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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