[LOGO] RELIANCE
A RELIANCE GROUP HOLDINGS COMPANY
SPECIFIC EXCESS WORKERS' COMPENSATION
AND EMPLOYERS' LIABILITY POLICY
PLANET INSURANCE COMPANY
A Stock Insurance Company, herein called the Company, agrees with the Insured,
named in the Declarations made a part hereof, in consideration of the payment of
the premium and in reliance upon the statements in the Declarations and subject
to the limit of liability, exclusions, conditions and other terms of this
policy:
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INSURING AGREEMENTS
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I. APPLICATION OF This policy applies to loss sustained by the Insured on
POLICY. account of:
(A) compensation and other benefits required of the Insured
by the workers' compensation law; and
(B) sums which the Insured shall become legally obligated to
pay as damages because of bodily injury by accident or
disease, including death at any time resulting
therefrom, sustained in the United States of America,
its territories or possessions, or Canada by any
employee of the Insured arising out of and in the course
of his employment by the Insured either in operations in
a state designated in Item 5 of the Declarations or in
operations necessary or incidental thereto,
as a result of injury(1) by accident occurring during the
policy period, or (2) by disease caused or aggravated by
exposure of which the last day of the last exposure, in the
employment of the Insured, to conditions causing the disease
occurs during the policy period.
II. RETENTION AND The Insured shall retain as its own retention in the amount
INDEMNITY. stated in Item 6 of the Declarations and the Company hereby
agrees to indemnify the Insured against loss in excess of
such retention, subject to the limit of indemnity stated in
Item 7 of the Declarations; provided, that the retention and
limit of indemnity apply as respects:
(A) bodily injury by accident, including death resulting
therefrom, sustained by one or more employees in each
accident; or
(B) bodily injury by disease, including death resulting
therefrom, sustained by each employee.
The inclusion herein of more than one Insured shall not
operate to increase the retention or the limit of indemnity.
III. CLAIM As respects each such accident and each such disease for
EXPENSES. which indemnity against loss is afforded by this policy, the
Company will indemnify the Insured against that proportion
of claim expenses (other than appeal claim expenses handled
as hereinafter provided) paid by the Insured that the amount
of the loss ultimately borne by the Company bears to the
total amount of the loss. As respects claim expenses
connected with appeal taken by the Insured from an award,
verdict or judgment which is in excess of the Insured's
retention hereunder, if the Company consents to such appeal
the Company shall indemnify the Insured against that
proportion of the claim expenses paid by the Insured in
connection with such appeal that the amount of such award,
verdict or judgment in excess of the Insured's retention
bears to the total amount of such award, verdict or
judgment.
Claim expenses are payable by the Company in addition to
the limit of indemnity of this policy.
IV. DEFINITIONS. (A) WORKERS' COMPENSATION LAW. The unqualified term
"workers' compensation law" means the workers'
compensation law and any occupational disease law of
a state designated in Item 5 of the Declarations,
while the Insured is a duly qualified self-insurer
under such law, but does not include those
provisions of any such law which provide
non-occupational disability benefits.
(B) STATE. The word "state" means any state or territory of
the United States of America and the District of
Columbia.
(C) BODILY INJURY BY ACCIDENT. An event or circumstance,
other than bodily injury by disease, which is unexpected
and unintended from the standpoint of the Insured and
results in injury or impairment to bodily or mental
function. The contraction of disease is not an accident
within the meaning of the word "accident" in the term
"bodily injury by accident" and only such disease as
results directly from a bodily injury by accident is
included within the term "bodily injury by accident".
(D) BODILY INJURY BY DISEASE. An illness or sickness, other
than bodily injury by accident, resulting in injury or
impairment to the bodily or mental functions. The term
"bodily injury by disease" includes only such disease
as is not included within the term "bodily injury by
accident".
(E) ASSAULT AND BATTERY. Under Section I B. of the of
Insuring Agreements, assault and battery shall be
deemed an accident unless committed by or at the
direction of the Insured.
(F) DAMAGES BECAUSE OF BODILY INJURY BY ACCIDENT OR DISEASE,
INCLUDING DEATH AT ANY TIME RESULTING THEREFROM. The
words "damages because of bodily injury by accident or
disease, including death at any time resulting
therefrom", in Section I B. of Insuring Agreements,
includes damages for care and loss of services and
damages for which the Insured is liable by reason of
suits or claims brought against the Insured by others
to recover the damages obtained from such others
because of such bodily injury sustained by employees of
the Insured arising out of and in the course of their
employment.
(G) LOSS. The word "loss" shall mean only such amounts as
are actually paid in cash by the Insured in payment of
benefits under the workers' compensation law, in
settlement of claims or in satisfaction of awards of
judgments; but the word "loss" shall not include claim
expenses, salaries paid to employees of the Insured, nor
annual retainers.
(H) CLAIMS EXPENSES. The term "claims expenses" shall mean
court costs, interest upon awards and judgments, and
allocated investigation, adjustment and legal expenses;
but the term "claim expenses" shall not include salaries
paid to employees of the Insured nor annual retainers.
(I) REMUNERATION. When used as a premium basis,
"remuneration" means the entire remuneration, computed
in accordance with the excess manuals and rating plans
in use by the Company, earned during the policy period
by (a) all executive officers and other employees of the
Insured engaged in operations covered by this policy,
and (b) any other person performing work which may
render the Insured liable for injury to or death of such
person in accordance with the workers' compensation law.
"Remuneration" shall not include the remuneration of any
person within division (b) foregoing if the Insured
maintains evidence satisfactory to the Company that the
payment of compensation and other benefits under such
law to such person is secured by other valid and
collectible insurance or by any other undertaking
approved by the governmental agency having jurisdiction
thereof.
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EXCLUSIONS
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This policy does not apply:
I. to loss arising out of operations (A) as respects to which the Insured
carries a full coverage workers' compensation or employers' liability
policy, or (B) as respect to which any workers' compensation law has been
rejected;
II. unless required by law or described in the Declarations, to domestic
employment or to farm or agricultural employment;
III. to any payments required on the Insured under the workers' compensation
law, in excess of the benefits regularly provided by such law, solely
because of injury to (A) any employee by reason of the serious and
willful misconduct of the Insured; or (B) any employee employed by the
Insured in violation of law with the knowledge or acquiescence of the
Insured or any executive officer thereof;
IV. under Subsection I B. of the Insuring Agreements, to liability assumed by
the Insured under any contract or agreement;
V. under Subsection I B. of the Insuring Agreements, (A) to punitive or
exemplary damages on account of bodily injury to or death of any employee
in violation of law, or (B) with respect to any employee employed in
violation of law with the knowledge or acquiescense of the Insured or any
executive officer thereof;
VI. under Subsection I B. of the Insuring Agreements, to bodily injury by
disease unless prior to thirty-six months after the end of the policy
period written claim is made or suit is brought against the Insured for
damages because of such injury or death resulting therefrom;
VII. under Subsection I B. of the Insuring Agreements, to any obligation for
which the Insured or any carrier as his insurer may be held liable under
any workers' compensation or occupational disease law of a state designated
in Item 5 of the Declarations, any other workers' compensation or
occupational disease law, any unemployment compensation or disability
benefits law, or under any similar law.
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CONDITIONS
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I. QUALIFIED The Insured, by the acceptance of this policy, warrants that
SELF-INSURER. it has qualified as a self-insurer as provided in the
workers' compensation law and will continue to maintain such
qualification during the period of this policy. In the event
the Insurer should at any time while this policy is in force
terminate its qualifications as a self-insurer or if such
qualification should be cancelled or revoked, this policy, to
the extent of such termination, cancellation or revocation,
shall automatically terminate at the same time.
II. PREMIUM. (A) The premium bases and rates for the classifications of
operations described in the Declarations are as stated
therein and for classifications not so described are
those applicable in accordance with the excess manuals
and rating plans in use by the Company. The policy is
issued by the Company and accepted by the Insured with
the agreement that if any change in classifications,
rates or rating plans is or becomes applicable to this
policy under any law regulating this insurance or because
of any amendments affecting the benefits provided by
the workers' compensation law, such change with the
effective date thereof shall be stated in an endorsement
issued to form a part of this policy.
(B) If the Declarations provide for adjustment of premium on
other than an annual basis, the Insured shall pay the
deposit premium to the Company upon the inception of this
policy and thereafter in interim premiums shall be
computed in accordance with the excess manuals and rating
plans in use by the Company and paid by the Insured
promptly after the end of each interval specified in the
Declarations. The deposit premium shall be retained by
the Company until termination of this policy and credited
to the final premium adjustment.
(C) The Insured shall maintain records of the information
necessary for premium computation on the bases stated in
the Declarations, and shall send copies of such records
to the Company at the end of the policy period and at
such times during the policy period as the Company may
direct. If the Insured does not furnish records of the
remuneration of persons within divisions (b) of the
definition of remuneration foregoing, the remuneration of
such persons shall be computed in accordance with the
excess manuals and rating plans in use by the Company.
(D) The premium stated in the Declarations is an estimated
premium only. Upon termination of this policy, the earned
premium shall be computed in accordance with the rules,
rates, premiums and minimum premium applicable to this
insurance in accordance with the excess manuals and
rating plans in use
by the Company. If the earned premium exceeds the premium
previously paid, the Insured shall pay the excess to the
Company; if less, the Company shall return to the Insured
the unearned portion paid by the Insured. All premiums
shall be fully earned whether any workers' compensation
law, or any part thereof, is or shall be declared invalid
or unconstitutional.
III. LONG-TERM If this policy is written for a period longer than one year,
POLICY. all the provisions of this policy shall apply separately to
each consecutive twelve-month period, or, if the first or
last consecutive period is less than twelve months, to such
period of less than twelve months, in the same manner as if a
separate policy had been written for each consecutive period.
The earned premium for each such period shall be computed as
provided by Section II under Conditions, subject, except as
otherwise provided in the excess manuals and rating plans in
use by the Company with respect to classifications of of
operations for which this policy provides a per capita
premium basis, to the following provisions:
(A) The premium rates for the first consecutive period shall
be those stated in the Declarations and those applicable
for such period in accordance with the excess manuals and
rating plans in use by the Company;
(B) The premium bases, classification of operations, rates,
rating plans, premiums and minimum premiums for each such
subsequent period shall be those applicable for such
period in accordance with the excess manuals and rating
plans in use by the Company.
IV. PARTNERSHIP If the Insured is a partnership or joint venture, such
OR JOINT insurance as is afforded by this policy applies to each
VENTURE partner or member thereof as an Insured only while he
AS INSURED. is acting within the scope of his duties as such partner or
member.
V. INSPECTION The Company and any rating authority having jurisdiction by
AND AUDIT. law shall each be permitted to inspect the workplaces,
machinery and equipment covered by this policy and to
examine and audit the Insured's books, vouchers, contracts,
documents and records of any and every kind at any reasonable
time during the policy period and any extension thereof and
within three years after termination of this policy, as far
as they relate to the premium bases or the subject matter
of this insurance.
VI. NOTICE OF When an injury occurs that appears reasonably likely to
INJURY. involve liability on the part of the Company, written notice
shall be given by or on behalf of the Insured to the Company
or any of its authorized agent as soon as practicable, except
that immediate notice shall be given to the Company where an
injury of the following type occurs:
(A) any claim, award or judgment or the reopening of any
claim which exceeds 50% of the retention specified in
Item 6 of the policy applicable to the occurrence which
gives rise to such claim, award or judgment, and any
action, suit or proceeding which might result in such an
award or judgment;
(B) any case involving:
(1) death;
(2) disability for a period of nine months or more;
(3) spinal cord injury;
(4) amputation of a major extremity;
(5) a permanent, total disability as defined in the
workers' compensation law of the applicable state
named in Item 5 of the Declarations;
(C) any occurrence which causes serious injury to two or
more employees;
Such notice shall contain particulars sufficient to identify
the Insured and also the fullest information obtainable at
the time. The Insured shall give like notice, with full
particulars, of any claim made on account of such injury. If
thereafter suit or other proceeding is instituted against the
insured to enforce such claim, the Insured shall, when
requested by the Company, forward to the Company every
demand, notice, summons, or other process or true copies
thereof, received by the
insured or the Insured's representative together with copies
of reports of investigations made by the Insured with respect
to such claim, suit or proceeding.
The Insured shall not make any voluntary settlement involving
loss to the Company hereunder except with the written consent
of the Company.
The Company, at its own election and expense, shall have the
right to participate with the Insured in the settlement,
defense or appeal of any claim, suit or proceeding which
might involve liability of the Company.
VII. COOPERATION The Company shall not be called upon to assume charge of the
OF THE settlement of defense of any claim made or suit or proceeding
INSURED. instituted against the Insured, but shall have the right and
shall be given the opportunity to associate with the Insured
in the defense and control of any claim, suit or proceeding
where the claim or suit involves, or appears reasonably
likely to involve the Company, in which event the Insured
and the Company shall cooperate in all things in the defense
of such claim, suit or proceeding.
VIII. LOSS The Company shall pay any loss for which it may be liable
PAYABLE. under this policy in the following manner:
(A) if a loss is payable under the workers' compensation law
of the applicable state, payment therefor shall first be
made by the Insured in accordance with the provisions of
the law, and the Company shall reimburse the Insured for
such loss periodically, at intervals of not less than one
month, upon receipt from the Insured of proper proofs of
payment. No voluntary commutation of compensation awards
to a lump sum basis shall be made by the Insured without
the consent of the Company.
(B) if a loss is not payable under the workers' compensation
law of the applicable state, and damages are recovered
against the Insured, payment therefor shall be made by
the Company within thirty (30) days after proper proof
of payment by the Insured shall have been received by the
Company.
IX. ACTION No action shall lie against the Company unless, as a condition
AGAINST precendent thereto, the Insured shall have fully complied with
COMPANY all the terms of this policy, nor until the amount of the
INSURING Insured's obligation to pay shall have been finally determined
AGREEMENTS either by judgment against the Insured after actual trial or
SECTION I B. by written agreement of the Insured, the claimant and the
Company.
Any person or organization or the legal representative thereof
who has secured such judgment or written agreement shall
thereafter be entitled to recover under this policy to the
extent of the insurance afforded by this policy. Nothing
contained in this policy shall give any person or organization
any right to join the Company as a co-defendant in any action
against the Insured to determine the Insured's liability.
Bankruptcy or insolvency of the Insured or of the Insured's
estate shall not relieve the Company of any of its obligations
under Insuring Agreements Section I B.
X. OTHER If the Insured carries other valid and collectible insurance
INSURANCE. covering a loss also covered by this policy (other than
insurance that is purchased to apply in excess of the sum of
the retention and the limit of liability hereunder of policies
of coinsurance within the limits of this policy), the
insurance afforded by this contract shall apply in excess of
and shall not contribute with such other insurance or
reinsurance.
XI. SUBROGATION. In the event of any payment under this policy, the Company
shall be subrogated of all rights of recovery therefor of the
Insured and any person entitled to the benefits of this policy
against any person or organization, and the Insured shall
execute and deliver instruments and papers and do whatever
else is necessary to secure such rights. The Insured shall do
nothing after a loss to prejudice such rights.
XII. CHANGES. Notice to any agent or knowledge possessed by any agent or by
any other person shall not effect a waiver or a change in any
part of this policy or estop the Company from asserting any
right under the terms of this policy; nor shall the terms of
this policy be waived or changed, except by endorsement
issued to form a part of this policy, signed by a duly
authorized representative of the Company.
XIII. ASSIGNMENT. Assignment of interest under this policy shall not bind the
Company until its consent is endorsed hereon.
XIV. CANCELLATION. This policy may be cancelled by the Insured by mailing to the
Company written notice stating when thereafter the
cancellation shall be effective. The policy may be cancelled
by the Company by mailing to the Insured at the address shown
in this policy written notice stating when not less than ten
days thereafter such cancellation shall be effective. The
mailing of notice as aforesaid shall be sufficient proof of
notice. The effective date of cancellation stated in the
notice shall become the end of the policy period. Delivery of
such written notice either by the Insured or by the Company
shall be equivalent to mailing.
If the Insured cancels, unless the excess manuals and rating
plans in use by the Company otherwise provide, earned premium
shall be (A) computed in accordance with the customary short
rate table and procedure; and (B) not less than the minimum
premium stated in the Declarations. If the Company cancels,
earned premium shall be computed pro rata. Premium adjustment
may be made at the time cancellation is effected and, if not
then made, shall be made as soon as practicable after
cancellation becomes effective. The Company's check or the
check of its representative mailed or delivered as aforesaid
shall be sufficient tender of any refund or premium due to
the Insured.
When excess insurance under the workers' compensation law may
not be cancelled except in accordance with such law, this
condition so far as it applies to the insurance under this
policy with respect to such law, is amended to conform to
such law.
XV. CONFORMITY TO Terms of this policy which are in conflict with the
STATUTE. provisions of the workers' compensation law are hereby
amended to conform to such law.
XVI. WARRANTY. By acceptance of this policy, the Insured warrants that the
statements in the Declarations are the Insured's agreements
and representations, that this policy is issued in reliance
upon the truth of such representations and that this policy
embodies all agreements existing between himself and the
Company or any of its agent relating to this insurance.
SPECIFIC EXCESS WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY POLICY
NXC 0105918 PLANET INSURANCE COMPANY
- --------------- Home 0ffice-Sun Prairie,
Renewal of NEW RELIANCE [LOGO] Wisconsin
Administrative 0ffices-
Philadelphia, Pennsylvania
Agency Code, Name and Address
DECLARATIONS 80-971
ITEM 1. NAME INSURED AND P. 0. ADDRESS BRENTWOOD SERVICES, INC.
(No., Street, Town, County, State) 213-A WARD CIRCLE
ASSOCIATED GENERAL CONSTRUCTORS OF BRENTWOOD, TN
FLORIDA SELF INSURANCE FUND
P.O. BOX 678148
ORLANDO, FL. 32867
ITEM 2. POLICY PERIOD:
From 1/1/93 To 1/1/94 12:01 a.m., standard time at the address of
the insured as stated herein.
ITEM 3. The Named Insured is: / / Individual / / Partnership / / Corporation
/X/ Other
ITEM 4. Locations--All usual workplaces of the insured at or from which
operations covered by this policy are conducted are located at the above
address unless otherwise stated herein:
ALL LOCATIONS
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ITEM 5. Subsection I (A) under Insuring Agreements applies to the workers'
compensation law and any occupational disease law of each of the
following states:
FLORIDA
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ITEM 6. Retention $750,000 ITEM 7. Limit of Indemnity $ SEE END'T. #1
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ITEM 8.
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ESTIMATED RATES PER ESTIMATED
CODE TOTAL ANNUAL $100 OF ANNUAL
CLASSIFICATION OF OPERATIONS NUMBER REMUNERATION REMUNERATION PREMIUMS
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AS ON FILE WITH THE COMPANY
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Minimum Premium $943,800 TOTAL ESTIMATED
-------- ANNUAL PREMIUM $
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Deposit Premium $1,048,668 - SEE END'T. #2
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RATE - .3703 PER $100 OF PAYROLL
If indicated below, interim adjustments of premium shall be made:
/ / Semi-Annually / / Quarterly / / Monthly
ITEM 9. The insured is not conducting other operations at or from the locations
described herein or any operation at or from any other location in a
state designated in Item 5; exception, if any
NOT APPLICABLE
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Countersigned by /s/ R. Villafane
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Authorized Representative
In Witness Whereof, the Company issuing this policy has cause this policy to be
signed by its authorized officers, but this policy shall not be valid unless
signed by a duly authorized representative of the Company.
PLANET INSURANCE COMPANY
/s/ Linda C. Hohn /s/ Robert M. Stanley
Secretary President
Company Numbers If this endorsement is issued concurrently with the policy, the Attaching Clause Endt. No. 1
need to be completed
1=RELIANCE INSURANCE -----------------------------------------------------------------------------------------------
COMPANY Issued by Co. No. Insured ASSOCIATED GENERAL CONSTRUCTORS OF FLORIDA SELF Policy No.
2 INSURANCE FUND NXC 0105918
2=PLANET INSURANCE -----------------------------------------------------------------------------------------------
COMPANY Effective Date Policy Period Addt'l Premium Return Premium Premium subject
1/1/93 1/1/93 TO 1/1/94 / / to audit
3=UNITED PACIFIC -----------------------------------------------------------------------------------------------
INSURANCE COMPANY Unearned Premium Factor All terms and conditions of the policy remain Countersigned
unchanged except as amended by this endorsement.
4=RELIANCE INSURANCE -----------------------------------------------------------------------------------------------
CO. OF ILLINOIS
Item 7, Limit of Liability, of the Declarations (Form # 32-003 ed. 1/92) is
completed as follows:
1. Coverage A - Workers' Compensation - Statutory.
2. Coverage B - Employers' Liability - $2,000,000.
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/ / THE PREMIUM FOR THIS ENDORSEMENT IF ON INSTALLMENTS IS PAYABLE AS FOLLOWS:
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ADDITIONAL RETURN REVISED ANNIVERSARY PREMIUM
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AT DATE OF ENDORSEMENT $ $ (NOT APPLICABLE)
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FIRST ANNIVERSARY $ $ $
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SECOND ANNIVERSARY $ $ $
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GEN-47c Ed. 03/87
Company Numbers If this endorsement is issued concurrently with the policy, the Attaching Clause Endt. No. 2
need to be completed
1=RELIANCE INSURANCE -----------------------------------------------------------------------------------------------
COMPANY Issued by Co. No. Insured ASSOCIATED GENERAL CONSTRUCTORS OF FLORIDA SELF Policy No.
2 INSURANCE FUND NXC 0105918
2=PLANET INSURANCE -----------------------------------------------------------------------------------------------
COMPANY Effective Date Policy Period Addt'l Premium Return Premium Premium subject
1/1/93 1/1/93 TO 1/1/94 / / to audit
3=UNITED PACIFIC -----------------------------------------------------------------------------------------------
INSURANCE COMPANY Unearned Premium Factor All terms and conditions of the policy remain Countersigned
unchanged except as amended by this endorsement.
4=RELIANCE INSURANCE -----------------------------------------------------------------------------------------------
CO. OF ILLINOIS
INSTALLMENT SCHEDULE
In consideration of the premium charged, it is agreed that the deposit
premium is payable as follows:
Due AMOUNT
--- ------
1/1/93 $262,167
3/1/93 $262,167
7/1/93 $262,167
10/1/93 $262,167
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/ / THE PREMIUM FOR THIS ENDORSEMENT IF ON INSTALLMENTS IS PAYABLE AS FOLLOWS:
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ADDITIONAL RETURN REVISED ANNIVERSARY PREMIUM
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AT DATE OF ENDORSEMENT $ $ (NOT APPLICABLE)
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FIRST ANNIVERSARY $ $ $
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SECOND ANNIVERSARY $ $ $
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GEN-47c Ed. 03/87
Company Numbers If this endorsement is issued concurrently with the policy, the Attaching Clause Endt. No. 3
need to be completed
1=RELIANCE INSURANCE -----------------------------------------------------------------------------------------------
COMPANY Issued by Co. No. Insured ASSOCIATED GENERAL CONSTRUCTORS OF FLORIDA SELF Policy No.
2 INSURANCE FUND NXC 0105918
2=PLANET INSURANCE -----------------------------------------------------------------------------------------------
COMPANY Effective Date Policy Period Addt'l Premium Return Premium Premium subject
1/1/93 1/1/93 TO 1/1/94 / / to audit
3=UNITED PACIFIC -----------------------------------------------------------------------------------------------
INSURANCE COMPANY Unearned Premium Factor All terms and conditions of the policy remain Countersigned
unchanged except as amended by this endorsement.
4=RELIANCE INSURANCE -----------------------------------------------------------------------------------------------
CO. OF ILLINOIS
AVIATION WORKER'S COMPENSATION ENDORSEMENT
IN CONSIDERATION OF THE PREMIUM CHARGED IT IS AGREED THAT COVERAGE FOR
INDUSTRIAL AID AIRCRAFT IS LIMITED TO THE AIRCRAFT LISTED BELOW::
YEAR AND MAKE HANGARED
------------- --------
(1) 1970 GULFSTREAM MARIANNA, FL.
(2) 1978 CESSNA 210 VAN AIR
NEWLY ACQUIRED AIRCRAFT WILL BE COVERED FOR A THIRTY DAY PERIOD DURING
WHICH THE AIRCRAFT MUST BE REPORTED TO THE COMPANY. ALL COVERAGE WILL CEASE
AUTOMATICALLY AT THE END OF THIRTY DAYS FROM THE DATE THE MEMBER OF THE
ASSOCIATED GENERAL CONTRACTORS SELF INSURANCE FUND ACQUIRED THE AIRCRAFT.
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/ / THE PREMIUM FOR THIS ENDORSEMENT IF ON INSTALLMENTS IS PAYABLE AS FOLLOWS:
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ADDITIONAL RETURN REVISED ANNIVERSARY PREMIUM
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AT DATE OF ENDORSEMENT $ $ (NOT APPLICABLE)
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FIRST ANNIVERSARY $ $ $
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SECOND ANNIVERSARY $ $ $
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GEN-47c Ed. 03/87
Company Numbers If this endorsement is issued concurrently with the policy, the Attaching Clause Endt. No. 4
need to be completed
1=RELIANCE INSURANCE -----------------------------------------------------------------------------------------------
COMPANY Issued by Co. No. Insured ASSOCIATED GENERAL CONSTRUCTORS OF FLORIDA SELF Policy No.
2 INSURANCE FUND NXC 0105918
2=PLANET INSURANCE -----------------------------------------------------------------------------------------------
COMPANY Effective Date Policy Period Addt'l Premium Return Premium Premium subject
1/1/93 1/1/93 TO 1/1/94 / / to audit
3=UNITED PACIFIC -----------------------------------------------------------------------------------------------
INSURANCE COMPANY Unearned Premium Factor All terms and conditions of the policy remain Countersigned
unchanged except as amended by this endorsement.
4=RELIANCE INSURANCE -----------------------------------------------------------------------------------------------
CO. OF ILLINOIS
ALL STATES ENDORSEMENT
It is agreed that:
A. In the event the Insured undertakes operations in any state not
designated in item 5 of the Declarations, other than North Dakota, or Wyoming,
the Company agrees as follows:
1. To indemnify the Insured excess of the Insured's Retention for all
compensation and other benefits under the Workers' Compensation law of such
State.
2. Such insurance as afforded by the policy under coverage I.(B) also
applies to Bodily Injury by Accident or Disease, including Death at any
time resulting therefrom, sustained by any employee of the Insured arising
out of and in the course of his employment in operations in such State or
in operations incidental thereto. The limit of liability for Bodily Injury
by Disease including Death resulting therefrom, applies as though each
State in which such operations are conducted were designated in Item 5 of
the Declarations.
3. Such insurance as is afforded by the policy by virtue of this
endorsement does not apply to such operations if the Insured has, under any
Workers' Compensation or Occupational Disease law, other insurance or is a
qualified self insurer or has rejected the Workers' Compensation or
Occupational Disease law applicable to such operations.
B. The agreements in paragraph A forgoing are subject to the following
Conditions:
1. The Insured shall give notice to the Company before or as soon as
practicable after the commencement of such operations but failure to give
such notice shall not invalidate the insurance afforded by this
endorsement.
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/ / THE PREMIUM FOR THIS ENDORSEMENT IF ON INSTALLMENTS IS PAYABLE AS FOLLOWS:
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ADDITIONAL RETURN REVISED ANNIVERSARY PREMIUM
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AT DATE OF ENDORSEMENT $ $ (NOT APPLICABLE)
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FIRST ANNIVERSARY $ $ $
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SECOND ANNIVERSARY $ $ $
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GEN-47c Ed. 03/87
Company Numbers If this endorsement is issued concurrently with the policy, the Attaching Clause Endt. No. 4
need to be completed CONT'D
1=RELIANCE INSURANCE -----------------------------------------------------------------------------------------------
COMPANY Issued by Co. No. Insured ASSOCIATED GENERAL CONSTRUCTORS OF FLORIDA SELF Policy No.
2 INSURANCE FUND NXC 0105918
2=PLANET INSURANCE -----------------------------------------------------------------------------------------------
COMPANY Effective Date Policy Period Addt'l Premium Return Premium Premium subject
1/1/93 1/1/93 TO 1/1/94 / / to audit
3=UNITED PACIFIC -----------------------------------------------------------------------------------------------
INSURANCE COMPANY Unearned Premium Factor All terms and conditions of the policy remain Countersigned
unchanged except as amended by this endorsement.
4=RELIANCE INSURANCE -----------------------------------------------------------------------------------------------
CO. OF ILLINOIS
Page - 2 -
2. The Insured shall take whatever action is necessary to bring
themselves into compliance with the Workers' Compensation or
Occupational Disease laws of such State with respects to such operations.
If the Insured becomes a qualified self insurer in the State,
the Company shall thereupon endorse this policy to include the State under
item 5 at a retention to be mutually agreed to.
3. The premium bases and rates for the classifications of operations in
such State or operations necessary or incidental thereto shall be those
which would have been applicable under the excess manuals in use by the
Company had coverage A of the policy applied to such operations and the
premium for the insurance afforded by this endorsement with respect to
such operations shall be computed accordingly and in accordance to the
provisions of Condition II of the policy.
4. The word "State" as used in this endorsement means any State of the
United States of America and the District of Columbia.
C. Such insurance as is afforded by the policy by virtue of this
endorsement shall not apply to:
1. To Injury or Death of the master or a member of the crew of vessel;or,
2. Any fines or penalties levied against the Insured for not being a
qualified self insurer in the State and/or for failure to comply with the
requirements of any Workers' Compensation law.
D. The insurance afforded the policy by virtue of this endorsement shall
not constitute Workers' Compensation insurance as required of an employer under
the laws of any State.
- --------------------------------------------------------------------------------------------
/ / THE PREMIUM FOR THIS ENDORSEMENT IF ON INSTALLMENTS IS PAYABLE AS FOLLOWS:
- --------------------------------------------------------------------------------------------
ADDITIONAL RETURN REVISED ANNIVERSARY PREMIUM
- --------------------------------------------------------------------------------------------
AT DATE OF ENDORSEMENT $ $ (NOT APPLICABLE)
- --------------------------------------------------------------------------------------------
FIRST ANNIVERSARY $ $ $
- --------------------------------------------------------------------------------------------
SECOND ANNIVERSARY $ $ $
- --------------------------------------------------------------------------------------------
GEN-47c Ed. 03/87
Company Numbers If this endorsement is issued concurrently with the policy, the Attaching Clause Endt. No. 5
need to be completed
1=RELIANCE INSURANCE -----------------------------------------------------------------------------------------------
COMPANY Issued by Co. No. Insured ASSOCIATED GENERAL CONSTRUCTORS OF FLORIDA SELF Policy No.
2 INSURANCE FUND NXC 0105918
2=PLANET INSURANCE -----------------------------------------------------------------------------------------------
COMPANY Effective Date Policy Period Addt'l Premium Return Premium Premium subject
1/1/93 1/1/93 TO 1/1/94 / / to audit
3=UNITED PACIFIC -----------------------------------------------------------------------------------------------
INSURANCE COMPANY Unearned Premium Factor All terms and conditions of the policy remain Countersigned
unchanged except as amended by this endorsement.
4=RELIANCE INSURANCE -----------------------------------------------------------------------------------------------
CO. OF ILLINOIS
VOLUNTARY COMPENSATION AND EMPLOYERS' LIABILITY COVERAGE
ENDORSEMENT
In consideration of the premium charged, it is agreed that the Specific
Excess Workers' Compensation and Employers' Liability Policy (form 32-005)
IS extended as follows:
In the event that any of the Insured's employees are exempt from the
Workers' Compensation Law(s) of the State designated on item 5 of the
Declarations and the Insured Voluntary agrees to cover them, this policy is
extended to cover said employees as if they were subject to the Worker's
Compensation Law(s) of the Covered State(s).
- --------------------------------------------------------------------------------------------
/ / THE PREMIUM FOR THIS ENDORSEMENT IF ON INSTALLMENTS IS PAYABLE AS FOLLOWS:
- --------------------------------------------------------------------------------------------
ADDITIONAL RETURN REVISED ANNIVERSARY PREMIUM
- --------------------------------------------------------------------------------------------
AT DATE OF ENDORSEMENT $ $ (NOT APPLICABLE)
- --------------------------------------------------------------------------------------------
FIRST ANNIVERSARY $ $ $
- --------------------------------------------------------------------------------------------
SECOND ANNIVERSARY $ $ $
- --------------------------------------------------------------------------------------------
GEN-47c Ed. 03/87
Company Numbers If this endorsement is issued concurrently with the policy, the Attaching Clause Endt. No. 6
need to be completed
1=RELIANCE INSURANCE -----------------------------------------------------------------------------------------------
COMPANY Issued by Co. No. Insured ASSOCIATED GENERAL CONSTRUCTORS OF FL S.I.F. Policy No.
2 NXC 0105918
2=PLANET INSURANCE -----------------------------------------------------------------------------------------------
COMPANY Effective Date Policy Period Addt'l Premium Return Premium Premium subject
1/1/93 1/1/93 TO 1/1/94 / / to audit
3=UNITED PACIFIC -----------------------------------------------------------------------------------------------
INSURANCE COMPANY Unearned Premium Factor All terms and conditions of the policy remain Countersigned
unchanged except as amended by this endorsement.
4=RELIANCE INSURANCE -----------------------------------------------------------------------------------------------
CO. OF ILLINOIS
BANKRUPTCY OR INSOLVENCY ENDORSEMENT
In consideration of the premium charged, it is agreed that the following
additional Condition is added to the Specific Excess Workers' Compensation and
Employers' Liability Policy (form 32-005)
In the event that the Insured is unable to pay part or all of the
Insured's Retention, as shown in Item 6 of the Declarations, by reason
of Bankruptcy or Insolvency, the coverage afforded by this policy shall
continue in effect but only excess of the amount shown in Item 6, Insured's
Retention.
- --------------------------------------------------------------------------------------------
/ / THE PREMIUM FOR THIS ENDORSEMENT IF ON INSTALLMENTS IS PAYABLE AS FOLLOWS:
- --------------------------------------------------------------------------------------------
ADDITIONAL RETURN REVISED ANNIVERSARY PREMIUM
- --------------------------------------------------------------------------------------------
AT DATE OF ENDORSEMENT $ $ (NOT APPLICABLE)
- --------------------------------------------------------------------------------------------
FIRST ANNIVERSARY $ $ $
- --------------------------------------------------------------------------------------------
SECOND ANNIVERSARY $ $ $
- --------------------------------------------------------------------------------------------
GEN-47c Ed. 03/87