1
`
`Readc A Bramer SBN 294016
`Elizabeth A Lee SBN 312957
`BACON L L P
`2 SHOOK HARDY
`One Montgomery Suite 2700
`San Franc sco California 94104 4505
`a s sa4 i yoo
`Teiepnone
`4J 5 391 0281
`4 Facsimile
`
`3
`
`F 1 L E D
`SUPERIOR COURT OF CALIFORNIA
`COUNTY OF SAN BERNARDINO
`SAN BERNARDINO DISTRICT
`
`NqqY
`
`6 2017
`
`Attorneys for Plaintiff
`COMMERCE AND INDUSTRY INSURANCE COMPANY
`
`BY
`
`u
`AMBER M
`
`R DEPUTY
`
`SUPERIOR COURT OF THE STATE OF CALIFORNIA
`
`COUNTY OF SAN BERNARDINO
`
`COMMERCE AND INDUSTRY INSURANCE
`COMPANY
`
`Case No CIVDS1701860
`
`c
`
`Plaintiff
`
`vs
`
`TOP PROFESSTONAL NETWORK LLC
`
`Defendant
`
`DECLARATION OF PLAINTIRF
`COMMERCE AND WDUSTRY
`INSURANCE COMPANY S DIRECTOR
`LEGAL COLLECTiON5 IN SUPPORT OF
`PLAINTiFF S REQUEST FOR COURT
`JUDGMENT
`
`Tn support of Plaintiff Commerce and Ind stry Insurance Company s Commerce
`
`request
`
`for courtjudgment
`
`I Catherine Bantly state
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`1
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`2
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`I am over the a e of eightcen years and am competent to make this declaration
`
`As an employee of the Law Department of AIG Property Casualty U S
`
`formerly
`
`Chartis U S
`
`I am authorized to make fhis declaration on behalf of Commerce a wholly owned
`
`subsidiary of AiG Property Casualty U S a division of ATG Property Casualty inc
`I am the Director Legal Collections for Plaintiff Commerce
`
`3
`
`As part of my
`
`responsibilities 1 maintain care custody and control of the file with respecc to Commerce s contracts
`
`and policies including those concerning Top Professional Network LLC Top Professional
`
`I
`
`BCLARATION OF PLAINTIFF S UIRFCTUF LEGA4 CbLLECTfONS SO Y4NNTIFP S
`REQUFST POR CnUR C JODGMGhT
`
`37 3064 V I
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`5
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`6 7 8 9
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`l0
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`ll
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`I
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`1
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`have personal knowledge of the Pollowing facts uid could if called and sworn as a witness
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`competently testify thereYo
`
`4
`
`In 2014 Commerce issued I op Professional Workers Compensation and Employers
`
`Liability Insurance Policy No WC 1613242 01314227 the Policy
`
`for the period August 15 2014
`
`to August 15 2015 Exhibit A is a true and conect copy oFthe Policy obtained from the Records
`
`6 Custodian
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`7
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`8
`9
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`10
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`13
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`14
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`IS
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`5
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`The Policy with all endorsements and schedules incorporated therein issued to Top
`
`a contract of insurance Uetween Commerce and Top
`Professional at coverage inception w s
`Professional See Exhibit A General Section of tl e Policy Subsection A p l of 6
`
`6
`
`Because Top Professional s
`
`fina payroll amounts could not be determined with
`
`certainty until after the end of the Policy Commerce billed Top Professional an initial estimated
`
`premium at
`
`the beginning of the Policy Period The Policy specifically states that the premium
`
`initially charged to Top Professionul
`
`is an estimate
`
`and the 6nal premium will bc determined
`
`after this policy ends by using the actual payroll and he proper classifications and rates determined
`
`via an audit Althougli provisional classifications and rates were assigned at the inception of the
`
`16 Policy based upon the information provided by Top Professional
`
`the audit process determined the
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`17
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`24
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`proper classifications rates and premium Uasis that applied to Top ProfessionaPs actual operations
`
`See Exhibit A Part 5 B E and G
`
`7
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`Pursuant
`
`to the Policy Commerce provided Top Professional with insurunce
`
`coverage for any bodily injury caused by accident or disease that was covered by the Policy s terms
`
`and occurred regarding Top Professional s employecs during the Policy period See Exhibit A Part
`
`Two Employers Liability lnsurance Section A p 2 of 6
`
`8
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`Pursuaz t to the terms aud couditions of tl c Policy Top Professional agreed to pny
`
`Commerce an estimated premium which Commerce calculated based upon documents and or
`
`information provided by Top ProfcssionaL See Exliibit A PatK 5
`
`9
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`Pursuant
`
`to the terms and conditions of the Policy Top Professional aoreed to pay
`
`Commerce a
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`tinal
`
`remium deterrnined after
`
`the Policy ended and calculated using Top
`
`2
`UCCLARATIpN UF P4AINTIfF S UTAGCTOR LLGAL COLLCCTIONS I50 PLAINTIPI S
`REQUES I FpR COURT JUDGMENT
`
`378064 VI
`
`

`

`l
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`Pcofessit nal s
`
`ietital paproll anr
`
`r per classiEicaticrns asid rates determinec3 via audlt See Bxhitiit
`
`2 A PartS G and Ci
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`3
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`4
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`5
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`6
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`I 1
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`t ap PresfessianaS ncce atcd t1 e insuruace cavera c unt cr Che I olic
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`vhich rzt uircc
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`1 a Professional tcr pay all premiums dwe See Hxhibit A C7an 3 I
`
`1 I
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`12
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`13
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`Commerce utly pe rformid sIt nc essaey cotiditic s aCt2ie Patiey
`
`The Ptiliey was i anoellcd n Aap 18 Z015
`
`Camrncrce conducted u pliysica audit af Tqp Professrc nal s books and records for
`
`thc Rolicy the Pqlicy Audit
`
`In thm Policy Audit Cammerce found thnt
`I5 T 288 63 in a lditionu insura ice reminEn
`
`1 op Prafessional a ved
`
`14
`
`On or about Navember Ifi 201G an invqicc was issued to Top Professionai for die
`
`outstandin insuranee prerniu n ofS157 28ti 63 due under tlie olicy Exhibit 13 is 1 true snd corrcct
`
`copy of the invoice oBtained 1 rom thc Records
`
`5to iian
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`15
`
`1 op Prafessional breaehed thc trrms of the contraet as s eciCked in the Poliey by
`
`l i
`
`15
`
`5 G
`S F
`failing to puy the premium awcd under Ute Policy See Lshibit A Parts 5 E
`Under tlie Policy Top
`ro essional agreed to remit the premium due and owing to
`ib Commerce but has failed to da so despite repeated anenrpis to collect payment
`
`16
`
`17
`
`Camrnerec has been damaged by f op Prvfessiona s breach in the ainountspecific8
`in Commerce s Request for Cnun lucigment
`
`t dectare under pcnalty of perjury of thc taws nnder the State of California that thc Faregoing
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`is vue and correct
`
`bA I E
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`1 7
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`f7
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`r
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`ptL 1 l
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`Cr1 IIERENE BAt t LY OI
`CflLL CTION5
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`Y f
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`CTOR LEGAL
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`17
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`araor v i
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`fit Ci11RA I ItSA Oi
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`iRl C fTRt i t nt COi LE C ClOt151Stt1 S AINTSFI S
`t k AiNl 13 t y i
`Ri1QUF5T FGR C011R1 JUI Gp7GNT
`
`

`

`Eifective 12 01 AM 08 15 2014
`
`Polioy No WC
`
`001 61 32b2
`
`IssuedtoTOP PROFESSIONAL NElWORK LLC
`
`By COMMERCE AND INDUSTRY INSURANCE COMPANY
`
`Partners n Productivity
`RiskTool System
`https www ai g com SWC
`
`Specialty Workers Compensation
`A division of AIG
`
`NOTICE TO POLICYMOLDER
`
`isk
`ioss p evention an9
`This notice is to alert ryou to Specialry Workera Cc mpensaifon s online
`management
`Iatform cal ed RiskTool S stem RiSkToo1 5 stem can assist ou in managing tlie risks
`Y
`P
`Y
`Y
`yourcompany and employees fece everyday
`
`As a valued customer you carcemploy this tool to assess youcspecific needs take steps to prevent
`injuries from occurting and build a d monitor your own loss prevention a d risk management program
`
`The RiskTool System can
`httos lwww aig com SWC
`
`be
`
`accessed at
`
`our Partneis
`
`in Productivity we6site
`
`at
`
`The site can also provide you with
`
`information about us frequently asked questions and Contact Us access
`information on workers compensation insurance
`the ability to locate medical providers fon an injured worker
`lhe abiiity to report voluntary premium audits and
`news and links to retate i workers compensation we6sites
`
`When accessing the Partners in Productivity website have youc policy cbse by so that you can entec the
`following information
`
`Policy Number
`Ageni or Broker Number
`Issuing Company
`
`This valuable service is only available to current policyholders and their brokers
`
`tf you have questions please call us toll free at 1 800 645 2259
`
`Mem6er Comnanies of AIG
`American Home Assurance Corripany AIG Assuranca Company AIU Ilnsurance ComPany
`Commerce and lndustry Insurance Company Granite State Insurance Company illinas National
`Insurance Company New HampShire9nsurance Company National Unio Fire Insurance Company
`of Pittsburgh Pa T he insurance Company of the State of Pennsylvania
`
`SWCPN
`Ed 12 09
`
`Archive Copy
`
`

`

`POIfCYHOLDER NOTICE
`
`Thank you for purchasing insucance from a AIG company AIG companies generally
`pay compensatiorn to 6rokers and inilependenf agents
`and may haye paid
`compensation in connection with your policyc You can review and olitain
`information about the nature and range of compensation paid by AIG companias
`to brokers and independent agents in tfie United States by Jisiting our website at
`www aig com producercompensation or by calling AIG at1 800 706 3102
`
`siz22
`
`Zio
`
`f64
`
`pY
`
`

`

`COMMERCE AND INDUSTRY IN URANCE COMPANY
`i5 i 72
`
`0075190 00
`
`l
`
`001 61 3242
`058 82 oBt4 t
`t
`
`TOP PROFESSIONAL NETWORK LLC
`i1030 ARRDW RTE STE 207
`RANCHO CUCAMONGA CA 91730 0000
`
`SEE EXTENSfON Of ITEAA 1 OF THE INPORMATION PAGE WC9y0610
`I D
`
`I
`
`I
`
`An AIG company
`
`EXECUTIVE OFFlCES
`6 WMer Stroqt
`Now York NY 0088
`
`ftS COMPEN3A710N ANDEMPLOYERSi
`WORI
`CIABWTYPOk1CY INFORMATION PACiE
`
`dNC
`
`PMC 1NSURANCE AGENCY
`209 BURLINGTON ROAD
`SUITE 109
`0 OOQO
`BEDFORD MA 0
`PREVIOUS POLiCYNIJM@Eq
`1NSURED 5
`LIMITED LIABILITY LOMPANY
`00767 242
`OTHER WORKPWCE6 NOT 6H6WN ABOVEr SEE EXTEN610N OF ITEM 1 OF THE INFORMATION PAGE WC990610
`E 12
`POIIGVPER10D1t Ot AM tandartl timeatlhoincund s
`ma111n0atlCreca
`
`08 151 15
`iu
`08 1 5 lA
`irem s q Workers Compensa0on Insurance Part One of the policy applles to the Workers Compensatlon Law of the states Ilsted
`here
`
`fROM
`
`CA
`
`B Emplayers Lia6ility Jnsuranca Part Two of the policy applies tp ho work in each state listed in item 3A
`The fimlts of our liabllity under Ped Two a ez
`7 000 000 eacli aceident
`Bodily Injury by AccidenL
`1 r00U r000 po icy limit
`Bodily Jnjvey by Disease 5
`1 00O OOO eaeh employee
`Bodlly InJury byDlseasu S
`
`C Othci Statea Insurenco Pert Thrce of the poliry applles to tfia st5tos lf any I stcd ho ci
`AK AL AR AZ tC0 CT DC DE F GA Ni
`IA ID IC N KS KY LA MA MD ME Md MN HO MS MT NC NE NH
`NJ NM NV NY OK OR IPA RI SC SD TN TX UT VA VT WI WV
`
`D Tliis policy Iniludes fheseiendorsements au i sctiedufe
`SEEEXTENSIONOF JTEM3 D OFTHEiNFORMATION PAGE WCJ906 11 r
`i EMa Thatpiemium for tfiis poHry will be detorni aed 6y aur Maa6als of Rules Classificatians Raterand Radng Plansi
`AIISinformatiorcaequirad 6elow is su6 acf to vsri iczNnn anH cfiange by auditb
`
`O aslficallons
`
`Qetle Numbor
`
`Remium Basis
`Ralo Por
`Totalk ntuneration
`S70o0PR
`Year munoratlon
`
`Mnuel
`
`Fslimalatl
`A amium
`
`p nWl
`
`3 Y0 i
`
`SEE EXTENSION OF ITEM 4 OF THE INFORMATION PAGE NC77Sd
`TAXES ASSESSMENTS SURCNARGES
`
`11 96
`
`E PCNSECpNBTANT EMCEPTWNERBAPyP LICABLBBYSTATE
`
`Z3O rCA
`
`MININUMPqEMIUM
`
`y rjO CA
`1CIOW IMfYlf11 Y1 1ISIIfIC I 6 W 1fERllllfllShallbE TfiflY
`
`ifI11 liGll
`
`1
`
`R17 LESTMAIEDANNUAL PREMIUM
`
`P6J O4 I
`
`ett11 MnUally
`
`Qlartedy
`
`Moltthty
`
`OEPOSIT PREMIIIb
`
`03 10115 PARSIRPANY
`
`beue Dme
`
`39B67 f Jd Mf
`
`Arch ve Copy
`
`lesulnp Office
`
`A tM1otiS tl Repraeantallva
`
`WC QO 00 OIA
`
`

`

`EXTENSION OF IT@M 3 D O TWE INFORMATION PAGE
`
`Policy Number
`
`1dC
`
`001 61 3242
`
`Effective Date
`
`OB 15 2014
`
`TRSMNOTA
`WC000114
`WC000301A
`MfC00D406
`WC000421C
`WC000422A
`WCOFAC
`107437
`55154WC
`PN049401E
`PN0499068
`PN049907
`PN99040T
`WC040002A
`WC0403016
`WC040303
`WC040310
`WC040317
`WC040361
`WCD40402
`WC040421
`WC040422
`WC990017
`WCgg0909
`WC990410
`WC990670
`
`FOREIGN TERRORISM POlHOLDR NOT PREM DTMN
`NOT ENDT OF PENDING f AW CHG TRIPRA 2007
`ALTERNATE EMPQOYER ENpORSEMENT
`PREMIUM DISCOUNT ENDORSEMENT
`CATASTROPNE PREMIUM EN60RSEMENT
`TRIRRA DISGLOSURE ENDORSEMENT
`NOTICE REG OFFICE OF FOREIGN ASSET CTRL
`PRIVACY POLfCY
`CALlfORNIA FRAUD ASSESSMENT
`POLlCYHOIDER NOTICE
`DUAL 41AGE POLICYHOLDER NOTICE
`CA
`AUDIT DUAL WAGE NIGH WAGE CONST
`CA
`CA NOTIF OF 10SS CONTROL SERVIGES
`CA ADMINISTRAIIDN REVOIVING FUND ASMNT
`CA
`POL9CY AF9EtiDATORY ENDT
`CA OFF f CERSBDIRECTORS COV EXCLUS IpN ENDT
`CA
`DUTY TO DEFENO
`CA EMPLOYEE INSURED BY GEN EMFLOYER EXCL
`CA BLANKET WAIVER
`CA MANDATQRY RATE CHANGE ENDT
`OPTIONAL PREMI UM INCREASE ENDT
`CA
`CA SHORT RATE CANCELLAT ON ENDT
`CALIFORNIA CANCELLATION ENDORSEMENT
`CA POI ICYHO DER NOTICE
`CIGA SURCHARGE
`POLICYNOLDER NOTICE
`NAMEp INSUREDS ADpRESSES
`
`WC 99 O6 12
`Ed 1l97 Rev d 04 08
`
`C 1 I E CO 1
`
`

`

`WORKERS COMPEPdSATlO V AND EMPLOYERS LIABILITY
`
`INSURANCE POLICY
`
`Na ional Union F e Insurance Company ot Piltsbu gfi Pa
`American Home Assurance Company
`The Insurance Company of TKe State of PennsylJania
`AIG PlOpefty CeSu8lty CompOny
`Commerce and Indusiry lnsurance Company
`Granite State Insurance Company
`Illinois National Insurance Company
`New Hampshire Insurance Company
`
`I
`
`xEcurivEOFFices
`17S WATER STREET 78TH GLOOR
`NEW YORK NY 10038
`
`Coverage is provided by tfie Company designaied on the information Page
`A Slock Insurance Company
`
`WORl
`
`RRS COMPEN5ATION AND EMPIOYERS UABWTY INSURANCE POWCY
`QUiCK REFERENGE
`
`CEyER1L8ECTTON
`
`A
`
`The Policy
`B Who Is Insured
`
`C Workers Compensation Law
`
`D State
`
`E
`
`Locations
`
`PART QNF WORKERti C INPENtiAT10 V iI SURA CE
`Now This iosurance Applies
`A
`E We Will BaY
`C Wa WIII Defend
`We Wiil Also PaY
`E
`Other Insurance
`Payments You Must Make
`F
`G RecoverY From 9thers
`Statutory Provisions
`H
`
`BEGINNING ON
`PAGE
`
`1
`
`1
`
`1
`
`1
`
`1
`
`t
`
`t
`
`1
`t
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`t
`
`1
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`2
`2
`
`2
`
`ftiN ABOVK RFb p RN Nf F p POL ICI YNOYISIORti WI fH 1 NK INNORNA 1 ION YAGE AVU F NDORSHMt N Pti
`IF A Y ISSUED TO ORh1 A P 1RT TFIf RFbF COAIPLETF THIS POL Cl
`
`WC 00 00 00 B STANDARO
`Ed 04 92J ReWd OB 10
`Archive Copy
`
`

`

`1
`
`i
`
`QUICK REFEREMCE
`
`60NTINUEO
`
`BEGINNINf ON
`PAGE
`
`PART TWO EMPL61 ERS I IABIL TY IBS6RAKCE
`A How This Insuranca APPlies
`B W e W I I I
`f ay
`C Euclusions
`
`D We Will Defend
`E We Will Also Pay
`F Other Insurance
`
`GLimits of Liability
`H Recovery From Pthers
`Action Againsl Us
`
`PART 7 iRFF OTRER STA7 I S TNSl7RA fF
`A How This Insuranco APPlies
`
`B Notiue
`
`YAR P I Uti YOUR DU74ES Ii
`
`IN lOItY OCCU1iS
`
`PART FI VN PNEDtIUM
`A Our Manuals
`
`B Ciassifications
`
`C Remuneratlon
`
`D Premium Payments
`E Fnal Premium
`
`F Records
`
`G Audit
`
`PAR7 SIX CON DITIOYS
`
`A In sPection
`lang Term PolicY
`G Transfer of Your Rights and Dulies
`
`6
`
`D Cancollation
`E Sole RePresen a ive
`
`2
`2
`2
`3
`
`3
`3
`
`4
`
`A
`
`4
`
`4
`
`d
`
`4
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`4
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`4
`
`5
`5
`5
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`@
`
`b
`5
`
`5
`
`5
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`6
`
`6
`
`6
`
`6
`6
`
`6
`
`PLEASE READ THE WORlCERS COMPEWSA710N AND EANpLOYERS LlABILJTY POLICY CARF ULLY
`
`Arci ive c rY
`
`I
`

`

`i
`
`WORKERS COMPENSATION AND EMPIOYER5 LIABILITY INSURANCE POUCY
`
`in returrtfor the payment of ttie premium and su6ject to
`ierms oi this policy we agree withryou as tollows
`all
`
`PART ONB
`WORKERS COMPENSATION INSURANCE
`
`GENERAL SECTION
`
`A The Poilcy
`its effective date the Infor
`This policy includes at
`maiion Page and aU endo sements and scfiedules
`is a contract of nsurance betw8en
`bsted there
`It
`you5 tfie err pioyennamed in item l ol the Informs
`tian Page and us the insurer named on the lnfo c
`Tfie only agreements relating o this
`insurance are stated in this polary The tenns oi ihis
`policy may not he cfianged or waived excspt
`tiy
`entlorsemenY issued by us to tie part of this polioy
`
`maliontPage
`
`B Who is insured
`You are insured if ou are an em lo er named iny p y
`
`
`Ilem i oi the information Bage
`If tfiaisemployeris a
`pertnership rand iif you are one oi
`itsrpertners you
`6ut only in your capaciiy as ari
`are insurad
`employer of ttie partneiship s empipyees
`
`Wo kers Compensation taw
`Workers Compensation law means the workers or
`faw and
`wakriien s compensation
`occupational
`in Item
`disease law ofaeach state o tenitory nemeri
`3 A rof
`the dnformation Page
`Il
`includes any
`amendments ioithat
`law which ars in effect iiuring
`the policy period
`It does not include any federai
`workers or workmen s corrmpensation law anyfed
`erei occupational disease law or thet provisions of
`any law stfiat prodide nonoccupational
`i isa6iliry
`benefits
`
`S4ate
`the United States of
`State means any s4ate of
`America and tHe Districtot Columbia
`
`E Locations
`This policy covers atl oi yourwoikQlaces listed in
`Items t or 4 of the Information Page and it covers
`all other workplaces in tkem 3 A states unless you
`have other insurance or are self insured for such
`workplaces
`
`A How This Insurance Applies
`This workers compensation insurance applies to tio
`diiy injury by accident or bodiry in ury by disease
`Bodily in ury includes resulting death
`1
`Bodily inyury by accideni must oacur during tfie
`policy penod
`Bodily in ury fiy disease must be ca sed ovag
`gravated tiy the cotlditions of your aempiqyment
`The employee s last day of lasi exposure to the
`c mtlitions causing or
`ggravating such bodily
`injury by dfsease must
`ioccur during the policy
`period
`
`2
`
`x
`
`6 We WIII Pay
`Wewill
`pay prompily when due the tienefits requiretl
`of you tiy the wbrkers compensation law
`
`C VNe V11111 Defend
`We have the rigfit and dury to defentl ata ou ex
`pense any claim proceeding or suit against you tor
`benefits payable 6y this insurance We have tfie
`riyht
`lo investigate and settle these claims pro
`ceedings or suits
`We fiaye no d ity to defend a claim proceeding or
`suit that is not covered by tHis insurance
`
`x
`
`request
`
`II Aiso Pay
`D We
`We wiil also pay these costs in additionrto other
`amourits paya6le under this insurance as part of
`any claim proceeding orsuit we defend
`t reasonable expenses incurced at our
`but not loss of eamings
`2 Rremiurtis forhonds ta eleasr attachmenta a d
`zfoc appeaC tronds in 6ond arriounts up to the
`amounYpayalileundertfiis insuranee
`Iitigatron costs taxed against you
`interesi on a judgrrient astequiredoby law untii
`we oNer
`theramounf due under this insurance
`
`3
`4
`
`5
`
`and
`expenses we incur
`
`Ei Othec lnsurance
`VVe will not pay more than our share of benefits and
`costs covered by this insurance end other
`
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`Archlve Copy
`CopyNght 2009 Natlonal Council on Compansation lnsuronco Ine AI Righta Rescrvod
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`iriaurance o self insurance Subject to ny limita of
`all shares wiil be equal until
`liab riity that may apply
`the Ioas is pnid
`If any insurance o Se4f insuranae is
`extiausted tlie sfiares of aS rerriaining insurance wiil
`be equai untii pie loss is paid
`
`F Payrrsents You Must Make
`Vou are responsitile fpi any payments in excess ot
`the benefits Iregularly provided by the workers
`eampensatlon daw inoluding Yhose rsguired bo
`causs
`
`1
`2
`
`3
`
`of your serious and willful misconduct
`yau knowing y emplay an empEoyee in iriolaticin
`of law
`you fail to complywith a fi ealth or safetylaw br
`raguladbn ror
`you dischetge coeice or otlierwiSe disarimiriat
`againslpany emplqyee in yiolationaof the workers
`compensation law
`ff we make anY Payments in ezcess of the benefits
`regularty provideds y the workeis compe satEoo law
`on your behalf you will refrii6urse us prcrmptly
`
`4
`
`G Recovety Frorn Others
`We have yQur righis and the rigfits of persons en
`titled to the ksenefits dithis insuiance t8recoveriout
`payments framranyaneslratiie far ifie ihjury Yau wiil
`do everything ecessary to pcotecf thosa ifc hts or
`us and to help us enfarce tliam
`
`N Statutory Frcivfsians
`Thess statements apply where they are requitedl5y
`law
`1
`
`As between an injured worker and us we have
`noNce of the in ury when nu kiave notice
`2 Your default or the bankrupkcy or inso yency of
`you or youc estate wili not telieve us ot our dU
`ties under tfiis insurancs alter a injury occurs
`3 We are dire cilp and primari y fiiahlat ta any psr
`son entiilecl Hyo ttie benefits ayablc by ihis in
`Those persons may enforce our
`surance
`duties so map an ag iicy authorized by lew
`Enforcernent may be against us or ac ainst yois
`antl us
`Jwisdic ion aver you is junsdicti6n pvet us tor
`pqrpase afttiepworkers comperisat oritiawi We
`are bound iby decisions againstr ypv under tfiat
`iaw subject to tho provisiane of this poiicy thai
`are not in conflict with that tew
`5 This insurance canforms to ihe parts af the
`
`4
`
`workers ca ripensalion law thaP ya ly i
`a
`tiensfits payable l y this insurance
`h
`speciai
`taxes
`iayrrients into seciarity or
`other sP ciai funds and assessments pay
`iable byius itnder that law
`Terms of
`this insurance thai conFlict with the
`workers compensatiori
`law are ctiar ged by tfiis
`statement to conform to tfiat iaw
`Nothing in rirese paragraphs relieves you of your du
`ties undarthis pnlicy
`
`6
`
`PART TWO
`EMPLOYBRS LIABILITY iNSURANCE
`A How Thi
`Insnrance Aprpiies
`This emptoyere liability insurance appiies tocbodily
`i Jury by accidenteor bodily injury by tlisease Bodily
`injury riciudes result ng desth
`ti The l odily injury musk arise out of and jn the
`coursebf thr
`in ured empioyee s empioyment by
`you
`Z Tha empinymsnt musi be necessery or inclderr
`taltto pour work in a state or terrilory lisYed in
`Iterri 3 A of 0e information iFage
`3 Bodlty nNryi bp accident inust occur during t4e
`paiicy period
`4 Boitily injury by diseasa musLpe caused or ag
`gravated 6y the ronditicans flf your erriployment
`The empfoyae s East day
`l
`iast exgosure kb the
`conditions causing ar aggravating such t odily
`in ury by diaesse mast occur during the policy
`
`period
`
`5
`
`tiie orsgina3 suit antl any reiaied
`if you are suei
`leyal actions for darrrages for botlily injury by
`accident or liy disease musl becbrought
`in ttie
`United States of Rmerica
`i s Fecritories ar
`pos sessions oi Canada
`
`B We Wi11 Pay
`We witl pay a i sums hei youF Iegally inust pay as
`damages aecsuse of bodily injury to yaur
`ern
`ployees provided the bodily injury is coJered by tliis
`Empioyers Liabitity lnsurance
`The damages we wili pay wfiere recovery is permit
`ted by Iaw includa dameges
`t
`Fprwtiich y6u a e liaGls to athilyd pa ty Byrea
`sonzof aclairii or suft against you 6y fhat tt rii
`partyto reooyer thetdamagesciaimed ageinst
`
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`m Gopytlght 2008 Natlunal Cpunci on Compons6tlan Insurancc Inc All RlQhts Rcsnrvod
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`

`9 Botlily in ury to any pereon in work subject to tfie
`Federal Ernployers
`Liability Act
`45 USCs
`any
`other
`federal
`laws
`51 60
`Secpons
`obligating an employer 110 pay damagas to an
`employee due to bodily injury arising out of ot in
`the course obempioyment or any amendm nls
`to those laws
`10 Bodily injury fo a masteror member of the c ew
`of any vessel
`imposed for violation of
`11 Fines or penafties
`federai o state law and
`12 Damages payable under the Migrant and Sea
`sonal Agricuiturai Worker Protection Act
`29
`USG Sections 1801 1872 and under any olher
`tederal
`law awarding damages for violation of
`those laws o regulations aissued lhere under
`and any amendments to lhose laws
`
`D We Will Defend
`We have the ijht and duty io defend at our ex
`pense any claim proceeiling or suit against you for
`damages rpaya6le by 1his insurance We have tFie
`right to investigate and settle these claims proceed
`ings and suits
`Weofiavo no duty Yo defend a claim proceeding o
`suit tfiat is not covered by tfiis insurance We fiave
`no duty to dsfend or continue defending afte we
`have paiii our applicable limit of liabilily underthis
`insurance
`
`E We Wilf AIso Pay
`We wilP also pay thesc costs win addiUon to oltien
`amounts payable under tfiis insurance as pert of
`any ciairri procee8mg o suit we defend
`1
`Reasonable cexpenses incu rred at our request
`but noY loss of earnings
`2 Premiums for bonds io release attachmenis and
`forappeaFtionds in band amounts up to the limii
`ofrourHabiuty under this insurance
`Litigation costs taiced against you
`f
`terest on a judgmanf as requiFedyby Iaw untiL
`we offer the amount due under tfiis nnsurance
`antl
`5 Ezpenses we incur
`
`3
`4
`
`such tFiird party as a result of injury to your
`mp oy
`For care antl lass of services and
`2
`3 For eonsequenUal
`liodily injury to a spouse
`child pa enh brolher or sister of
`ifie inju ed
`employee provided that these damages areritie
`direct consequence oi bpddy injury that arises
`in
`the iinjuied
`the cou se of
`out of and
`empioyee s employmeni by you and
`4 Because ot bodily injury to youn empioyee that
`a ises out of and in tfie course oi employment
`ctaimed against you in a capacity othertthan a
`employe
`
`G Exelusions
`This insurence does nof cover
`This
`1
`Liabiliiy assumed under a coMract
`ezclosion does not apply to a warranty that your
`worli will 6e done in a woricmanlike mannerj
`2r Punitive oc exemplaryr damages tiecause oLbo
`dily injury to an emplyyee employed imviolffiion
`of law
`Bodily injury to an employee while employed in
`law witti your ectuals knowledge oC
`violation of
`the actual knowledges of any af your exeoutive
`officersr
`
`3
`
`4
`
`6
`
`Any
`6y
`imposed
`a workers
`obligation
`compensafion occupational disease unernploy
`ment compensa4ion or disatiiliry benefits law or
`any similai law
`5 Bodify injury inlentionally causetl4or aggravatetl
`qy you
`8odily njury occurring outside tfie United Siates
`of America ifs teiritories or possessions
`and
`Canada Thisexclusion does nohapply to bodily
`injury to a citizem or residont of ihe United
`Stafes of America or Canada wfio is temporarily
`outside iHese countiies
`T Demages adsing out df coercion criticism de
`rtiotion evaluation reassignment disciplino de
`famation
`haressment
`hurciiliation
`discrimina
`jion against or termination of any employee or
`any
`personnel
`policies
`acts or
`pPaclices
`omissions
`8 Bodily injury to any person in work sutiject Fo the
`Longshore and Heiba N orkers Compensation
`33 USC Sections
`901 950
`the
`Act
`5
`Non appropriated fund lnstrumentalities Act
`the
`buter
`USC Sections
`817 1 8173
`Contlnental Shelf Cands Act 43 USC Sectlqns
`1331 1356aj
`the Defense Base Act 42 USC
`Sections 1651 1554
`the FederaP Coal Mine
`Safety and Heaith Act
`30 USC Sections
`807 945
`any other
`ederal workers
`or
`workmen s compensalfo i law or other fedeial
`occupational disease law or any amendments to
`these Iaws
`
`qrchive Copy
`wc o0 00 0o s
`Ed 7111
`O Copyright 2009 Natiunaltounail ori Compensation Ir suranoeLlnc Ai Rights Raserved
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`a or s
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`

`F Other insuranca
`We will not pay more than our sfiare nt damages
`anif ciists caveieci by this insuras ce and ather
`inaurance or self insuranoe Subject to a y limlt of
`tailiry that apply all shares wi I be equal untiilthe
`li
`loss is paid fany insurance oc selGinsuience is
`ezhausted the stsaresof ail remaining Insuranceand
`sel
`insurenGe will be equaP until tfie loss is paid
`
`G Llmits af Liablltty
`Our tiab lly fo pay tnr demagea s IimiEod Ouraifm ts
`of Ifabllity are slirnvn in Item 3 8 of 3he info meiibn
`Page 7hey apply as
`xplained below
`8odity injury by Accider t
`The iimit shawn far
`1
`tiodily injury by acciderit eaoh accideot
`is the
`most we will pay far all damagescovered by this
`insurance because of bodily injury to one or
`more eniptoyees ica any one aesidAnt
`A disease isr ot bodily injurylby aqcident unless
`it results directly irnrn bodily injuryby accidenL
`The limit showrs for
`2 Bodily injury by t isease
`bodtly ir jury i y dissaSe po4 Cy limi
`is the mosf
`we will pay for ail damages cbvereti by this
`insuranbe and arising out raP tiodily injury k y
`disease reg dlass o the humbei of emptoyeEs
`The liniit
`who sustain tiodilyriltjury k y disease
`ilisease each
`bddily
`injury
`by
`for
`sFiown
`is the niosi we will pay tai all
`employee
`damages 6eca se of boiliiy injury by disease to
`any one empioyee
`include
`does nat
`Bodily
`injury by diseas
`disease that resuits direqtiy ftom a badiiy injury
`Dyaqcident
`3 We will r ql pay any claims tardamages aften we
`have paid iihe applicable lirnib of our
`liatii ity
`under this insurance
`
`H Rmccvery From Othora
`W i have ya ur rights to recovdr our paymenl irorr
`anyotie liable tor an injury coyered by iiis insurance
`Ypu wili do everylhinc necessary to prertect
`ifios
`ri hts for us and to hslp usienfarce tfiem r
`9
`
`I ActionsAgainsf Us
`lhare wiU be no righk of aclion against us undertYiis
`insurance unlBsx
`1
`You heve compfied with aIt the terms of this
`policy and
`
`2 Tfia amount you owe hes beed deterniinetl witN
`ou consent pNby acluai tna and final judgment
`This irisurance d4es nitt give ariyone the righti tci adtf
`us as ardetendant in an acian against you to detei
`mi e yiiur liahility The dankruptcy
`cinso rtency of
`yod ar your estate will not
`relieye us of oun
`o6ligatiansuncler this Part
`
`PAF2T TM13EE
`QTNER STATES iMSURAPI
`
`A How This fnsurance Applies
`1
`ihisaother states insurance applies anfy if one op
`mbie sfates aie shawn inuftem 3 G oi ttie nfar
`mationpage
`2 If you begin work irt any one of those states af
`ier the effeckive date of this policy and are noi
`in ured ar are not salf insured tor such work aS
`provisions ofilhe policy wiil apply as ttiough tfiat
`stat were listed in ftema3 A pf the infnrmation
`Page
`3 WB wiii retmburse you for ihe benefis required
`by t fie wo icers compensatron law of that state if
`we are nof pe rmifted lo pay the benefits direcUy
`to p rsosis enfiEied ta tfieinc
`this
`if yau have work on tfie effective date of
`policy in any state riot listed im Item 3 A af tfie
`iritprmation Page cave age wNl not ba affo ded
`foc tiat state riCess we are nofified wilhin thirty
`days
`
`4
`
`B Natice
`Feli us at onee if yausbegin work ln rany atate Sisted
`in Item 3 G oT lhe Information Pager
`
`PART FOUR
`YOUR DUTIES IF INJURY OCCURS
`
`in ury occurs ttial may be covered
`Telltus a1 once if
`by fhis poficy You o har duties aee Iisted hsre
`1
`Piavideior imrnediatevrneBical anii otfier r ervic
`es required Ciy the workeis compensation law
`2 Give us ar puragent the names arid addresses
`of
`the injured persons and oi witnesses and
`otlier intormation we may needf
`Promptly give us elhnotices demands and tegaL
`
`3
`
`WC OQ 00 00 B
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`Copyriqht 20p9 Nztlbnai Cauncll on Comgonsatinn Inaurnnp
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`a of s
`Inc AII Rlghts Rezorved
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`

`

`4
`
`papers related to tFie injury claim proceeding or
`suit
`Cooperate with us and assist us as we may re
`in the inJestigation settlement or defense
`quest
`of any c aim proceeding oc si it
`5 Do notfiing after an injury occurs lhahwould in
`leriere with our rigfit to recovej from others
`6 Do notrooluntarily make payments assume obli
`gations or incur ezpenses except af your Q n
`costs
`
`BAR7 FIVE BREMIUM
`
`A Our ARanuals
`Alhpremium forthis policy wilf be determmed by our
`manuals of rules 7ates rrating plans and classifica
`tions We may change our manuals and apply the
`ctianges to this policy if autfiorized by law ei a go
`yemmental agency regulating tliis insurance
`
`B Classifications
`the Informalion Fage shows the 3te and
`Item 4 of
`certain
`business o wo k
`premium F basis
`for
`classifcations These classifications were assigned
`based on an estimate of tfie exposures you wouid
`have Buring ihe policy period
`If your actual
`exposures are nat psoped y describeiJ by those
`classificafions we will assign iproper classi ications
`rates and premium basis tiy endorsement
`to his
`policy
`
`C Remuneration
`Premium fo each work classificaiion Is determined
`by multiptying a rate times a pcemium basis
`Remuneretion is tfie ritost common pcemium basis
`ihis premium basis includes payroil and all other
`remuneration paid or payable duiing the policy
`period for ths services of
`1
`ail yourofticers and einployees eiigaged in woik
`cavered by Ihis policy and
`all ottier persons engaged in wrnk ltial could
`make us liable unde r Part One Workers Gorri
`pens5tion lnsuranoe ofrthis policy If you do not
`records foF lhese persons
`have payroll
`the
`for theiY servicQs and malerials
`conlract pricff
`may be usetl as tfie premium basis Tfiis para
`graph 2 will not apply rf you give us proof that
`the employers of these persons lawtulty secured
`their workers compencation obiigationsi
`
`2
`
`D Premfum Payments
`You wiQ pay all p emium v hen due You will pay the
`premium oven if part or all of a workers com
`pensation law is not valitl
`
`E Final Premium
`The premiuni shpwn on the dnformalion Page
`schedules anif endorsements is an estimete The
`finaf premium will be dete mined after tfiis policy
`ends
`6y using the
`actuai
`not
`the estimated
`premium basis and the propeF classificationa and
`rates lfiaf
`laivFully apply to ihe business and work
`coyered by this policy
`R the final premium i more
`thary the premium you paid to us you must pay ua
`the 6aiance
`If
`it
`is less we will refund the balance
`to you The finalEpramium will not be 1ess than the
`highesl minimum premium for
`the classifications
`co4eredpy this policy
`finaL premium will be
`IE this pohcy is canceled
`deiermined in the following way unless our manuals
`provide otherwise
`1
`ft we cancel
`final premium will be calGulated pro
`rata based on the time this policy was in force
`Fin l premium will not he less ttian the pro rata
`share of the mioimum preniium
`If you cancel
`final p emium will be more than
`prp rata 8 will be kiasedron the time tfiisrpolicy
`was
`in force and inc eased 6y our short rate
`cancelaiion tatiie and proceduiex Final premium
`wiil nol be less tfian the ininimum premium
`
`2
`
`F Records
`information needed to
`Vou wiil keep records of
`compute premiumr You will provide us with copies
`ofdhose records when we ask focihem
`
`G Audlt
`let us axamine and 5udit all your records
`You will
`that
`relate to this policy
`These records include
`Iedgers joumals regisiers vouchers contracts tax
`reports
`payroil
`end disbursemenb recads
`and
`programs for storing antl retrieving data We may
`conduct
`the audits dudng regular 6usiness liours
`during the policyiperiod and withimfhree years atter
`th
`policy perioill ends
`Information developed iby
`autlit wiU tie used tor deiermtne final premium
`Insyrance rate service organiiahons tiaye the same
`rights we have under thisproyision
`
`WC 00 00 OD B
`Ed 7 19
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`ACCIIlVG CO QJ
`s or s
`0 Copydpht2009 Nstional Councilbn ComponsuHon InsurSnco inc A Rights Rescrvod
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`

`

`PART SIX CONDITIONS
`
`A Inspection
`We fiave the right but aie not o6liged to inspect
`yoiir workplaces at