n Filing/ Filing at a Glance Companies: Great American Insurance Company, Great American Assurance Company, Great American Insurance Company of New York, Great American Alliance Insurance Company Alt Mkts Excess Farm SERFF Tr Num: GACX- State: Wisconsin Employers' Liability Exclusio G126939229 TOI: 17.1 Other Liability-Occ Only SERFF Status: Closed-Filed State Tr Num: Sub-TOI: 17.1020 Commercial Umbrella and Co Tr Num: State Status: Excess Filing Type: Form Reviewer(s): Shasta Hoffhein Author: SPI GAICSPI Disposition Date: 12/09/2010 Date Submitted: 12/09/2010 Disposition Status: Filed Effective Date Requested (New): 03/10/2011 Effective Date (New): Effective Date Requested (Renewal): 03/10/2011 Effective Date (Renewal): General Information Project Name: n Status of Filing in Domicile: Pending Filing Project Number: Domicile Status Comments: Reference Organization: Reference Number: Reference Title: Advisory Org. Circular: Filing Status Changed: 12/09/2010 State Status Changed: Deemer Date: 01/07/2011 Created By: SPI GAICSPI Submitted By: SPI GAICSPI Corresponding Filing Tracking Number: Filing Description: The Great American Insurance Group wishes to place on file the following new form for our Commercial Excess Liability Program: GAI 66 97 (Ed. 12/10) - Farm Employers' Liability Exclusion The purpose of this optional endorsement is to exclude Farm Employers' Liability when the Excess Liability Coverage form is written over a policy that utilizes ISO's Farm Employers' Liability and Farm Employees' Medical Payments Insurance to provide sub-limited farm employer's liability coverage.
n Filing/ This endorsement does not have any premium impact. Company and Contact Filing Contact Information Sharon Geiger, Sr. Product Analyst sgeiger@gaic.com 49 East 4th Street 513-333-6950 [Phone] Cincinnati, OH 45202 513-333-6996 [FAX] Filing Company Information Great American Insurance Company CoCode: 16691 State of Domicile: Ohio 580 Walnut Street Group Code: 84 Company Type: Cincinnati, OH 45202 Group Name: Great American State ID Number: Insurance Group (513) 369-5000 ext. [Phone] FEIN Number: 31-0501234 --------- Great American Assurance Company CoCode: 26344 State of Domicile: Ohio 580 Walnut Street Group Code: 84 Company Type: Cincinnati, OH 45202 Group Name: Great American State ID Number: Insurance Group (513) 369-5000 ext. [Phone] FEIN Number: 15-6020948 --------- Great American Insurance Company of New CoCode: 22136 State of Domicile: New York York 580 Walnut Street Group Code: 84 Company Type: Cincinnati, OH 45202 Group Name: Great American State ID Number: Insurance Group (513) 369-5000 ext. [Phone] FEIN Number: 13-5539046 --------- Great American Alliance Insurance Company CoCode: 26832 State of Domicile: Ohio 580 Walnut Street Group Code: 84 Company Type: Cincinnati, OH 45202 Group Name: Great American State ID Number: Insurance Group (513) 369-5000 ext. [Phone] FEIN Number: 95-1542353 --------- Filing Fees
n Filing/ Fee Required? Retaliatory? Fee Explanation: Per Company: No No No
Correspondence Summary n Filing/ Dispositions Status Created By Created On Date Submitted Filed Shasta Hoffhein 12/09/2010 12/09/2010
Disposition n Filing/ Disposition Date: 12/09/2010 Effective Date (New): Effective Date (Renewal): Status: Filed Comment: Used with form filings that are subject to file & use under s. 631.20(1)(c) and (1m) Wis. Stat. Effective July 1st, 2008, changes in insurance law exempted certain policy forms from receiving prior approval before use. This filing may be used 30 days after receipt by OCI. USE DATE:01/07/2011 Rate data does NOT apply to filing. Overall Rate Information for Multiple Company Filings Overall Percentage Rate Indicated For This Filing 0.000% Overall Percentage Rate Impact For This Filing 0.000% Effect of Rate Filing-Written Premium Change For This Program $0 Effect of Rate Filing - Number of Policyholders Affected 0
n Filing/ Schedule Schedule Item Schedule Item Status Public Access Supporting Document Appraisal or Arbitration Provision Filed Yes Supporting Document Certification of Compliance Filed Yes Supporting Document Explanatory Memo Filed Yes Form FARM EMPLOYERS LIABILITY EXCLUSION Filed Yes
Form Schedule n Filing/ Schedule Form Name Form # Edition Form Type Action Action Specific Readability Attachment Item Status Date Data Filed FARM GAI 66 97 (Ed. Endorseme New 0.000 GAI 66 12/09/2010 EMPLOYERS LIABILITY EXCLUSION 12/10) XS nt/amendm ent/conditi ons 97_12-10 - Farm Employers Liability Exclusion.P DF
Administrative Offices 580 Walnut Street Cincinnati, Ohio 45202 Tel: 1-513-369-5000 GAI 66 97 (Ed 12 10) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance under the following: EXCESS LIABILITY COVERAGE FORM FARM EMPLOYERS LIABILITY EXCLUSION The following exclusion is added to Section IV. EXCLUSIONS: Any liability, including, but not limited to, settlements, judgments, costs, charges, expenses, costs of investigations, or the fees of attorneys, experts, or consultants: 1. for which coverage is afforded by any of the underlying insurance pursuant to a FARM EMPLOYERS LIABILITY AND FARM EMPLOYEES MEDICAL PAYMENTS INSURANCE endorsement; 2. because of bodily injury to: a. an employee of any Insured, arising out of and in the course of: or (1) employment by any Insured; or (2) performing duties related to the conduct of any Insured s business; b. the spouse, child, parent, brother or sister of that employee, as a consequence of paragraph 2.a. above. This exclusion applies whether the Insured may be liable as an employer or in any other capacity and to any obligation to share damages with or repay someone else who must pay damages because of the injury. This endorsement does not change any other provision of the policy. GAI 66 97 (Ed. 12/10) XS
Rate Information n Filing/ Rate data does NOT apply to filing.
n Filing/ Supporting Document Schedules Item Status: Status Date: Bypassed - Item: Appraisal or Arbitration Provision Filed 12/09/2010 Bypass Reason: N/A Comments: Item Status: Status Date: Satisfied - Item: Certification of Compliance Filed 12/09/2010 Comments: Attachment: WI - CERTIFICATE OF COMPLIANCE.PDF Item Status: Status Date: Satisfied - Item: Explanatory Memo Filed 12/09/2010 Comments: Attachment: Explanatory Memo.PDF
Ins 6.05 Appendix A CERTIFICATE OF COMPLIANCE I, Tony C. Pedoto, CPCU, AIC, AIAF, (name), an officer of Great American Insurance Company (See Attached) (company name), hereby certify that I have authority to bind and obligate the company by filing this (these) form(s). I further certify that, to the best of my information, knowledge and belief: 1. The accompanying form(s) as identified by the attached listing comply(ies) with all applicable provisions of the Wisconsin Statutes and with all applicable administrative rules of the Commissioner of Insurance; 2. The form(s) does (do) not contain any inconsistent, ambiguous, or misleading clauses; 3. The form(s) does (do) not contain specification or conditions that unreasonably or deceptively limit the risk purported to be assumed in the general coverage of the policy form(s); 4. The only variations from a form currently on file with the commissioner of insurance and the only unconventional policy provisions are clearly marked or otherwise indicated pages of the attached form(s) or in an attachment; and 5. The attached form(s) is (are) in final printed format or typed facsimile and is (are) as will be offered for issuance or delivery in Wisconsin after approval by the Commissioner of Insurance, except for hypothetical data and other appropriate variable material. (signature) Divisional Vice President (title) 12/9/10 (date) Individual responsible for this filing: Name: Sharon A. Geiger Title: Sr. Product Analyst Address: 49 East 4th Street Cincinnati OH 45202 Phone Number: 513-333-6950 Date: 12/9/10 Register, March, 2008, No. 627 INS02291
Additional Companies Company Name(s) Great American Assurance Company Great American Insurance Company of New York Great American Alliance Insurance Company Register, March, 2008, No. 627 INS02291
Great American Insurance Company Great American Alliance Insurance Company Great American Assurance Company Great American Insurance Company of New York Commercial Excess Liability Coverage Form Filing Explanatory Memorandum COMMERCIAL EXCESS LIABILITY PROGRAM (GAI 6524 06/97) GAI 66 97 (Ed. 12/10) XS Farm Employers Liability Exclusion The purpose of this optional endorsement is to exclude Farm Employers Liability when the Excess Liability Coverage form is written over a policy that utilizes ISO s FL 04 65 10 06 Farm Employers Liability and Farm Employees Medical Payments Insurance to provide sub-limited farm employer s liability coverage. This endorsement does not have any premium impact.