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042-2012 - Human Resources - RMD - Worker's Comp
z Insurer: EMPLOYERS SECURITY INSURANCE COMPANY Policy Number: 07-6000001248-05 Previous Policy: 07-6000001248-04 Workers Compensation and Employers�Liability Policy Information Page (1) Name and Mailing Address of the Insured Richmond City of 50 North 5th Street Richmond, IN 47374-4247 Fed ID Number: 35-6001174 Bureau ID Number: 130132995 Agency: RMDIPatti Insurance & Financial Services 36 South 9th Street P.O. Box 1167 Richmond, IN 47375 Agency Code: 8801 Legal Entity: Municipality NCCI Company Number: 30376 Other workplaces: See Additional Locations — Extension of Information Page (2) Policy Period: From 03/01/2012, to 03/01/2013, 12:01 a.m. standard time at the insured's mailing address. (3) Coverage: A. Workers Compensation Insurance: Part One of this policy applies to the Workers Compensation Law of the following states: IN B. Employers Liability Insurance: Part Two of this policy applies to work in each of the states listed in item (3)A. The limits of our liability under Part Two are as follows: Bodily Injury by Accident - each accident $1,000,000 Bodily Injury by Disease - policy limit $1,000,000 Bodily Injury by Disease - each employee $1,000,000 C. Other States' Insurance: Part Three of this policy applies to all states except any state listed in item (3)A. and the states of NORTH DAKOTA, OHIO, WASHINGTON, WYOMING. D. This policy includes the following forms and endorsements: See Listing of Endorsements -- Extensiop of Information Page (4) The premium for this policy will be determinedour Manual of Rules, Classifications, Rates and Rating Plans. All information required below ' ubject to verification and change by audit. See Schedule of Operations — Minimum Premium $1,000 Expense Constant $250 Countersigned by n of Information Page Total Estimated Annual Premium $133,242 Contract No. 42-2012 Insured Copy WC 00 00 01A Insurer: EMPLOYERS SECURITY INSURANCE COMPANY Policy Number: 07-6000001248-05 Extension of Information Page Additional Locations Other work place locations not listed on Page 1, Item 1: 0001 Parks Department, Richmond, IN 47374-4247 0002 Mayors Operations, Richmond, IN 47374-4247 0003 Finance Operations, Richmond, IN 47374-4247 0004 Clerks Operations, Richmond, IN 47374-4247 0005 Council Operations, Richmond, IN 47374-4247 0006 Engineering Operations, Richmond, IN 47374-4247 0007 Planning, Richmond, IN 47374-4247 0008 Administration, Richmond, IN 47374-4247 0009 Department of Public Works, Richmond, IN 47374-4247 0010 RSVP Action, Richmond, IN 47374-4247 0011 Widow Persons, Richmond, IN 47374-4247 0012 Homebound, Richmond, IN 47374-4247 0013 Birth to Five, Richmond, IN 47374-4247 0014 Motor Vehicle/ Highway, Richmond, IN 47374-4247 0015 Municipal Airport, Richmond, IN 47374-4247 0016 Off Street Parking, Richmond, IN 47374-4247 0017 Public Transit, Richmond, IN 473744247 0018 Sanitary District, Richmond, IN 47374-4247 0019 Police Department, Richmond, IN 47374-4247 0020 Law Department, Richmond, IN 47374-4247 0021 Fire Department, Richmond, IN 47374-4247 Insured Copy WC 00 00 01A Insurer: EMPLOYERS SECURITY INSURANCE COMPANY Policy Number: 07-6000001248-05 Extension of Information Page Additional Endorsements Additional endorsement and schedules not listed on Page 1, Item 3.D: WC000001A (0711) Information Page WC00000013 (0711) Coverage Part WC000404 (0484) Pending Rate Change Endorsement WC000414 (0790) Notification of Change in Ownership WC000419 (0101) Premium Due Date Endorsement WC000403 (0484) Experience Rating Modification Endt WC990420 (1202) Deductible Endorsement WC000406A (0795) Premium Discount Endorsement WC000422A (0908) Terrorism Risk Insurance Program Reauthorization Act Disclosure WC000421 C (0908) Catastrophe (Other than Certified Acts of Terrorism) WC000311A (0492) Voluntary Comp. and Employers Liability Coverage INST-1 (0698) Installment Billing Schedule Insured Copy WC 00 00 01A Insurer. EMPLOYERS SECURITY INSURANCE COMPANY Policy Number: 07-6000001248-05 Extension of Information Page Schedule of Operations State: IN Location #1: Parks Department Richmond, IN 47374-4247 Premium Basis Total Estimated Estimated Code Annual Rate Per $100 of Annual Classifications No. Effective Remuneration Remuneration Premium ROSTERED VOLUNTEERS MEDICAL ONLY 7698 03/01/2012 $0 1.61 $0 AUTOMOBILE SERVICE OR REPAIR CENTER & DRIVERS 8380 03/01/2012 $34,575 2.44 $844 CLERICAL OFFICE EMPLOYEES NOC 8810 03/01/2012 $417,142 .20 $834 CLUB -COUNTRY, GOLF, FISHING OR YACHT-& CLERICAL 9060 03/01/2012 $158,156 1.25 $1,977 PARK NOC-ALL EMPLOYEES & DRIVERS 9102 03/01/2012 $703,863 2.82 $19,849 Location #2: Mayors Operations Richmond, IN 47374-4247 Premium Basis Total Estimated Estimated Code Annual Rate Per $100 of Annual Classifications No. Effective Remuneration Remuneration Premium CLERICAL OFFICE EMPLOYEES NOC 8810 03/01/2012 $165,338 .20 $331 Location #3: Finance Operations Richmond, IN 47374-4247 Premium Basis Total Estimated Estimated Code Annual Rate Per $100 of Annual Classifications No. Effective Remuneration Remuneration Premium CLERICAL OFFICE EMPLOYEES NOC 8810 03/01/2012 $218,158 .20 $436 Location #4: Clerks Operations Richmond, IN 473744247 Premium Basis Total Estimated Estimated Code Annual Rate Per $100 of Annual Classifications No. Effective Remuneration Remuneration Premium CLERICAL OFFICE EMPLOYEES NOC 8810 03/01/2012 $102,865 .20 $206 Location #5: Council Operations Richmond, IN 47374-4247 Premium Basis Total Estimated Estimated Code Annual Rate Per $100 of Annual Classifications No. Effective Remuneration Remuneration Premium CLERICAL OFFICE EMPLOYEES NOC 8810 03/01/2012 $55,665 .20 $111 Location #6: Engineering Operations Richmond, IN 47374-4247 Premium Basis Total Estimated Estimated Code Annual Rate Per $100 of Annual Classifications No. Effective Remuneration Remuneration Premium CLERICAL OFFICE EMPLOYEES NOC 8810 03/01/2012 $6,921 .20 $14 MUNICIPAL, TOWNSHIP, COUNTY OR STATE EMPLOYEE NOC 9410 03/01/2012 $162,384 2.50 $4,060 Location #7: Planning Richmond, 1N 47374-4247 Classifications Code Effective Premium Basis Rate Per $100 of Estimated Insured Copy WC 00 00 01A Insurer: EMPLOYERS SECURITY INSURANCE COMPANY Policy Number: 07-6000001248-05 Extension of Information Page Schedule of Operations No. Total Estimated Annual Remuneration CLERICAL OFFICE EMPLOYEES NOC 8810 03/01/2012 $289,771 MUNICIPAL, TOWNSHIP, COUNTY OR STATE EMPLOYEE NOC 9410 03/01/2012 $115,848 Location #8: Administration Richmond, IN 47374-4247 Classifications CLERICAL OFFICE EMPLOYEES NOC Location #9: Department of Public Works Richmond, IN 47374-4247 Classifications CLERICAL OFFICE EMPLOYEES NOC BUILDINGS -OPERATION BY OWNER, LESSEE, OR REAL ESTATE MANAGEMENT FIRM: PARK NOC-ALL EMPLOYEES & DRIVERS Location #10: RSVP Action Richmond, IN 47374-4247 Classifications CLERICAL OFFICE EMPLOYEES NOC Location #11: Widow Persons Richmond, IN 47374-4247 Classifications CLERICAL OFFICE EMPLOYEES NOC Location #12: Homebound Richmond, IN 47374-4247 Classifications CLERICAL OFFICE EMPLOYEES NOC Location #13: Birth to Five Richmond, IN 47374-4247 Classifications CLERICAL OFFICE EMPLOYEES NOC Location #14: Motor Vehicle / Highway Richmond, IN 47374-4247 Classifications Insured Copy Premium Basis Total Estimated Code Annual No. Effective Remuneration 8810 03/01/2012 $67,464 Premium Basis Total Estimated Code Annual No. Effective Remuneration 8810 03/01/2012 $10,036 9015 03/01/2012 $29,702 9102 03/01/2012 $0 Premium Basis Total Estimated Code Annual No. Effective Remuneration 8810 03/01/2012 $151,601 Premium Basis Total Estimated Code Annual No. Effective Remuneration 8810 03/01/2012 IF ANY Premium Basis Total Estimated Code Annual No. Effective Remuneration 8810 03/01/2012 IF ANY Remuneration .20 2.50 Rate Per $100 of Remuneration .20 Rate Per $100 of Remuneration .20 3.07 2.82 Rate Per $100 of Remuneration .20 Rate Per $100 of Remuneration .20 Rate Per $100 of Remuneration .20 Annual Premium $580 $2,896 Estimated Annual Premium $135 Estimated Annual Premium $20 $912 $0 Estimated Annual Premium $303 Estimated Annual Premium $0 Estimated Annual Premium $0 Premium Basis Total Estimated Estimated Code Annual Rate Per $100 of Annual No. Effective Remuneration Remuneration Premium 8810 03/01/2012 IF ANY .20 $0 Code Effective Premium Basis Rate Per $100 of Estimated WC 00 00 01 A Insurer: EMPLOYERS SECURITY INSURANCE COMPANY Policy Number: 07-6000001248-05 Extension of Information Page Schedule of Operations No. Total Estimated Remuneration Annual Annual Premium Remuneration STREET OR ROAD CONSTRUCTION: PAVING OR REPAVING & DRIVERS 5506 03/01/2012 $798,335 5.35 $42,711 AUTOMOBILE SERVICE OR REPAIR CENTER & DRIVERS 8380 03/01/2012 $68,665 2.44 $1,675 CLERICAL OFFICE EMPLOYEES NOC 8810 03/01/2012 $99,636 20 $199 Location #15: Municipal Airport Richmond, IN 47374-4247 Premium Basis Total Estimated Estimated Code Annual Rate Per $100 of Annual Classifications No. Effective Remuneration Remuneration Premium AVIATION: ALL OTHER EMPLOYEES & DRIVERS 7403 03/01/2012 $90,699 3.35 $3,038 Location #16: Off Street Parking Richmond, IN 47374-4247 Premium Basis Total Estimated Estimated Code Annual Rate Per $100 of Annual Classifications No. Effective Remuneration Remuneration Premium AUTOM0131LE STORAGE GARAGE, PARKING LOT OR PARKING STATION, VALET SERVI 8392 03/01/2012 $13,000 2.34 $304 Location #17: Public Transit Richmond, IN 47374-4247 Premium Basis Total Estimated Estimated Code Annual Rate Per $100 of Annual Classifications No. Effective Remuneration Remuneration Premium BUS CO.: ALL OTHER EMPLOYEES & DRIVERS 7382 03/01/2012 $490,209 3.35 $16,422 CLERICAL OFFICE EMPLOYEES NOC 8810 03/01/2012 $89,217 .20 $178 Location #18: Sanitary District Richmond, IN 47374-4247 Premium Basis Total Estimated Estimated Code Annual Rate Per $100 of Annual Classifications No. Effective Remuneration Remuneration Premium EXCAVATION & DRIVERS 6217 03/01/2012 $204,306 3.93 $8,029 SEWAGE DISPOSAL PLANT OPERATION & DRIVERS 7580 03/01/2012 $795,302 2.23 $17,735 AUTOMOBILE SERVICE OR REPAIR CENTER & DRIVERS 8380 03/01/2012 $386,048 2.44 $9,420 CLERICAL OFFICE EMPLOYEES NOC 8810 03/01/2012 $858,657 .20 $1,717 STREET CLEANING & DRIVERS 9402 03/01/2012 $125,549 5.21 $6,541 GARBAGE, ASHES OR REFUSE COLLECTION & DRIVERS 9403 03/01/2012 $690,358 5.25 $36,244 MUNICIPAL, TOWNSHIP, COUNTY OR STATE EMPLOYEE NOC 9410 03/01/2012 $0 2.50 $0 Location #19: Police Department Richmond, IN 47374-4247 Premium Basis Total Estimated Estimated Code Annual Rate Per $100 of Annual Classifications No. Effective Remuneration Remuneration Premium POLICE OFFICERS & DRIVERS 7720 03/01/2012 $157,554 2.68 $4,222 Insured Copy WC 00 00 01A Insurer: EMPLOYERS SECURITY INSURANCE COMPANY Policy Number: 07-6000001248-05 Extension of Information Page Schedule of Operations POLICE OFFICERS -MEDICAL ONLY-& DRIVERS 7726 03/01/2012 $2,862,947 1.94 $55,541 AUTOMOBILE SERVICE OR REPAIR CENTER & DRIVERS 8380 03/01/2012 $35,647 2.44 $870 CLERICAL OFFICE EMPLOYEES NOC 8810 03/01/2012 $372,684 .20 $745 PARK NOC-ALL EMPLOYEES & DRIVERS 9102 03/01/2012 $0 2.82 $0 Location #20: Law Department Richmond, IN 47374-4247 Premium Basis Total Estimated Estimated Code Annual Rate Per $100 of Annual Classifications No. Effective Remuneration Remuneration Premium CLERICAL OFFICE EMPLOYEES NOG 8810 03/01/2012 IF ANY .20 $0 ATTORNEY -ALL EMPLOYEES & CLERICAL, MESSENGERS, DRIVERS 8820 03/01/2012 $74,023 .13 $96 Location #21: Fire Department Richmond, IN 47374-4247 Premium Basis Total Estimated Estimated Code Annual Rate Per $100 of Annual Classifications No. Effective Remuneration Remuneration Premium FIREFIGHTERS -MEDICAL ONLY & DRIVERS 7699 03/01/2012 $3,256,902 2.94 $95,753 AUTOMOBILE SERVICE OR REPAIR CENTER & DRIVERS 8380 03/01/2012 $0 2.44 $0 CLERICAL OFFICE EMPLOYEES NOC 8810 03/01/2012 $148,164 .20 $296 Classification Totals $14,307,391 $335,244 Increased Employers Liability Limit: 9812 03/01/2012 0.028 $9,387 PREMIUM SUBJECT TO MODIFICATION 03/01/2012 $344,631 Estimated Modified Premium: Exp Mod 1 9898 03/01/2012 .980 ($6,893) TOTAL MODIFIED PREMIUM 03/01/2012 $337,738 Schedule Rating Factor: 9887 03/01/2012 -20.00% ($67,548) Deductible Credit: 9663 03/01/2012 48.70% ($131,583) Subtotal Risk -Rated Premium: $138,607 Less Premium Discount: 0064 03/01/2012 8.40% ($11,643) Plus Expense Constant: 0900 03/01/2012 $250 Terrorism: 9740 03/01/2012 0.020 $2,861 Catastrophe (Other than Certified Acts/Terronsm): 9741 03/01/2012 0.010 $1,431 Total Estimated Annual Premium: 03/01/2012 $131,506 Second Injury Fund Surcharge: 0935 03/01/2012 0.66% $1,736 Total State Cost: $133,242 Insured Copy WC 00 00 01A WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY 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 A. The Policy This policy includes at its effective date the Infor- mation Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Informa- tion Page) and us (the insurer named on the Infor- mation Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this pol- icy. B. Who is Insured You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an employer of the partnership's employees. C. Workers Compensation Law Workers Compensation Law means the workers or workmen's compensation law and occupational 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 the policy period. It does not include any federal workers or workmen's compensation law, any fed- eral occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D. State State means any state of the United States of America, and the District of Columbia. E. Locations This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A. states unless you have other insurance or are self -insured for such workplaces. WC 00 00 00 B Ed. (7-11) PART ONE WORKERS COMPENSATION INSURANCE A. How this Insurance Applies This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. Bodily injury by accident must occur during the policy period. 2. 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 Pay We will pay promptly when due the benefits required of you by the workers compensation law. C. We Will Defend We have the right and duty to defend at our expense any claim, proceeding or suit against you for bene- fits payable by this insurance. We have the right to investigate and settle these claims, proceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. D. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend: 1. reasonable expenses incurred at our request, but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. E. Other insurance We will not pay more than our share of benefits and costs covered by this insurance and other 1 of 6 O Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. WC 00 00 00 B WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Ed. (7-11 insurance or self-insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self- insurance is exhausted, the shares of all remaining 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 violation of law; 3. you fail to comply with a health or safety law or regulation; or 4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G. Recovery From Others We have your rights, and the rights of persons enti- tled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H. Statutory Provisions These statements apply where they are required by law. 1. As between an injured worker and us, we have notice of the injury when you have notice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our du- ties under this insurance after an injury occurs. 3. We are directly and primarily liable to any per- son entitled to the benefits payable by this in- surance. Those persons may enforce our duties; so may an agency authorized by law. Enforcement may be against us or against you and us. 4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law. 5. This Insurance conforms to the parts 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 paragraphs relieves you of your du- ties under this policy. PART TWO EMPLOYERS LIABILITY INSURANCE A. How This 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 employment by you. 2. The employment must be necessary or incidental to your work in a state or territory listed in Item 3.A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or ag- gravated 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. 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 pos- sessions, or Canada. B. We Will Pay We will pay all sums that you legally must pay as damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers Liability Insurance_ The damages we will pay, where recovery is permitted 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 2of6 © Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY 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 consequence 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 employment, claimed against you in a capacity other than as employer. C. Exclusions This insurance does not cover: 1. Liability assumed under a contract. This exclusion 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 actual knowledge of any of your executive officers; 4. Any obligation imposed by a workers compen- sation, occupational disease, unemployment compensation, or disability benefits law, or any similar law; 5. Bodily injury intentionally caused or aggravated by you; 6. 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 out- side these countries; 7. Damages arising out of coercion, criticism, de- motion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimi- nation against or termination of any employee, or any personnel practices, policies, acts or omissions; 8. Bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901-950), the Non - appropriated Fund Instrumentalities Act (5 USC Sections 8171---8173), the Outer Continental Shelf Lands Act (43 USC Sections 1331-1356a), the Defense Base Act (42 USC Sections 1651- 1654), the Federal Coal Mine Safety and Health WC 00 00 00 B Ed. (7-11) Act (30 USC Sections 801-945), any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws; 9. Bodily injury to any person in work subject to the Federal Employers' Liability Act (45 USC Sections 51--60), any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws; 10. Bodily injury to a master or member of the crew of any vessel; 11, Fines or penalties imposed for violation of federal or state law; and 12. Damages payable under the Migrant and Sea- sonal Agricultural Worker Protection Act (29 USC Sections 1801-1872) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws. D. We Will Defend We have the right and duty to defend, at our expense, 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 to other amounts payable under this insurance, as part of any claim, proceeding, or suit we defend: 1. Reasonable expenses incurred at our request, 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 until we offer the amount due under this insurance; and 5. Expenses we incur. 3of6 © Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. WC 00 00 00 B WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Ed. (7-11) 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 remaining 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 3.13. of the Information 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 any one accident_ A disease is not bodily injury by accident unless 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 injury by disease, regardless of the number of employees who sustain bodily injury by disease. 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 any one employee. Bodily injury by disease does not include disease 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 liability under this insurance. H. Recovery From Others We have your rights to recover our payment from anyone liable for an injury covered by this insurance. You will do everything necessary to protect those rights for us and to help us enforce them. 1. 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. The bankruptcy or insolvency of you or your estate will not relieve us of our obligations under this Part. PART THREE OTHER STATES INSURANCE A. How This Insurance Applies 1. This other states insurance applies only if one or more states are shown in Item 3.C. of the Information Page. 2. If you begin work in any one of those states after the effective date of this policy and are not insured or are not self -insured for such work, all provisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page. 3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have work on the effective date of this policy in any state not listed in Item 3.A. of the Information Page, coverage will not be afforded for that state unless we are notified within thirty days. B. Notice Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. 4 of 6 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 services required by the workers compensation law. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need. 3. Promptly give us all notices, demands and legal 0 Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY papers related to the injury, claim, proceeding 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 right to 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 insurance. 11 C Classifications Item 4 of the Information Page shows the rate and premium basis for certain business or work classifications. These classifications 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 classifications, rates and premium basis by endorsement to this policy. Remuneration Premium for each work classification is determined by multiplying a rate times a premium basis. Remuneration is the most common premium 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 compensation obligations. WC000000B Ed. (7-11) D. Premium Payments You will pay all premium when due. You will pay the premium even if part or all of a workers compensation 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 estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium 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 policy 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. You 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. 5 of 6 © Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. WC 00 00 00 B Ed. (7-11) A. B. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY PART SIX —CONDITIONS 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 insurability of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organizations have the same rights we have under this provision. 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. 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 representative 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. 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 conflict with a law that controls the cancelation of the insurance in this policy is changed by this statement to comply with the law. E. Sole Representative The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancelation. 6of6 © Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 04 (Ed. 4-84) PENDING RATE CHANGE ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective on (DATE) Policy No. of the Issued to Premium (if any) $ at 12:01 A.M. standard time, forms a part of Authorized Representative A rate change filing is being considered by the proper regulatory authority. The filing may result in rates different from the rates shown on the policy. If it does, we will issue an endorsement to show the new rates and their effective date. If only one state is shown in Item 3.A of the Information Page, this endorsement applies to that state. If more than one state is shown there, this endorsement applies only in the state shown in the Schedule. State IN Schedule Copyright, 19133 National Council on Compensation Insurance, Inc. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 0414 (Ed. 07190) NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT Experience rating is mandatory for all eligible insureds. The experience rating modification factor, if any, applicable to this policy, may change if there is a change in your ownership or in that of one or more of the entities eligible to be combined with you for experience rating purposes. Change in ownership includes sales, purchases, other transfers, merges, consolidations, dissolutions, formations of a new entity and other changes provided for in the applicable experience rating plan manual. You must report any change in ownership to us in writing within 90 days of such change. Failure to report such changes within this period may result in revision of the experience rating modification factor used to determine your premium. WC 00 0414 (Ed. 07190) O 1990 National Council on Compensation Insurance. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 19 (Ed. 01101) PREMIUM DUE DATE ENDORSEMENT Section D. of Part Five of the policy is replaced by this provision. PART FIVE PREMIUM D. Premium is amended to read: You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. The due date for audit and retrospective premiums is the date of the billing. WC 00 04 19 (Ed. 01101) © 2000 National Council on Compensation Insurance, Inc. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 03 (Ed. 4-84) EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy) This endorsement, effective on (DATE) Policy No. Endorsement No of the EMPLOYERS SECURITY INSURANCE COMPANY issued to Premium (if any) $ at 12:01 A.M. standard time, forms a part of Authorized Representative The premium for the policy will be adjusted by an experience rating modification factor. The factor was not available when the policy was issued. The factor, if any, shown on the information Page is an estimate. We will issue an endorsement to show the proper factor, if different from the factor shown, when it is calculated. Copyright, 1983, 1994 National Council on Compensation Insurance, Inc. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 04 20 (Ed. 12/02) DEDUCTIBLE ENDORSEMENT This insurance applies subject to the following provisions: 1. We will pay promptly the benefits required of you by the Workers Compensation Law and Employers Liability Insurance provided by this policy. You will reimburse us for any amounts paid, including Allocated Loss Adjustment Expense, up to the deductible amounts stated below: $150,000 Each Accident $500,000 Aggregate This deductible agreement is between you and us. It does not affect or alter the rights of others under the policy. 2. The deductible amounts apply as follows: A. The deductible amount stated as applicable to Each Accident applies to all benefits and damages insured under this policy, including Allocated Loss Adjustment Expense, sustained as the result of any one accident. Losses arising out of Bodily Injury by disease, including death at any time resulting there from, sustained by any one employee shall be deemed to arise out of a single accident. As used in this endorsement, Allocated Loss Adjustment Expense means actual expense payments and unpaid expenses, as estimated by us, for items of expense directly and definitely chargeable to a specific claim, but does not include the cost of investigation or adjustment of claims by our salaried employees except an attorney employed by us who is assigned to defined such claim. B. The total deductible amount applicable to all benefits and damages insured under this policy, including Allocated Loss Adjustment Expense, will not exceed the amount stated as Aggregate. C. We will pay all loss amounts, including Allocated Loss Adjustment Expense, up to the deductible amount. Periodically, we will send you a statement of losses and reimbursements. You must reimburse us within 30 days of the statement date. Your failure to reimburse us may result in cancellation of coverage as provided in Part Six (Conditions), Section D (Cancellation) of the policy. Any return premium may be applied to the deductible amounts due. D. Any payment made by use which includes such deductible amounts will not increase our liability with respects to our obligations under this policy. E. The terms of this policy, including Part One, Section C — We Will Defined; Part Two, Section D — We will Defend; and Part Four — Your Duties If Injury Occurs, apply irrespective of the application of the deductible amount. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: Insured: Insurance Company: Policy No: Countersigned by Endorsement No: Premium: ©1995 National Council on Compensation Insurance, Inc. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 04 20 (Ed. 12102) 3. You will pay a handling fee, which will be charged each time there is a loss reimbursement. This fee will be calculated by applying the following factor to the total amount of each reimbursement: Handling Fee: 1.11% 4. The premium is reduced in consideration of this deductible. The Deductible Credit is shown in the State Schedule(s). 5. The Deductible Credit factors shown here are based on estimates of standard premium. If the actual standard premium is within the range of estimated standard premiums shown here, the Deductible Credit Factor will be obtained by linear interpolation to the nearest one -tenth of 1%. If the actual standard premium is not within the range of estimated standard premiums, the Deductible Credit Factor will be recalculated. 6 i�lllTllrnom El iy��y �/{p C i I�YIQ ySA ' axim 1.f11.1t Y Estimated Premium: $135,095 $270,190 $405,285 Deductible Credit Factor: 43.7% 48.7% 53.7% (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: Insured: Insurance Company: Policy No: Countersigned by Endorsement No: Premium: ©1995 National Council on Compensation Insurance, Inc. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 06 A (Ed. 07/95) PREMIUM DISCOUNT ENDORSEMENT The premium for this policy and the policies, if any, listed in item 3 of the Schedule may be eligible for a discount. This endorsement shows your estimated discount in Items 1 or 2 of the Schedule. The final calculation of premium discount will be determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective rating is not subject to premium discount. Schedule 1. State Tk 2. Average percentage discount: 3. Other policies Estimated Eligible Premium First Next Next Balance $10,000 $190,000 $1,550,000 $1,750,000 0% 9.1 % 11.3% 12.3% 4. If there are no entries in Items 1, 2 and 3 of the Schedule, see the Premium Discount Endorsement attached to your policy number: WC 00 04 06 A (Ed. 07195) 1995 National Council on Compensation Insurance. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 22 A (Ed. 09/08) 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 2007. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. 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 resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2007. "Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, 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 (and, except for Pennsylvania, 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, 2008, and ending on December 31, 2014, an amount equal to 20% of our direct earned premiums, over the calendar year immediately preceding the applicable Program Year. "Program Year" refers to each calendar year between January 1, 2008 and December 31, 2014, as applicable. WC000422A (Ed. 09/08) 0 2008 National Council on Compensation Insurance, Inc. %A1 Q. RKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 22 A (Ed. 09/08) Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a Program 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 exceeds $100,000,000 in a Program Year, the United States Government would pay 85% 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 premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in Item 4 of the Information Page or in the Schedule below:. Schedule State Rate Premium IN 0.020 $2,861 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: Policy No: Endorsement No: Insured: Premium: Insurance Company: Countersigned by WC 00 04 22 A (Ed. 09/08) Q 2008 National Council on Compensation Insurance, Inc. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 21 C (Ed. 09-08) CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT This endorsement is notification that your insurance carrier is charging premium to cover the losses that may occur in the event of a Catastrophe (other than Certified Acts of Terrorism) as that term is defined below. Your policy provides coverage for workers compensation losses caused by Catastrophe (other than Certified Acts of Terrorism). This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22A), attached to this policy. For purposes of this endorsement, the following definitions apply: • Catastrophe (other than Certified Acts of Terrorism): Any single event, resulting from an Earthquake, Noncertified Act of Terrorism, or Catastrophic Industrial Accident, which results in aggregate workers compensation losses in excess of $50 million. • Earthquake: The shaking and vibration at the surface of the earth resulting from underground movement along a fault plane or from volcanic activity. • Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary of Treasury pursuant to the Terrorism Risk Insurance Act of 2002 (as amended) but that meets all of the following criteria: a. It is an act that is violent or dangerous to human life, property, or infrastructure. b. The act results in damage within the United States, or outside of the United States in the case of the premises of United States missions or air carriers or vessels as those terms are defined in the Terrorism Risk Insurance Act of 2002 (as amended); and C. It is an act that 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. Catastrophic Industrial Accident: A chemical release, large explosion, or small blast that is localized in nature and affects workers in a small perimeter the size of a building. The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism) is shown in item 4 of the Information Page or in the Schedule below: Schedule State Rate Premium IN 0.010 $1,431 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: Policy No: Endorsement No: Insured: Insurance Company: Countersigned by Premium: WC000421C (Ed. 09-08) © 2008 National Council on Compensation Insurance, Inc. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 11 A (Ed. 4-92) VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT This endorsement adds Voluntary Compensation Insurance to the policy. A. How this Insurance Applies This insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must be sustained by an employee included in the group of employees described in the Schedule. 2. The bodily injury must arise out of and in the course of employment necessary or incidental to work in a state listed in the Schedule. 3. The 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 exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. We Will Pay We will pay an amount equal to the benefits that would be required of you if you and your employees described in the Schedule were subject to the workers compensation law shown in the Schedule. We will pay those amounts to the persons who would be entitled to them under the law. C. Exclusions This insurance does not cover: 1. any obligation imposed by a workers compensation or occupational disease law, or any similar law. 2. Bodily injury intentionally caused or aggravated by you. D. Before We Pay Before we pay benefits to the persons entitled to them, they must: 1. Release you and us, in writing, of all responsibility for the injury or death. 2. Transfer to us their right to recover from others who maybe responsible for the injury or death. 3. Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. Copyright, 1992 National Council on Compensation Insurance, Inc. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 11 A (Ed. 4-92) (Continued) If the persons entitled to the benefits of this insurance fail to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. E. Recovery From Others If we made 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 (Employers Liability Insurance) applies to bodily injury covered by this endorsement as though the State of employment shown in the Schedule were shown in item 3.A. of the Information Page. Schedule Designated Workers Employees State of Employment Compensation Law All Employees IN IN Copyright, 1992 National Council on Compensation Insurance, Inc. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INST - 1 (Ed 6-98) INSTALLMENT BILLING SCHEDULE This endorsement forms a part of policy number 6000001248 issued to Richmond City of by EMPLOYERS SECURITY INSURANCE COMPANY. Billing — Direct Installment Option — ME - 12 equal Transaction Due Date Premium Installment No 01 03/16/2012 $11,154.00 Installment No 02 04/01/2012 $11,100.00 Installment No 03 05/01/2012 $11,100.00 Installment No 04 06/01/2012 $11,100.00 Installment No 05 07/01/2012 $11,100.00 Installment No 06 08/01/2012 $11,099.00 Installment No 07 09/01/2012 $11,099.00 Installment No 08 10/01/2012 $11,098.00 Installment No 09 11/01/2012 $11,098.00 Installment No 10 12/01/2012 $11,098.00 Installment No 11 01/01/2013 $11,098.00 Installment No 12 02/01/2013 $11,098.00 * Please note that the above installments do not include installment fees. EMPLOYERS SECURITY INSURANCE COMPANY 25 Race Avenue PO Box 83777 Lancaster, PA 17608-3777 and EMPLOYERS' LIABILITY INSURANCE POLICY In Witness Whereof, we have caused this policy to be executed and attested, and, if required by state law, this policy shall not be valid unless countersigned by our authorized representative. caew jP' . Michael L. Boguski, President Scott C. Penwell, Secretary If you need to report a claim, please call the following telephone number: 1-800-336-3658 Questions or concerns about your policy should be directed to your producer. If you need further assistance, contact us at 1-888-654-7100 or at the following address: Underwriting — Policy Information P.O. Box 83777 Lancaster, PA 17608 wC 99 06 00 (11108)