WORKERS COMPENSATION POLICY
@ VVe~t~~~~!iS~~~!~~y~6s~~~g~p~~y ---,
Administrative Office
Hamilton, Ohio
45026
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
l__~_
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
QUICK REFERENCE
BEGINNING ON
Page
Information Page. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. i
General Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1
A. The Policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1
B. Who is Insured. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:. 1
C. Workers Compensation Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1
D. State.............................................................................. 1
E. Locations........................................................................... 1
PART ONE - WORKERS COMPENSATION INSURANCE.................................... 1
A. How This Insurance Applies .............................. . . . . . . . . . . . . . . . . .. . . . . ..: .. 1
B. We Will Pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,. 1
C. We Will Defend .................................................................. .. 1
D. We Will Also Pay. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1
E. Other Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . ; . . . . . . . . . . . . .. 2
F. Payments You Must Make. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2
G. Recovery From Others. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2
H. Statutory Provisions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2
PART TWO - EMPLOYERS LIABILITY INSURANCE .............................. . . . . . . . . .. 2
A. How This Insurance Applies .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2
B. We Will Pay .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3
C. Exclusions......................................................................... 3
D. We Will Defend.................................................................. .. 3
E. We Will Also Pay. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3
F. Other Insurance. . . . . . . . . . . .. . . . , . ; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3
G. Limits of Liability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3
H. Recovery From Others. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4
I. Actions Against Us ............................................................... .. 4
Form No. CW 3000 (4-84)
Copyright 1982 National Council on Compensation Insurance.
we 00 00 00 (Standard)
! if
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QUICK REFERENCE - CONTINUED
BEGINNING ON
Page
PART THREE - OTHER STATES INS.URANCE. . .. . . . .. . . . . . . . . . .. . .. . . .. .. . . . .. . .. . . . , . ... . 4
A. How This Insurance Applies .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ..4
B. Notice................................................................. .... ,. , .. ... 4
PART FOUR - YOUR DUTIES IF INJURY OCCURS. . . .. . .. . . . . .. . . .. .. .. . .. . . . . . . . . . . .. . . .. 4
PART FIVE - PREMIUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4
A. Our Manuals. . . . . . . . . . . . . . . . . . . . . . . . . . . ".". . . . . . . . . . . . . . . . . . .. .... ... .. . ; ; .'<. . .... 4
B. Classifications.....................................................,...... ,.. . . ; . . . . . .. 4
C. Remuneration...................................................................... 5
D. Premium Payments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., . . ; , . .. 5
E. Final Premium ......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .., . . . . . . . . . .. 5
F. Records............................................................................ 5
G. Audit............................................................,.. .... . . . . . . . . . " 5
PART SIX - CONDITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . .. . .' . .. 5
A. Inspection.....................................................;................... 5
B. Long Term Policy........................... ......... ;..;....;.................... .. 5
C. Transfer of Your Rights and Duties. . . . . . . . . . . . . . . . . . . . . . . . . . . . ." . . . . . . . . . . . . . . . , . ... 6
D. Cancelation........................................................................ 6
E. Sole Representative. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... .... 6
IMPORTANT: This Quick Reference is not part of the Workers Compensation and Employers Liability Policy
and does not provide coverage. Refer to the Workers Compensation and Employers Liability
Policy itself for actual contractual provisions.
PLEASE READ THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CAREFULLY.
CQPyright 19132 National Council.on Compensation Insurance.
. Issued by The Stock Company Herein Called Th.pany
, West Am~rica:a Insurance Company
2600 East NutwGod Avenue
Fullerton, California 92631
INCORPORATED UNDER THE LAWS OF California
A_UMBER
09 00 l~Ol IWOW
FEIN: 59-19756578
POLICY NUMBER
4. 00 04,92 I!
1718
~ J~~raS~~i~pS~sualty Group
Item 1. NAMED INSURED & MAILING ADDRESS
INFORMATION PAGE
WORKERS' COMPENSATION AND
EMPLOYERS' LIABILITY POLICY
PRODUCER'S NAME & MAILING ADDRESS
Clearwater Beach Seafood, Inc.
37 Causeway Boulevard
Clearwater, Florida 33515
AIM Insurance Agency, Inc.
P. O. Box 5025
Clearwater, Florida 33518
INSURED IS COBPORATIO PREVIOUS POLICY NUMBER
Locations - All usual workplaces of the insured at or from which operations covered by this policy are conducted are located at the above address
unless otherwise stated herein.
Item 2. POLICY PERIOD ;lt~: I~~~;e~t~~d;t~~e\jme at the address FROM 5-31-84 TO 5-31-85
Item 1 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here:
Florida
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item lA.
The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insurance: Part Three of the policy.
Item 4. CLASSIFICATION OF OPERATIONS Estimated Total Rate per Estimated
Entries in .this item, except as specifically provided elsewhere in this policy, do not modify any of the Remuneration $100 of Re- Premium
other prOVisions of thiS policy. -J Annual D 3 Year muneration Annual D 3-Year
Store: Meat Retail
Restaurant - NOC
8031
9079
26,000
30 ,000
5.07
3.59
1,318.
1.077.
2,395.
- 479.
1,916.
Less Premium Deviation
9034
EXPENSE CONSTANT (EXCEPT WHERE APPLICABLE BY STATE)
Deposit Premium $
35.
1,951.
1,951.
MINIMUM PREMIUM $ 215.
If indicated below, interim adjustments of premium shall be made.
o Semi-Annually 0 Quarterly 0 Monthly
ENDORSEMENTS (FORM NUMBER)
TOTAL ESTIMATED PREMIUM
Issue Date
5-22-84/mvs
AIM !nsurancerl
Authorized Representati
C.3010
INSURED'S COPY
,
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@ West American Insurance Company
BRANCH OFFICE: 9720 Executive Center Drive. Post Office Box 20948, St. Petersburg, Florida 33742 - Telephone: B13/576.6137
EUGENE McNALLY, Manager
IMPORTANT NOTICE
To: FLORIDA
WORKMEN'S COMPENSATION POLICYHOLDERS
Re: Insured's Workers Compensation Policy
"THE FLORIDA SAFE EMPLOYMENT ACT" is applicable to every employer in a business
affecting commerce, who has one or more employees. The responsible state agency for ad-
ministering the Act is the [Jepartment of Labor and Employment Security, Division of
Workers' Compensation.
Compliance with all rules, regulations, opinions and standards of this law rests with you.
A copy of the act and its requirements may be obtained from:
State of Florida
Department of Labor and Employment Security
Division of Workers' Compensation
2551 Executive Center Circle, West
Lafayette Bldg., Suite 204
Tallahassee, FL 32301.
We encourage you to voluntarily comply with the requirements of "The Florida Safe Em-
ployment Act". Should you feel the need for consultative services, please write or phone us
at:
The Ohio Casualty Group of Companies
Attention: Underwriting Department
Branch Office
9720 Executive Center Drive
St. Petersburg, Florida 33702
Telephone: 813/576-5137
WAM Compo 1718 1-82
.
.
STATE OF FLORIDA DEPARTMENT OF COMMERCE
Division of Labor
1321 ExeouUve Center Drive - B_t. Tallah__ 32301
TO: CARRIER COVERED EMPLOYERS
NOTICE OF S100.00 PENALTY
You have compIled with the Florida Workmen's Compensation
Law by obtaining an insurance policy from a company of your
own choosing.
The Workmen's Compensation Law provides that
employers shall be subject to a civil penalty of $100.00
for each failure or refusal to file a report of injury. To
avoid this penalty, file a report of injury with your insurance
company immediately upon knowledge of an injury.
'SSg
E. Other Insurance
We will not pay more than our share of benefits
and costs covered by this insurance and other
insurance or self-insurance. Subject tcr any limits
of liability that may apply, all shares will be equal
until the loss is paid; If snyinsurance or self-
insurance is exhausted, the shares of all remain-
ing insurance will be equal until the loss is paid.
F. Payments You Must Make
You are responsible for any payments in excess
of the benefits 'regularly provided by the workers
compensation law including those required be-
cause:
1. of your serious and .willful misconduct;
2. you knowingly employ an employee in viola-
tion of law;
3. you fail to comply with a health or safety law
or regulation; or
4. you discharge, coerce or otherwise discrimi-
nate against any employee in violation of the
workers compensation law.
If we make any payments in excess of the bene-
fits regularly provided by the workers compensa-
tion law on your behalf, you will reimburse us
promptly.
G. RecoveryFrom:Others,
We have your rights, and the rights of persons
entitled to the benefits of this insurance, to reCOver
our payments from anYQn~ liable for the injury, You
will do everything necessary to protect those rights
for us and to help us enforce them.
H. StatutoryProvis.!ons
These statements apply where they are required
by law.
1. As between an ir,jured worker and us, we
have notice of th:e injury when you have
notice.
2. Your default or the ,bankruptcy or insolvency
of you or your estate will not relieve us of our
duties under this insurance after an injury
occurs.
3. We are directly and primarily liable to any
person entitled to the benefits payable by this
insurance. Those persons may enforce our
duties; so may an agency authorized by law.
Enforcement may be ,against us ora,gainst
you. and us.
4. Jurisdiction over you is jurisdiction over us
for purposes of the workers compensation
law. Weare bound by deCisions against you
I.Jtider that law,subjecttothe prOvisions of
this policy that are.not:n conflict with that
law.
5. This insurance conforms to the parr.. of the
workers compensation law that apply to:
a. benefits payable by this insurance;
b. special taxes, payments into security or
other special funds, and assessments
payable by us under that law.
6. Terms of this insurance that conflict with the
workers compensation law are changed by
this statement to conform to that law.
Nothing in these pa'ragraphs relieves you of your
duties under thispolic;::y~ .
PART TWO-eMPLOYERS LlABIUTYfNSURANCE
A. Ho~ Thi.~ Insurance Applies
This employers liability insurance applies to bodily
injury by accident or bodily injury by disease.
Bodily injury includes resulting death.
1. The bodily injury must arise out of and in the
course of the injured employee's employ-
ment by you. ,
2. The employment mu~t be necessary or in-
cidental to your work in a state or territory
listed in item 3A of the Information Page.
, 3., Bodily injury by accident must occur during
the policy period. ' ,
4. Bodily injury by disease must be caused or
aggravated by the conditions of your employ-
ment. The employee's last day of last expo-
sure to the conditions causing or aggravating
such bodily injury by disease must occur dur-
ing the policy period.
5. If you are sued, the 'original suit and any
related legal actions for damages for bodily
injury by accident or by disease must be
brought in the United States of America, its
. territories or possessions, or Canada.
Page 2 of 6
Copyright 1982 National Council on Compensation Insurance.
ATT1ACH FORM AND ENDORSEMENTS (IF ANY) HERE
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLlCY
In return for the payment' of the premium and subject to all terms . of this policy I we agree with you as follows.
GENERAL SECTION
A. The Policy
This polioy' includeasi at ,its effective date the In-
formation' Pagel and1'l!ltl endorsements and sched-
. uleslisted1therlf:"ltis'a corntractof insurance be-
tween you !(the ~mployer'namedin item' 1 of the
Information Page) and us (the ,insurer named on
the Information Page); The onlyqgreements re-
;lating to this !I1S\jlran~arestated in this policy.
The.term.,ot,. poli<;:Y may,notl;:le changed or
waived exaeptibyendorsement issued by us to
I bepartofthispolicy., ,("
S. Whe'lslnsured
Youare,insur~d..H>'()u are,an employer named in
item tpf t~e Jriforr:na,ijon P~ge. 'I,f}hat employer is
a partnership!and,ityou ate ()ne of its partners,
y?U a~e insurep, bu,tonly.in your capaqity <;is an
employer .of th,e ,pa~,ner~hlp.'sempIOVees.
PART ONE - WORKERS COMP~NSA,.16N'iINSlJ~ANCI:
A. How This Insurance Applies
This workers compensation insurance applies to
bodily injury by accident or bodily injury by dis-
ease: Bodily injury includes resultingdeCit/1l;
1. Bodily injury by accident must occur during
the policy period.
2. Bodily injury by disease must be caused or
aggravatedby1thei'Conditions of your employ-
ment. The employee's lastday of last expo-
suretq.th,econditions cal!sing()r . aggravat-
ing such bodily "inju.ry by diSeaSe:fTlust occur
.during the policy.period. .' , '
a. We Will. Pay
We will pay promptly when due ,. the benefits re-
quired of you by the workers compensation law.
C. We Will De'.end
We have ther,ight :and duty to defend at our ex-
pense any cl.aim, proceeding .or suit against you
for benefits payable by this insurance. We have
C. Worke.~s Compensation Law
Workers Compensation '. Lawmean~ the workers
or WOJ/(men's compensatiqnlaw. and occupa-
tional disease law of each state or territory named
in item 3;A. of the Information Page: It includes any
amendments to that law which are in effect during
thepoHcy period. It does notincludetheprovisions
of any law that provide nonoccupational disability
benefits. ,
D. State
State meansanys,tate of thei United States of
America, and the DistriotQfColumbia.
E. Locations
, '
ThispoH~ycovers aJI. of your wprkplaC13s listed in
items 1 or 4 of the Information Page; and it cov-
ers all other workplaces in item 3.A. states unless
you have other insurance or are self-insured for
such )JYorkpl~ce~i
the right t61nvestigate and settle tHese claims,
proceedings or suits.
We have no duty to defend a claim, proceeding
or suit that is,Rot cover13d by this insurance.
D. We Will Also Pay
We will also pay these costs, ihaddition to other
amounts payable under this insurance, as part of
any claim,. proceeding or suit we c1efend:
1. ' reasonable expel1ses incurred at our re-
quest,' but not loss of earnings; .
2. premiums for bonds to release attachments
ahd for appeaFbonds in bond amounts up to
the amount . paYable under this 'insurance;
3. litigation costs taxed against you;
4. interest on a judgm~nt as reql!ired by law un-
til we Offer the' amount due under this in-
suranqe; apd
5. expenses we incur.
Page 1 of6
Copyright 1982.I'JE!tipnIl1. Council\l[1 Compensation Insuranc:e.
.
~.
B. We Will Pay
We will pay all sums you legally must pay as
damages because of bodily injury to your em-
ployees, provided the bodily injury is covered by
this Employers Liability Insurance.
The damages we will pay, where recovery is per-
mitted by law, include damages:
1. 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;
2. for care and loss of services; and
3. for consequential bodily injury to a spouse,
child, parent, brother or sister of the injured
employee;
provided that these damages are the direct con-
sequence of bodily injury that arises out of and in
the course of the injured employee's employment
by you; and
4. because of bodily injury to your employee
that arises out of and in the course of em-
ployment, claimed against you in a capacity
other than as employer.
~
I,
C. Exclusions
This insurance does not cover:
1 . liability assumed under a contract. This ex-
clusion does not apply to a warranty that
your work will be done in a workmanlike
manner;
2. punitive or exemplary damages because of
bodily injury to an employee employed in
violation of law;
3. bodily injury to an employee while employed
in violation of law with your actual knowledge
or the a.ctual knowledge of any of your ex-
ecutive officers;
4. any obligation imposed by a workers com-
pensation, occupational disease, unemploy-
ment compensation, or disability benefits
law, or any similar law;
5. bodily injury intentionally caused or ag-
gravated by you;
6. bodily injury occurring outside the United
States of America, its territories or posses-
sions, 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;
.
.-
7. damages arising out of the discharge of,
coercion of, or discrimination against any
employee in violation of law.
D. We Will Defend
We have the right and duty to defend, at our ex-
pense, any claim, proceeding or suit against you
for damages payable by this insurance. We have
the right to investigate and settle these claims,
proceedings and suits.
We have no duty to defend a claim, proceeding
or suit that is not covered by this insurance. We
have no duty to defend or continue defending
after we have paid our applicable limit of liability
under this insurance.
E. We Will Also Pay
We will also pay these costs, in addition fo other
amounts payable under this insurance, as part of
any claim, proceeding or suit we defend;
i. reasonable expenses incurred at our re-
quest; but not loss of earnings;
2. premiums for bonds to release attachments
and for appeal bonds in bond amounts up to
the limit of our liability under this insurance;
3. litigation costs taxed against you;
4. interest on a judgment as required by law un-
til we offer the amount due under this in-
su rance; and
5. expenses we incur.
F. Other Insurance
We will not pay more than our share of damages
and costs covered by this insurance and other
insurance or self-insurance. Subject to any limits
of liability that apply, all shares will be equal until
the loss is paid. If any insurance or self-
insurance is exhausted, the shares of all remain-
ing insurance and self-insurance will be equal
until the loss is paid.
G. Limits of Liability
Our liability to pay for damages is limited. Our
limits of liability are shown in item 3.B. of the In-
formation Page. They apply as explained below.
1. Bodily Injury by Accident. The limit shown for
"bodily injury by accident-each accident" is
the most we will pay for all damages covered
by this insurance because of bodily injury to
one or more employees in anyone accident.
Copyright 1982 National Council on Compensation Insurance,
Page 3 of 6
t-
.
A disease is not bodily injury by accident un-
less it results directly from bodily injury by
accident.
2. Bodily Injury by Disease. The limit shown for
"bodily injury by disease-policy limit" is the
most we will pay for all damages covered
by this insurance and arising out of bodily in-
jury by disease, regardless of the number of
employees who sustain bodily injury by dis-
ease. The limit shown for "bodily injury by
disease-each employee" is the most we will
pay for all damages because of bodily injury
by disease to anyone employee.
Bodily injury by disease does not include dis-
ease that results directly from a bodily injury
by accident.
3. We will not pay any claims for damages after
we have paid the applicable limit of our liabil-
ity under this insurance.
.
H. Recovery From Others
We have your rights to recover our payment from
anyone liable for an injury covered by this insur-
ance. You will do everything necessary to protect
those rights for us and to help us enforce them.
'~
I. Actions Against Us
There will be no right of action against us under
this insurance unless:
1. You have complied with all the terms of this
policy; and
2. The amount you owe has been determined
with our consent or by actual trial and final
judgment.
This insurance does not give anyone the right to
add us as a defendant in an action against you to
determine your liability.
PART THREE - OTHER STATES INSURANCE
A. How This Insurance Applies
1. This other states insurance applies on1y if
one or more states are shown in item 3.G. of
the Information Page.
2. If you begin work in anyone of those states
and are not insured or are not self-insured for
such work, the policy will apply as though
that state were listed in item 3.A. of the In-
formation Page.
3. We will reimburse you for the benefits re-
quired by the workers compensation law of
that state if we are not permitted to pay the
benefits directly to persons entitled to
them.
B. Notice
Tell us at once if you begin work in any state
listed in item 3.G. of the Information Page.
PART FOUR - YOUR DUTIES IF INJURY OCCURS
Tell us at once if injury occurs that may be covered
by this policy. Your other duties are listed here.
1 . Provide for immediate medical and other ser-
vices required by the workers compensation
law.
2. Give us or our agent the names and addres-
ses of the injured persons and of witnesses,
and other information we may need.
3. Promptly give us all notices, demands and
legal papers related to the injury, claim, pro-
ceeding or suit.
4. Cooperate with us and assist us, as we may
request, in the investigation, settlement or
defense of any claim, proceeding or suit.
5. Do nothing after an injury occurs that would
interfere with our righUo recover from others.
6. Do not voluntarily make payments, assume
obligations or incur expenses, except at your
own cost.
PART FIVE - PREMIUM
A. Our Manuals
All premium for this policy will be determined by
our manuals of rules, rates, rating plans and
classifications. We may change our manuals and
apply the changes to this policy if authorized by
law or a governmental agency regulating this in-
surance.
B. Classifications
Item 4 of the Information Page shows the rate
and premium basis for certain business or work
Copyright 1982 National Council on Compensation Insurance.
Page 4 of 6
I 'f" Th I .f' t'
c ass I Icatlons. ese c assl Ica Ions were
assigned based on an estimate of the exposures
you would have during the policy period. If your
actual exposures are not properly described by
those classifications, we will assign proper classi-
fications, rates and premium basis by endorse-
ment to this policy.
C. Remuneration
Premium for each work classification is deter-
mined by multiplying a rate times a premium
basis. Remuneration is the most common pre-
mium basis. This premium basis 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 (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 com-
pensation obligations.
D. Premium Payments
You will pay all premium when due. You will pay
the premium even if part or all of a workers com-
pensation law is not valid.
E. Final Premium
The premium shown on the Information Page,
schedules, and endorsements is an estimate.
The final premium will be determined after this
policy ends by using the actual, not the esti-
mated, premium basis and the proper classifica-
.
tions and rates That lawfully apply to the business
and work covered by this policy. If the final pre-
mium is more than the premium you paid to us,
you must pay us the balance. If it is less, we will
refund the balance to you. The final premium will
not be less than the highest minimum premium
for the classifications covered by this policy.
If this policy is canceled, final premium will be
determined in the following way unless our
manuals provide otherwise.
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.
2. If you cancel, final premium will be more than
pro rata; it will be based on the time this pol-
icy was in force, and increased by our short
rate cancelation table and procedure. Final
premium will not be less than the minimum
premium.
F. Records
You will keep records of information needed to
compute premium. Yoll will provide us with
copies of those records when we ask for them.
G. Audit
You will let us examine and audit all your records
that relate to this policy. These records include
ledgers, journals, registers, vouchers, contracts,
tax reports, payroll and disbursement records,
and programs for storing and retrieving data. We
may conduct the audits during regular business
hours during the policy period and within three
years after the policy period ends. Information
developed by audit will be used to determine final
premium. Insurance rate service organizations
have the same rights we have under this
provision.
PART SIX - CONDITIONS
!
A. Inspection
We have the right, but are not obliged to inspect
your workplaces at any time. Our inspections are
not safety inspections. They relate only to the in-
surability of the workplaces and the premiums to
be charged. We may give you reports on the con-
ditions we find. We may also recommend
changes. While they may help reduce losses, we
do not undertake to perform the duty of any per-
son to provide for the health or safety of your em-
ployees or the public. We do not warrant that
e,
your workplaces are safe or healthful or that they
comply with laws, regulations, codes or stand-
ards. Insurance rate service organizations have
the same rights we have under this provision.
B. Long Term Policy
If the policy period is longer than one year and
sixteen days, all provisions of this policy will apply
as though a new policy were issued on each
annual anniversary that this policy is in force.
Copyright 1982 National Council on Compen'Sation Insurance.
Page 5 of 6
.
C. Transfer of Your Rights and Duties
Your rights or duties under this policy may not be
transferred without our written consent.
If you die and we receive notice within thirty days
after your death, we will cover your legal repre-
sentative as insured.
D. Cancelation
1. You may cancel this policy. You must mail or
deliver advance written notice to us stating
when the cancelation is to take effect.
2. We may.cancel this policy. We must mail or
deliver to you not less than ten days advance
written notice stating when the cancelation 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.
3. The policy period will end on the day and
hour stated in the cancelation notice.
4. Any of these provisions that conflicts with a
law that controls the cancelation of the insur-
ance in this policy is changed by this state-
ment to comply with that law.
E. Sole Representative
The insured first named in item 1 of the Informa-
tion Page will act on behalf of all insureds to
change this policy, receive return premium, and
give or receive notice of cancelation.
In Witness Whereof, this Company has executed and attested these presents; but this policy shall not be valid
unless countersigned by the duly authorized Agent of this Company at the agency hereinbefore mentioned.
crH--~
Secretary
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~
~aA...c...~ President
"
.
Copyright 1982 National Council on Compensation Insurance.
Page 6 of 6