WORKERS CO MPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

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1 WORKERS CO MPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY ABCDEFGHIJ 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 disease law of each state or territory named in Item This policy includes at its effective date the 3.A. of the Information Page. It includes any Information Page and all endorsements and amendments to that law which are in effect during schedules listed there. It is a contract of insurance the policy period. It does not include any federal between you (the employer named in Item 1 of the workers or workmen's compensation law, any Information Page) and us (the insurer named on the federal occupational disease law or the provisions Information Page). The only agreements relating to of any law that provide nonoccupational disability this insurance are stated in this policy. The terms benefits. of this policy may not be changed or waived except D. State by endorsement issued by us to be part of this State means any state of the United States of policy. America, and the District of Columbia. B. Who Is Insured E. Locations You are insured if you are an employer named in This policy covers all of your workplaces listed in Item 1 of the Information Page. If that employer is a Items 1 or 4 of the Information Page; and it covers partnership, and if you are one of its partners, you all other workplaces in Item 3.A. states unless you are insured, but only in your capacity as an have other insurance or are self-insured for such employer of the partnership's employees. workplaces. C. Workers Compensation Law Workers Compensation Law means the workers or workmen's compensation law and occupational PART ONE - WORKERS COMPENSATION INSURANCE A. How This Insurance Applies C. We Will Defend This workers compensation insurance applies to We have the right and duty to defend at our bodily injury by accident or bodily injury by disease. expense any claim, proceeding or suit against you Bodily injury includes resulting death. for benefits payable by this insurance. We have the 1. Bodily injury by accident must occur during the right to investigate and settle these claims, policy period. proceedings or suits. 2. Bodily injury by disease must be caused or We have no duty to defend a claim, proceeding or aggravated by the conditions of your suit that is not covered by this insurance. employment. The employee's last day of last D. We Will Also Pay exposure to the conditions causing or We will also pay these costs, in addition to other aggravating such bodily injury by disease must amounts payable under this insurance, as part of occur during the policy period. any claim, proceeding or suit we defend: B. We Will Pay 1. reasonable expenses incurred at our request, We will pay promptly when due the benefits but not loss of earnings; required of you by the workers compensation law. Page 1 of 6

2 2. premiums for bonds to release attachments and will do everything necessary to protect those rights for appeal bonds in bond amounts up to the for us and to help us enforce them. amount payable under this insurance; H. Statutory Provisions 3. litigation costs taxed against you; These statements apply where they are required by 4. interest on a judgment as required by law until law. we offer the amount due under this insurance; 1. As between an injured worker and us, we have and notice of the injury when you have notice. 5. expenses we incur. 2. Your default or the bankruptcy or insolvency of E. Other Insurance you or your estate will not relieve us of our We will not pay more than our share of benefits and duties under this insurance after an injury costs covered by this insurance and other occurs. insurance or self-insurance. Subject to any limits of 3. We are directly and primarily liable to any liability that may apply, all shares will be equal until person entitled to the benefits payable by this the loss is paid. If any insurance or self-insurance insurance. Those persons may enforce our is exhausted, the shares of all remaining insurance duties; so may an agency authorized by law. will be equal until the loss is paid. Enforcement may be against you and us. F. Payments You Must Make 4. Jurisdiction over you is jurisdiction over us for You are responsible for any payments in excess of purposes of the workers compensation law. the benefits regularly provided by the workers We are bound by decisions against you under compensation law including those required that law, subject to the provisions of this policy because: that are not in conflict with that law. 1. of your serious and willful misconduct; 5. This insurance conforms to the parts of the workers compensation law that apply to: 2. you knowingly employ an employee in violation of law; a. benefits payable by this insurance; 3. you fail to comply with a health or safety law or b. special taxes, payments into security or regulation; or other special funds, and assessments payable by us under that law. 4. you discharge, coerce or otherwise discriminate against any employee in violation of the 6. Terms of this insurance that conflict with the workers compensation law. workers compensation law are changed by this statement to conform to that law. If we make any payments in excess of the benefits regularly provided by the workers compensation Nothing in these paragraphs relieves you of your duties law on your behalf, you will reimburse us promptly. under this policy. G. Recovery From Others We have your rights, and the rights of persons entitled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You PART TWO - EMPLOYERS LIABILITY INSURANCE A. How This Insurance Applies 2. The employment must be necessary or This employers liability insurance applies to bodily incidental to your work in a state or territory injury by accident or bodily injury by disease. listed in Item 3.A. of the Information Page. Bodily injury includes resulting death. 3. Bodily injury by accident must occur during the 1. The bodily injury must arise out of and in the policy period. course of the injured employee's employment 4. Bodily injury by disease must be caused or by you. aggravated by the conditions of your employment. The employee's last day of last Page 2 of 6

3 exposure to the conditions causing or 5. Bodily injury intentionally caused or aggravated aggravating such bodily injury by disease must by you; occur during the policy period. 6. Bodily injury occurring outside the United 5. If you are sued, the original suit and any related States of America, its territories or possessions, legal actions for damages for bodily injury by and Canada. This exclusion does not apply to accident or by disease must be brought in the bodily injury to a citizen or resident of the United States of America, its territories or United States of America or Canada who is possessions, or Canada. temporarily outside these countries; B. We Will Pay 7. Damages arising out of coercion, criticism, We will pay all sums that you legally must pay as demotion, evaluation, reassignment, discipline, damages because of bodily injury to your defamation, harassment, humiliation, dis- employees, provided the bodily injury is covered by crimination against or termination of any this Employers Liability Insurance. employee, or any personnel practices, policies, acts or omissions; The damages we will pay, where recovery is permitted by law, include damages: 8. Bodily injury to any person in work subject to the Longshore and Harbor Workers' 1. For which you are liable to a third party by Compensation Act (33 USC Sections ), reason of a claim or suit against you by that the Nonappropriated Fund Instrumentalities Act third party to recover the damages claimed (5 USC Sections ), the Outer against such third party as a result of injury to Continental Shelf Lands Act (43 USC Sections your employee; a.), the Defense Base Act (42 USC 2. For care and loss of services; and Sections ), the Federal Coal Mine 3. For consequential bodily injury to a spouse, Safety and Health Act (30 USC Sections 801- child, parent, brother or sister of the injured 945) any other federal workers or workmen's employee; provided that these damages are the compensation law or other federal occupational direct consequence of bodily injury that arises disease law, or any amendments to these laws; out of and in the course of the injured 9. Bodily injury to any person in work subject to employee's employment by you; and the Federal Employers' Liability Act (45 USC 4. Because of bodily injury to your employee that Sections 51-60), any other federal laws arises out of and in the course of employment, obligating an employer to pay damages to an claimed against you in a capacity other than as employee due to bodily injury arising out of or in employer. the course of employment, or any amendments to those laws; C. Exclusions 10. Bodily injury to a master or member of the crew This insurance does not cover: of any vessel; 1. Liability assumed under a contract. This 11. Fines or penalties imposed for violation of exclusion does not apply to a warranty that your federal or state law; and work will be done in a workmanlike manner; 12. Damages payable under the Migrant and 2. Punitive or exemplary damages because of Seasonal Agricultural Worker Protection Act bodily injury to an employee employed in (29 USC Sections ) and under any violation of law; other federal law awarding damages for 3. Bodily injury to an employee while employed in violation of those laws or regulations issued violation of law with your actual knowledge or thereunder, and any amendments to those the actual knowledge of any of your executive laws. officers; D. We Will Defend 4. Any obligation imposed by a workers com- We have the right and duty to defend, at our pensation, occupational disease, expense, any claim, proceeding or suit against you unemployment compensation, or disability for damages payable by this insurance. We have benefits law, or any similar law; the right to investigate and settle these claims, proceedings and suits. Page 3 of 6

4 We have no duty to defend a claim, proceeding or A disease is not bodily injury by accident unless suit that is not covered by this insurance. We have it results directly from bodily injury by accident. no duty to defend or continue defending after we 2. Bodily Injury by Disease. The limit shown for have paid our applicable limit of liability under this ''bodily injury by disease - policy limit'' is the insurance. most we will pay for all damages covered by E. We Will Also Pay this insurance and arising out of bodily injury by We will also pay these costs, in addition to other disease, regardless of the number of amounts payable under this insurance, as part of employees who sustain bodily injury by any claim, proceeding or suit we defend: disease. The limit shown for ''bodily injury by disease - each employee'' is the most we will 1. Reasonable expenses incurred at our request, pay for all damages because of bodily injury by but not loss of earnings; disease to any one employee. 2. Premiums for bonds to release attachments Bodily injury by disease does not include and for appeal bonds in bond amounts up to the disease that results directly from a bodily injury limit of our liability under this insurance; by accident. 3. Litigation costs taxed against you; 3. We will not pay any claims for damages after 4. Interest on a judgment as required by law until we have paid the applicable limit of our liability we offer the amount due under this insurance; under this insurance. and H. Recovery From Others 5. Expenses we incur. We have your rights to recover our payment from F. Other Insurance anyone liable for an injury covered by this We will not pay more than our share of damages insurance. You will do everything necessary to and costs covered by this insurance and other protect those rights for us and to help us enforce insurance or self-insurance. Subject to any limits of them. liability that apply, all shares will be equal until the I. Actions Against Us loss is paid. If any insurance or self-insurance is There will be no right of action against us under this exhausted, the shares of all remaining insurance insurance unless: and self-insurance will be equal until the loss is paid. 1. You have complied with all the terms of this policy; and G. Limits of Liability 2. The amount you owe has been determined with Our liability to pay for damages is limited. Our our consent or by actual trial and final limits of liability are shown in Item 3.B. of the judgment. Information Page. They apply as explained below. This insurance does not give anyone the right to 1. Bodily Injury by Accident. The limit shown for add us as a defendant in an action against you to ''bodily injury by accident-each accident'' is the determine your liability. The bankruptcy or most we will pay for all damages covered by insolvency of you or your estate will not relieve us this insurance because of bodily injury to one or of our obligations under this Part. more employees in any one accident. PART THREE - OTHER STATES INSURANCE A. How This Insurance Applies state were listed in Item 3.A. of the Information 1. This other states insurance applies only if one Page. or more states are shown in Item 3.C. of the 3. We will reimburse you for the benefits required Information Page. by the workers compensation law of that state if 2. If you begin work in any one of those states we are not permitted to pay the benefits directly after the effective date of this policy and are not to persons entitled to them. insured or are not self-insured for such work, all 4. If you have work on the effective date of this provisions of the policy will apply as though that policy in any state not listed in Item 3.A. of the Page 4 of 6

5 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. PART FOUR - YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered 4. Cooperate with us and assist us, as we may by this policy. Your other duties are listed here. request, in the investigation, settlement or 1. Provide for immediate medical and other defense of any claim, proceeding or suit. services required by the workers compensation 5. Do nothing after an injury occurs that would law. interfere with our right to recover from others. 2. Give us or our agent the names and addresses 6. Do not voluntarily make payments, assume of the injured persons and of witnesses, and obligations or incur expenses, except at your other information we may need. own cost. 3. Promptly give us all notices, demands and legal papers related to the injury, claim, proceeding or suit. PART FIVE - PREMIUM A. Our Manuals 2. all other persons engaged in work that could All premium for this policy will be determined by our make us liable under Part One (Workers manuals of rules, rates, rating plans and Compensation Insurance) of this policy. If you classifications. We may change our manuals and do not have payroll records for these persons, apply the changes to this policy if authorized by law the contract price for their services and or a governmental agency regulating this insurance. materials may be used as the premium basis. This paragraph 2 will not apply if you give us B. Classifications proof that the employers of these persons Item 4 of the Information Page shows the rate and lawfully secured their workers compensation premium basis for certain business or work obligations. classifications. These classifications were D. Premium Payments assigned based on an estimate of the exposures you would have during the policy period. If your You will pay all premium when due. You will pay actual exposures are not properly described by the premium even if part or all of a workers those classifications, we will assign proper compensation law is not valid. classifications, rates and premium basis by E. Final Premium endorsement to this policy. The premium shown on the Information Page, C. Remuneration schedules, and endorsements is an estimate. The Premium for each work classification is determined final premium will be determined after this policy by multiplying a rate times a premium basis. ends by using the actual, not the estimated, Remuneration is the most common premium basis. premium basis and the proper classifications and rates that lawfully apply to the business and work This premium basis includes payroll and all other covered by this policy. If the final premium is more remuneration paid or payable during the policy than the premium you paid to us, you must pay us period for the services of: the balance. If it is less, we will refund the balance 1. All your officers and employees engaged in to you. The final premium will not be less than the work covered by this policy; and highest minimum premium for the classifications covered by this policy Page 5 of 6

6 If this policy is cancelled, final premium will be G. Audit determined in the following way unless our manuals You will let us examine and audit all your records provide otherwise: that relate to this policy. These records include 1. If we cancel, final premium will be calculated ledgers, journals, registers, vouchers, contracts, tax pro rata based on the time this policy was in reports, payroll and disbursement records, and force. Final premium will not be less than the programs for storing and retrieving data. We may pro rata share of the minimum premium. conduct the audits during regular business hours 2. If you cancel, final premium will be more than during the policy period and within three years after pro rata; it will be based on the time this policy the policy period ends. Information developed by was in force, and increased by our short rate audit will be used to determine final premium. cancellation table and procedure. Final Insurance rate service organizations have the same premium will not be less than the minimum rights we have under this provision. 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. PART SIX - CONDITIONS A. Inspection D. Cancellation We have the right, but are not obligated to inspect 1. You may cancel this policy. You must mail or your workplaces at any time. Our inspections are deliver advance written notice to us stating not safety inspections. They relate only to the when the cancellation is to take effect. insurability of the workplaces and the premiums to 2. We may cancel this policy. We must mail or be charged. We may give you reports on the deliver to you not less than ten days advance conditions we find. We may also recommend written notice stating when the cancellation is to changes. While they may help reduce losses, we take effect. Mailing that notice to you at your do not undertake to perform the duty of any person mailing address shown in Item 1 of the to provide for the health or safety of your Information Page will be sufficient to prove employees or the public. We do not warrant that notice. your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. 3. The policy period will end on the day and hour Insurance rate service organizations have the same stated in the cancellation notice. rights we have under this provision. 4. Any of these provisions that conflict with a law B. Long Term Policy that controls the cancellation of the insurance in this policy is changed by this statement to If the policy period is longer than one year and comply with that law. sixteen days, all provisions of this policy will apply E. Sole Representative as though a new policy were issued on each annual anniversary that this policy is in force. The insured first named in Item 1 of the Information C. Transfer of Your Rights and Duties Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive Your rights or duties under this policy may not be notice of cancellation. 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. Page 6 of 6

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