Arch Insurance Group
Harborside 3
210 Hudson Street, Suite 300
Jersey City, NJ 07311
T: 201.743.4000
F: 201.743.4005
archinsurance.com
Arch Insurance Group Los Angeles Branch: 550 South Hope Street, Suite 2600, Los Angeles CA 90071 T: 213 283 3500 July
20, 2022
Jennifer Rodriguez
Alliant Insurance Services, Inc.
18100 Von Karman Avenue, 10th Floor
Irvine, CA 92612
RE: City of Thousand Oaks
Policy No.: WCX 0066795 01
Dear J
ennifer:
Enclosed please find our Policy that has been prepared in accordance with your instructions and in conformity with our renewal quotation.
As w
e stated in our original policy cover letter, we want to take an active role in claims administration. Therefore, please advise of any changes in the Insured’s or the service organization’s claims contacts. You may send this information to the address listed on the enclosed Notice to Policy holders.
In
the event of any claims issues or questions involving this coverage, please feel free to contact us at any time.
Sin
cerely,
Dym
phna Menendez
Assistant Vice President
encl.
ATTACHMENT #2
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf 05 ML0002 05A 12 14 Page 1 of 1
C
alifornia Signature Page
IN WITNESS WHEREOF, Arch Insurance Company has caused this policy to be executed and attested.
John Mentz Regan Shulman
President Secretary
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf Arch Insurance Group
Harborside 3
210 Hudson Street, Suite 300
Jersey City, NJ 07311
T: 201.743.4000
F
: 201.743.4005
archinsurance.com
NOTICE TO POLICYHOLDERS WITH REGARD TO PROVIDING
A
NY NOTICE, REPORT OR CLAIM TO US
A
ll notices, reports or claims you are required to provide to us under this policy should be directed to Arch at the following address:
Arch Insurance Group
P.O. Box 542033
Omaha, Nebraska 68154
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf 00 ML0065 00 06 07 Includes copyrighted material of Insurance Services Page 1 of 1 Office, Inc. with its permission.
U.S. TREASURY DEPARTMENT’S OFFICE OF FOREIGN
A
SSETS CONTROL (“OFAC”)
ADVISORY NOTICE TO POLICYHOLDERS
No coverage is provided by this Policyholder Notice nor can it be construed to replace any provisions of your poli- c
y. You should read your policy and review your Declarations page for complete information on the coverages you are provided.
This Notice provides information concerning possible impact on your insurance coverage due to directives issued by OFAC. Please read this Notice carefully.
The Office of Foreign Assets Control (OFAC) administers and enforces sanctions policy, based on Presidential declarations of “national emergency”. OFAC has identified and listed numerous:
● F
oreign agents;
● F
ront organizations;
● T
errorists;
● T
errorist organizations; and
● N
arcotics traffickers;
a
s “Specially Designated Nationals and Blocked Persons”. This list can be located on the United States Treasury’s web site – http://www.treas.gov/ofac.
In accordance with OFAC regulations, if it is determined that you or any other insured, or any person or entity claiming the benefits of this insurance has violated U.S. sanctions law or is a Specially Designated National and Blocked Person, as identified by OFAC, this insurance will be considered a blocked or frozen contract and all provisions of this insurance are immediately subject to OFAC. When an insurance policy is considered to be such a blocked or frozen contract, no payments nor premium refunds may be made without authorization from OFAC.
Other limitations on the premiums and payments also apply.
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf 05 GL0400 00 (01 08) Page 1 of 2
ARCH INSURANCE COMPANY
(A Missouri Corporation)
Home Office Address: Administrative Address:
2345 Broadway, Suite 900 One Liberty Plaza, 53rd Floor
Kansas City, MO 64108 New York, NY 10006
Tel: (800) 817-3252
SPECIFIC EXCESS WORKERS COMPENSATION AND
EMPLOYERS LIABILITY INSURANCE POLICY
DECLARATIONS
Policy Number: WCX 0066795 01
Item 1: Named Insured: City of Thousand Oaks
Address: 2100 East Thousand Oaks Boulevard, Thousand Oaks, California 91362 Producer Name: Alliant Insurance Services, Inc.
Address: 18100 Von Karman Avenue, 10th Floor, Irvine, California 92612 Item 2: Policy Period: Inception
Date:
July 1, 2022 Expiration
Date:
July 1, 2023
at 12:01 A.M. Standard Time at your mailing address as shown in Item 1 above.
Item 3: This insurance applies to the Workers Compensation and Occupational Disease Laws of the following states: California
Item 4: Premiums
Estimated Total Annual Remuneration: $ 39,156,667
Rate per $100 of Remuneration: .2764
Deposit Premium: $ 108,229
(Terrorism Premium Included In Policy Premium ): $ 3,247 Minimum Premium: $ 97,406
Item 5: Your Retained Limit
Part One – Excess Workers Compensation Insurance and Part Two - Excess Employers Liability Insurance:
Your Retained Limit of Liability – Each Accident $500,000 Your Retained Limit of Liability – Disease, Each Employee $500,000 HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf 05 GL0400 00 (01 08) Page 2 of 2
Item 6: Our Limit of Liability
A. Part One – Excess Workers Compensation Insurance:
Our Limit of Liability – Each Accident Statutory
Our Limit of Liability – Disease, Each Employee Statutory B. Part Two – Excess Employers Liability Insurance:
Our Limit of Liability - Each Accident $ 2,000,000
Our Limit of Liability - Disease, Each Employee $ 2,000,000 Our Limit of Liability - Aggregate $ 2,000,000
Policy Forms and Endorsements: See Schedule of Endorsements Forming a Part of this Policy Authorized Representative: .D ate: July 20, 2022
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf 00 ML0012 00 01 03 Page 1 of 1
SCH
EDULE OF FORMS AND ENDORSEMENTS
NAMED INSURED: City of Thousand Oaks TERM: July 1, 2022 to July 1, 2023 POLICY NUMBER: WCX 0066795 01
ENDT. NO. FORM NO. TITLE
1 00 GL0386 00 (01 08) LOSSES REDEFINED TO INCLUDE ALLOCATED LOSS
ADJUSTMENT EXPENSES ENDORSEMENT
2 00 GL0368 05 (01 08) CALIFORNIA VOLUNTEER COVERAGE – EXCESS
VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY
COVERAGE ENDORSEMENT
3 00 GL0877 05 (01 21) CALIFORNIA TERRORISM RISK INSURANCE PROGRAM
REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT
4 00 GL0403 05 (01 08) CALIFORNIA AMENDATORY ENDORSEMENT 00 GL0401 00 (01 08) SPECIFIC EXCESS WORKERS COMPENSATION AND
EMPLOYERS LIABILITY INSURANCE POLICY
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf 00 GL0386 00 (01 08) Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
LOSSES REDEFINED TO INCLUDE ALLOCATED LOSS ADJUSTMENT EXPENSES
ENDORSEMENT
This endorsement modifies insurance provided under the following:
SPECIFIC EXCESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
1. PART FIVE – DEFINITIONS, E. “Loss(es)” is deleted in its entirety and replaced by the following:
E. “Loss(es)” means any payments for benefits required to be paid by you under the “ Workers Compensation Law ” or any payments for damages arising out of “ bodily injury by accident ” or “bodily injury by disease” covered either by PART ONE or PART TWO of this policy. “ Loss(es)” include “allocated loss adjustment expenses”.
2. PART SEVEN – ALLOCATED LOSS ADJUSTMENT EXPENSES is deleted in its entirety.
All other terms and conditions of this policy remain unchanged.
Endorsement Number: 1
Policy Number: WCX 0066795 01
Named Insured: City of Thousand Oaks
This endorsement is effective on the inception date of this Policy unless otherwise stated herein:
Endorsement Effective Date: July 1, 2022
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf Endorsement Number: 2
Policy Number: WCX 0066795 01
Named Insured: City of Thousand Oaks
This endorsement is effective on the inception date of this Policy unless otherwise stated herein:
Endorsement Effective Date: July 1, 2022
00 G
L0368 05 (01 08) Page 1 of 2
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CALIFORNIA VOLUNTEER COVERAGE - EXCESS VOLUNTARY COMPENSATION
AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT
This endorsement modifies insurance provided under the following:
SPECIFIC EXCESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY A. How This Insurance Applies
This insurance applies, with respect to this endorsement, to “ bodily injury by accident ” or “bodily injury by disease” provided that the:
1. “Bodily injury” must be sustained by a person included in the group of volunteers described in the Schedule;
2. “Bodily injury ” must arise out of and in the course of volunteer activities necessary or incidental to your operations in a “state” listed Schedule below;
3. “Bodily injury” must occur in the United States of America, its territories or possessions, or Canada, and may occur elsewhere if the employee is a United States or Canadian citizen temporarily away from those places; and
4. “Bodily injury by accident” must occur during the “policy period”.
5. “Bodily injury by disease” must be caused or aggravated by the conditions of your operations. The volunteer ’s last day of last exposure to the conditions causing or aggravating such “bodily injury by disease” must occur during the “policy period”.
SCHEDULE
Volunteers Designated Workers Compensation Law
All volunteers who donate their services to you and
are not subject to Workers Compensation Law or
Occupational Disease Law
Workers Compensation Law and Occupational
Disease Law of the “ state” where the injury takes
place.
B. We Will Reimburse
We will reimburse you for the amount equal to the benefits that is excess of Your Retained Limit stated in Item 5 of the Declarations Page that would be required of you if you and your volunteer(s) described in the Schedule above were subject to the “Workers Compensation Law ” shown in the Schedule. This reimbursement by us will not exceed Our Limit of Liability as stated in Item 6 A. of the Declarations Page.
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf
CALIFORNIA VOLUNTEER COVERAGE - EXCESS VOLUNTARY COMPENSATION
AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT
C. Exclusions – Payments You Must Make
This insurance does not cover, nor is Your Retained Limit satisfied by, any of the following types of payments.
1. Any obligation imposed by a workers compensation or occupational disease law, unemployment compensation, or disability benefits law or any similar law;
2. “ Bodily injury” intentionally caused or aggravated by you; or
3. Liability for any consequence, whether direct or indirect, of war, invasion, act of foreign enemy, hostilities (whether war be declared or not), civil war, insurrection, rebellion, revolution, or military or usurped power. No endorsement now or subsequently attached to this policy will be construed as overriding or waiving this limitation unless specifically referenced.
D. Our Reimbursement
Before we will reimburse you for the amount equal to the benefits that is excess of Your Retained Limit, the claimants must:
1. Transfer to us the claimant ’s right to recover from others who may be responsible for the injury or death; and
2. Cooperate with us and do everything necessary to enable us to enforce the right of recovery from others.
If the claimants make a recovery from others, the claimant must reimburse us for any benefits we have reimbursed you.
If the persons entitled to the benefits fail to do these things, our duty to reimburse ends at once. If they claim damages from us for the injury or death, our duty to reimburse ends at once.
E. Employers Liability Insurance
PART TWO – EXCESS EMPLOYERS LIABILITY INSURANCE applies to “ bodily injury” covered by this endorsement as though the “ state(s)” shown in the Schedule were listed in the Item 3 of the Declarations Page subject to Your Retained Limit indicated in Item 5 of the Declarations Page.
Our reimbursement will not be more than Our Limit of Liability stated in Item 6 B. of the Declarations Page.
All other terms and conditions of this Policy remain unchanged.
Endorsement Number: 2
Policy Number: WCX 0066795 01
N
amed Insured: City of Thous and Oaks
This endorsement is effective on the inception date of this Policy unless otherwise stated herein:
Endorsement
Effective Date: July 1, 2022
00 GL0368 05 (01 08)
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf 00 GL0877 05 (01 21) Includes copyright material of the National Council on Compensation Insurance, Inc. with its permission.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CALIFORNIA TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION
ACT DISCLOSURE ENDORSEMENT
This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2019.
Definitions
The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply.
“Act” means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2019.
“Act of Terrorism” means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States as meeting all of the following requirements:
a. The act is an act of terrorism.
b. The act is violent or dangerous to human life, property or infrastructure. c. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has 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.
“Insured Loss” means any loss resulting from an act of terrorism (including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels.
“Insurer Deductible” means, for the period beginning on January 1, 2021, and ending on December 31, 2027, an amount equal to 20% of our direct earned premiums, during the immediately preceding calendar year.
Limitation of Liability
The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a calendar year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury.
Policyholder Disclosure Notice
1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses occurring in any calendar year exceed $200,000,000 the HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf 00 GL0877 05 (01 21) Includes copyright material of the National Council on Compensation Insurance, Inc. with its permission.
United States Government would pay 80% of our Insured Losses that exceed our Insurer Deductible.
2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceeds $100,000,000,000.
3. The additional premium charged for the coverage for Insured Losses under the policy is included in the deposit premium listed in Item 4 of the Declarations Page and is itemized in the Schedule below.
SCHEDULE
State Rate per $100 of Remuneration
California .0083
All other t
erms and conditions of this Policy remain unchanged.
Endorsement Number: 3
Policy Number: WCX 0066795 01
Named Insured:
City of Thousand Oaks
This endorsement is effective on the inception date of this Policy unless otherwise stated herein: Endorsement
Effective Date: July 1, 2022
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf Endorsement Number: 4
Policy Number: WCX 0066795 01
Named Insured: City of Thousand Oaks
This endorsement is effective on the inception date of this Policy unless otherwise stated herein:
Endorsement Effective Date: July 1, 2022
00 GL0403
05 (01 08) Page 1 of 2
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CALIFORNIA AMENDATORY ENDORSEMENT
This endorsement modifies insurance provided under the following:
SPECIFIC EXCESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY I. PART FOUR - VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE , D.
Our Reimbursement is deleted in its entirety and replaced with the following:
D. Our Reimbursement
Before
we will reimburse you for the amount equal to the benefits that is excess of Your Retained Limit, the claimants must:
1. Transfer to us the claimant ’s right to recover from others who may be responsible for the injury or death; and
2. Cooperate with us and do everything necessary to enable us to enforce the right of recovery from others.
If the persons entitled to the benefits fail to do these things, our duty to reimburse ends at once.
If they claim damages from us for the injury or death, our duty to reimburse ends at once.
II. PART NINE – CONDITIONS, Condition K. Cancellation or Non -renewal is deleted in its entirety and replaced with the following:
K. Cancellation
1. You may cancel this policy. You must mail or deliver advance notice to us stating when the cancellation is to take effect.
2. We may cancel this policy for one or more of the following reasons:
a. Non- payment of premium;
b. Failur
e to report payroll;
c. Failur
e to permit us to audit payroll as required by the terms of the policy or of a previous policy issued by us;
d. to pay
any additional premium as a result of a audit of payroll as required by the terms of the policy or of a previous policy issued by us
e. Material
misrepresentation made by you or your agent;
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf Endorsement Number: 4
Policy Number: WCX 0066795 01
Named Insured: City of Thousand Oaks
This endorsement is effective on the inception date of this Policy unless otherwise stated herein:
Endorsement Effective Date: July 1, 2022
00 GL0403 0
5 (01 08) Page 2 of 2
CALIFORNIA AMENDATORY ENDORSEMENT
f. Failure t
o cooperate with us in the investigation of a claim;
g. Failure t
o comply with federal or state safety orders;
h. Failure t
o comply with written recommendations of the insurer's designated loss control representative;
i. The occurr
ence of a material change in ownership or any change in your business; j. The occurr
ence of any change in your business or operations that materially increases the hazard for frequency or severity of loss;
k. The occurr
ence of any change in your business or operations that requires additional or different classifications for premium calculations; or
l. The occurr
ence of any change in your business or operations which contemplates an activity excluded by our reinsurance treaties.
If we cancel for any reason listed in (a) through (f), we will give you ten ( 10) days advance written notice stating when the cancellation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information page will be sufficient to prove notice. If we cancel for any reason listed in (g) through (l), we will give you thirty ( 30) days advance written notice; however, we agree that in the event cancellation and reissuance of a policy effective upon a material change in ownership or operations, notice will not be provided.
3. In additi
on, if we cancel this policy, we will deliver thirty (30) days advance written notice to:
Office of Self-Insurance Plans
11050 Olson Drive, Suite 230
Rancho Cordova, CA 95670
4. The “policy period” will end on the day and hour stated in the cancellation notice.
All other t
erms and conditions of this policy remain unchanged.
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf
00 GL0401 00 (01 08) Page 1 of 15
SPECIFIC EXCESS WORKERS COMPENSATION AND EMPLOYERS LIABILITY
INSURANCE POLICY
In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows:
GENERAL SECTION
Throughout this policy the words “you” and “your” refer to the Named Insured shown in the Declarations Page. The words “we”, “us” and “our” refer to the insurance company shown in the Declarations Page.
Other words and phrases that appear in quotation marks have special meaning. Refer to PART FIVE - DEFINITIONS.
A. The Policy
This policy includes at its effective date the Declarations Page, this coverage form and all endorsements and schedules listed. It is a contract between you and us. The terms of this policy may not be changed or waived except by endorsement issued by us to become a part of the policy.
B. Who Is Insured
You are insured if:
1. You are the employer named in Item 1 of the Declarations Page.
2. The employer named in Item 1 of the Declarations Page is a partnership or joint venture, and you are a partner in that partnership or a member of that joint venture, you are an insured, but only in your capacity as an employer of the employees in the partnership or joint venture;
3. You are a subsidiary, division or an affiliated company, as hereafter may be constituted, you are an insured, provided, however, that:
a. We are notified in writing within thirty (30) days of your becoming a subsidiary, division or an affiliated company;
b. We consent in writing to your being an insured hereunder; and c. At least a 51% majority interest in you is owned or controlled by an employer named in Item 1 of the Declarations Page.
4. You are a business entity over which an employer named in Item 1 of the Declarations Page has day-to-day management control.
C. Qualified Self-Insurer
By acceptance of this policy, you represent that you are a qualified self-insurer under the “Workers Compensation Law” of each of the “state(s)” listed in Item 3 of the Declarations Page, and that you will continue to maintain such qualifications during the term that this policy is in effect. Your status as a qualified self-insurer is a condition precedent to coverage. If you are not a duly qualified self- insurer at the date the “bodily injury” covered under this policy occurs no coverage will be afforded under this policy. To the extent that we make any payments with respect to the “bodily injury” covered under this policy that occurred when you were not a qualified self-insurer, you will promptly fully reimburse us for such payments.
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf
00 GL0401 00 (01 08) Page 2 of 15
PART ONE – EXCESS WORKERS COMPENSATION INSURANCE
A. How this Insurance Applies
This Excess Workers Compensation Insurance applies to “bodily injury” provided that the:
1. “Bodily injury by accident” occurs during the “policy period”; and
2. “Bodily injury by disease” must be caused by 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”.
B. We Will Reimburse
You are responsible for all benefit payments required by “Workers Compensation Law”. We will reimburse you for the amount of benefits actually paid by you as a qualified self-insurer under the “Workers Compensation Law”, that is excess of Your Retained Limit stated in Item 5 of the Declarations Page. This reimbursement by us will not exceed Our Limit of Liability as stated in Item 6 A. of the Declarations Page.
C. Exclusions – Payments You Must Make
This insurance does not cover, nor is Your Retained Limit satisfied by, any of the following types of payments:
1. Payments in excess of any benefits or awards typically provided by the “Workers Compensation Law”, including payments required because:
a. Of your serious and willful misconduct;
b. You knowingly employ an employee in violation of law; c. You fail to comply with a health or safety law or regulation; however, this does not apply to recommendations promulgated by the Joint Commission for Accreditation of Healthcare.
d. Of your discharge, coercion, criticism, evaluation, reassignment, discipline, harassment, discrimination against, defamation, or termination of any employee, or any personnel policies, practices, omissions or acts;
2. Payments of fines or penalties imposed for violation of law whether “state” or federal;
3. Payments of any obligation imposed by any of the following statutes, or any regulations promulgated under them, including any amendments: the Federal Employers Liability Act (45 USC Section 51-60), the Defense Base Act (42 USC Sections 1651-1654), the Longshore and Harbor Workers’ Compensation Act (33 USC Sections 901-950), the Non-Appropriated Fund Instrumentalities Act (5 USC Section 8171-8173), the Outer Continental Shelf Lands Act (43 USC Sections 1331-1356), the Federal Coal Mine Health and Safety Act of 1969 (30 USC Sections 901-942), the Merchant Marine Act of 1920, also known as the Jones Act (46 USC Section 688 as amended), the Migrant and Seasonal Agricultural Worker Protection Act (29 USC Sections 1801-1872 or any other federal workers or workmen’s compensation law or other federal occupational disease law.
You are also responsible for payments arising out of operations:
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf
00 GL0401 00 (01 08) Page 3 of 15
a. Which you insure with an insurance carrier or for which you are required to purchase a Workers Compensation or Employers Liability Policy;
b. For which you have formally rejected or opted out of any “Workers Compensation Law”; or
c. For any benefit payments on domestic employment unless required by law.
PART TWO – EXCESS EMPLOYERS LIABILITY INSURANCE
A. How This Insurance Applies
This Excess Employers Liability Insurance applies to “bodily injury by accident” or “bodily injury by disease” provided that the:
1. “Bodily injury” arises out of and in the course of the injured employee’s employment by you;
2. Employment is necessary or incidental to work conducted by you in a “state” listed in Item 3 of the Declarations Page;
3. “Bodily injury by accident” occurs during the “policy period”;
4. Injured employee normally is employed in a “state” listed in Item 3 of the Declarations Page; and
5 “Bodily injury by disease” is 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”.
This insurance will only apply if the original suit and any related legal actions for damages for “bodily injury by accident” or “bodily injury by disease” are brought in the United States of America, its territories or possessions or Canada.
B. We Will Reimburse
You are responsible for all “loss” payments covered under PART TWO – EXCESS EMPLOYERS LIABILITY INSURANCE of the policy. We will reimburse you for the amount of “loss” actually paid by you in the settlement of claims, or in satisfaction of verdicts, awards, or judgments that are in excess of Your Retained Limit indicated in Item 5 of the Declarations Page. Our reimbursement will not be more than Our Limit of Liability stated in Item 6 B. of the Declaration Page.
The “loss” we will reimburse, where recovery is permitted by law, includes “loss”:
1. For care and loss of services;
2. For which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against such third party as a result of injury to your employee; and
3. For consequential “bodily injury” to a spouse, child, parent, sister, or brother of the injured employee;
provided that these “losses” are the direct consequence of “bodily injury” that arises out of and in the course of the injured employee’s employment by you; and HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf
00 GL0401 00 (01 08) Page 4 of 15
4. Because of “bodily injury” to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer.
C. Excess Stop Gap Insurance
If it is determined by the State Workers Compensation Board or the regulatory authority, that any employee of yours, who is reported and declared under the workers compensation law(s) of the state(s) of North Dakota, Ohio, Washington, West Virginia, Wyoming, Puerto Rico, any territories or possessions of the United States, and any of the provinces of Canada, sustains “bodily injury by accident” or “bodily injury by disease” in the course of his/her employment by you, but is not entitled to receive (or elects not to accept) the benefits provided by the aforementioned law, then we will reimburse you for the amount of “loss” actually paid by you in the settlement of claims, or in satisfaction of verdicts, awards, or judgments that are in excess of Your Retained Limit indicated in Item 5 of the Declarations Page. Our reimbursement will not be more than Our Limit of Liability stated in Item 6 B. of the Declaration Page. You are responsible for all “loss” payments covered under Excess Stop Gap Insurance.
In addition to the Exclusions – Payments You Must Make described in D. below, this insurance shall not cover, nor is Your Retained Limit satisfied by, any of the following types of payments:
1. Any premium assessment, penalty, fine or other obligation imposed by any workers compensation law;
2. “Bodily injury” suffered or caused by any person knowingly employed by you in violation of any law as to age, or under the age of 14 years, regardless of such law;
3. “Bodily injury” suffered or caused by any employee whose remuneration has not been included in the total remuneration upon which the premium for this policy is based; or
4. Any claim for “bodily injury” with respect to which you are deprived of any defense or defenses or are otherwise subject to penalty because of default in premium payment under, or any other failure to comply with, the provisions of the workers compensation law or laws of the states named above.
D. Exclusions – Payments You Must Make
This insurance does not cover, nor is Your Retained Limit satisfied by, any of the following types of payments:
1. Liability assumed by any contract or agreement;
2. Punitive or exemplary damages and fines arising out of:
a. Any “bodily injury” to any employee employed in violation of the law; or b. Any “bodily injury” intentionally caused or aggravated by you;
3. For which insurance liability is prohibited by law, or is contrary to public policy;
4. “Bodily injury” to an employee employed in violation of the law with your actual knowledge or acquiescence;
5. “Bodily injury” intentionally caused or aggravated by you; HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf
00 GL0401 00 (01 08) Page 5 of 15
6. Any obligation imposed by a workers compensation or occupational disease law, unemployment compensation, or disability benefits law or any similar law;
7. “Bodily injury” occurring outside the United States of America, its territories or possessions and Canada. This exclusion does not apply to “bodily injury” to a citizen or resident of the United States of America or Canada who is temporarily outside these countries.
8. Any obligation imposed by any of the following statutes, or any regulations promulgated under them, including any amendments: the Federal Employers’ Liability Act (45 USC Section 51-60), the Defense Base Act (42 USC Sections 1651-1654) the Longshore and Harbor Workers’ Compensation Act (33 USC Sections 901-950), the Non-Appropriated Fund Instrumentalities Act (5 USC Section 8171-8173), the Outer Continental Shelf Lands Act (43 USC Sections 1331-1356), the Federal Coal Mine Health and Safety Act of 1969 (30 USC Sections 901-942), the Merchant Marine Act of 1920, also known as the Jones Act (46 USC Section 688 as amended), the Migrant and Seasonal Agricultural Worker Protection Act (29 USC Sections 1801-1872 or any other federal workers or workmen’s compensation law or other federal occupational disease law;
9. For which you have formally rejected or opted out of any “Workers Compensation Law”;
10. Arising out of your discharge, coercion, criticism, evaluation, reassignment, discipline, harassment, discrimination against, defamation, or termination of any employee, or any personnel policies, practices, omissions or acts;
11. Fines or penalties imposed for violation of law whether “state” or federal; or
12. “Bodily injury” arising out of termination of employment.
PART THREE – OTHER STATES INSURANCE
If you begin work after the effective date of this policy in any state, any territory or possession of the United States or any province of Canada, for which you are not insured, or are not a qualified self-insured for such work, this insurance will apply as though that state were listed in Item 3 of the Declarations Page, and will apply in excess of Your Retained Limit listed in Item 5 of the Declarations Page, but only if you notify us in writing within ninety (90) days from the date you begin such work.
Moreover, the coverage provided under PART ONE - EXCESS WORKERS COMPENSATION INSURANCE includes “loss” paid by you as required by the workers or workmen’s compensation law of a “state” not listed in Item 3 of the Declarations Page provided the:
1. Injured employee was working within the scope of his employment, at your direction;
2. Injured employee was regularly employed in a “state” listed in Item 3 of the Declarations Page;
3. Work in the other “state” was incidental to work in a “state” listed in Item 3 of the Declarations Page; and
4. Work in the other “state” was temporary and transitory.
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf
00 GL0401 00 (01 08) Page 6 of 15
PART FOUR - VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE A. How This Insurance Applies
This insurance applies to “bodily injury by accident” or “bodily injury by disease” provided that the:
1. “Bodily injury” must be sustained by an employee included in the group of employees described in Item 3 of the Declarations Page.
2. “Bodily injury” must arise out of and in the course of employment necessary or incidental to work in a “state” listed in Item 3 of the Declarations Page.
3. “Bodily injury” must occur in the United States of America, its territories or possessions, or Canada, and may occur elsewhere if the employee is a United States or Canadian citizen temporarily away from those places.
4. “Bodily injury by accident” must occur during the “policy period”.
5. “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”.
B. We Will Reimburse
We will reimburse you for the amount equal to the benefit that is excess of Your Retained Limit stated in Item 5 of the Declarations Page that would be required of you if you and your employee(s) described in Item 3 of the Declarations Page were subject to the “Workers Compensation Laws” of the state(s) of employment listed in Item 3 of the Declarations Page. This reimbursement by us will not exceed Our Limit of Liability as stated in Item 6 A. of the Declarations Page.
C. Exclusions – Payments You Must Make
This insurance does not cover, nor is Your Retained Limit satisfied by, any of the following types of payments:
1. Any obligation imposed by a workers compensation or occupational disease law, unemployment compensation, or disability benefits law or any similar law;
2. “Bodily injury” intentionally caused or aggravated by you.
D. Our Reimbursement
Before we will reimburse you for the amount equal to the benefits that is excess of Your Retained Limit, the claimants must:
1. Release you and us, in writing, of all responsibility for the injury or death;
2. Transfer to us the claimant’s right to recover from others who may be responsible for the injury or death; and
3. Cooperate with us and do everything necessary to enable us to enforce the right of recovery from others.
If the persons entitled to the benefits fail to do these things, our duty to reimburse ends at once. If they claim damages from us for the injury or death, our duty to reimburse ends at once.
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf
00 GL0401 00 (01 08) Page 7 of 15
E. Recovery From Others
If we make a recovery from others, we will keep an amount equal to our expenses of recovery and the benefits we paid. We will pay the balance to the persons entitled to it. If the persons entitled to the benefits of this insurance make a recovery from others, they must reimburse us for the benefits we paid them.
F. Employers Liability Insurance
PART TWO – EXCESS EMPLOYERS LIABILITY INSURANCE applies to “bodily injury” provided under this Part as though the “state” of employment were shown in Item 3, subject to Your Retained Limit indicated in Item 5 of the Declarations Page.
Our reimbursement will not be more than Our Limit of Liability stated in Item 6 B. of the Declarations Page.
PART FIVE – DEFINITIONS
A. “Allocated loss adjustment expenses” means the following costs which can be directly allocated to a particular claim:
1. Medical cost containment expenses incurred with respect to a particular claim, whether by an outside vendor or done internally by an employee for the purpose of controlling “losses”.
These expenses include:
a. Bill auditing expenses for any medical or vocational services rendered, including hospital bills (inpatient or outpatient), nursing home bills, physician bills, chiropractic bills, pharmacy charges, medical equipment charges, medical or vocational rehabilitation vendor bills or physical therapy bills.
b. Hospital and other treatment utilization reviews.
c. Preferred provider network expenses.
d. Medical fee review panel expenses.
2. Fees of attorney or authorized representatives where permitted for legal services.
3. Court, Alternative Dispute Resolution and other specific items of expense such as:
a. Medical examinations of a claimant to determine the extent of our liability, degree of permanency or length of disability;
b. Autopsy;
c. Witnesses and summonses;
d. Copies of documents and records such as birth and death certificates, and medical treatment records;
e. Arbitration fees;
f. Surveillance;
g. Interest as required by law on awards or judgments; and h. Appeal bonds costs and appeal filing fees.
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf
00 GL0401 00 (01 08) Page 8 of 15
4. Expenses which are not defined as “losses” and are directly related to and directly allocated to the handling of a particular claim which are required to be performed by statute or regulation.
However, “allocated loss adjustment expenses” do not include:
1. Salaries, overhead and traveling expenses of your employees or employees of any claim service company, except for employees while doing activities previously listed as “allocated loss adjustment expenses.”
2. Fees paid to independent claims professionals or attorneys (hired to perform the functions of claim investigation usually handled by claim adjusters), for developing and investigating a claim so that a determination can be made of the cause, extent or responsibility for the injury or disease, including the evaluation and settlement of covered claims.
3. Expenses which are identified as either an indemnity or medical loss.
B. “Bodily injury” means “bodily injury by accident” and “bodily injury by disease”.
C. “Bodily injury by accident” means an event or circumstance, other than “bodily injury by disease”, which is unexpected and unintended from your standpoint and results in injury or impairment to bodily or mental function. The contraction of disease is not an accident within the meaning of the word accident in the term “bodily injury by accident” and only such disease as results directly from “bodily injury by accident” is included within the term “bodily injury by accident”. “Bodily injury by accident” includes resulting death. With respect to PART TWO – EXCESS EMPLOYERS LIABILITY INSURANCE, assault and battery shall be deemed an accident unless committed by or at your direction.
D. “Bodily injury by disease” means an illness or sickness, other than “bodily injury by accident”, resulting in injury or impairment to the body or mental functions. “Bodily injury by disease” includes resulting death. The term “bodily injury by disease” is not included within the term “bodily injury by accident”.
E. “Loss(es)” means any payments for benefits required to be paid by you under the “Workers Compensation Law” or any payments for damages arising out of “bodily injury by accident” or “bodily injury by disease” covered either by PART ONE or PART TWO of this policy. “Loss(es)” does not include “allocated loss adjustment expenses”.
F. “Policy period” means the period shown in the Declarations Page. This policy will remain in full effect during the period, unless cancelled as provided in PART NINE - CONDITIONS, Condition K. of this policy.
G. “State(s)” means any state(s) of the United States of America and the District of Columbia.
H. “Workers Compensation Law” means the workers or workmen’s compensation law and occupational disease law of the “states” named in Item 3 of the Declarations Page. “Workers Compensation Law” includes any amendments of that law which are in effect during the “policy period”. “Workers Compensation Law” does not include provisions of any law that provides non- occupational disability benefits.
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf
00 GL0401 00 (01 08) Page 9 of 15
PART SIX -YOUR RETAINED LIMIT – OUR LIMIT OF LIABILITY
How Your Retained Limit and Our Limit of Liability Apply Our liability to reimburse for “loss” is limited to the amounts shown in Item 6 of the Declarations Page.
These limits apply as explained below.
Regardless of the number of insureds covered by this policy, the number of people who sustain injury or the number of claims made or suits brought, Our Limit of Liability will be for “loss” in excess of Your Retained Limit as stated in Item 5 of the Declarations Page, only up to, but not exceeding, Our Limit of Liability for PART ONE – EXCESS WORKERS COMPENSATION INSURANCE as stated in Items 6 A. of the Declarations Page and for PART TWO – EXCESS EMPLOYERS LIABILITY INSURANCE as stated in 6 B. of the Declarations Page.
Your Retained Limit and Our Limit of Liability stated in the Declarations apply to “losses” paid by you as a qualified self-insurer of Workers Compensation and Employers Liability, and incidental claims paid under PART THREE - OTHER STATES INSURANCE as follows:
1. To one or more employees because of “bodily injury by accident”.
2. To any one employee for “bodily injury by disease”.
Our Limit of Liability as stated in 1. and 2. above apply separately to PART ONE and PART TWO of this policy.
Your Retained Limit as stated in 1. and 2. above applies to PART ONE – EXCESS WORKERS COMPENSATION INSURANCE and PART TWO – EXCESS EMPLOYERS LIABILITY INSURANCE of this policy combined. Your Retained Limit does not include any amount paid as benefits or damages which would be excluded under this policy. Naming more than one employer in Item 1 of the Declarations Page does not increase Your Retained Limit or Our Limit of Liability.
If a Limit of Liability is shown in Item 6 B. of the Declarations Page for Our Limit of Liability – Aggregate, such amount will be the maximum amount we will reimburse under PART TWO of this policy for all “losses” covered under PART TWO of this policy. Naming more than one employer in Item 1 of the Declarations Page does not increase Our Limit of Liability - Aggregate.
PART SEVEN – ALLOCATED LOSS ADJUSTMENT EXPENSES
We will reimburse you for a portion of the “allocated loss adjustment expenses” incurred by you with respect to a covered claim. The amount of your reimbursement will be the percentage of your “allocated loss adjustment expenses” determined by the ratio that the amount of “loss” paid by us bears to the total amount of the “loss”. Such payments to reimburse you for “allocated loss adjustment expenses” are included in and are not in addition to Our Limit of Liability.
Notwithstanding the above, we have no duty to defend any claim or suit. We do, however, have the right to join in the defense, trial, or hearing of any claim or suit if we believe the claim or suit may create an obligation for us to reimburse you under the terms of this policy. If we avail ourselves of this right, we will pay any expense we incur.
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf
00 GL0401 00 (01 08) Page 10 of 15
PART EIGHT – PREMIUMS
A. Premium
The premium listed in Item 4 of the Declarations Page is due and payable on the effective date of the policy or as identified in a premium payment schedule that has been agreed to by you and us.
This premium is an estimated premium and it is subject to adjustment, according to the terms of a premium schedule, agreement, or other endorsement attached to this policy. You will pay the premium even if part or all of a “Workers Compensation Law” is not valid.
B. Deposit Premium
At the beginning of the “policy period” you must pay us the deposit premium shown in Item 4 of the Declarations Page. 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:
but in any event, we shall retain the policy Minimum Premium as stated in Item 4 of the Declarations Page.
C. Final Premium
The deposit premium shown in Item 4 of the Declarations Page is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis which includes payroll and all other remuneration paid or payable during the “policy period” for the services of:
1. All your officers and employees engaged in work covered by this policy; and
2. All other persons engaged in work that could make us liable under PART ONE - EXCESS WORKERS COMPENSATION INSURANCE of this policy. If you do not have payroll records for these persons, the contract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the employers of these persons lawfully secured their workers compensation obligations.
If this policy is cancelled, final premium will be determined in the following way:
1. If we cancel, 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 shown in Item 4 of the Declarations Page.
2. If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short rate cancellation table and procedure. Final Premium will not be less than the short rate share of the Minimum Premium shown in Item 4 of the Declarations Page.
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf
00 GL0401 00 (01 08) Page 11 of 15
PART NINE – CONDITIONS
A. Notice of an Accident
1. You must give us written notice as soon as possible if an injury to your employee occurs involving:
a. Quadriplegia;
b. Paraplegia;
c. A fatality;
d. A major extremity or multiple minor extremity amputation; e. Partial or total blindness;
f. Any serious head injury including but not limited to brain or brain stem injury, or unconsciousness exceeding 24 hours;
g. Asbestosis, mesothelioma, silicosis or any other such disease or condition. h. Second or third degree burns over 25 percent or more of the body; i. Any disability where it appears reasonably likely that there will be a disability greater than one year.
j. Any accident which causes serious injury to two or more employees.
2. You must also give us prompt written notice if any of the following occurs:
a. Any claim or action is commenced against you which exceeds or is likely to exceed 50% of Your Retained Limit shown on the Declarations Page. b. Any disability claims whether or not contested by you where it appears reasonably likely that such disability will exceed one year in duration or where such disability actually exceeds one year in duration; or
c. A claim is re-opened in which further award might involve Our Limit of Liability.
3. Notice should include all notices of injury you receive, as well as the demand and legal papers related to the injury, claim proceeding or suit.
4. You must also:
a. Cooperate and assist us, as we may request, in the investigation, settlement, or defense of any claim proceeding or suit.
b. You or your designated representative must be diligent and exercise prudence and good faith in the investigation, defense and settlement of all claims, suits or proceedings. You or your representative may not unreasonably refuse to settle any claim which, in the exercise of sound judgment, should be settled. However, you or your designated representative must not make or agree to any settlement on a lump sum basis or which would involve indemnity by us without our prior approval.
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf
00 GL0401 00 (01 08) Page 12 of 15
c. Do nothing after an injury or death occurs that would interfere with our right to recover from others.
B. Loss Payable
We will reimburse you the amount of “loss” in excess of Your Retained Limit for which we may be liable under this policy. We will reimburse you at such time as:
1. Under PART ONE, you shall become legally obligated to pay a “loss” and have paid that part of such “loss” which falls within Your Retained Limit.
2. Under PART TWO, you have become legally obligated to pay a “loss” as a result of any settlement or judgment, and have paid that part of such “loss” which falls within Your Retained Limit.
C. Appeals
If you or any other insurer elects to appeal a judgment or award, we will not pay any costs or interests incidental to the appeal. We have the right to pursue an appeal at our own cost and expense. If we decide to appeal, our liability on such an award or judgment will not exceed Our Limit of Liability in Item 6 of the Declarations Page, plus the costs, disbursement and interest related to such appeal. Regardless of who elects to appeal, any amounts recovered will be applied as follows:
1. First, to our costs and expenses in pursuing the appeal;
2. Second, to reimburse any interest (including your interest) that may have paid any amounts in excess of our liability under the policy;
3. Then, to reimburse us for all amounts paid under the policy, and
4. Lastly, to reimburse all other interest (including your interest), with respect to the residual, if any.
D. Subrogation – Recovery From Others
In the event of any payment under this policy, we shall be subrogated to all your rights of recovery and the rights of recovery of any person entitled to benefits under this policy against any person or organization. You must do nothing after a “bodily injury” to impair these rights. At our request you will bring suit or transfer those rights to us and help us enforce them. Regardless of who recovers, the amount of recovery will be applied as follows:
1. First, to reimburse any interests, (including your interest) that may have paid any amounts in excess of Our Limit of Liability on this policy.
2. Then to reimburse us for all amounts paid under the policy.
3. Finally, the remainder, if any, to reimburse all other interests (including your interest).
When we have elected to participate in the exercise of your right of recovery, reasonable expenses that result will be apportioned among all interests in the ratio of their respective recoveries.
If there should be no recovery as a result of proceedings brought solely at our request, we will bear the entire expense of such proceedings.
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf
00 GL0401 00 (01 08) Page 13 of 15
In the event of any payment under this policy for a “loss” for which you have waived the right of recovery in a written contract entered into prior to the “bodily injury” covered under this policy, we hereby agree to also waive our right of recovery but only with respect to such “loss”.
E. Inspection
We have the right, but no obligation, to inspect your operations and workplaces. These inspections are not safety inspections. They relate only to the insurability of the workplaces and the premiums to be charged. We may give you reports on the conditions found during these inspections. While these may help reduce “losses”, we do not undertake to perform the duty of any person to provide for the health and safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with the regulations, laws, codes, or standards.
F. Records and Audits
1. You must keep records of information needed to compute premium. You will provide any copies of these records upon demand by us.
2. We have the right, but not obligation, to examine or audit all of your records that relate to this policy. These records include ledgers, journals, vouchers, contracts, tax reports, payroll and disbursement records. This includes any programs for the storing and retrieving of the data contained by these aforementioned records. Information developed by the audit will be used to determine final premium.
3. We may examine and audit your books and records as they relate to this policy at any time during the “policy period” and up to three years afterward.
G. Bankruptcy or Insolvency
Your default or bankruptcy will not relieve us of our duties under this insurance after an injury has occurred. After Your Retained Limit has been satisfied, payments due under this policy will be made as if you had not become bankrupt or insolvent. In no case will these payments exceed either Our Limit of Liability or Our Limits of Liability – Aggregate as set forth in the Declarations.
H. Assignment
An assignment of your rights or duties under this policy will not be valid without our express written consent.
I. Sole Representative
The insured first named in Item 1 of the Declarations Page is authorized to act on behalf of all insureds under this policy with respect to the giving or receiving notice of cancellation, receiving refunds, and agreeing to any changes in this policy.
J. Action Against Us
There is no right of action against us by any person or organization to:
1. Join us as a party or otherwise bring us into a suit asking for damages from you; or
2. Sue us unless all of this policy’s terms have been complied with.
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf
00 GL0401 00 (01 08) Page 14 of 15
K. Cancellation or Non-Renewal
1. You may cancel this policy. You must mail or deliver advance notice to us stating when the cancellation is to take effect.
2. We may cancel this policy by mailing or delivering to you written notice of cancellation at least:
a. 10 days before the effective date of cancellation if we cancel for non-payment of premium; or
b. 30 days before the effective date of cancellation if we cancel for any other reason.
3. The “policy period” will end on the day and hour stated in the cancellation notice.
4. Any of these provisions that conflicts with a law that controls the cancellation of the insurance in this policy is changed by this statement to comply with that law.
5. If we choose not to renew we will provide you with thirty (30) days advance notice prior to the effective date of non-renewal.
6. If notice is mailed, proof of mailing will be sufficient proof of notice.
L. Responsibility for Your Retained Limit
This insurance will not take the place of your obligation to pay any amount within the applicable retained limit, whether or not such obligation becomes invalid, suspended, unenforceable or uncollectible for any reason, including bankruptcy or insolvency.
The entire risk of such invalidity, suspension, unenforceability or uncollectability is retained by you and your obligees, not by us.
M. Representation
By accepting this policy, you agree:
1. The statements in the Declarations are accurate and complete;
2. Those statements are based on the representations you made to us; and
3. We have issued this policy in reliance upon your representation.
N. Cooperation
You shall give us such information and cooperation as we may reasonably require.
O. Other Insurance
If any other excess insurance, reinsurance or indemnity exists protecting you against “loss” covered by this policy, the insurance afforded by this policy shall apply in excess of such other excess insurance, reinsurance or indemnity.
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf
00 GL0401 00 (01 08) Page 15 of 15
P. Unintentional Errors and Omissions
Your failure or omission to disclose all hazards existing as of the inception date of the policy shall not prejudice you with respect to the coverage afforded by this policy provided such failure or omission is not intentional and you did not know about such hazards prior to the commencement of the “policy period”.
Q. Omnibus Reconciliation Act Government Access Clause
We will make available this policy and all documents needed to confirm the premium paid by you if the Secretary of Health and Human Services or the Comptroller General of the United States find that this policy is a contractor described in Section 1861 of the Social Security Act, 42 USC Section 1395, or any amendment to it, and they or you ask for our documents.
If the Secretary of Health and Human Services or the Comptroller General asks for access to our documents, we will immediately notify you and make these documents available to you.
The right to access will be determined by the above statute, or any amendment to it, or any rules or regulations established under it.
HRD: 180-30\sj\H:\Common\Ins\22-23\SR\110723 Excess WC Ins Att 2.pdf