Workers Comp Insurance PolicyMEMORANDUM
April 28, 2003
TO:The Honorable Mayor and City Council Members
FROM:Michael C. Van Milligen, City Manager
SUBJECT:Excess Workers Compensation Insurance Policy
Personnel Manager Randy Peck is recommending City Council approval of the Excess
Workers' Compensation Policy with Safety National Casualty Corporation for the period
July 1, 2002 to June 30, 2003. The reason for the extensive delay in bringing this to
City Council is that the policy was not received until March 12, 2003.
I concur with the recommendation and respectfully request Mayor and City Council
approval.
Michael C. Van Milligen
MCVM/jh
Attachment
cc: Barry Lindahl, Corporation Counsel
Cindy Steinhauser, Assistant City Manager
Randy Peck, Personnel Manager
CITY OF DUBUQUE, IOWA
MEMORANDUM
April 22, 2003
TO:Michael C. Van Milligen
City Manager
FROM: Randy Peck
Personnel Manager
SUBJECT: Excess Worker's Compensation Insurance Policy
The Excess Worker's Compensation Insurance Policy is with Safety National
Casualty Corporation and it is in effect from July 1,2002 to June 30, 2003. The annual
premium is $24,942 and the previous years premium was $15,041. The policy provides
for statutory limits for each accident or disease, a $1,000,000 employer liability limit and
an insured retention of $400,000 for each accident or disease. The policy has been
reviewed by Bill Robinson of Gallagher Byerly, Inc., our Benefit and Actuarial
Consultant, and Corporation Counsel Barry Lindahl and they find it acceptable. The
reason for the extensive delay in bringing this to you is that we did not receive the policy
until Mamh 12, 2003. The requested action is for the City Council to pass a motion
authorizing you to approve the Excess Workers' Compensation Insurance Policy with
Safety National Casualty Corporation.
If you have any questions, please feel free to call.
RP:bf
Cottingham & Butler
C&B Insurance I SlSCO ] HealthCorp I Safety Management
gstablished 1887
February 4, 2003
Mr. Ken TeKippe
City of Dubuque
50 W. 13th Street - City Hall
Dubuque, IA 52001
Re: Excess Workers' Compensation Policy
Dear Ken,
Attached is your new Workers' Compensation Policy for 2002/2003. The policy replaces
the binder you have been holding as evidence of coverage.
The enclosed cover notes highlight your policy coverages and exclusions. Please read your
policy to become familiar with all coverages and exclusions.
If you have any questions regarding your policies, please call.
C&B Insurance
563-58%5288
Enclosure
CITY OF DUBUQUE
COVER NOTES
2002/2003
Excess Workers Compensation
THIS INSURANCE SUMMARY PRESENTS HIGHLIGHTS OF COVERAGES.
READ THE POLICIES FOR COMPLETE DATA.
-- Cover Note --
KIND OF INSURANCE: Excess Workers Compensation
INSURER: Safety National Casualty Corporation
POLICY NO.: SP4780IA
A.M. Best Rating and Status: "A" VIII
DATE PREPARED: 01/04103
TERM: Annual
PREMIUM: $24,942
EXPIRATION: 07101/03
As Of: 02/04/03
I.Limits of Indemnity
Statutory Workers Compensation Each Accident
Statutory Workers Compensation Each Employee for Disease
$1,000,000 Employers Liability
II.Insureds Retention
$400,000 Each Accident
$400,000 Each Employee for Disease
HI. Estimated annual premium is based on estimated annual payroll of $15,395,215.
IV. Exclusions: Police Officers and Fire Fighters.
Cottingham & Butler, Inc. - Dubuque, Iowa 52004-0028
(563) 583-7344
Cover Note presents highlights of the coverage. Read policy form for complete data.
No. SP -4780-~
SPECIFIC EXCESS
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE AGREEMENT
NATIONAL CASUALTY CORPORATION
ST. LOUIS, MISSOURI
(Hereinafter called 'the CORPORATION),
In consideration of the payment of premium and subject to all the terms of this Agreement, hereby agrees with the EMPLOYER named
in the Declarations (hereinafter called the EMPLOYER), as follows:
A. Coverage of Agreement
This Agreement applies only to Loss sustained by the
EMPLOYER because of liability imposed upon the EMPLOYER
by the Workers' Compensation b~ Employers' Liability Laws of:
(1) the State(s) designated in the Declarations, or
(2) other State(s), provided that the "Loss" shall not be
greater than it would have been had liability been imposed
by the State(s) specified in the Declamfions,
on account of bodily injury by accident or bodily injury by
occupational disease due to Occurrences taking place within the
Liability Period to Employees of the EMPLOYER engaged in the
business operations specified in the Declarations and all other
operations necessary, incidental, or appurtenant thereto. Bodily
injury includes resulting death.
The inclusion of more than one EMPLOYER in the Declara-
nor the CORPORATION's Maximum Limit of Indemnity.
The insurance afforded by this Agreement applies to operations
in the State(s) specified in the Declarations, including, however,
incidental operations conducted by Employees who are regularly
engaged in operations in the specified State(s), but who may be
temporarily outside the specified State(s).
In no event shall the CORPORATION be liable for an~ Loss
voluntarily assumed by the EMPLOYER under any contract or
agreement, expressed or implied.
In no event shall this Agreement apply to Loss for which the
EMPLOYER carries a full coverage Workers' Compensation and
EmplOyers' Liability policy, nor shall this Agreement apply to
provisions of any law that provides non-occupational disability
benefits.
B. Specific Excess Insurance
With respect to each Occurrence taking place within a Liability
Period, the EMPLOYER shall retain as its own Loss, as defined
below, the amount specified in Item 7 of the Declarations, and the
CORPORATION agrees to reimburse the EMPLOYER only for
such Loss in excess of such Salf-lnsured Retention, subject to the
Maximum Limit of Indemnity Per Occurrence, or the Employers'
Liability Maximum Limit of Indemnity Per Occurrence, which-
ever is applicable, as specified in Item 8 of the Declarations. The
separate Employers' Liability Maximum Limit of Indemnity Per
Occurrence shall not operate, in any case, to increase the total
amount the CORPORATION agrees to reimburse the
EMPLOYER for Loss per any one OccUrrence as per Item 8 (a) of
the Declarations. For Agreements having multi-year Liability
Periods, the Self-Insured Retention established for the
EMPLOYER is subject to annual review and possible revision.
C. Deli'tuitions
(1) "Loss"- shall mean actual payments legally made by the
EMPLOYER to Employees and their dependents in satisfac-
tion of: (a) statutory benefits, Co) serdemants of suits and
claims, and (c) awards and judgments. "Loss" shall also
include Claim Expenses, paid by the EMPLOYER, as defined
in Paragraph (2) of this Section. The term "Loss" shall not
(2)
(3)
include the items specifically excluded by Paragraph (3) of this
Section.
"Claim Expenses" - shall mean interest upon awards and
judgments and the reasonable costs of investigation, adjust-
ment, defense, and appeal (provided that the prosecution of
such appeal is approved by CORPORATION) of claims,
suits or other proceedings brought against the EMPLOYER
under the Workers' Compensation or Employers' Liability
Laws of the State(s) designated in the Declarations, or other
State(s), as provided in Section A, for bodily injury or
occupational disease sustained during the respective Liabil-
ity Period by the Employees engaged in the business opera-
tions to which this Agreement applies, even though such
claims, suits, proceedings or demands are wholly gronnd-
less, false, or fraudulent, provided the CORPORATION is
promptly notified of every claim, suit, or proceeding and is
given the opportunity to participate in the defense. Claim-
Expenses shall not include fees to the EMPLOYER's Ser-
vice Company.
"Exclusions from Loss" - shall refer to the following
amounts paid by the EMPLOYER, and specifically excluded
from the term "Loss":
(a) Salaries, wages, and remuneration provided to Em-
ployees;
(b) Fees to the EMPLOYER's Service Company and/or
costs of self-administrafion of claims;
(c) Punitive or exemplary damages;
(d) Fines or penalfies assessed against the EMPLOYER for
any violation by the EMPLOYER, or its representa-
five(s), of any statute or regulation, or as a result of any
proceedings brought by or against any Employee of the.
EMPLOYER;
(e) Assessments and taxes made upon the EMPLOYER as
self-insurer whether imposed by statute, regulation, or
otherwise;
(f) Any amounts required to be paid by the EMPLOYER
because of:
1) Serious and willful misconduct of the
EMPLOYER, including intentional acts or omis-
sions resulting in injury,
2) Coemion, criticism, demotion, evaluation, re-
assignment, discipline, defamation, harassment,
humiliation, discrimination against or termination
of any Employee and/or related personnel prac-
tices, policies, acts, or omissions by the
EMPLOYER,
3) Knowingly employing an Employee in violation
of law,
4) Rejection by the EMPLOYER of any Workers'
Compensation law,
5) Failure to comply with any health, safety, or noti-
fication law or regulation, and
(g) Injury sustained by any Employee in, upon, entering,
or alighting from any EMPLOYER owned, leased, or
regularly chartered aircraft unless coverage is intended
by inclusion in Item 6 of the DeClarations or by endorse-
ment to this Agreement. Coverage will extend to aircraft
purchased, leased, or regularly chartered only if the
EMPLOYER notifies the CORPORATION within thirty
~,~ (30) days from the date of the initial exposure. In the
' event of such notification, however, the CORPORA-
~ TION may modifi/ coverage and/or charge additional
premiums.
(4) "Occurrence" - shall mean accident. In addition, bodily
injury by occupational disease must be caused or aggravated
by the conditions of employment and shall be deemed to have
occurred on the last day of the last exposure to those condi-
tions of employment causing or aggravating such injury by
occupational disease, or such date as is otherwise established
by the Workers' Compensation and Employers' Liability
Laws of the appropriate State(s). Bodily injury by occupa-
tional disease sustained by each Employee shall be deemed to
be a separate Occurrence unless such disease results directly
from an accident·
(5) "Employee" - as respects liability imposed upon the EM-
PLOYER by the Workers' Compensation Law of any State,
die word "Employee" shall mean any person performing
work'which renders the EMPLOYER liable under the Work-
ers' Compensation Law of a State hamed in Item 2 of the
Declarations, which is the state of the injured Employee's
normal employment, for bodily injuries or occupational dis-
ease sustained by such person.
(6) "State" - shall mean any state, territory, or possession of the
United States of America and the District of Columbia·
D. Reimbursement
If the EMPLOYER pays any Loss incurred in any Liability
CORPORATION shall reimburse the EMPLOYER upon receipt of
~.a formal proof of loss and other evidence acceptable to the CORPO-
?~,.TION of such payment. Within a reasonable Period of time,
.~4:eimbursement payments shill be mede by the CORPORATION.
The CORPORATION shall have, and may exercise at any time,
and from time to time, the right to offset any balance or balances,
whether on account of premiums or otherwise, due from the
EMPLOYER to the CORPORATION against any balance or bal-
ances, whether on account of Losses or otherwise, due from the
CORPORATION to the EMPLOYER under this Agreement.
E. Liability Period
The liability of the CORPORATION for Loss hereunder shall be
determined separately for each Liability Period. The initial Liabil-
ity Period shall commence at 12:01 A.M. on the Effective Date and
end at 12:01 A.M. on the Anniversary Date, designated in Items 3
and 4 respectively, of the Declarations. Each succeeding Liability
Period shall begin concurrently with the end of the previous Liabil-
ity Period and continue for the same number of consecutive months
as the initial Liability Period. All time is stated in the local time for
the State(s) designated in the Declarations.
In the event the Employer fails to give express written intent to
continue coverage at the end of a given Liability Period, the
Agreement shall be deemed terminated, and the Anniversary Date
shall serve as the termination date of the Agreement.
E Premium
Upon acceptance of the Agreement and at die beginning of each
Payroll Reporting Period, as specified in Item 12 of the Declara-
tions, the EMPLOYER shall pay to the CORPORATION the
amount of the Deposit Premium specified in Item 11 of the Declara-
tions The Deposit Premium shall be held by the CORPORATION
u, nfil the expiration of the Payroll Reporting Period· Within thirty
,~0) days after the close of each Payroll Reporting Period, the
~MPLOYER shall render to the CORPORATION a repOrt, upon a
form satisfactory to the CORPORATION, exhibiting, by classifica-
tion, the amount of such remuneration earned by Employees during
such reporting period, and the EMPLOYER shall therewith pay to
the CORPORATION the excess of ttle Earned Premium over
the Deposit Premium previously paid. In case the Deposit Premium_
paid exceeds the Earned'Premium, the Corporation shall return to
the EMPLOYER the amount of such excess or give appropfiat~
credit, subject to the proportion of Minimum Premium for the
Liability Period in the case of multi-year Liability Periods.
Upon expiration of a Liability Period, a summary of voluntary_-
payroll reports for such Liability Period shall be made to determine
the Earned Premium under this Agreement. In no event, however,
shall the Earned Premium in respect of any Liability Period be less
than the Minimum Premium specified in the Declarations.
For each Payroll Reporting Period, the CORPORATION shall
compute the Earned Premium as follows:
(1) Remuneration - The remuneration earned, or man-hours accu-
mulated, during such period by all Employees, including
volunteers, engaged in each classification covered by this
Agreement shall be computed in accordance with the rules set
forth in the appropriate Manual of Workers' Compensation
and Employers' Liability Insurance.
(2) Manual and Standard Premium- The remuneration, or mun-
hours, so computed for Employees engaged in each such
classification shall be multiplied by the Manual Rate per $100
of remuneration/man-hour, in effect at the inception of each
Payroll Reporting Period, and the products so obtained shall
be added together to determine the Manual Premium. An
Experience Modification Factor may be applied to the Manual
Premium to determine a Standard Premium. Such Experience
Modification Factor shall be determined at the inception of
this Agreement and is subject to annual review and possible
revision. A Standard Premium takes precedence over any
Manual Premium.
(3) Earned Premium - Against the Manual or Standard Premium
shall be applied the Premium Rate, as specified in Item 9 of
the Declarations, to determine the appropriate Earned Pree
This Agreement is issued by the CORPORATION and accepted
by the EMPLOYER subject to the agreement that, in the event of
any Change in the Rates per $100 remuneration/man-hour, as stated
in Item 6 of the Declarations, because of any general rate increase
or any legislative amendment affecting the benefits under the
Workers' Compensation Law of any State(s) named in Item 2 of the
Declarations, such change, upon the effective date thereof, shall
be, without endorsement, made a part of this Agreement.
G. Serf-Insurer
The EMPLOYER, by acceptance of this Agreement, warrants
that it is a duly qualified Self-Insurer in the State(s) designated in
the Declarations, and will continue to maintain such qualifications
during the currency of this Agreement. In the event the
PLOYER should at any time while this Agreement is in fome
terminate such tlualifieations or if die,/ should be cancelled or
revoked, such loss of qualLqcafions shall operate as notice of cancel'-
lation of this Agreement by the EMPLOYER, subject to the eddi-
tional terms of the Cancellation Section of this Agreement·
H. Service and Administration
This Agreement contemplates the concurrent and continued exist-
ence of a separate service agreement between the EMPLOYER and
the Service Company, its designated representative, named in Item 5
of the Declaratioas ~ providing services approved by the CORPORA-
TION. The EMPLOYER agrees that its Service Company shall
furnish the CORPORATION with quarterly loss runs concurrent
with each Liability Period of this Agreement. The provision of loss
runs alone does not relieve the EMPLOYER of its reporting obliga -
tions as set forth in Section I of this Agreement. In addition, the
electrortic transfer of loss information by a Service Company of the
EMPLOYER shall nor constitute notice of a claim.
Cancellation of the service agreement between the Service Com-
pany and the EMPLOYER shall operate as notice of cancellation of
this Agreement by the EMPLOYER, subject to the additional terms
of the Cancellation Section of this Agreement. Any change in
service companies must be immediately communicated to and ap-
proved by the CORPORATION.
I. Prompt Reporting of Cia.mas
As soon as the EMPLOYER becomes aware, the EMPLOYER
must provide prompt notice to the CORPORATION of: (a) any
claim or action commenced against the EMPLOYER winch ex-
~eeds, or is likely to exceed, fifty percent (50%) of the Self-Insured
~,etention Per Occurrence specified in Item 7 of the Declarations;
Co) the reopening of any claim in which a further award might
involve liability of the CORPORATION under this Agreement; and
(c) any disability claim, whether or not contested by the EM-
PLOYER, where it appears reasonably likely that such disability
will exceed one year in duration, or where such disability actually
exceeds one year in duration.
In addition, the following categories of claims shall be reported
to the CORPORATION immediately, regardless of any question of
potential involvement of the CORPORATION: 1. Fatalities;
2. Paraplegics and quadriplegics;
3. Serious burns;
4. Brain injury;
5. Spinal cord injury;
6. Amputation of a major extremity; and
7. Any Occurrence which results in serious injury to two or
more Employees.
Failure to render prompt notice of any claim in a manner suf-
ficient to the CORPORATION by the EMPLOYER, or its desig-
nated representative(s), may result in the disclaimer of coverage for
the particular claim. To constitute prompt, sufficient notice, the
EMPLOYER must provide complete information as to the details of
the injury, disease, or death.
J. Defense of Claims
The EMPLOYER shall invest~ate and settle or defend all claims
and shall conduct the defense and appeal of all actions, suits, and
proceedings commenced against it. The EMPLOYER shall forward
.~promptty to the CORPORATION copies of any pleadings or reports
'}s may be requested. The CORPORATION shall not be obliged to
_.fissume charge of the investigation, defense, appeal or se~lement of
any claim, suit, or proceeding brought against the EMPLOYER,
but the CORPORATION shall be given the opportunity to investi-
gate, defend, or participate with the EMPLOYER in the investiga-
tion and defense of any claim, if, in the opinion of the CORPORA-
TION, its liability under this Agreement might be involved.
K. Good Faith Claims Administration
The EMPLOYER shall use diligence, prudence, and good faith
in the investigation, defense, and settlement of all such claims and
shall not unreasonably refuse to settle any claim which, in the
exercise of sound judgment with respect to the entire claim, should
be settled, provided, however, that the EMPLOYER shall not
make any payment or agree to any setfleurent for any sum winch
would involve the limits of the CORPORATION's liability here-
under without the approval of the CORPORATION. The
EMPLOYER's failure to exercise diligence, prudence, and good
faith may result in the disclaimer of coverage for the particular
claim.
L. Inspection and Audit
The CORPORATION shall have the right, but not the obligation,
to inspect the promises and equipment and/or to audit the books and
records of the EMPLOYER and of its agents and representatives,
including all records relating to payroll and claims matters, at any
reasonable time during the period of this Agreement and within
three (3) years after final settlement of all claims due to Occur-
fences happening during the term of this Agreement. An audit to
determine Manual or Standard Premium shall supersede any and all
~'~ riot voluntary payroll reports by the EMPLOYER, and will be
sed to determine the final adjustment of premiums due to the
CORPORATION.
M. Other Insurance
If the EMPLOYER carries other valid and collectible insurance,
reinsurance, or indemnity with any other insurer or reinsurer cover-
ing a Loss also covered by this Agreement (other than insurance or
reinsurance that is purchased to apply in excess of the sum of the
Self-Insured Retention and the Maximum Limits of Indemnity
hereunder), the insurance afforded by this Agreement shall apply in
excess of and shall not contribute with such other insurance or
reinsurance.
N. Commutation
Beginning thirty-six (36) months after receipt of notice by the
CORPORATION of a claim, the CORPORATION may then, or at
any time thereafter, submit such claim for commutation. If the
CORPORATION so elects, the claim shall be submitted to an
actuary or appraiser to be mutually appointed by the CORPORA-
TION and the EMPLOYER, or, should the CORPORATION and
the EMPLOYER fail to agree upon an actuary or appraiser, then
each party shall select an actuary or appraiser who shall then select
an independent actuary or appraiser who shall fix a lump sum
amount, and the CORPORATION, at its option, may pay the lump
sum amount, which payment shall constitute a full and final release
of the CORPORATION's liability for such claim. However, such
lump sum payment shall not constitute a full and final release of the
CORPORATION s liability 'f, subsequent to such lump sum pay-
ment, any supplemental award is made increasing the amount of
benefits payable to the Employee and his/her dependents, and any
additional liability, at the CORPORATION's election, may imme-
diately be commuted via the process set forth above, and the
CORPORATION may discharge any additional liability by pay-
ment of another lump sum.
~ ~bro~g~tl
The EMPLOYER agrees to prosecute any and all valid claims the
EMPLOYER may have against third parties, arising out of any
Occurrence, resulting in payment of a Loss by the CORPORA-
TION, and return to the CORPORATION any amount so recov-
ered, less the reasonable expense of collecting such amounts.
Should the EMPLOYER fail to prosecute any valid claim against
third parties, and the CORPORATION becomes liable for Loss to
the EMPLOYER, the CORPORATION shall be subrogated to all
rights of the EMPLOYER. Any amounts recovered by the CORPO-
RATION shall be used to pay the expenses of collection and to
reimburse the CORPORATION for any amount it may have paid
the EMPLOYER for the Liability Period concerned, and all remain-
ing amounts collected shall be paid to the EMPLOYER.
P. Change in Agreement
No condition, provision, or declaration of this AgO'cement s~all
be waived or altered at any time, except as specified in Section F,
except by endorsement signed by the President or a Vice President
and the Secretary or an Assistant Secretary of the CORPORA-
TION.
This Agreement hereby terminates, supersedes, and replaces all
previously issued Workers' Compensation Insurance or Rainsur-
ance Agreements, as amended, between the EMPLOYER and the
CORPORATION.
If terms of this Agreement are in conflict with any law applicable
to this Agreement, this statement amends this Agreement to con-
form to such law. In addition, in the event any terms are in conflict
with applicable laws, the remaining terms of the Agreement shall
be enforceable.
Q. Cancellation
This Agreement may be cancelled by either party giving the other
party written notice not less than sixty (60) days prior to the date of
cancellation, except, that if the CORPORATION cancels for non-
payment of any premium, the cancellation shall become effective
~ve (5) days after dispatch of notice by the CORPORATION. The
dare of cancellation then becomes the termination dare of the final
Liability Period. This Agreement does not apply to Loss as a result
of Occurrences taking place after the effective date of such cancel-
lation.
If cancellation is effected by the EMPLOYER, the Manual or
Standard Premium shall be determined by the short rote tables used
for casualty insurance, and the Earned Premium shall be the
product of the Premium Rate (Item 9) times the Manual or Standard
Premium (or the Total Annual Remuneration) so arrived at, but not
less than the Minimum Premium specified in the Declarations.
If cancellation is effected by the CORPORATION for
non-payment of premium, the EMPLOYER shall pay the
CORPORATION Earned Premium for the period up to the date of
cancellation.
If the CORPORATION cancels for any other reason, the Man-
ual or Standard Premium (or the Total Annual Remuneration)
shall be determined upon a pre rata basis and the Earned Premium
adjusted in accordance therewith.
R. Assignment
An assignment of interest under this Agreement will not bind
the CORPORATION unless an endorsement signed by the Presi-
dent or a Vice President and the Secretary or an Assistant Secre-
tary of the Corporation assigning interest under this Agreement is
issued by the CORPORATION.
S. Bankruptcy or Insolvency of Employer
~)eThe bankruptcy or insolvency of the EMPLOYER will not
lieve the CORPORATION or the EMPLOYER of its duties and
liabilities under this Agreement. After payments have been made
by or on behalf of the EMPLOYER, reimbursements due under
this Agreement will be made by the CORPORATION as if the
EMPLOYER ;had not become bankrupt or insolvent, but not in
excess of the CORPORATION's limit of indeumity.
T. Sole Representative
If more than one EMPLOYER is named in Item 1 of the
Declarations, or an endorsement related thereto, the EMPLOYER
first named in Item 1, or a related endorsement, will act on behalf
of all EMPLOYERS to give or to receive notice of cancellation, to
receive return premium or reimbursement, or to request changes
in this Agreement.
U. Acceptance
By acceptance of this Agreement, the EMPLOYER agrees that
the statements in this Agreement, in the Declarations, and in the
application are the EMPLOYER's representations; that this
Agreement is issued in reliance upon such representations; that
this Agreement embodies all agreements existing between the
EMPLOYER and the CORPORATION, or any of its agents,
relating to this excess insurance, and that full compliance by the
EMPLOYER with all terms of this Agreement is a condition
precedent to the CORPORATION's liability hereunder.
IN WITNESS WHEREOF. the SAFETY NATIONAL CASU-
ALTY CORPORATION has caused this Agreement to be exe-
cuted by printing below the facsimile signatures of its President
and Secretary and by the actual signature of its Secretary on the
Declarations.
SAFETY NATIONAL CASUALTY CORPORATION
2043 WOODLAND PARKWAY
OT. LOUIS, MO 63146
DECLARATIONS
SP -4780-1A
Item 1.
Item 2.
Item 3.
Item 4.
Item 5.
Employer: CITY OF DUBUQUE
Address: 50W. 13TH STREET, DUBUQUE, IA 52001
This Agreement covers all business operations of the EMPLOYER as a Self-Insurer in the following State(s):
IOWA
Effective Date: 12:01 A.M. July 1, 2002
Anniversary Date: 12:01 A.M. July 1, 2003
The Service Company shall be ALTERNATIVE SERVICE CONCEPTS LLC OF BEq-i'ENDORF, IOWA
See Affached
Total Estimated Manual Premium
SNCC Experience Modification Factor
Total Estimated Standard Premium
7. Self-Insured Retention Per Occurrence
Item 8. (a) Maximum Limit of Indemnity Per Occurrence
(b) Employers' Liability Maximum Limit of Indemnity Per Occurrence
Item 9. Premium Rate $0.155 per $100. of Payroll
Item 10. Minimum Premium for the Liability Period
Item 11. Deposit Premium for the Payroll Reporting Period
Item 12. Payroll Reporting Period Annually as of July 1st
Item 13. Endorsements See Endorsement Schedule
Signed at St. Louis, Missouri on October 22, 2002.
$ N/A
N/A
$ N/A
$ 400,000
$ STATUTORY
$ 1,000,000
$ 24,942
$ 24,942
Secretary
Countersigned this
By: N/A
day of
DSP-0195
RE: CiTY Of DUBUQUE
t~0_fleiCy No: SP -4780-1A
ctive Date: 12:01 A.M. July 1, 2002
Declarations:
Item 6.
Code
St Classifications of Operations No.
Estimated
Total Annual
Remuneration/
Manhoura
Rate per $100
Remuneration/
Manhours
IA
Tree Pruning. Spraying, Repairing, & Ddvers 0106
Machinery or Equipment Erec~on or Repair NOC & 3724
Drivers
Vending/Coin Operated Mach 5192
Inst alJ/S ervice/Repair/S alesperson/D r.
Street or Road Construction: Paving or Repaying & 5506
Drivers
Limousine Co.: All Other Employees & Drivers 7382
AlrcraffJHelicopter Opera6on - all ether employees & 7423
drivers
Waterworks Operation & Drivers 7520
Sewage Disposal Plant Operation & Drivers 7580
Automobile Storage Garage or Parking Station & Drivers 8392
Clerical Off'me Employees NOC 8810
Hospital: Veterinary & Drivers 8831
Nursing-Home Health, Public and Traveling-All 8835
Employees
Building - Operation by Owner or Lessee 9015
Amusement Park or Exhibition Operation & Ddvers 9016
Club-Country. Goff, Fishing or Yacht-& Cledcal 9060
$ 130,381
85,801
75,115
685,392
439,138
244.299
912,550
806,359
506,011
6.485,381
36,547
84,311
480,315
70,224
223,862
College or School: All Other Employees 9I 01 75,311
Theater NOC All Other Employees 9154 351,655
Athletic Team or Park: Operation & Drivers 9182 1,042,107
Street Cleaning & Drivers 9402 220.871
Garbage, ashes or refuse collection & drivers 9403 1,090,291
Municipal, Township. County or State Employee NOC 9410 2,045,889
$16,091,610
N/A
Estimated
Premium
N/A
~E: CITY OF DUBUQUE
Policy No: SP -4780-1A
Effective Date: 12:01 A.M. July 1, 2002
Endorsement Schedule
Number Title
XSNC 0097 00 0295 IOWA NOTICE TO COMMISSIONER
XWC 0276 00 1291 BROAD FORM ALL STATES
XWC 0292 00 1291 FOREIGN VOLUNTARY WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY
XWC 0382 00 1294 ELIMINATION OF COMMUTATION SECTION
XWC 0823 00 0301 PREMIUM DUE DATE ENDORSEMENT
XWC 097 O0 0295
ENDORSEMENT #1
IOWA NOTICE TO COMMISSIONER
Effective 12:01 A.M., Local Time, July 1, 2002
in consideration of the payment of premium and adherence by both parties to the terms of this Agreement, it is
hereby understood and agreed as follows:
NOTICE TO IOWA COMMISSIONER
No notice of cancellation, termination or alteration of coverage hereunder shall be effective unless
written notice of such cancellation, termination, or alteration of coverage is provided to the
Commissioner of Insurance of the State of Iowa ninety (90) days pdor to the effective date of
cancellation, termination, or alteration of coverage.
All other terms, conditions, agreements and stipulations remain unchanged.
Attached to and forming a part of Excess Workers' Compensation and Employers' Liability Insurance Agreement
I~1o. SP -4780-1A, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to CITY OF
DUBUQUE, dated July 1, 2002.
Secretary
SAFETY NATIONAL CASUALTY CORPORATION
President
XWC 276 O0 1291
ENDORSEMENT #2
BROAD FORM ALL STATES
Effective 12:01 A.M., Local Time, July 1, 2002
In consideration of the payment of premium and adherence by both parties to the terms of this Agreement, it
is hereby understood and agreed that this Agreement shall include the following:
If the EMPLOYER undertakes operations in any State not designated in Item 2 of the
Declaratiot~s, this Agreement applies to such operations.
This Agreement also applies to Loss sustained by the EMPLOYER because of liability
imposed upon the EMPLOYER by the Workers' Compensation and Employers' Liability
Laws of such non-designated State.
This Agreement applies to operations of the EMPLOYER covered by this Endorsement.
However, such Loss is subject to all the limitations of this Agreement including but not
limited to the Self-Insured Retention Per Occurrence or the Limitation Per Occurrence
and the Maximum Limit(s) of Indemnity of the CORPORATION for the Liability Period.
The w~rd "State" as used in this Endorsement shall mean any State of the United States
of America and the District of Columbia.
The EMPLOYER shall give notice to the CORPORATION before or within a reasonable
time after the commencement of such operations. The EMPLOYER shall take whatever
action is necessary to come within the Workers' Compensation and occupational disease
laws of such State.
The insurance afforded by this Endorsement does not cover fines or penalties imposed
on the EMPLOYER for failure to comply With the requirements of any Workers'
Compensation Law.
All of the provisions of this Agreement, insofar as such provision are not inconsistent
herewith, are applicable to the insurance afforded by the Agreement by virtue of this
Endorsement.
All other terms, conditions, agreements and stipulations remain unchanged.
Attached to and forming a part of Excess Workers' Compensation and Employers' Liability Insurance Agreement
No. SP -4780-1A, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missoud to CITY OF
DUBUQUE, dated July 1, 2002.
Secretary
SAFETY NATIONAL CASUALTY CORPORATION
President
XVVC 292 00 1291
ENDORSEMENT ~3
FOREIGN VOLUNTARY WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY
Effective 12:01 A.M., Local Time, July 1, 2002
SECTION 1. SCOPE OF INSURANCE
B.
C.
D.
The insurance afforded by this Agreement also applies to Employees, as defined in Section 2 of
this Endorsement, who are employed to work at locations within the following country or
countries: WORLDWIDE.
Benefits payable under this Endorsement are the same as those that would be payable if the
Employees in question were subject to the Worker's Compensation Law of the following State or
State(s):lOWA
The CORPORATION'S Limit of Liability for repatriation expenses is limited to $25,000 with
respect to any one Employee.
The CORPORATION'S Limit of Liability for Coverage B - Employer's Liability is limited to
$50,000.
SECTION 2. EMPLOYEES COVERED
A. It is agreed that the insurance provided by this Agreement also applies to those Employees of the
EMPLOYER who are hired or assigned by the EMPLOYER to work at locations within the country
or countries stated in this Endorsement.
B. This insurance, with respect to any such Employee, shall attach from the moment such Employee
is hired or assigned for such work and shall cease from the moment the employment or
assignment for such work is terminated. If the Employee has been hired in the United States of
Amedca, coverage continues after termination of employment until the Employee returns to the
United States of Amedca or for a reasenable pedod of time for the opportunity to return to the
United States of Amedca, unless termination of employment is due to the Employee's resignation.
C. This insurance shall not apply to persons other than citizens or residents of the United States of
America within the country or countries stated in this Endorsement except as stated herein:
NONE
All other terms, conditions, agreements and stipulations remain unchanged.
Attached to and forming a part of Excess Workers' Compensation and Employers' Liability Insurance Agreement
No. SP -4780-1A, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Misseud to CITY OF
DUBUQUE, dated July 1, 2002.
Secretary
SAFETY NATIONAL CASUALTY CORPORATION
President Y"~-'
XWC 382 00 1294
ENDORSEMENT #4
ELIMINATION OF COMMUTATION SECTION
Effective 12:01 A.M., Local Time, July 1, 2002
In consideration of the payment of premium and adherence by both parties to the terms of this Agreement, it is
hereby understood and agreed as follows:
The Commutation Section of this Agreement (Section N) is hereby deleted from this Agreement.
All other terms, conditions, agreements and stipulations remain unchanged.
Attached to and forming a part of Excess Workers' Compensation and Employers' Liability Insurance Agreement
No. SP -4780-1A, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to CITY OF
DUBUQUE, dated July 1, 2002.
Secretary
SAFETY NATIONAL CASUALTY CORPORATION
President
XWC 823 00 0301
ENDORSEMENT
PREMIUM DUE DATE ENDORSEMENT
Effective 12:01 A.M., Local Time, July 1, 2002
In consideration of the payment of premium and adherence by both padies to the terms of this Agreement, it is
hereby understood and agreed that the Section rifled Premium is amended by adding the following new paragraph:
The EMPLOYER shall pay premiums when due. The due date for audit premiums is
thirty (30) days after the date of billing.
All other terms, conditions, agreements and stipulations remain unchanged.
Attached to and forming a part of Excess Workers' Compensation and Employers' Liability Insurance Agreement
No. SP -4780-1A, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missoud to CITY OF
DUBUQUE, dated July 1, 2002.
Secretary
SAFETY NATIONAL CASUALTY CORPORATION
~re~i~ent