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`Michael A. Marcelli, Esq., SBN 163929
`Kathleen A. Sauer, Esq. SBN 167411
`MARCELLI LAW OFFICES,
`A Professional Law Corporation
`2655 First Street, Ste. 250
`Simi Valley, CA 93065
`Telephone: (805) 527-7875
`Facsimile: (805) 527-7048
`Email: kasauer@marcellilaw.com
`
`Attorneys for Plaintiff
`
`8/9/2021
`
`SUPERIOR COURT OF THE STATE OF CALIFORNIA
`
`COUNTY OF SAN MATEO
`
`Oak River Insurance Company, a Nebraska
`
`Case No.: 20-CIV-04394
`
`corporation,
`
`Plaintiff,
`
`vs.
`
`)
`)
`)
`)
`)
`)
`PLAINTIFF'S EXHIBITS IN SUPPORT
`) OF REQUEST FOR ENTRY OF
`)
`COURT JUDGMENT
`)
`[CCP 5851
`)
`)
`Casera, Inc., a corporation and Does 1 through ) HEARING DATE: August 25, 2021
`)
`TIME: 9:00 a.m.
`100, Inclusive,
`) DEPT: 2
`)
`)
`) UNLIMITED CIVIL JURISDICTION
`)
`)
`)
`)
`)
`
`Defendants.
`
`
`
`TO THE HONORABLE COURT
`
`COMES NOW, Plaintiff, Oak River Insurance Company and Submits its Exhibits In
`
`Support of Its Request for Entry of Judgement as follows:
`
`/ / /
`
`/ / /
`
`/ / /
`
`EXHIBITS IN SUPPORT OF COURT JUDGMENT - I
`
`

`

`1
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`EXHIBIT 1:
`
`Pertinent excerpts from Oak River Insurance Company policy no.
`
`CAWC929094
`
`EXHIBIT 2:
`
`Pertinent excerpts from Oak River Insurance Company policy no.
`
`CAWC036920
`
`EXHIBIT 3:
`
`Pertinent excerpts from the Worker's Compensation Insurance Rating
`
`Bureau's Uniform Statistical Reporting Plain
`
`EXHIBIT 4:
`
`Letter dated October 18, 2019 from Plaintiff to Defendant regarding audit
`
`requirements.
`
`EXHIBITS:
`
`Letter dated November 22, 2019 from Plaintiff to Defendant regarding
`
`audit requirements.
`
`EXHIBIT 6:
`
`Letter dated December 9, 2019 from Plaintiff to Defendant regarding audit
`
`requirements.
`
`EXHIBIT 7:
`
`December 24, 2019 Notice of Non-Compliance Worker's Compensation
`
`Invoice and May 6, 2020 Final Audit Endorsement for Policy CAWC929094.
`
`EXHIBIT 8:
`
`January 30, 2020 letter from Plaintiff to Defendant regarding audit
`
`requirements.
`
`EXHIBIT 9:
`
`February 19, 2020 letter from Plaintiff to Defendant regarding audit
`
`requirements.
`
`EXHIBIT 10: March 5, 2020 letter from Plaintiff to Defendant regarding audit
`
`requirements.
`
`EXHIBIT 11: March 20, 2020 Notice of Non-Compliance Workers' Compensation
`
`Invoice and May 6, 2020 Final Audit Endorsement for policy CAWC036920.
`
`EXHIBIT 12: April 30, 2020 copy of Ins. Code Section 11760.1 letter and a scanned
`
`copy of the certified receipt from Oak River's Mail Services.
`
`EXHIBIT 13: Miscellaneous correspondence between Plaintiff and Defendant's
`
`insurance agent respecting the formation of policy CAWC929094.
`
`EXHIBIT 14: Miscellaneous correspondence between Plaintiff and Defendant's
`
`insurance agent respecting the formation of policy CAWC036920.
`
`EXHIBITS IN SUPPORT OF COURT JUDGMENT -2
`
`

`

`EXHIBIT 15: USPS.com tracking information.
`
`Dated: August 9, 2021
`
`Respectfully submitted,
`
`MARCELLI LAW OFFICES, A PLC
`
`By:
`
`Michael A. Marcelli, Attorney
`for Plaintiff, Oak River Insurance
`Company
`
`1
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`2
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`EXHIBITS IN SUPPORT OF COURT JUDGMENT - 3
`
`

`

`NCCI# 15458
`
`Oak River Insurance Company
`
`WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
`This information page with "Policy Provisions" completes the below numbered
`
`Insured's Name and Mailing Address - ITEM 1
`Casera, Inc.
`1755 E. Bayshore Road, Suite 14A
`Redwood City, CA 94063
`
`Other Workplaces, not shown above:
`SEE LOCATION SCHEDULE ATTACHED
`
`Federal Employer I.D. No. 47-4018835
`
`Policy No. CAWC929094
`
`Renewal Or Rewrite Of No. CAWC821822
`
`Agent: CAH02885
`
`UVIS - MICHELETTI INSURANCE SERVICES
`99 Almaden Boulevard Suite 800
`San Jose, CA 95113
`
`Issue Date: 11/01/2018
`Servicing Office: San Francisco
`Bureau I.D. No.
`7290843
`
`Effective - ITEM2:
`
`Form of Business:
`
`From: 11/01/2018 To: 11/01/2019 at 12:01 A.M. Standard Time at the insured's mailing address
`Ei Individual
`
`0 Partnership El Corporation El Joint Venture
`
`0 Other
`
`Coverage - ITEM3:
`A. Workers compensation Insurance: Part One of the policy applies to the Workers compensation Law
`of the states listed here.
`
`CA
`
`B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A.
`The limits of our liability under Part Two are:
`Bodily Injury by Accident
`Bodily Injury by Disease
`Bodily Injury by Disease
`
`$1,000,000 Each Accident
`$1,000,000 Policy Limit
`$1,000,000 Each Employee
`
`C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
`All States Except: ND, OH, WA, WY
`
`D. This poky includes these endorsements and schedules: See Schedule Attached
`
`Premium - ITEM4: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and
`Rating Plans. All information required below is subject to verification and change by audit.
`
`Classification
`
`Code
`No.
`
`Premium Basis Total
`Estimated Annual
`Remuneration
`
`Rates Per
`$100 of
`Remuneration
`
`Estimated Annual
`Premium
`
`See Schedule Attached
`
`Premium Adjustment Period: Annual
`
`Total Estimated Annual Premium:
`
`$ 25,478
`
`WC 99 03 12
`(Ed. 7-12)
`
`1
`
`

`

`WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
`
`EXTENSION OF INFORMATION PAGE
`
`Policy Information Page Schedule
`
`Item 4
`
`Insured Name: Casera, Inc.
`
`Effective Date: 11/01/2018
`
`Expiration Date: 11/01/2019
`
`Classification
`State California
`
`Effective 1/01/2018-11/01/2019
`
`Building Operation N.O.C.
`
`Budding Operation N.O.C.
`
`Blanket Waiver of Subrogation
`
`Experience Modification
`
`Risk Adjustment
`
`Tot Est Standard Premium 11/01/2018-11/01/2019
`
`Premium Discount
`
`Minimum Premium
`
`$3,000
`
`Tot Est Standard Premium for California
`
`Policy Number: CAWC929094
`
`Code
`No.
`
`Premium Basis Total
`Estimated Annual
`Remuneration
`
`Rate Per
`$100
`Remuneration
`
`Estimated
`Annual
`Premium
`
`8740
`
`9015
`
`0930
`
`9898
`
`0063
`
`IF ANY
`
`2.23
`
`0
`
`450,000
`
`10.47
`
`47,115
`
`1.020
`
`.740
`
`942
`
`-12,495
`
`-10,171
`
`25,391
`
`.051
`
`-13
`
`25,378
`
`WC 99 03 13
`(Ed. 9-14)
`
`2
`
`

`

`WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
`
`EXTENSION OF INFORMATION PAGE
`
`Policy Information Page Schedule
`
`Item 4
`
`Policy Number: CAWC929094
`
`Insured Name: Casera, Inc.
`
`Effective Date: 11/01/2018
`
`Expiration Date: 11/01/2019
`
`Policy Totals
`
`Total Estimated Premium for California
`
`Expense Constant
`
`Total Estimated Annual Premium
`
`CA CA Workers Compensation Administration Revolving Fund 11/01/2018-11/01/2019 0.8146%
`
`CA CA Workers Compensation Fraud Account Assessment 11/01/2018-11/01/2019 0.2550%
`
`CA CIGA Surcharge 11/01/2018-11/01/2019 2.0000%
`
`CA CA Subsequent Injuries Benefits Trust Fund Assessment 11/01/2018-11/01/2019 0.3599%
`
`CA CA Uninsured Employers Benefits Trust Fund Assessment 11/01/2018-11/01/2019 0.0573%
`
`CA CA Occupational Safety and Health Fund Assessment 11/01/2018-11/01/2019 0.2655%
`
`CA CA Labor Enforcement and Compliance Fund 11/01/2018-11/01/2019 0.2150%
`
`Total Estimated Cost for CAWC929094
`
`25,378
`
`100
`
`25,478
`
`208
`
`65
`
`510
`
`92
`
`15
`
`68
`
`55
`
`26,491
`
`WC 99 03 13
`(Ed. 9-14)
`
`3
`
`

`

`WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
`
`PremPayTable
`
`Insured Name:
`
`Casera, Inc.
`
`Effective Date:
`
`Expiration Date:
`
`11/01/2018
`
`11/01/2019
`
`Policy Term
`
`11/01/2018 - 11/01/2019
`
`Premium Payment Table
`
`Policy No.
`
`CAWC929094
`
`Due Date
`
`11/15/2018
`
`12/24/2018
`
`01/23/2019
`
`02/25/2019
`
`03/25/2019
`
`04/23/2019
`
`05/23/2019
`
`06/24/2019
`
`07/23/2019
`
`08/23/2019
`
`Premium
`
`$4,834.70
`
`$2,406.26
`
`$2,406.26
`
`$2,406.26
`
`$2,406.26
`
`$2,406.26
`
`$2,406.26
`
`$2,406.26
`
`$2,406.26
`
`$2,406.22
`
`$26,491.00
`
`4
`
`

`

`WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
`
`WC 00 00 00 C
`
`(Ed. 1-15)
`
`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:
`
`PART ONE
`WORKERS COMPENSATION INSURANCE
`
`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 Infor-
`mation Page) and us (the insurer named on the In-
`formation 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
`policy.
`
`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 em-
`ployer 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.
`
`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 ag-
`gravated by the conditions of your employment.
`The employee's last day of last exposure to the
`conditions causing or aggravating such bodily in-
`jury 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 benefits
`payable by this insurance. We have the right to in-
`vestigate 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;
`litigation costs taxed against you;
`interest on a judgment as required by law until
`we offer the amount due under this insurance;
`and
`5. expenses we incur.
`
`3.
`4.
`
`E. Other Insurance
`We will not pay more than our share of benefits and
`costs covered by this insurance and other
`
`0 Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.
`
`Page 1 of 6
`
`5
`
`

`

`WC 00 00 00 C
`
`(Ed. 1-15)
`
`WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
`
`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
`because:
`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. Enforce-
`ment 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 oth-
`er 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 inci-
`dental 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 in-
`jury by disease must occur during the policy
`period.
`If you are sued, the original suit and any related
`legal actions for damages for bodily injury by ac-
`cident or by disease must be brought in the
`United States of America, its territories or pos-
`sessions, or Canada.
`
`5.
`
`B. We Will Pay
`We will pay all sums that you legally must pay as
`damages because of bodily injury to your employ-
`ees, provided the bodily injury is covered by this
`Employers Liability Insurance.
`The damages we will pay, where recovery is permit-
`ted by law, include damages:
`1. For which you are liable to a third party by rea-
`son of a claim or suit against you by that third
`party to recover the damages claimed against
`
`0 Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.
`
`Page 2 of 6
`
`6
`
`

`

`WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
`
`WC 00 00 00 C
`
`(Ed. 1-15)
`
`9. Bodily injury to any person in work subject to the
`Federal Employers' Liability Act (45 U.S.C. Sec-
`tions 51 et seq.), any other federal laws obligat-
`ing 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, and does not cover punitive dam-
`ages related to your duty or obligation to provide
`transportation, wages, maintenance, and cure
`under any applicable maritime law;
`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
`U.S.C. Sections 1801 et seq.) 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 ex-
`pense, any claim, proceeding or suit against you for
`damages payable by this insurance. We have the
`right to investigate and settle these claims, proceed-
`ings 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.
`
`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 em-
`ployee; provided that these damages are the di-
`rect 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 exclu-
`sion does not apply to a warranty that your work
`will be done in a workmanlike manner;
`2. Punitive or exemplary damages because of bodi-
`ly 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 compensa-
`tion, occupational disease, unemployment com-
`pensation, or disability benefits law, or any simi-
`lar 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 outside
`these countries;
`7. Damages arising out of coercion, criticism, de-
`motion, evaluation, reassignment, discipline,
`defamation, harassment, humiliation, discrimina-
`tion 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 U.S.C. Sections 901 et seq.), the
`Nonappropriated Fund Instrumentalities Act (5
`U.S.C. Sections 8171 et seq.), the Outer Conti-
`nental Shelf Lands Act (43 U.S.C. Sections 1331
`et seq.), the Defense Base Act (42 U.S.C. Sec-
`tions 1651-1654), the Federal Mine Safety and
`Health Act (30 U.S.C. Sections 801 et seq. and
`901-944), any other federal workers or work-
`men's compensation law or other federal occu-
`pational disease law, or any amendments to the-
`se laws;
`
`M Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.
`
`Page 3 of 6
`
`7
`
`

`

`WC 00 00 00 C
`
`(Ed. 1-15)
`
`WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
`
`F Other Insurance
`We will not pay more than our share of damages
`and costs covered by this insurance and other in-
`surance or self-insurance. Subject to any limits of li-
`ability that apply, all shares will be equal until the
`loss is paid. If any insurance or self-insurance is ex-
`hausted, 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 3.8. 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 dis-
`ease, regardless of the number of employees
`who sustain bodily injury by disease. The limit
`shown for "bodily injury by disease—each em-
`ployee" 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 dis-
`ease that results directly from a bodily injury by
`accident.
`3. We will not pay any claims for damages after we
`have paid the applicable limit of our liability un-
`der 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.
`
`I. Actions Against Us
`There will be no right of action against us under this
`insurance unless:
`1. You have complied with all the terms of this poli-
`cy; 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 deter-
`mine your liability. The bankruptcy or insolvency of
`you or your estate will not relieve us of our obliga-
`tions under this Part.
`
`PART THREE
`OTHER STATES INSURANCE
`
`2.
`
`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 Infor-
`mation Page.
`If you begin work in any one of those states after
`the effective date of this policy and are not in-
`sured 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 pol-
`icy in any state not listed in Item 3.A. of the In-
`formation 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
`by this policy. Your other duties are listed here.
`1. Provide for immediate medical and other ser-
`vices required by the workers compensation law.
`2. Give us or our agent the names and 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 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.
`
`Page 4 of 6
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`8
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`WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
`
`WC 00 00 00 C
`
`(Ed. 1-15)
`
`papers related to the injury, claim, proceeding
`or suit.
`4. Cooperate with us and assist us, as we may re-
`quest, in the investigation, settlement or defense
`of any claim, proceeding or suit.
`5. Do nothing after an injury occurs that would in-
`terfere with our right to recover from others.
`6. Do not voluntarily make payments, assume obli-
`gations 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 classifica-
`tions. We may change our manuals and apply the
`changes to this policy if authorized by law or a gov-
`ernmental agency regulating this insurance.
`
`B. Classifications
`Item 4 of the Information Page shows the rate and
`premium basis for certain business or work classifi-
`cations. 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.
`
`C. Remuneration
`Premium for each work classification is determined
`by multiplying a rate times a premium basis. Remu-
`neration is the most common premium basis. This
`premium basis includes payroll and all other remu-
`neration 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 Com-
`pensation Insurance) of this policy. If you do not
`have payroll records for these persons, the con-
`tract 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 em-
`ployers of these persons lawfully secured their
`workers compensation obligations.
`
`D. Premium Payments
`You will pay all premium when due. You will pay the
`premium even if part or all of a workers compensa-
`tion 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, premi-
`um 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 bal-
`ance. 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 de-
`termined 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.
`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.
`
`2.
`
`F. Records
`You will keep records of information needed to com-
`pute 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 ledg-
`ers, journals, registers, vouchers, contracts, tax re-
`ports, payroll and disbursement records, and pro-
`grams for storing and retrieving data. We may con-
`duct the audits during regular business hours during
`the policy period and within three years after the pol-
`icy 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.
`
`@ Copyright 2013 National Council on Compensation Insurance, Inc. An Rights Reserved.
`
`Page 5 of 6
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`WC 00 00 00 C
`
`(Ed. 1-15)
`
`WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
`
`PART SIX—CONDITIONS
`A. Inspection
`We have the right, but are not obliged to inspect
`your workplaces at any time. Our inspections are not
`safety inspections. They relate only to the insurabil-
`ity 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 organiza-
`tions have the same rights we have under this
`provision.
`
`B. Long Term Policy
`If the policy period is longer than one year and six-
`teen 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 af-
`ter your death, we will cover your legal representa-
`tive as insured.
`
`D. Cancelation
`1. You may cancel this policy. You must mail or de-
`liver advance written notice to us stating when
`the cancelation is to take effect.
`2. We may cancel this policy. We must mail or de-
`liver to you not less than ten days advance writ-
`ten 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 com-
`ply 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.
`
`(2 Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.
`
`Page 6 of 6
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`

`WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
`
`WC 00 04 21 D
`(Ed. 1-15)
`
`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 a 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 22 B), 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