801– 1872),theMerchantMarineActof1920alsoknownastheJonesAct(46USCSection688)andanyotherfederal workers’compensationlaworotherfederaloccupationaldiseaselaw,oranyamendmentstotheselaws,obligating anemployertopaydamagestoanemployeeduetobodilyinjuryarisingoutoforinthecourseofemployment; 16.Bodilyinjurytoamaster or member ofthecrewofanyvessel;or 17.FinesorpenaltiesimposedforviolationofanyfederalorStatelaw. PARTTHREE – AGGREGATEEXCESS INDEMNITY THISPARTTHREESHALLNOTAPPLY,ANDTHECOVERAGEAFFORDEDUNDERTHISPARTTHREE SHALLNOTBEPROVIDEDTOYOU,IFTHEWORDS“NOTAPPLICABLE”ARESTATEDINSCHEDULE ITEMS9(a),9(b), 9(c),9(d)AND10. A.YourAggregateRetention.TheamountofLossyoumustretainasaresultofallaccidentsanddiseaseexposures occurringduringthePolicyPeriodshallbecomputedasshowninScheduleItem9(a).ThisAggregateRetentionapplies toPartOneLossandtoPartTwoLosscombined.IncalculatingyourAggregateRetention,Losspertainingtoeach accidentordiseaseshallbelimitedtotherespectiveamountshowninScheduleItem9(d).UnlesswecancelthisPolicy, EWC-ISI(2013)Page4of10 yourAggregateRetentionshallnotbelessthantheMinimumRetentionshowninScheduleItem9(c).Ifwecancelthis Policy,yourAggregateRetentionshallnotbelessthantheprorataportionoftheMinimumRetentionshownin ScheduleItem9(c)baseduponthenumberofdaysfromtheeffectivedateofthisPolicyto(andincluding)thedateof cancellation.Namingmorethanone InsuredinSchedule Item1doesnotincreaseyourAggregateRetention. NormalPremiumisdefinedinPartFive–Premium,SectionC.FinalPremiumofthisPolicy. B.OurAggregateIndemnity.WeshallindemnifyyouunderPartThreeofthisPolicyforLosspaidbyyouinexcessof yourAggregateRetentionasaresultofallaccidentsanddiseaseexposuresoccurringduringthePolicyPeriod.In calculatingourindemnity,Losspertainingtoeachaccidentordiseaseshallbelimitedtotherespectiveamountshownin Schedule Item9(d). C.OurAggregateLimit.ThemaximumLossweshallindemnifyyouforunderPartThreeofthisPolicyasaresultofall accidentsanddiseaseexposuresoccurringduringthePolicyPeriodisshowninScheduleItem10.Thislimitappliesto PartOneLoss andtoPartTwoLosscombined.NamingmorethanoneInsuredinScheduleItem1doesnotincreaseour AggregateLimitunderPart ThreeofthisPolicy. PARTFOUR – CLAIMS A.Claimmeansanyadministrativefiling,causeofaction,demand,suit,legalaction,proceedingorliabilityasserted againstorimposeduponyouforwhichyouhavepaidLossormaybeliabletopayLossunderPartOne,PartTwoor PartThreeofthisPolicy. B.ClaimsInformationmeansanyinformationcollected,maintained,analyzedorgeneratedbyyou,yourService Company,claimsconsultant,attorney,pharmacybenefitsmanager,billreviewerandanyotheroutsidevendorsor entities retainedonyour behalf,that relatestoanyClaim,injuryorLossoccurringduringthePolicyPeriod. C.ElectronicDataInterchangemeansthesecuretransmissionofClaimsInformationfromyoutousbyelectronicmeans, inaspecificformandmannerthatisapprovedbyus. D.FirstNoticeofLossmeansawrittenformacceptabletousthatprovidesthecompletedetailsoftheinjury,disease, deathorClaim.Providingalossrun,orClaimsInformationasrequiredbySectionH.YourDutytoSendClaims Information,doesnotconstituteaFirstNoticeofLoss. E.FullandFinalSettlementmeansasettlementthatextinguishesandreleasesyoufromliabilitytomakeanyfuture monetarypaymentsonaClaimbyyourpaymentofasumcertainamount,whichmayincludealumpsum,annuity premium,seedmoney,attorneyfees,costs,lienwaiverand/orotherconsideration. F.YourClaimsHandlingDuties.Itisyourdutyandresponsibilitytoinvestigate,handle,settle,defendandappealall Claims. G.YourSpecificClaimsReportingDuties.TotheextentthatthisPolicyprovidesSpecificExcessIndemnitycoverageas statedintheSchedule,itisyour dutyand responsibilitytoprovideuswithaFirstNoticeofLossforeachinjuryorClaim asspecifiedbythisSection. 1.CatastrophicandSeriousInjuryClaims–RequiringFirstNoticeofLossWithinFive(5)Days.Youmustsend usaFirstNoticeofLosswithinfive(5)daysaftertheoccurrenceofanyaccidentordiseaseexposureinvolvingan Employeewhosustainedanyofthefollowinginjuries,evenifyouarecontestingyourliability: a.Fatality; b.Braininjury; c.Spinalcordinjury; d.Paralysisofanypartofthebody; e.Seriousburninjury (burnsover 25%ormoreofthebody); f.Amputationofamajorextremity; g.Crushingormassiveinternalinjury;or h.Partialortotallossofvisioninoneorbotheyes. 2.EmployerLiabilityClaims–FirstNoticeofLossWithinThirty(30)Days.YoumustsendusaFirstNoticeof Losswithinthirty(30)daysofyournoticeofaClaimthatmayfallunderPartTwo–EmployersLiabilityofthis Policy. 3.OtherClaimsRequiringReportingbyFirstNoticeofLossWithinThirty(30)Days.YoumustsendusaFirst NoticeofLosswithinthirty (30)daysaftertheoccurrenceofanyofthefollowingeventsonanindividualClaim: a.ThetotalpaidLossexceeds$250,000orthetotalincurredamountofLoss(paidandreserves)exceeds50%of yourSpecificRetention,whichevereventoccursfirst; EWC-ISI(2013)Page5of10 b.AninjuredEmployeemissesfifty-two(52)weeksofworkasaresultoftheinjury,eveniftheClaimisbeing contestedbyyou; c.AninjuredEmployeehaspetitionedtobedeemed,isacceptedas,awarded,orfoundtobecatastrophicallyor permanentlyandtotallydisabledundertheWorkers’CompensationLaw; d.AnaccidentordiseaseexposureinvolvinginjurytotwoormoreEmployees;or e.AnEmployeeisdiagnosedwithcancer,heartdisease,lungdisease,infectiousdiseaseorotherdiseasethatis presumedtobe,orfoundtobe,compensableundertheWorkers’CompensationLaw. 4.ConsequenceofYourFailuretoSendUsATimelyFirstNoticeofLoss.IfyoudonotsendusaFirstNoticeof LossofaninjuryorClaimwithinthetimespecifiedinthisSectionandweareprejudicedasaresult,wemaydeny youindemnificationunderthisPolicyforLossthatarisesoutofor resultsfromthatinjuryorClaim. H.YourDutytoSendClaimsInformation.YouagreetoprovideuswithanyClaimsInformationthatwemayrequest, whichmayinclude,butisnotlimitedto: 1.ProvidingdetailedClaimsInformationonaspecificindividualClaim; 2.SendingusspecifiedClaims Informationonaperiodicand recurringbasisforallClaimswithinthePolicyPeriod; 3.TransmittingClaimsInformationthrough ElectronicData Interchange;and 4.Grantinguson-lineread-onlyaccesstoyourServiceCompany’sor,ifyouareself-administered,yourcomputerized Claimssystem,sothatwemayviewClaimsInformation. YouauthorizethereleaseanddisclosureofrequestedClaimsInformationdirectlytousfromyourServiceCompanyor anyotherthird partythatpossessessuchClaims Information. I.ClaimsParticipationbyUs.Atourownelectionandexpense,wehavetherightandshallbegiventheopportunityto participatewithyouintheinvestigation,handling,settlement,defenseorappealofanyClaimwhichmightinvolvea Losstous,andyouagreetofullycooperatewithusifwesoelecttoparticipate.Wehavenodutytoinvestigate,handle, settle,defendorappealanyClaim. J.GoodFaithClaimsHandlingandSettlements.Itisyourdutyandresponsibilitytousediligence,prudenceandgood faithintheinvestigation,handling,defense,settlementandappealofallClaims.Yourdutyandresponsibilityinclude, butarenotlimitedto,thefollowing: 1.InvestigationandDefense.Youshalldiligentlyandcompetentlyinvestigate,handleanddefendallClaims.You shallnotengageinfrivolouslitigationorconductthatisunreasonable,sanctionableorinbadfaith.Youshall complywithallapplicableWorkers’CompensationLaws andcourtrulesthatgoverntheinvestigation,handlingand defenseofClaims. 2.PursuitofSettlement.YoushallpursuesettlementofeachClaimwhenitisreasonabletodoso.Youshallengage insettlementdiscussionsandparticipateingoodfaithinsettlementconferencesandvoluntarymediationwhen available. 3.SettlementWithinYourRetention.IfyouarepresentedwithareasonableopportunitytoreachaFullandFinal SettlementofaClaimwithinyourRetention,youshallsettleit.IfaClaimisfiledinaStatethatwillnotallowa FullandFinalSettlement,andyouarepresentedwithareasonableopportunitytoreachapartialsettlementofthe ClaimwithinyourRetention,youshallsettleit. 4.SettlementInvolvingLosstoUs.Youshallnotagreetoanyvoluntarysettlementormakeavoluntarylumpsum settlementpaymentinvolvingLosstousunderthisPolicywithoutourwrittenconsent.Ifwegiveyouourwritten consenttoa reasonablesettlementwhichinvolvesLosstous,youshallnot refusetoacceptthesettlement.Youshall dowhatisnecessarytoconsummatesuchsettlement,includingexecutingallnecessarysettlementdocumentsand remittingthesettlementpaymentinatimelyfashion. K.Recovery. 1.RecoverymeansanyamountrecoveredwhichmaymitigateLosscoveredbythisPolicy,including,butnotlimited toamountspaid: a.Onbehalfofanythirdparty,personorentitythatmaybeliableforanyinjury,LossorClaimcoveredbythis Policy; b.BytheapplicableStatesecondinjuryfund,specialdisabilityfundorsimilarfundortrustexistingunderthe Workers'CompensationLaworotherStatelaw,whichentitleyoutoreimbursementforpastpaymentsor benefitsmadebyyouand/orreduceyourliabilitytomakefuturepaymentsorbenefits; c.Insatisfactionofyourstatutorylien rights;or d.Onaccountofoverpayments,offsets,deductionsorcreditsagainstyourobligationstomakepaymentsor providebenefitsundertheWorkers’CompensationLaworotherStatelaw. EWC-ISI(2013)Page6of10 2.YourDutytoPursueRecovery.Itisyourdutyandresponsibilitytodiligently,prudentlyandingoodfaith, investigateandprosecuteyour rightstoRecovery. 3.SubrogationofYourRights.TotheextentthatwehavepaidLossorwebelievethatwemayincurLossunderthis Policy,weshallbesubrogatedtoyourrightstoRecovery.Youshalldoeverythingnecessarytoprotectthoserights forus andtohelpus enforcethem.Atourelection,wemaytakeoveryourrightstoRecovery andyou agreetofully assistus,includingassigningortransferringyour rightstousorallowingustopursuetheprosecutioninyourname. 4.AllocationofAmountsRecovered.AnyRecoveryreceivedbyyouorusshallfirstbeusedtopayreasonable expensesofcollectionandthentoreimburseusforanyamountwehavepaidtoyouunderthisPolicy.Thebalance ofRecovery,if any,shallbepayabletoyou andshallreducetheLosspaidbyyouunderyourSpecificRetentionfor thisPolicy. 5.Non-WaiverofYourRecoveryRights.Youagreenottowaive,settleorcompromiseyourrighttoRecovery withoutourwrittenconsentifwehavepaidLossormayincurLossunderthisPolicy. 6.GoodFaithSettlementofRecoveryActions.YouagreenottorefusetosettleanyrighttoRecoverywhich,inthe exerciseofgoodfaithandsoundjudgment,shouldbesettled. L.ReimbursableClaimHandlingExpense.ReimbursableClaimHandling Expensemeansandislimitedtothefollowing expenses,butonlyiftheyare reasonableanddirectlyallocatedtoaparticularClaimcoveredbythisPolicy: 1.Feesforattorneysortheirauthorized representativesthataredirectlyinvolvedinlitigationoftheClaim; 2.Litigationexpensesincludingcourtcosts,depositioncosts,witnessfees,subpoenaandsummonsservicefees; 3.Alternativedisputeexpensessuchasmediationandarbitrationfeesandexpenses; 4.Appealbondsandappealfees; 5.Surveillanceandinvestigationfees; 6.Expertwitnessfees; 7.Independentmedicalandforensicexaminationfees; 8.Independentnursecasemanagementand rehabilitationconsultantfees; 9.Feesformedicaltreatmentutilization reviewsifperformedbyanurseordoctor; 10.Medicalbill review,auditingor re-pricingcosts; 11.Medicalpreferredprovidernetwork/organization (PPN/PPO)fees; 12.Medicalfee reviewpanelexpenses;and 13.Expenseswhichare requiredbytheapplicableWorkers’CompensationLaw. IfanyotherexpensethatisnotlistedaboveandisnototherwiseexcludedfromLossisneverthelessdirectlyrelatedtoa specificcoveredClaim,itshallbeconsideredaReimbursableClaimHandlingExpenseonlyifwegiveyouwritten consentpriortotheexpensebeingincurred. M.ProofofLoss.YoumustprovideuswithaProofofLossacceptabletoustoreceivepromptindemnificationunderthis PolicyfortheparticularexcessindemnitycoverageprovidedtoyouasstatedontheSchedule.AProofofLossshall containthefollowinginformation: 1.SpecificProofofLoss.YoumustprovideuswithapaymentregisterlistingallpaymentsmadeontheClaimand anysupportingdocumentationthatwe request,inaformacceptabletous. 2.AggregateProofofLoss.YoumustprovideuswithadetailedlossrunlistingeachClaiminthePolicyPeriod,the dateofLossofeachClaim,theamountpaid,anyremainingreserves,andanysupportingdocumentationthatwe request,inaformacceptabletous. N.CommutationbyMutualAgreement.WithregardtoanyoutstandingorunsettledClaimsreportedhereunder,either partymayrequestthatourliabilityforincurredLossthatexceedstheSpecificRetentioninScheduleItem6ofthis Policybecommuted.Ifthereismutualagreementbetweenyouandusthatacommutationshouldbeconsideredwith regardtoaClaimorClaims,thenthefollowingshallapply: 1.Withinsixty(60)daysaftersuchmutualagreementtocommute,youshallsubmitastatementofvaluationforthe outstandingClaimorClaimsshowingtheelementsconsidered reasonabletoestablishthecommutedvalueofLoss. EWC-ISI(2013)Page7of10 2.ThecommutedvalueofLossshallbecalculatedasthediscountedpresentvalueoftheLossthatexceedsthe SpecificRetentioninSchedule Item6,subjecttothelimitsofliabilityshowninScheduleItems7and8. 3.Ifthecommutedvaluesubmittedbyyouisnotacceptabletous,wemaysubmitacounterproposaltoyoufor commutation.Ifbothpartiesareunabletoreachanagreementonthecommutedvalue,thenthepartiesshalleither abandonthecommutationeffortoragreetomutuallyappointanactuaryorappraisertoinvestigateanddetermine thecommutedvalue.Ifbothpartiesthenagreetothecommutedvaluearrivedatbytheactuary/appraiser,weshall paytheamountdeterminedtobethecommutedvalueoftheClaimorClaimsunderthisPolicy. 4.Ifthecommutedvaluedeterminedbytheappraiseraboveisnotacceptabletobothparties,theyshalleitherabandon thecommutationeffortoragreetosettleanydifferenceusingapanelofthreeactuaries,onetobechosenbyeach party,andathirdchosenbythetwosochosen.Ifthetwoactuariesfailtoagreeontheselectionofathirdactuary withinsixty(60)daysoftheirappointment,eachofthemshallnametwo,ofwhomtheothershalldeclineoneand thedecisionshallbemadebydrawinglots.Alltheactuariesshallberegularlyengagedinthevaluationofworkers’ compensationclaimsandshallbeFellowsorAssociatesintheCasualtyActuarialSociety.Noneoftheactuaries shallhaveafinancialinterestinnorbeacurrentorformeremployeeoftheparties,andalloftheactuariesshallbe disinterestedintheoutcomeofthecommutation. Eachpartyshallsubmititscasetoitsactuarywithinsixty(60)daysoftheappointmentofthethirdactuary.The decisioninwritingofanytwoactuaries(fromthepanelofthree),whenfiledwiththepartiesheretoshallbefinal andbindingonbothpartiesandweshallpaytheamountsodeterminedtobethecommutedvalueoftheClaimor Claims.Theexpenseoftheactuariesandofthecommutationshallbeequallydividedbetweenbothparties.Said commutationshalltakeplaceinSt.LouisCounty,Missouri,unlesssomeotherlocationismutuallyagreeduponby theparties. 5.PaymentbyusofthecommutedvalueoftheClaimorClaimsshallconstitutefullandfinalreleaseofourliability forsuchClaimorClaimsandyourreceiptofsuchpaymentshallconstituteafullandfinalreleaseofanyandall obligationswehaveunderthisPolicy. O.ClaimsAuditandComputerAccess.YoushallletusorourrepresentativesexamineandauditClaimsfilesuponour request.YoushallalsoletusorourrepresentativesexamineandaudityourServiceCompany’sor,ifyouareself- administered,yourClaimspractices,procedures,andrecordsrelatingtoClaimshandling,disabilityandmedical management,reserving,Claimsreportingcomplianceandfileconclusion.YouagreetograntusaccesstoyourService Company’sor,ifyouareself-administered,yourcomputerizedClaimssystem,includingon-line read-onlyaccess. P.Inspection.Youshallletusorourrepresentativesinspectyourpremises,workplacesandequipmentuponourrequest. Anysuchinspectionisnotasafetyinspection.Ifwecommunicateanyfindingsorissuestoyouafteraninspection,it shallbeforgeneralpurposesonly.Byperforminganinspectionwearenotundertakinganydutytoassurethatyour premises,workplacesandequipmentaresafeandincompliancewithapplicablelawsorindustrystandards. PARTFIVE –PREMIUM A.DepositandAdjustmentPremiums.AtthebeginningofthePolicyPeriod,youmustpayustheDepositPremiumand anyflatchargesshownintheSchedule. AttheendofthePolicyPeriod: 1.YoushalloweustheamountbywhichtheFinalPremiumisgreaterthantheDepositPremium;or 2.WeshalloweyoutheamountbywhichtheDepositPremiumisgreaterthantheFinalPremium. B.PayrollReport.Withinforty-five(45)daysaftertheendofthePolicyPeriod,youmustsendusareportshowingthe amountofPayrollearnedbyyour EmployeesduringthePolicyPeriod.ThereportmustshowPayrollseparatelyforeach classificationidentifiedinSchedule Item11. C.Final Premium.TheFinalPremiumduetousforthePolicyPeriodshallbecomputedasshowninSchedule Item12(a). NormalPremiummeansthesumoftheproductsofyourauditedPayrollwithineachclassificationshowninSchedule Item11foreachStatenamedinScheduleItem3multipliedbytherateshowninScheduleItem11fortherespective classification,theproductofwhichshallbefurthermultipliedbythe ExperienceModificationFactorshowninSchedule Item11(a)and/oranyOtherModificationFactorshowninSchedule Item11(b). UnlessthisPolicyiscancelled,FinalPremiumshallbeatleastthe MinimumPremiumshownintheSchedule. WhendeterminingFinalPremium,anyflatchargesshownintheSchedulearenotsubjecttoadditionalcomputationsor modificationfactors. EWC-ISI(2013)Page8of10 IfwecancelthisPolicy,FinalPremiumshallbecalculatedproratabasedonthetimethisPolicywasinforce.Final Premiumshallnotbelessthanthepro ratashareofthe MinimumPremiumshownintheSchedule. IfyoucancelthisPolicy,FinalPremiumshallbemorethanprorata;itshallbebasedonthetimethisPolicywasin force,andincreasedbythecustomaryshortratetableandprocedure.FinalPremiumshallnotbelessthantheMinimum PremiumshownintheSchedule. IfthisPolicyisautomaticallycancelledbecauseofthelossofyourdulyqualifiedself-insurerstatusasstatedinSection A.Self-InsuranceoftheGeneralSectionofthisPolicy,FinalPremiumshallbemorethanprorata;itshallbebasedon thetimethisPolicywasinforce,andincreasedbythe customaryshortratetableandprocedure.FinalPremiumshallnot belessthantheMinimumPremiumshownintheSchedule. TheFinalPremiumduetousshallnotbereducedbytheexistenceofanyotherinsurance,reinsurance,indemnity agreementorother reimbursementagreementprotectingyouagainstLosscoveredbythisPolicy. D.PayrollmeansthegrosspayofyourEmployeesforthePolicyPeriodplusotheramountsanditemsearnedbyyour Employeesaspartoftheir payforthePolicyPeriod.Payrollalsoincludes: 1.Grosspayplusotheramountsanditemsearnedbyyour officersifcoveredunderthisPolicy; 2.ThecontractpriceformaterialsandservicesperformedbyanyindividualdeemedtobeyourEmployeeforliability purposesundertheWorkers’CompensationLaw,ifyoudonothavePayroll recordsforthisindividual;and 3.AssignedPayrollattributedtovolunteersforwhomyouarelegallyobligatedtoprovidebenefitsundertheWorkers’ CompensationLaw.AssignedPayrollmeans: a.Forvolunteersotherthanvolunteerfirefightersandvolunteerpoliceofficers,thefederalminimumhourlywage asoftheeffectivedateofthisPolicymultipliedbythehoursworkedbythevolunteers,unlessthework performedbythevolunteersissimilartoworkperformedbyapaidEmployeewhoisreceivingmorethanthe federalminimumhourlywage,inwhicheventthewagereportedforthevolunteerworkershallbethesameas thewage reportedforthepaidEmployee;and b.Forvolunteerfirefightersorvolunteerpoliceofficers,thegreaterof$12,500peryearorthesamewageas reportedforapaidEmployeeperformingsimilarworkshallbeincludedinPayrollforeachsuchvolunteer firefighter or volunteer policeofficer. Dutiesperformedbyvolunteersshallbeassignedtotheclassificationcodewhichthedutieswouldbeassignedtoif performedby regularEmployees. NoamountisincludedinAssignedPayrollforanyvolunteerworkerwhoisnotcoveredundertheWorkers’ CompensationLawbecausePartOneofthisPolicydoesnotapplywith respecttothatworker. E.Records.Youshallkeeprecordsofinformationneededtocomputepremium.Youshallprovideuswithcopiesofthose recordswhenweaskforthem. F.Audit.Uponourrequest,youshallletusorourrepresentativesexamineandauditallyourPayrollrecords.Payroll recordsinclude,butarenotlimitedto,ledgers,journals,registers,vouchers,contracts,taxreports,Payrolland disbursementrecords,andprogramsforstoringandretrievingdata.Theauditsmaybeconductedduringyourregular businesshours. PARTSIX – CONDITIONS A.AgreementUponTerms.YouracceptanceofthisPolicymeansthatyouagreewithusuponthetermsofthisPolicy,the Scheduleandanyattachedendorsements.Youwarrantthatthestatementsyoumadeintheapplication,andinany supplementalmaterialsorinformationyousubmittedtous,aretrueandaccurate,andunderstandthatwehaveissuedthis Policyinrelianceuponthose representations.Youagreethatyourfullcompliancewithalloftheterms andconditionsof thisPolicyisaconditionprecedenttoourindemnityobligationsunderthisPolicy.Youshallhavenorightofaction againstusunlessyouhavecompliedwithallofthetermsandconditionsofthisPolicy. B.SoleRepresentative.TheInsuredfirstnamedinScheduleItem1shallactonbehalfofallInsuredstoaccept any agreed uponchangetothisPolicy,toacceptLosspayments,toreceivereturnpremiumandtogiveorreceivenoticeof cancellation. C.BankruptcyorInsolvency.YourbankruptcyorinsolvencyshallnotrelieveusfromthepaymentofanyLosscovered bythisPolicy.AftertheRetentionshownontheSchedulehasbeenpaid,paymentsshallbemadebyusasifyouhadnot becomebankruptorinsolventbutnotinexcessoftheSpecificLimitortheAggregateLimitshownontheSchedule. PaymentshallbemadetotheTrusteeinBankruptcyorasdirectedbyanappropriatecourt.Weshallnevermake paymentsbelowtheRetentionshownontheSchedule,norshallourindemnityobligationsunderthisPolicyeverbe increasedorbroadenbecauseofyour bankruptcyorinsolvency. EWC-ISI(2013)Page9of10 D.OtherInsurance.Ifanyotherinsurance,reinsurance,indemnityagreementorotherreimbursementagreementexists protectingyouagainstLosscoveredbythisPolicy,theindemnitycoverageaffordedunderthisPolicyshallapplyin excessofsuchotherinsurance, reinsurance,indemnityagreementorother reimbursementagreement. E.Offset.Wehavetherighttooffsetanybalanceoramountyouoweus,whethersuchbalanceisonaccountofpremium due,Recoverydue,expenses,orotheramountowed,againstanyindemnificationforLoss,premiumrefundorother amountweoweyouunderthisPolicyorunderanyother policyoragreemententeredintobetweenyouandus. F.TransferorAssignmentofYourRightsandDuties.YourrightsordutiesunderthisPolicyshallnotbetransferred withoutourexpresswrittenconsent. G.NoThird-PartyRights.ThisPolicyissolelybetweenyouandus.NothinginthisPolicyshallinanymannercreate any obligationsorestablishanyrightsofactionagainstusinfavorofanythirdparties,orpersonsnotapartytothisPolicy, includingbutnotlimitedtoanyEmployeesorclaimants. H.ServiceandAdministration.ThisPolicycontemplatestheconcurrentandcontinuedexistenceofaseparateservice agreementbetweenyouandtheServiceCompanynamedinScheduleItem14relatingtotheadministrationofClaims. Youagreetoprovideusacopyofsuchserviceagreementatourrequest.Youfurtheragreetoimmediatelynotifyusin theeventthattheserviceagreementisamended,cancelledorterminated.WemustagreetoanychangeintheService Company. IfScheduleItem14states“ApprovedforSelf-Administration,”thenwehaveagreedtoyourself-administrationof ClaimscoveredbythisPolicy.Ifyouhavebeenapprovedforself-administration,youmustobtainourconsentpriorto movingyouradministrationofClaimstoaServiceCompany. TheobligationsunderthisSectionshallsurvivetheexpirationofthePolicyPeriodandanysubsequentrenewalofthis Policy. I.Cancellation.YoumaycancelthisPolicybygivingusatleastsixty(60)daysadvancewrittennoticestatingthe cancellationdate.WemaycancelthisPolicybygivingyouatleastsixty(60)daysadvancewrittennoticestatingthe cancellationdate.OurdeliveryofnoticetoyouraddressshowninScheduleItem2shallbesufficientproofthatwe cancelledthisPolicy. IfthisPolicyiscancelled,thePolicyPeriodshallendat12:01 A.M.onthecancellationdate.ThisPolicydoesnotapply tolossorliabilitywhicharisesoutofbodilyinjurybyaccidentorbodilyinjurybydiseasethatoccursaftertheeffective dateofsuchcancellation. Ifyoufailtopaypremiumduetousbytheduedate,wehavethe righttocancelwithten (10)dayswrittennoticetoyou. Inthe eventofcancellationofthisPolicy,FinalPremiumshallbecalculatedassetforthinPartFive–Premium,Section C.FinalPremiumofthisPolicy. J.Non-Conformance.IfthetermsofthisPolicyareinconflictwithanylawapplicabletothisPolicy,thisstatement amendsthisPolicytoconformtosuchlaw. WehaveexecutedthisPolicybyprintingbelowthefacsimilesignaturesofourPresidentandSecretaryandbytheactual signatureofourauthorized representativeontheScheduleif requiredbylaw. MIDWESTEMPLOYERSCASUALTYCOMPANY SignatureSignature SecretaryPresident EWC-ISI(2013)Page10of10 PrivacyNotice MidwestEmployersCasualtyCompany(the“Company”),amember companyoftheW.R.BerkleyCorporation(“Berkley”)groupof companiesandeach othermemberoftheBerkleygroupofcompanies(“Affiliates”)understandsourcustomers’concernaboutprivacyoftheirinformationcollectedbythe Company.OurCompanyisdedicatedtoprotectingtheconfidentialityandsecurityofnonpublicpersonalinformationwecollectaboutourcustomersin accordancewithapplicablelawsandregulations.ThisnoticereferstotheCompanybyusingtheterms“us,”“we,”or“our.”Thisnoticedescribesour privacypolicyanddescribeshowwe treat thenonpublicpersonalinformationaboutour customers thatwereceive fromthem(“Information”). WhyWeCollectandHowWeUse Information WecollectanduseInformationforbusinesspurposeswithrespecttoourinsuranceproductsandservicesandotherbusinessrelationsinvolvingour customers.WegatherthisInformationtoevaluateyourrequestforinsurance,toevaluateyourinsuranceclaims,toadminister,maintainorreviewyour insurancepolicy,andtoprocessyourinsurancetransactions.Wealsoaccumulatecertaininformationaboutyouasmayberequiredorpermittedby law. Yourinsuranceagentorbrokeralso collectsthisInformationandmayuseittohelpwithyouroverallinsuranceprogramor tomarketadditionalproducts and servicestoyou.WemayalsouseInformationtoofferyouotherproductsorservices thatweorour Affiliatesprovide. HowWeCollectInformation MostInformationcollectedbyusisprovidedbyyouoryourinsuranceagentorbrokertous.WeobtainInformationfrom(i)applicationsorotherforms submittedbyyou,yourinsuranceagentorbrokeroryourauthorizedrepresentativestousandourAffiliates,and(ii)yourtransactionswithusorour Affiliates.WemayalsoobtainInformationfromothersourcessuchas(i)consumerreportingagencies,(ii)otherinstitutionsorinformationservices providers(thirdpartyadministrators),(iii)employers,(iv)otherinsurers,or(v)your familymembers. InformationWeDisclose WediscloseanyInformationwhichwebelieveisnecessarytoconductourbusinessaspermittedbyapplicablelaworwhererequiredbyapplicablelaw. Thisdisclosuremayinclude(i)InformationwereceivefromyouonapplicationsorotherformsprovidedtousandourAffiliates,suchasnames, addresses,socialsecuritynumbers,assets,employerinformation,salaries,etc.(ii)InformationaboutyourtransactionswithusandourAffiliates,such aspolicycoverages,premiums,paymenthistory,etc.,and(iii)Informationwereceivefromaconsumerreportingagency,suchascreditworthinessand credithistory. ToWhomWeDisclose Information Wemay,aspermittedorrequiredbyapplicablelaw,discloseyour Informationtononaffiliated thirdparties, suchas(i)yourinsuranceagentorbroker,(ii) independentclaimsadjusters,(iii)insurancesupportorganizations,(iv)processingcompanies,(v)actuarialorganizations,(vi)lawfirms,(vii)other insurancecompaniesinvolvedinaninsurancetransactionwithyou,(viii)lawenforcement,regulatory,orgovernmentalagencies,(ix)courtsorparties thereinpursuant toasubpoenaorcourtorder,(x)businesseswithwhomwehaveamarketingagreement,or(xi)ourAffiliates. WemayshareInformationwithourAffiliatessothattheymayofferyouproductsandservicesfromtheBerkleygroupofcompaniesortoanalyzeour bookofbusinessand to consolidatenecessaryinformation.Wedonotdisclose Information toothercompaniesororganizationsnotaffiliatedwithus for thepurposeofusingInformationtoselltheirproductsorservicestoyou.Forexample,wedonotsellyournametounaffiliatedmailorderordirect marketing companies. HowWeProtectInformation WerequireouremployeestoprotecttheconfidentialityofInformationasrequiredbyapplicablelaw.AccesstoInformationbyouremployeesislimited toadministering,offering,servicing,processingormaintainingofourproductsandservices.Wealsomaintainphysical,electronicandprocedural safeguardsdesignedtoprotectInformation.WhenweshareorprovideInformationtootherpersonsororganizations,wecontractuallyobligatethem,if requiredbylaw, to treat Informationasconfidentialandconform toourprivacypolicyandapplicablelawsandregulations. CorrectionandAccessto Information UponourreceiptofyourwrittenrequesttousatMidwestEmployersCasualtyCompany,14755NorthOuterFortyDrive,Suite300,Chesterfield,MO 63017(Attn:ThomasE.Lentz,AssistantSecretary),wewill,generally,makeavailableInformationforyourreview.IfyoubelievetheInformationwe haveaboutyouisincorrectorinaccurate,youmayrequestthatwemakeanynecessarycorrections,additionsordeletions.Ifweagreewithyourbelief, wewillcorrectourrecordsifrequiredbyapplicablelaw.Ifwedonotagree,youmaysubmittousashortstatementofdispute,whichwewillincludein any futuredisclosurebyusofsuch Informationifrequiredbyapplicablelaw. RequirementsforPrivacyNotice Thisprivacynoticeisbeingprovidedduetorecentlyenactedfederalandstatelawsandregulationsestablishingnewprivacystandardsandrequiresus toprovidethisprivacypolicy.Foradditionalinformationregardingourprivacypolicy,pleasewritetousatMidwestEmployersCasualtyCompany, 14755NorthOuterFortyDrive,Suite300,Chesterfield,MO63017(Attn:ThomasE.Lentz, AssistantSecretary). Adopted:July1,2001