Excess Workers Compensation Agreement (2019-2021)Exce ss Wor ke rs'Comp en sat io n
Bi nde r
Insu re r:Mi dw est Emp lo ye rs Casua lt y Compa ny
Insu red:Cit y of S ali na, KS
Po lic y Numbe r:EW C0063 79 Effec tiv e Da te:05/01/2019
Quo te Numbe r:02203 98 Exp ir ati on Da te:05/01/2021
Na med St at es:Kan sa s
Se rv ice Co mp an y:CC MS I
10740 Nal l
Sui te 38 0
Ove rland Pa rk, KS 66211-
In cl ude s th e fo llo wing En dor se men ts:(see att ac he d)
SPECIF IC:Spe ci fi c Li mi t:ST AT UT OR Y
Spe ci fi c Re te nt ion:$400,000
EM P LIABI LI TY:Em ploy er s Li abi lit y Li mi t:$1,00 0,000
AGG REG AT E:Agg reg at e Li mi t:N/A
Agg reg at e Re ten ti on (N/A):N/A
Mini mu m Ag gr ega te Re ten ti on:N/A
Agg reg at e Lo ss Li mi ta ti on:N/A
RAT ING BASE:Poli cy Es ti ma te d Pa yr oll:$53,213,90 4
Poli cy Es ti ma te d Wo rk er H ou rs:N/A
Poli cy Es ti ma te d Pe r Ca pit a:N/A
Poli cy No rm al Pre miu m:$1,307,934
Ra te per$10 0 of Pa yr oll: .32 01
PRE MI UM:To tal Es ti ma ted Po li cy Pre miu m (in clu din g fl at cha rg es):$170,338
Poli cy Mini mu m Pre mi um:$153,304
Depo si t Pre mi um:$85,16 9
Depo si t Fl at C har ge(s):N/A
To tal Dep osi t Du e:$85,16 9
Te rro ris m Ris k In su ra nc e Ac t of 200 2:$2,555
(in clu ded in To ta l Dep osi t Due ab ov e)
04/30/2019
Mi dw es t Em ploy er s Ca sua lt y Da te
BIND-ISI 0002132
Endor sem en t Sc he dule
Bi nder
In su re r:Mid we st E mplo ye rs Ca sual ty Co mpany
Poli cy Ef fe ct iv e Da te:05/01/2019
In su red:Ci ty of S alina, KS Poli cy Ex pir at ion Da te:05/01/2021
Poli cy#:EW C006379
Po licy In clud es the foll ow ing Endo rse me nts:
Am endm ent to Sc hedul e Item 11
CMB-11
Tw o Yea r Po lic y Sho rt Rate Tab le
CMB-187
Po lic yho lde r Di scl os ur e Noti ce o f Te rro ri sm Ins ur ance
CMB-197
Aircr af t Exc lu si on
IS I-254-EXC
Mor e Than One Pr em iu m Ad ju st ment
IS I-285
Kan sas
IS I-KS
Page 1 of 1 Da te Prin ted:04/30/2019
KAN SAS DE PAR TM EN T OF LA BO R
ww w.do l.ks.gov
CE RTI FIC AT E OF EXC ESS IN SU RA NCE
K-WC 129(Rev.6-12)
DAT E:04/30/2019
Th is ce rt if ie s that a Wo rk er s Com pens ati on Exc ess In su ran ce Po li cy ha s be en iss ued and de li ve red to the em pl oy er
nam ed bel ow,and that by issuan ce a nd d el ive ry of sa id p oli cy an d th e fi li ng of this ce rt if ic ate of in su ra nc e,it is adm itted
that sa id exc ess poli cy wa s eff ec tiv e on the dat e sta ted b el ow and tha t th e co ve rage pr ov id ed the re in is app lic ab le to
benef it s unde r the Wo rk er s Com pens ati on Ac t of the State of Kan sa s and that sa id p oli cy sh all re ma in in fu ll fo rce and
eff ec t until 20 day s af ter re ce ipt by the Di visi on of Wo rk er s Com pens ati on of not ic e of it s can ce lla ti on o r ex pi rat io n and/o r
non-re new al.
Nam e of Em pl oy er In su red:Ci ty of Sa li na,KS
Add re ss:300 We st As h, Room 200
Sa li na,KS 674 01-
Nam e of Ins ur er:Mi dwe st Em pl oy ers Cas ua lt y Co mpa ny
Add re ss:1475 5 Nor th Ou te r Fo rt y Dr iv e,Su it e 30 0
Ches ter fi el d,Mi ssou ri 630 17
Po li cy Num ber:EW C006379 Eff ec tiv e Dat e:05/01/2 01 9
Ex pi ra ti on Da te:05/01/2 02 1
FO RM OF CO VER AG E
*Sp eci fic Ex ce ss*Agg re ga te Exc ess
Po li cy Li mi t:ST AT UT OR Y Po li cy Li mi t:N/A
(Pe r occ urr enc e)Loss Fund Pe rce nta ge:N/A
Spe ci fi c Rete nt io n:$400,000 Mi ni mu m Loss Fund:N/A
(Pe r occ urr enc e)Es ti mated Lo ss Fu nd:N/A
Po li cy Te rm:05/01/2 019 to 05/0 1/20 21 Po li cy Te rm:05/01/2 019 to 05/0 1/20 21
If mo re th an one in su re r is pr ov iding co ve ra ge,you mu st pr ov ide se par at e ce rti fic at es fo r ea ch ins ur er.
*No chang es sh all be ma de to the Se lf-insu re d Spe cifi c Re ten tion Amoun t or ot her li mit s of the pol ic y upon ren ew al un til
appr ov al i s gr an ted by the Di vi si on of Wor ke rs Com pen sa tion.
Ins ur er:Mi dwe st Em pl oy ers Cas ua lt y Co mpa ny
Aut ho ri ze d Repr es enta ti ve Sig nat ur e:
Add re ss:1475 5 Nor th Ou te r Fo rt y Dr iv e,Su it e 30 0
Ches ter fi el d,Mi ssou ri 630 17
DIVISIO N OF WO RKERS COM PENSA TI ON
401 SW Top ek a Bl vd., Su it e 2,Tope ka, KS 666 03-31 05• Ph one (785)296-4000•wcs el fi ns ur an ce @d ol.ks.gov