55-CV-23-1818
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`DISTRICT COURT
`
`THIRD JUDICIAL DISTRICT
`CASE TYPE: CONTRACT
`
`
`Court File No. 55-CV-23-1818
`Judge Christina K. Stevens
`
`
`
`
`
`
`THIRD-PARTY DEFENDANT WEST
`BEND INSURANCE COMPANY’S
`ANSWER TO THIRD-PARTY
`COMPLAINT, AND COUNTERCLAIM
`FOR DECLARATORY RELIEF
`
`STATE OF MINNESOTA
`
`COUNTY OF OLMSTED
`
`
`
`
`
`
`
`
`
`Plaintiff,
`
`Defendants,
`
`
`Austin Fredrik Hoover,
`
`
`
`v.
`
`Turf Tye Spicer and Custom Fabricating &
`Repair, Inc.,
`
`
`
`and
`
`Custom Fabricating & Repair, Inc.,
`
` Third-Party Plaintiff,
`
`v.
`
`Great American E&S Insurance Company
`and West Bend Insurance Company f/d/b/a
`West Bend Mutual Insurance Company,
`
` Third-Party Defendants.
`
`
`COMES NOW Third-Party Defendant West Bend Insurance Company f/d/b/a West Bend
`
`Mutual Insurance Company (hereinafter “West Bend”), and for its Answer to Custom Fabricating
`
`& Repair, Inc.’s Third-Party Complaint, and Counterclaim for Declaratory Relief, states and
`
`alleges as follows:
`
`ANSWER TO THIRD-PARTY COMPLAINT
`
`1.
`
`Except as hereinafter admitted, qualified, or otherwise answered, generally denies
`
`all allegations in Custom Fabricating & Repair, Inc.’s Third-Party Complaint (hereinafter
`
`

`

`55-CV-23-1818
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`“Custom” and “Custom’s Third-Party Complaint”).
`
`2.
`
`In response to the allegations in paragraph 1 of Custom’s Third-Party Complaint,
`
`admits only that this is a declaratory judgment action. Specifically denies that it breached the
`
`Employers Liability Coverage Part of the Standard Workers Compensation and Employers
`
`Liability Policy it issued to Custom for the policy period of 2/6/2021 to 2/6/2022 (hereinafter the
`
`“Policy”), and puts Custom to its strict proof thereof.
`
`3.
`
`In response to the allegations in paragraph 2 of Custom’s Third-Party Complaint,
`
`admits only that one of the bases for its coverage denial is that Plaintiff Austin Fredrik Hoover’s
`
`Complaint does not allege “bodily injury”…aris[ing] out of and in the course of the injured
`
`employee’s employment by [Custom]”, and thus does not trigger a duty to defend under the Policy.
`
`4.
`
`Paragraph 3 of Custom’s Third-Party Complaint sets forth statements and
`
`conclusions of law to which no response is required from West Bend under Civil Procedure Rule
`
`8.04. To the extent that a response is deemed required, denies same and puts Custom to its strict
`
`proof thereof.
`
`5.
`
`6.
`
`Admits the allegations in paragraph 4 of Custom’s Third-Party Complaint.
`
`The allegations in paragraph 5 of Custom’s Third-Party Complaint are directed to
`
`another third-party defendant, and thus constitute averments to which no response is required from
`
`West Bend under Civil Procedure Rule 8.04.
`
`7.
`
`8.
`
`Admits the allegations in paragraph 6 of Custom’s Third-Party Complaint.
`
`Admits upon information and belief the allegations in paragraph 7 of Custom’s
`
`Third-Party Complaint.
`
`9.
`
`Lacks sufficient information to form a belief as to the truth of the allegations in
`
`paragraph 8 of Custom’s Third-Party Complaint.
`
`
`
`2
`
`

`

`55-CV-23-1818
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`10.
`
`In response to the allegations in paragraph 9 of Custom’s Third-Party Complaint,
`
`admits only that Olmsted County is a proper venue for the determination of West Bend’s and
`
`Custom’s respective rights and obligations under the Policy, if any, with respect to the claims
`
`asserted against Custom by Plaintiff Austin Fredrik Hoover.
`
`11.
`
`The allegations in paragraphs 10 through 15 of Custom’s Third-Party Complaint
`
`are directed to another third-party defendant, and thus constitute averments to which no response
`
`is required from West Bend under Civil Procedure Rule 8.04.
`
`12.
`
`13.
`
`14.
`
`Admits the allegations in paragraph 16 of Custom’s Third-Party Complaint.
`
`Admits the allegations in paragraph 17 of Custom’s Third-Party Complaint.
`
`In response to the allegations in paragraph 18 of Custom’s Third-Party Complaint,
`
`admits only that Custom accurately quotes the initial coverage grant in the Employers Liability
`
`Policy section of the Policy.
`
`15.
`
`In response to the allegations in paragraph 19 of Custom’s Third-Party Complaint,
`
`admits only that Custom accurately quotes two of the conditions of the initial coverage grant in
`
`the Employers Liability Policy section of the Policy.
`
`16.
`
`17.
`
`Admits the allegations in paragraph 20 of Custom’s Third-Party Complaint.
`
`In response to the allegations in paragraph 21 of Custom’s Third-Party Complaint,
`
`admits only that Custom quotes part of the payment provision of the Employers Liability Policy
`
`section of the Policy. Affirmatively alleges that Custom omits from paragraph 21 of its Third-
`
`Party Complaint the qualifying clause, “provided the bodily injury is covered by this Employers
`
`Liability Insurance”.
`
`18.
`
`In response to the allegations in paragraph 22 of Custom’s Third-Party Complaint,
`
`admits only that Custom quotes part of the defense payment provision of the Employers Liability
`
`
`
`3
`
`

`

`55-CV-23-1818
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`Policy section of the Policy. Affirmatively alleges that Custom omits from paragraph 22 of its
`
`Third-Party Complaint the qualifying sentence, “We have no duty to defend a claim, proceeding
`
`or suit that is not covered by this insurance.”
`
`19.
`
`20.
`
`Admits the allegations in paragraph 23 of Custom’s Third-Party Complaint.
`
`Admits upon information and belief the allegations in paragraph 24 of Custom’s
`
`Third-Party Complaint.
`
`21.
`
`Admits that paragraphs 25 through 36 of Custom’s Third-Party Complaint describe
`
`some of the allegations and claims in Plaintiff Austin Fredrik Hoover’s Complaint, as well as
`
`Defendant Turf Tye Spicer’s default status.
`
`22.
`
`The allegations in paragraphs 37 through 40 of Custom’s Third-Party Complaint
`
`are directed to another third-party defendant, and thus constitute averments to which no response
`
`is required from West Bend under Civil Procedure Rule 8.04.
`
`23.
`
`In response to the allegations in paragraph 41 of Custom’s Third-Party Complaint,
`
`admits only that Custom notified it of Plaintiff Austin Fredrik Hoover’s Complaint, and requested
`
`defense and indemnification under the Policy.
`
`24.
`
`In response to the allegations in paragraph 42 of Custom’s Third-Party Complaint,
`
`admits only that one of the bases for its coverage denial is that Plaintiff Austin Fredrik Hoover’s
`
`Complaint does not allege “bodily injury”…aris[ing] out of and in the course of the injured
`
`employee’s employment by [Custom]”, and thus does not trigger a duty to defend under the Policy.
`
`25.
`
`Paragraph 43 of Custom’s Third-Party Complaint sets forth a conclusion of law to
`
`which no response is required from West Bend under Civil Procedure Rule 8.04. To the extent
`
`that a response is deemed required, denies same and puts Custom to its strict proof thereof.
`
`26.
`
`Admits the allegations in paragraph 44 of Custom’s Third-Party Complaint.
`
`
`
`4
`
`

`

`55-CV-23-1818
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`27.
`
`28.
`
`29.
`
`Admits the allegations in paragraph 45 of Custom’s Third-Party Complaint.
`
`Admits the allegations in paragraph 46 of Custom’s Third-Party Complaint.
`
`Admits that paragraph 47 of Custom’s Third-Party Complaint quotes part of West
`
`Bend’s reasoning in denying coverage under the Policy for the claims asserted by Plaintiff Austin
`
`Fredrik Hoover. Affirmatively alleges that the denial letter speaks, in full, for itself.
`
`30.
`
`Admits that paragraph 48 of Custom’s Third-Party Complaint quotes part of West
`
`Bend’s reasoning in denying coverage under the Policy for the claims asserted by Plaintiff Austin
`
`Fredrik Hoover. Specifically denies Custom’s allegation that it cited no legal support for the
`
`applicability of the personnel practices exclusion to negligent supervision and negligent retention
`
`claims. Affirmatively alleges that the denial letter speaks, in full, for itself.
`
`31.
`
`The allegations in paragraphs 49 through 53 of Custom’s Third-Party Complaint
`
`are directed to another third-party defendant, and thus constitute averments to which no response
`
`is required from West Bend under Civil Procedure Rule 8.04.
`
`32.
`
`In response to the allegations in paragraph 54 of Custom’s Third-Party Complaint,
`
`re-states and re-alleges the preceding paragraphs of this Answer as if fully set forth herein.
`
`33.
`
`The allegations in paragraphs 55, 57 and 58 of Custom’s Third-Party Complaint
`
`are directed to another third-party defendant, and thus constitute averments to which no response
`
`is required from West Bend under Civil Procedure Rule 8.04.
`
`34.
`
`35.
`
`Admits the allegations in paragraph 56 of Custom’s Third-Party Complaint.
`
`Specifically denies the allegations in paragraphs 59 and 60 of Custom’s Third-Party
`
`Complaint, and puts Custom to its strict proof thereof.
`
`36.
`
`The allegations in paragraphs 61 through 69 of Custom’s Third-Party Complaint
`
`are directed to another third-party defendant, and thus constitute averments to which no response
`
`
`
`5
`
`

`

`55-CV-23-1818
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`is required from West Bend under Civil Procedure Rule 8.04.
`
`37.
`
`38.
`
`39.
`
`Admits the allegations in paragraph 70 of Custom’s Third-Party Complaint.
`
`Admits the allegations in paragraph 71 of Custom’s Third-Party Complaint.
`
`Specifically denies the allegations in paragraphs 72 through 77 of Custom’s Third-
`
`Party Complaint, and puts Custom to its strict proof thereof.
`
`40.
`
`Specifically denies that Custom is entitled to any of the relief requested in the
`
`WHEREFORE clause of its Third-Party Complaint, or otherwise, from West Bend.
`
`AFFIRMATIVE DEFENSES
`
`Custom’s Third-Party Complaint fails to state a claim upon which relief can be
`
`41.
`
`granted against West Bend.
`
`42. West Bend’s coverage obligations under the Policy, if any, are subject to all policy
`
`provisions, declarations, terms, definitions, exclusions, conditions, or endorsements.
`
`43.
`
`Custom’s claims may be barred by one or more of the other affirmative defenses
`
`contemplated by Rule 8.03 of the Minnesota Rules of Civil Procedure. Whether any of these other
`
`affirmative defenses are applicable is unknown to West Bend at the time of this Answer and,
`
`therefore, so as to avoid waiver, West Bend hereby incorporates all such defenses as set forth in
`
`Rule 8.03.
`
`COUNTERCLAIM FOR DECLARATORY RELIEF
`
`
`
`West Bend, for its Counterclaim for Declaratory Relief against Custom, states and alleges
`
`as follows:
`
`INTRODUCTION
`
`1.
`
`This is a counterclaim for declaratory relief pursuant to the Uniform Declaratory
`
`Judgments Act, Minn. Stat. § 555.01 et seq.
`
`
`
`6
`
`

`

`55-CV-23-1818
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`2.
`
`An actual controversy exists between West Bend and Custom as to whether West
`
`Bend owes Custom any duty of defense or indemnification under the Policy with respect to the
`
`claims asserted against Custom by Plaintiff Austin Fredrik Hoover.
`
`JURISDICTION AND VENUE
`
`3.
`
`This Court has jurisdiction over this counterclaim pursuant to Minn. Stat. § 555.01,
`
`which provides that “Courts of record within their respective jurisdictions shall have power to
`
`declare rights, status, and other legal relations whether or not further relief is or could be claimed.”
`
`4.
`
`This action is properly venued in Olmsted County pursuant to Minn. Stat. §542.09,
`
`which allows a party to initiate suit in a county in which the cause of action or some part thereof
`
`arose. Here, some part of Plaintiff Austin Fredrik Hoover’s claims for negligent supervision and
`
`negligent retention, which give rise to Custom’s claim for coverage under the Policy, arose in
`
`Olmsted County.
`
`HOOVER’S CLAIMS AGAINST CUSTOM
`
`5.
`
`In the Complaint, Plaintiff Austin Fredrik Hoover (“Hoover”) alleges the
`
`following:
`
`
`
`
`
`
`
`a.
`
`b.
`
`c.
`
`d.
`
`Defendant Turf Tye Spicer (“Spicer”), while in the State of Minnesota for
`the purpose of engaging in business on behalf of Custom, committed an act
`in Minnesota causing injury or property damage.
`
`On or about August 24, 2021, Hoover and Spicer were present on the
`premises located at 4323 Highway 52 North, Rochester, Minnesota 55901,
`specifically the Country Inn and Suites. At all times material, Hoover and
`Spicer were employees of Custom.
`
`Hoover and Spicer were temporarily residing at the Country Inn and Suites
`with other employees of Custom for an extended period of time while in the
`Rochester area engaged in their occupations.
`
`Hoover, Spicer, employees, and supervisors of Custom were present at the
`Country Inn and Suites after they had gotten off work.
`
`7
`
`

`

`55-CV-23-1818
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`e.
`
`f.
`
`g.
`
`Spicer became angry with Hoover and his co-employees as a result of a
`verbal exchange.
`
`In reaction to the verbal exchange, Spicer struck Hoover in the head with
`his fist causing Hoover to fall to the ground and strike his head on the
`cement surface of the parking lot.
`
`As a direct result of Spicer’s striking him, Hoover has suffered serious and
`permanent injury to his head and brain, other damages including emotional
`distress and mental anguish, pain and suffering, past and future medical
`expenses, loss of earnings and loss of earning capacity and other harm.
`
`
`
`6.
`
`Based on these allegations, Hoover asserts assault and battery counts against Spicer,
`
`and negligent supervision and negligent retention counts against Custom.
`
`7.
`
`In support of the negligent supervision count, Hoover alleges the following:
`
`a.
`
`b.
`
`c.
`
`d.
`
`e.
`
`f.
`
`Spicer and Hoover were at the Country Inn and Suites solely at the behest
`of Custom to perform work for it in the general location of the hotel.
`
`While at the hotel and while on site, Hoover and Spicer were under
`Custom’s supervision.
`
`The managers and supervisors of Custom knew or should have known its
`employees, including Spicer, were engaging in consuming alcoholic
`beverages at the hotel.
`
`The managers and supervisors of Custom knew or should have known
`consumption of alcohol by their employees, and in particular Spicer,
`increased the likelihood of confrontation between its employees which
`posed a threat of physical injury to its employees or others.
`
`Despite this knowledge, Custom failed to monitor or act in any way to curb
`or regulate the consumption of alcohol by its employees, including Spicer,
`while staying at the hotel. Custom’s failure to use reasonable care to
`monitor or act in any way to curb or regulate the consumption of alcohol by
`its employees while in a location for purposes of performing work was
`negligent or reckless.
`
`As a direct and proximate result of Custom’s failure to supervise the
`activities of its employees, as alleged, Hoover has suffered serious,
`disabling, and permanent injuries.
`
`
`
`
`
`
`
`
`
`8.
`
`In support of the negligent retention count, Hoover alleges the following:
`
`8
`
`
`
`
`
`

`

`55-CV-23-1818
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`a.
`
`b.
`
`c.
`
`d.
`
`e.
`
`f.
`
`g.
`
`Upon information and belief, Spicer has had physical altercations that
`Custom either knew about or with reasonable diligence, should have known
`about.
`
`Upon information and belief, supervisors and other employees of Custom
`had witnessed Spicer get into altercation with other employees both on work
`sites and off work sites.
`
`Upon information and belief, supervisors working for Custom had
`attempted to fire Spicer for blatant violations of company policies and
`misconduct.
`
`In 2017, Spicer was charged with aggravated assault, a felony, in Butte
`County, California. Custom knew or should have known about Spicer’s
`charge with reasonable diligence. Custom knew or should have known of
`Spicer’s dangerous propensities for physical assault and that Spicer posed a
`safety risk to other coworkers, given his dangerous propensities.
`
`Despite this knowledge, Custom failed to investigate allegations of
`aggressive behavior by Spicer, discipline, discharge, or reassign him.
`
`Custom’s failure to take reasonable action to regulate, investigate,
`discipline, discharge, or reassign Spicer for his confrontational behavior
`towards his fellow employees was reckless and/or negligent. It was
`reasonably foreseeable that an employee who has propensity to confront and
`become violent with his or her co-workers would injury a co-worker if left
`unregulated.
`
`As a direct and proximate result of Custom’s failure to investigate,
`discipline, discharge, or reassigned Spicer, after it had knowledge or should
`have had knowledge of his proclivity towards confrontational and
`potentially violent behavior, as alleged, Hoover has suffered serious,
`disabling, and permanent injuries.
`
`
`
`
`
`
`
`
`
`
`
`
`
`THE WEST BEND INSURANCE POLICY
`
`9.
`
`West Bend issued a Standard Workers Compensation and Employers Liability
`
`Policy to Custom for the policy period of 2/6/2021 to 2/6/2022. A true and correct copy of the
`
`Policy is appended hereto as Exhibit A.
`
`10.
`
`The Policy’s Employers Liability Insurance applies to work in several states,
`
`including Wisconsin and Minnesota. The applicable coverage form, WC 00 00 00 C (Ed. 1-15),
`
`
`
`9
`
`

`

`55-CV-23-1818
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`provides in pertinent part as follows:
`
`PART TWO
`EMPLOYERS LIABILITY INSURANCE
`
`A. How This Insurance Applies
`
`This employers liability insurance applies to bodily injury by accident or bodily
`injury by disease. Bodily injury includes resulting death.
`
`1. The bodily injury must arise out of and in the course of the injured
`employee’s employment by you.
`2. The employment must be necessary or incidental to your work in a state or
`territory listed in Item 3.A. of the Information Page.
`3. Bodily injury by accident must occur during the policy period.
`4. Bodily injury by disease must be caused or aggravated by the conditions of
`your employment. The employee’s last day of last exposure to the
`conditions causing or aggravating such bodily injury by disease must occur
`during the policy period.
`5. If you are sued, the original suit and any related legal actions for damages
`for bodily injury by accident or by disease must be brought in the United
`States of America, its territories or possessions, or Canada.
`
`B. We Will Pay
`
`We will pay all sums that you legally must pay as damages because of bodily
`injury to your employees, provided the bodily injury is covered by this
`Employers Liability Insurance. The damages we will pay, where recovery is
`permitted by law, include damages:
`
`1. For which you are liable to a third party by reason of a claim or suit against
`you by that third party to recover the damages claimed against such third
`party as a result of injury to your employee;
`2. For care and loss of services; and
`3. For consequential bodily injury to a spouse, child, parent, brother or sister
`of the injured employee; provided that these damages are the direct
`consequence of bodily injury that arises out of and in the course of the
`injured employee’s employment by you; and
`4. Because of bodily injury to your employee that arises out of and in the
`course of employment, claimed against you in a capacity other than as
`employer.
`
`C. Exclusions
`
`This insurance does not cover:
`
`10
`
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`
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`
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`

`

`55-CV-23-1818
`
`*
`
`*
`
`*
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`
`
`
`
`
`
`
`
`
`
`7. Damages arising out of coercion, criticism, demotion, evaluation,
`reassignment,
`discipline,
`defamation,
`harassment,
`humiliation,
`discrimination against or termination of any employee, or any personnel
`practices, policies, acts or omissions; …
`
`*
`
`*
`
`*
`
`D. We Will Defend
`
`We have the right and duty to defend, at our expense, any claim, proceeding or
`suit against you for damages payable by this insurance. We have the right to
`investigate and settle these claims, proceedings and suits.
`
`We have no duty to defend a claim, proceeding or suit that is not covered by
`this insurance. We have no duty to defend or continue defending after we have
`paid our applicable limit of liability under this insurance.
`
`WEST BEND’S REQUEST FOR DECLARATORY RELIEF
`
`11.
`
`In a letter dated January 26, 2024, West Bend denied Custom’s tender of defense
`
`with respect to the claims asserted against it by Hoover in the Complaint in this action. West Bend
`
`explained that the Complaint does not allege “bodily injury”…aris[ing] out of and in the course of
`
`the injured employee’s employment by [Custom Fabricating]”, and thus does not trigger a duty to
`
`defend under the Policy. West Bend further explained that the legal theories Hoover asserts against
`
`Custom -- negligent supervision and negligent retention -- seek damages arising out of Custom’s
`
`personnel practices, acts or omissions, and thus fall within Exclusion C.7 to the Employers
`
`Liability Coverage Part, which excludes damages “…arising out of…any personnel practices,
`
`policies, acts or omissions”. A true and correct copy of the January 26, 2024 letter is appended to
`
`Custom’s Third-Party Complaint as Exhibit C.
`
`12.
`
`A controversy of a justiciable nature exists between West Bend, on the one hand,
`
`and Custom, on the other, as to whether the Policy provides coverage for the claims asserted by
`
`Hoover against Custom in the Complaint.
`
`
`
`11
`
`

`

`55-CV-23-1818
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`13.
`
`This Counterclaim for Declaratory Relief is properly initiated pursuant to Minn.
`
`Stat. § 555.01 et seq. to obtain a determination as to whether West Bend is obligated under the
`
`Policy to defend and/or to indemnify Custom with respect to the claims asserted by Hoover in the
`
`Complaint.
`
`PRAYER FOR RELIEF
`
`WHEREFORE, West Bend prays for judgment as follows:
`
`1. That Custom takes nothing by its purported causes of action;
`
`2. Declaring and adjudging that West Bend has no obligation to defend or indemnify
`Custom with respect to any claims for damages, attorneys’ fees, or costs incurred with
`respect to the claims asserted against it by Hoover in the Complaint; and
`
`
`3. Providing such other and further relief as the Court deems just and equitable.
`
`
`
`
`
`
`
`
`
`
`
`
`
`GOETZ & ECKLAND P.A.
`
`Dated: April 2, 2024
`
`
`
`
`
`
`
`
`
`
`
`
` By:
`William A. Celebrezze (#227997)
`Kaitlyn C. Falk, Esq. (#0403562)
`615 1st Avenue NE, Suite 425
`Minneapolis, MN 55413
`(612) 874-1552
`(612) 331-2473 (fax)
`bcelebrezze@goetzeckland.com
`kfalk@goetzeckland.com
`
`Attorneys for Defendant
`West Bend Insurance Company
`
`ACKNOWLEDGMENT
`
`The undersigned hereby acknowledges that costs, disbursements and reasonable attorney
`and witness fees may be awarded pursuant to Minn. Stat. §549.21, Subd. 2, to the party against
`whom the allegations in this pleading are asserted.
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`William A. Celebrezze, Esq.
`
`
`
`
`
`
`
`12
`
`
`
`
`
`

`

`55-CV-23-1818
`
`AFFIDAVIT
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`Paige Ru ka
`
`, being first duly sworn on oath, deposes and says: That she is a duly
`
`authorized custodian of the records of West Bend Mutual Insurance Company, and she has the authority to
`
`certify those records.
`
`Based upon my review of policy records, the policy attached to this Affidavit is a true copy of the
`
`Workers Compensation
`
`policy, bearing policynumber_- as that policy was in effect on
`«MamPaige Ruka
`
`8/24/2021
`
`Subscribed and sworn to before me on
`
`12/14/2023
`
`\"\\
`'\
`
`mum,
`I
`SC '1'],
`H°<»'<,'
`OTARy
`
`.
`
`.
`-
`
`anuo
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`
`Exhibit A
`
`

`

`55-CV-23-1818
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`Policy Change Summary Declarations
`
`Endorsement
`
`Customer Number:
`Policy Number:
`
`Named Insured and Address:
`Custom Fabricating & Repair Inc
`PO Box 296
`Marshfield, WI 54449
`
`Policy Period: 02/06/2021 to 02/06/2022
`at 12:01 AM Standard Time at Your Mailing Address Shown Below
`
`Agency Name and Address:
`MARSHFIELD INS AGENCY INC
`208 W 5TH STREET
`MARSHFIELD, WI 54449
`715-387-4443
`
`48601
`
`Changes have been made to the above policy at your request or at the request of your agent.
`
`Below is a summary of the changes to the Coverage(s) that are impacted. All other terms, conditions, exclusions and
`provisions of the policy remain the same.
`
`To view a complete copy of your policy, visit us at http://insured.thesilverlining.com or on the West Bend mobile app.
`
`To request a complete copy of your policy, please email CustomerService@wbmi.com.
`
`Effective Date of Change: 02/06/2021
`Coverage Part and Description of Change
`
`Coverage Part
`
`Workers Compensation
`
`Modified:
`The TX location has been amended to, 7811 CR 42500, Paris TX
`
`Summary
`The above changes result in the following Total Net Premium Change
`(Including Taxes, Fees, and Surcharges)
`
`Net Additional Premium:
`
`This is not a bill.
`
`Any premium changes will be reflected on your next scheduled invoice.
`
`DPCS 01 11 18
`
`08/25/2021 13:02:39
`
`

`

`55-CV-23-1818
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`MEMBERSHIP AND VOTING NOTICE
`
`
`MUTUALS – MEMBERSHIP AND VOTING NOTICE
`The named insured is notified that by virtue of this policy, the named insured is a member of the West Bend
`Mutual Insurance Company of West Bend, Wisconsin and is entitled to vote either in person or by proxy at any
`and all meetings of said Company. The Annual Meetings are held in its Home Office, on the second Tuesday of
`March commencing in 2007 and each year thereafter, at 10:00 a.m.
`MUTUALS – PARTICIPATION CLAUSE WITH CONTINGENT LIABILITY
`No Contingent Liability: This policy is nonassessable. The policyholder is a member of the company and shall
`participate, to the extent and upon the conditions fixed and determined by the Board of Directors in accordance
`with the provisions of law, in the distribution of dividends so fixed and determined.
`In Witness Whereof, we have caused this policy to be executed and attested.
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Christopher C. Zwygart
`Secretary
`
`Kevin A. Steiner
`President and Chief Executive Officer
`
`West Bend Mutual Insurance Company
`1900 S. 18th Avenue
`West Bend, WI 53095
`800-236-5010
`
`WB 214 01 19
`
`
`
`West Bend Mutual Insurance Company
`West Bend, Wisconsin 53095
`
`Page 1 of 1
`
`

`

`55-CV-23-1818
`
`NCCI Carrier Code:
`1. Named Insured and Address:
`Custom Fabricating & Repair Inc
`PO Box 296
`Marshfield, WI 54449
`
`Endorsement
`Standard Workers Compensation and Employers Liability Policy
`Customer Number:
`Policy Number:
`Agency Name and Address:
`MARSHFIELD INS AGENCY INC
`208 W 5TH STREET
`MARSHFIELD, WI 54449
`715-387-4443
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`48601
`
`FEIN:
`Legal Entity – Corporation
`2. Policy Period: 02/06/2021 to 02/06/2022 at 12:01 AM Standard Time at Your Mailing Address Shown Above
`
`Interstate Risk ID #: 918093982
`
`Intrastate Risk ID #:
`
`Other Workplaces not shown above: See Attached Schedule
`3A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states listed
`here: WI IA MI MN MO NE AR AZ KY SC TN TX IL KS CO FL GA ID NM OR PA UT IN LA MS NV MA
`NY CA NJ
`3B. 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:
`$1,000,000 Each Accident
`Bodily Injury by Accident
`$1,000,000 Each Employee
`Bodily Injury by Disease
`$1,000,000
`Total Policy
`Bodily Injury by Disease
`3C. Other States Insurance: Part three of the policy applies to states, if any, listed here: All states except those listed in
`Item 3.A. and ND OH WA and WY
`3D. See attached schedule for list of endorsements forming a part of this policy.
`4. 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 of Operations
`
`Loc
`
`Class
`Code
`
`Description
`
`Exposure
`
`Rate
`
`Premium
`
`See Extension of Information Page
`
`Minimum Premium
`
`Assessments and Taxes
`
`Countersignature:
`
`Premium Discount: 10.1%
`Expense Constant:
`Estimated Annual Premium:
`Deposit Premium:
`
`(Authorized Representative)
`
`Date:
`
`DWC 01 0414
`
`08/25/2021 13:02:39
`
`

`

`55-CV-23-1818
`
`NCCI Carrier Code:
`1. Named Insured and Address:
`Custom Fabricating & Repair Inc
`PO Box 296
`Marshfield, WI 54449
`
`Endorsement
`Standard Workers Compensation and Employers Liability Policy
`Customer Number:
`Policy Number:
`Agency Name and Address:
`MARSHFIELD INS AGENCY INC
`208 W 5TH STREET
`MARSHFIELD, WI 54449
`715-387-4443
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`48601
`
`FEIN:
`Legal Entity – Corporation
`2. Policy Period: 02/06/2021 to 02/06/2022 at 12:01 AM Standard Time at Your Mailing Address Shown Above
`
`Interstate Risk ID #: 918093982
`
`Intrastate Risk ID #:
`
`State of IA
`
`Classification of Operations
`
`Class
`Code
`
`Description
`
`5183 PLUMBING NOC AND DRIVERS
`
`8742 SALESPERSONS OR COLLECTORS--OUTSIDE
`
`Exposure
`
`$85,086
`
`$260,204
`
`Rate
`
`Premium
`
`Loc
`
`2
`
`2
`
`Subtotal
`
`
`Increased Limits
`
`
`Experience Modification
`
`
`Terrorism
`
`
`
`Catastrophe
`
`9812
`
`9898
`
`9740
`
`9741
`
`Total for Iowa
`
`DWC 02 04 14
`
`08/25/2021 13:02:39
`
`

`

`55-CV-23-1818
`
`NCCI Carrier Code:
`1. Named Insured and Address:
`Custom Fabricating & Repair Inc
`PO Box 296
`Marshfield, WI 54449
`
`Endorsement
`Standard Workers Compensation and Employers Liability Policy
`Customer Number:
`Policy Number:
`Agency Name and Address:
`MARSHFIELD INS AGENCY INC
`208 W 5TH STREET
`MARSHFIELD, WI 54449
`715-387-4443
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`48601
`
`FEIN:
`Legal Entity – Corporation
`2. Policy Period: 02/06/2021 to 02/06/2022 at 12:01 AM Standard Time at Your Mailing Address Shown Above
`
`Interstate Risk ID #: 918093982
`
`Intrastate Risk ID #:
`
`Exposure
`
`$231,576
`
`Rate
`
`Premium
`
`Classification of Operations
`
`State of IL
`
`Class
`Code
`
`Description
`
`5183 PLUMBING NOC AND DRIVERS
`
`Loc
`
`13
`
`Subtotal
`
`
`Increased Limits
`
`
`Experience Modification
`
`
`Terrorism
`
`
`
`Catastrophe
`
`9812
`
`9898
`
`9740
`
`9741
`
`
`IIC Operations Fund Surcharge
`
`Total for Illinois
`
`DWC 02 04 14
`
`08/25/2021 13:02:39
`
`

`

`55-CV-23-1818
`
`NCCI Carrier Code:
`1. Named Insured and Address:
`Custom Fabricating & Repair Inc
`PO Box 296
`Marshfield, WI 54449
`
`Endorsement
`Standard Workers Compensation and Employers Liability Policy
`Customer Number:
`Policy Number:
`Agency Name and Address:
`MARSHFIELD INS AGENCY INC
`208 W 5TH STREET
`MARSHFIELD, WI 54449
`715-387-4443
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`48601
`
`FEIN:
`Legal Entity – Corporation
`2. Policy Period: 02/06/2021 to 02/06/2022 at 12:01 AM Standard Time at Your Mailing Address Shown Above
`
`Interstate Risk ID #: 918093982
`
`Intrastate Risk ID #:
`
`Classification of Operations
`
`State of IN
`
`Class
`Code
`
`Description
`
`5183 PLUMBING NOC AND DRIVERS
`
`8810 CLERICAL OFFICE EMPLOYEES NOC
`
`Loc
`
`23
`
`23
`
`Subtotal
`
`Rate
`
`Premium
`
`Exposure
`
`$46,676
`
`$135,000
`
`
`Increased Limits
`
`
`Experience Modification
`
`
`Terrorism
`
`
`
`Catastrophe
`
`
`Second Injury Fund
`
`9812
`
`9898
`
`9740
`
`9741
`
`0935
`
`Total for Indiana
`
`DWC 02 04 14
`
`08/25/2021 13:02:39
`
`

`

`55-CV-23-1818
`
`NCCI Carrier Code:
`1. Named Insured and Address:
`Custom Fabricating & Repair Inc
`PO Box 296
`Marshfield, WI 54449
`
`Endorsement
`Standard Workers Compensation and Employers Liability Policy
`Customer Number:
`Policy Number:
`Agency Name and Address:
`MARSHFIELD INS AGENCY INC
`208 W 5TH STREET
`MARSHFIELD, WI 54449
`715-387-4443
`
`Filed in District Court
`State of Minnesota
`4/2/2024 4:00 PM
`
`48601
`
`FEIN:
`Legal Entity – Corporation
`2. Policy Period: 02/06/2021 to 02/06/2022 at 12:01 AM Standard Time at Your Mailing Address Shown Above
`
`Interstate Risk ID #: 918093982
`
`Intrastate Risk ID #:
`
`Exposure
`
`$59,436
`
`Rate
`
`Premium
`
`Classification of Operations
`
`State of KS
`
`Class
`Code
`
`Description
`
`5183 PLUMBING NOC AND DRIVERS
`
`Loc
`
`14
`
`Subtotal
`
`
`Increased Limits
`
`
`Experience Modification
`
`
`Terrorism
`
`
`
`Catastrophe
`
`9812
`
`9898
`
`9740
`
`9741
`
`Total for Kansas
`
`DWC 02 04 14
`
`08/25/2021 13:02:39
`
`

`

`55-CV-23-1818
`
`NCCI Carrier Code:
`1. Named Insured and Address:
`Custom Fabricating & Repair Inc
`PO Box 296
`Marshfield, WI 54449
`
`Endorsement
`Standard Workers Compensation and Empl