Workers Compensation School Bus
Resume:
WLTR***
THE HARTFORD
BUSINESS SERVICE CENTER
SAN ANTONIO TX 78251 September 15, 2022
PACHECO AND ASSOCIATES INC / 42631126
GAITHERBURG MD 20877
Policy Information:
Policy Holder Details: ODIS PAINTING LLC
7601 16TH AVE
TAKOMA PARK MD 20912
Policy Number: 42 WEC AU1ZL0
You can find information about your client’s policy enclosed. You can also find this info online at https://agency.thehartford.com.
If you have any questions or concerns about what you see, contact us at any of the options listed on this page. Thanks for choosing us for your business insurance needs. Sincerely,
The Hartford
Form 97485 18th Rev. Printed in U.S.A. Page 1 of 4 Process Date: 09/15/22 Policy Expiration Date: 09/15/23 Policy Number 42 WEC AU1ZL0 Policy Effective Date 09/15/22 ODIS PAINTING LLC
7601 16TH AVE
TAKOMA PARK MD 20912
Dear Hartford Insured,
Re: An Important Message to Workers Compensation Policyholders The control of workplace accidents and injuries should be among the highest priorities of your firm. Each accident wastes precious human and financial resources, and introduces inefficiencies into your operations. From a practical standpoint, the control of accidents, and their inevitable costs, simply makes good business sense. An effective risk engineering program can save you money and aggravation, can positively impact your loss experience (and thus your premium), and most importantly, can help you maintain solid control of your operations. As a service to you, our valued customer, the Risk Engineering Department of The Hartford in cooperation with your independent agent, can assist you in establishing risk engineering strategies. If you would like assistance, please complete and return to us the reply portion of this brochure, or contact your independent agent. Services Available
The following is a description of some of the services that we provide. The types of services that may be appropriate for your business depend upon the nature and size of your operations and the specific risk engineering services you have requested. The cost of risk engineering services may or may not be a part of your insurance premium. This depends on the extent of the requested services, agreements stated in your insurance policy and program, and statutory regulations that may require us to provide risk engineering services.
1) Reference Materials – Information about risk engineering topics that can be provided or made available to you to help you to enhance your risk engineering program. 2) Telephone Consultation – We can hold a teleconference with you to help you to evaluate your risk engineering program, identify areas for improvement, and recommend ways to implement such improvements.
3) Onsite Consultation – This consists of visiting your premises and helping you to assess and remedy your risk engineering needs onsite. This level of service is usually only appropriate for larger, higher hazard operations. The following are examples of some of the services that could be provided onsite: o A review of your safety program to determine its adequacy and recommend modifications to that plan where needed.
o Specific hazard evaluations, including ergonomics, industrial hygiene or material handling. o An initial survey and evaluation to address potential safety and health hazards. o Consultation to help management establish a comprehensive loss prevention Program. o Periodic summaries of accidents and analysis of causes. o Follow-up visits to check on progress and to provide continuing assistance when required. Form 97485 18th Rev. Printed in U.S.A. Page 2 of 4 A Word About OSHA
The Occupational Safety and Health Act of 1970 and similarly approved State Plans require employers to provide their employees with safe and healthful places to work. The Occupational Safety and Health Administration
(OSHA) of the U.S. Department of Labor and similar State agencies enforce the regulations and apply penalties
(civil and criminal) for non-compliance.
New standards have been developed, and through application and interpretation, standards change. You should make yourself aware of the standards that are applicable to your operations, and assure yourself that reasonable efforts are made to be in compliance. Copies of the standards are available through most libraries, or can be obtained through OSHA or the U.S. Government Printing Office. You should know that neither The Hartford, nor any other party, can fulfill your obligations under the Law. Questions related to your legal obligations should be referred to your legal counsel. Some Safety Reminders from The Hartford:
Have you considered:
o The need to formalize your safety efforts to assure compliance and document your efforts? o The need to acquire Material Safety Data Sheets on all hazardous materials and the need for training on appropriate safety measures for your employees?
o Requirements for record keeping of injuries, illnesses, and exposure to hazardous substances? o Assessing each job task to determine hazards and needed controls? o Measuring each exposure to hazardous substances to determine the need for control or personal protective equipment?
o What mechanisms are in place to periodically verify that exposure controls (guards, ventilation systems, etc.) are still in place and working?
o What specific training your employees and your supervisors need to avoid hazards in the workplace? o What specific OSHA standards apply to your business? o What mechanism exists to promptly investigate all accidents and ‘near-misses’ to limit the chance of another occurrence?
o The financial impact an injury or illness has on your business? o What resources are available to you to help prevent accidents and illnesses? Thank you for your business.
Sincerely,
The Hartford's Risk Engineering Department
Form 97485 18th Rev. Printed in U.S.A. Page 3 of 4 THIS BROCHURE IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY. IT IS NOT INTENDED TO BE A SUBSTITUTE FOR A COMPLETE ON-SITE SAFETY INSPECTION CONDUCTED BY A QUALIFIED RISK ENGINEERING SPECIALIST. READERS ARE ENCOURAGED TO HAVE SUCH AN INSPECTION CONDUCTED BOTH TO PROMOTE WORKPLACE SAFETY AND TO COMPLY WITH APPLICABLE LAW. FOR ADDITIONAL INFORMATION OR ASSISTANCE, EITHER TELEPHONE OR MAIL THIS FORM TO YOUR HARTFORD AGENT OR NEAREST OFFICE OF THE HARTFORD
NOTICE TO ARKANSAS POLICYHOLDERS
The Hartford is required by law to provide its policyholders with certain accident prevention services at no additional cost as required by ARK. Code Ann. §11-9-409(D) and Rule 32. If you would like more information, call The Hartford’s Risk Engineering Department, One Hartford Plaza, COG1, Hartford, CT 06155 at 1-866-***-****. If you have any questions about this requirement, call the Health and Safety Division, Arkansas Workers’ Compensation Commission at 1-800-***-****.
NOTICE TO CALIFORNIA POLICYHOLDERS
The Hartford is required by law to provide its policyholders with certain occupational safety and health risk engineering consultation services as required by the California Labor Code, §6354.5, at no additional charge. If you would like more information call The Hartford’s Risk Engineering Department at 1-866-***-**** for occupational safety and health risk engineering consultation services. California Workers Compensation insurance policyholders may register comments about the insurer’s risk engineering consultation service by writing to:
State of California
Department of Industrial Relations
Division of Occupational Safety and Health
P.O. Box 420603
San Francisco, California 94142
NOTICE TO PENNSYLVANIA POLICYHOLDERS
The Hartford maintains and provides accident and illness prevention services as required by the nature of the policyholder's business or its operation, in accordance with the Pennsylvania Workers' Compensation Act. For more information about these services contact your Hartford Agent or nearest office of The Hartford. NOTICE TO TEXAS POLICYHOLDERS
Pursuant to Texas Labor Code §411.066, The Hartford is required to notify its policyholders that accident prevention services are available from The Hartford at no additional charge. These services may include surveys, recommendations, training programs, consultations, analyses of accident causes, industrial hygiene and industrial health services.
The Hartford is also required to provide return-to-work coordination services as required by Texas Labor Code
§413.021 and to notify you of the availability of the return-to-work reimbursement program for employers under Texas Labor Code §413.022.
If you would like more information, contact The Hartford at 1-866-***-**** and email **********************@***********.*** for accident prevention services or 1-877-***-**** and email ******************.*****@***********.*** for return-to-work coordination services. For information about these requirements call the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) at 1-800-***-**** or for information about the return-to-work reimbursement program for employers call the TDI-DWC at 1-512-***-****.
If The Hartford fails to respond to your request for accident prevention services or return-to-work coordination services, you may file a complaint with the TDI-DWC in writing at http://www.tdi.texas.gov or by mail to Texas Department of Insurance, Division of Workers’ Compensation, P.O. Box 12050, Austin, Texas 78711. Form 97485 18th Rev. Printed in U.S.A. Page 4 of 4 Request for Technical Resources
To The Hartford's Risk Engineering Department:
Yes - I am interested in obtaining information concerning: General Topics Business Continuity Construction
Accident Analysis Business Travel Safety Construction Site Consultation Accident Investigations Contingency Planning Overview Construction Equipment Hazards Establishing a Risk Engineering
Program
Emergency/Disaster Response Hazard Communication
Hazard Recognition Emergency Evacuation Drills Ladders & Scaffolds Safety Committees Emergency Preparedness Planning Trenching & Evacuation Fall Protection
Ergonomics Industrial Hygiene Property
Back Injury Prevention Hazard Communication Automatic Sprinkler System Computer Workstation Industrial Hygiene (general) Flammable Liquids Cumulative Trauma Disorders Indoor Air Quality Fire Prevention and Protection Ergo Train-the-Trainer Noise Exposures Fire Drill and Evacuation Telecommuting Respiratory Protection Hot Work Permit Program Transportation Workers' Compensation Other Topics
3-D Driver Training Bloodborne Pathogens Business Risk Management Driving Defensively Drug Screening General Liability Investigations Fleet Newsletter Machine Safeguarding Product Liability Programs Guide to Successful Driver Mgmt Return to Work Programs Safety Training School Bus Driving Tips Slip and Falls Security/Terrorism Name
Company Policy #
Address
City & State Zip Code
Email Address: Telephone
For more information on the above, you can visit our website at https://www.thehartford.com/riskengineering
Or you may forward your request to:
Fax line: 1-860-***-****
Or mail to:
The Hartford Financial Services Group
Risk Engineering Department
One Hartford Plaza, COG1
Hartford, CT 06155
Form WC 99 00 02 (03/14) Page 1 of 1
Workers’ Compensation
and Employers’ Liability
Business Insurance Policy
(Policy Provisions: WC000000C)
INFORMATION PAGE
WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 09/15/22 Policy Expiration Date: 09/15/23 INSURER: Hartford Fire Insurance Company
ONE HARTFORD PLAZA HARTFORD CT 06155
NCCI Company Number: 13269
Company Code: 1
Suffix
LARS RENEWAL
POLICY NUMBER: 42 WEC AU1ZL0
Previous Policy Number: New
1. Named Insured and Mailing Address:
(No., Street, Town, State, Zip Code)
ODIS PAINTING LLC
7601 16TH AVE
TAKOMA PARK MD 20912
FEIN Number: 87-3738931
State Identification Number(s):
The Named Insured is: LLC
Business of Named Insured: Paint and Wall Covering Contractors Other workplaces not shown above: 7601 16TH AVE
TAKOMA PARK MD 20912
2. Policy Period: From 09/15/22 To 09/15/23 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer’s Name: PACHECO AND ASSOCIATES INC
525 SOUTH FREDERICK AVENUE
GAITHERBURG MD 20877
Producer’s Code: 42631126
Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD
SAN ANTONIO TX 78251
Total Estimated Annual Premium: $5,060
Deposit Premium:
Policy Minimum Premium: $942 MD (Includes Increased Limit Min. Prem.) Audit Period: ANNUAL Installment Term: Twelve Pay (8.33%Down+11@8.33%) The policy is not binding unless countersigned by our authorized representative. Countersigned by 09/15/22
Authorized Representative Date
INFORMATION PAGE (Continued) Policy Number: 42 WEC AU1ZL0 Form WC 00 00 01 A (1) Printed in U.S.A. Page 2
Process Date: 09/15/22 Policy Expiration Date: 09/15/23 3. A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states listed here: MD
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are:
Bodily injury by Accident $1,000,000 each accident Bodily injury by Disease $1,000,000 policy limit
Bodily injury by Disease $1,000,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE.
D. This policy includes these endorsements and schedule: SEE ENDORSEMENT-WC 99 03 68
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications
Code Number and
Description
Premium Basis
Total Estimated
Annual
Remuneration
Rates Per
$100 of
Remuneration
Estimated
Annual
Premium
Total Standard Premium $4,785
Expense Constant $200
Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement $60 Catastrophe (Other Than Certified Acts Of Terrorism) $15 Estimated Annual Premium (before Surcharges) $5,060
*See the attached Schedule(s) of Operations for Location and State Level Premium Information Total Estimated Annual Premium: $5,060
Deposit Premium:
Policy Minimum Premium: $942 MD (Includes Increased Limit Min. Prem.) Interstate/Intrastate Identification Number: Refer to Schedule of Operations NAICS: 238320
Labor Contractors Policy Number: SIC: 1721
Form WC 99 03 68 Printed in U.S.A.
Process Date: 09/15/22 Policy Expiration Date: 09/15/23 EXTENSION OF THE INFORMATION PAGE - ITEM 3.D - ENDORSEMENTS Policy Number: 42 WEC AU1ZL0 Endorsement Number:
Effective Date: 09/15/22 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: ODIS PAINTING LLC
7601 16TH AVE
TAKOMA PARK MD 20912
Item 3.D. of the Information Page is completed to include the following endorsements: WC000000C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC000001A.1 INFORMATION PAGE
WC000001A.2 INFORMATION PAGE
WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT WC000403 EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT WC000414A 90-DAY REPORTING REQUIREMENT- NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT
WC000419A PART FIVE - PREMIUM AMENDATORY ENDORSEMENT WC000421F CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT
WC000422C TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT
WC000424 AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT
WC190402A MARYLAND ALCOHOL- AND DRUG-FREE WORKPLACE PREMIUM CREDIT ENDORSEMENT
WC190601G MARYLAND CANCELLATION AND NONRENEWAL ENDORSEMENT WC190602 MARYLAND NOTIFICATION OF 45-DAY UNDERWRITING PERIOD ENDORSMENT WC990001J Signature/Copyright
WC990002 WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY BUSINESS INSURANCE POLICY
WC990005 SCHEDULE OF OPERATIONS
WC990302B WORKERS COMPENSATION BROAD FORM ENDORSEMENT Form WC 99 03 68 Printed in U.S.A.
Process Date: 09/15/22 Policy Expiration Date: 09/15/23 EXTENSION OF THE INFORMATION PAGE - ITEM 3.D - ENDORSEMENTS Policy Number: 42 WEC AU1ZL0 Endorsement Number:
Effective Date: 09/15/22 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: ODIS PAINTING LLC
7601 16TH AVE
TAKOMA PARK MD 20912
Item 3.D. of the Information Page is completed to include the following endorsements: WC990358B AMENDMENT TO WORKERS COMPENSATION BROAD FORM ENDORSEMENT - EMPLOYERS LIABILITY STOP GAP COVERAGE
WC990368 EXTENSION OF THE INFORMATION PAGE - ITEM 3.D. - ENDORSEMENTS WC990628 MINIMUM RETAINED PREMIUM ENDORSEMENT
WC990689 GOODS AND SERVICES ENDORSEMENT
SCHEDULE OF OPERATIONS
This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below:
INSURER: HARTFORD FIRE INSURANCE COMPANY
Company Code: 1
Policy Number: 42 WEC AU1ZL0 Schedule Number: 01-19-01 Effective Date: 09/15/22 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Location Address of operations covered by this schedule: ODIS PAINTING LLC
7601 16TH AVE
TAKOMA PARK MD 20912
NAICS: 238320
FEIN: 87-3738931 SIC: 1721 NO. OF EMPL: 1
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications
Code Number and
Description
Premium Basis
Total Estimated
Annual
Remuneration
Rates Per
$100 of
Remuneration
Estimated
Annual
Premium
Countersigned by
Authorized Representative
Form WC 99 00 05 (1) Printed in U.S.A.
Process Date: 09/15/22 Policy Expiration Date: 09/15/23 5474
PAINTING NOC & SHOP OPERATIONS, DRIVERS
150,000.00 3.110000 4,665
Total State Summary
Total Class Premium 4,665
Emp liab increased limits 0.011000 51
Employer Liability Increase Limits balance to Minimum Premium
69
Total Estimated Annual Standard Premium 4,785
Expense constant 200
Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement
150,000.00 0.040000 60
Catastrophe (other than certified acts of terrorism) 150,000.00 0.010000 15 Total Estimated Annual Premium 5,060
Form WC 66 01 56 B Printed in U.S.A.
Process Date: 09/15/22 Policy Expiration Date: 09/15/23 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY QUICK REFERENCE
Beginning Beginning
on Page on Page
INFORMATION PAGE PART TWO - Continued
1 G. Limits of Liability 4 General Section 1 H. Recovery From Others 4 A. The Policy 1 I. Actions Against Us 4 B. Who Is Insured 1 C. Workers Compensation Law 1 PART THREE - OTHER STATES INSURANCE 4 D. State 1 A. How This Insurance Applies 4 E. Locations 1 B. Notice 5 PARTONE- WORKERS COMPENSATION INSURANCE... 1 PART FOUR - YOUR DUTIES IF INJURY OCCURS 5 A. How This Insurance Applies 1 B. We Will Pay 1 PART FIVE - PREMIUM 5 C. We Will Defend 1 A. Our Manuals 5 D. We Will Also Pay 1 B. Classifications 5 E. Other Insurance 2 C. Remuneration 5 F. Payments You Must Make 2 D. Premium Payments 5 G. Recovery From Others 2 E. Final Premium 5 H. Statutory Provisions 2 F. Records 6 G. Audit 6 PART TWO - EMPLOYERS LIABILITY INSURANCE 2
A. How This Insurance Applies 2 PART SIX - CONDITIONS 6 B. We will Pay 3 A. Inspection 6 C. Exclusions 3 B. Long Term Policy 6 D. We Will Defend 3 C. Transfer of Your Rights and Duties 6 E. We Will Also Pay 4 D. Cancellation 6 F. Other Insurance 4 E. Sole Representative 6 IMPORTANT: This Quick Reference is not part of the Workers Compensation and Employers Liability Policy and does not provide coverage. Refer to the Workers Compensation and Employers Liability Policy itself for actual contractual provisions.
PLEASE READ THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CAREFULLY. Form WC 00 00 00 C Printed in U.S.A. Page 1 of 6
Process Date: 09/15/22 Policy Expiration Date: 09/15/23 WORKERS COMPENSATION AND EMPLOYERS
LIABILITY INSURANCE POLICY
In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows: GENERAL SECTION
A. The Policy
This policy includes at its effective date the
Information Page and all endorsements and schedules listed there. It is a contract of insurance between you
(the employer named in Item 1 of the Information
Page) and us (the insurer named on the Information Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement
issued by us to be part of this policy.
B. Who Is Insured
You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a
partnership, and if you are one of its partners, you are insured, but only in your capacity as an employer of the partnership's employees.
C. Workers Compensation Law
Workers Compensation Law means the workers or
workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to
that law which are in effect during the policy period. It does not include any federal workers or workmen's
compensation law, any federal occupational disease law or the provisions of any law that provide
nonoccupational disability benefits.
D. State
State means any state of the United States of
America, and the District of Columbia.
E. Locations
This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A. states unless you have other insurance or are self-insured for such
workplaces.
PART ONE - WORKERS COMPENSATION INSURANCE
A. How This Insurance Applies
This workers compensation insurance applies to
bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death.
1. Bodily injury by accident must occur during the policy period.
2. Bodily injury by disease must be caused or
aggravated by the conditions of your employment.
The employee's last day of last exposure to the
conditions causing or aggravating such bodily
injury by disease must occur during the policy
period.
B. We Will Pay
We will pay promptly when due the benefits required of you by the workers compensation law.
C. We Will Defend
We have the right and duty to defend at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to
investigate and settle these claims, proceedings or suits.
We have no duty to defend a claim, proceeding or
suit that is not covered by this insurance.
D. We Will Also Pay
We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend:
1. reasonable expenses incurred at our request, but not loss of earnings;
Form WC 00 00 00 C Printed in U.S.A. Page 2 of 6
2. premiums for bonds to release attachments and
for appeal bonds in bond amounts up to the
amount payable under this insurance;
3. litigation costs taxed against you;
4. interest on a judgment as required by law until we offer the amount due under this insurance; and
5. expenses we incur.
E. Other Insurance
We will not pay more than our share of benefits and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid.
F. Payments You Must Make
You are responsible for any payments in excess of the benefits regularly provided by the workers
compensation law including those required because: 1. of your serious and willful misconduct;
2. you knowingly employ an employee in violation of law;
3. you fail to comply with a health or safety law or regulation; or
4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers
compensation law.
If we make any payments in excess of the benefits
regularly provided by the workers compensation law on your behalf, you will reimburse us promptly.
G. Recovery From Others
We have your rights, and the rights of persons entitled to the benefits of this insurance, to recover our
payments from anyone liable for the injury.
You will do everything necessary to protect those
rights for us and to help us enforce them.
H. Statutory Provisions
These statements apply where they are required by
law.
1. As between an injured worker and us, we have
notice of the injury when you have notice.
2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our duties under this insurance after an injury occurs.
3. We are directly and primarily liable to any person entitled to the benefits payable by this insurance. Those persons may enforce our duties; so may
an agency authorized by law. Enforcement may
be against you and us.
4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We
are bound by decisions against you under that
law, subject to the provisions of this policy that are not in conflict with that law.
5. This insurance conforms to the parts of the
workers compensation law that apply to:
a. benefits payable by this insurance;
b. special taxes, payments into security or other
special funds, and assessments payable by
us under that law.
6. Terms of this insurance that conflict with the
workers compensation law are changed by this
statement to conform to that law.
Nothing in these paragraphs relieves you of your duties under this policy.
PART TWO - EMPLOYERS LIABILITY INSURANCE
A. How This Insurance Applies
This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death.
1. The bodily injury must arise out of and in the
course of the injured employee's employment by
you.
2. The employment must be necessary or incidental
to your work in a state or territory listed in Item 3.A. of the Information Page.
3. Bodily injury by accident must occur during the policy period.
4. Bodily injury by disease must be caused or
aggravated by the conditions of your
employment. The employee's last day of last
Form WC 00 00 00 C Printed in U.S.A. Page 3 of 6
exposure to the conditions causing or aggravating
such bodily injury by disease must occur during
the policy period.
5. If you are sued, the original suit and any related legal actions for damages for bodily injury by
accident or by disease must be brought in the
United States of America, its territories or
possessions, or Canada.
B. We Will Pay
We will pay all sums that you legally must pay as
damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers Liability Insurance.
The damages we will pay, where recovery is permitted by law, include damages:
1. For which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against such third
party as a result of injury to your employee;
2. For care and loss of services; and
3. For consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee; provided that these damages are the direct
consequence of bodily injury that arises out of and in the course of the injured employee's
employment by you; and
4. Because of bodily injury to your employee that
arises out of and in the course of employment,
claimed against you in a capacity other than as
employer.
C. Exclusions
This insurance does not cover:
1. Liability assumed under a contract. This exclusion does not apply to a warranty that your work will be done in a workmanlike manner;
2. Punitive or exemplary damages because of bodily injury to an employee employed in violation of law; 3. Bodily injury to an employee while employed in
violation of law with your actual knowledge or the actual knowledge of any of your executive officers; 4. Any obligation imposed by a workers com-
pensation, occupational disease, unemployment
compensation, or disability benefits law, or any
similar law;
5. Bodily injury intentionally caused or aggravated by you;
6. Bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these
countries;
7. Damages arising out of coercion, criticism,
demotion, evaluation, reassignment, discipline,
defamation, harassment, humiliation, dis-
crimination against or termination of any
employee, or any personnel practices, policies,
acts or omissions;
8. Bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation
Act (33 U.S.C. Sections 901 et seq.), the
Noappropriated Fund Instrumentalities Act (5
U.S.C. Sections 8171 et seq.), the Outer
Continental Shelf Lands Act (43 U.S.C. Sections
1331 et seq.), the Defense Base Act (42 U.S.C.
Sections 1651-1654), the Federal Mine Safety
and Health Act (30 U.S.C. Sections 801 et seq.
and 901-944) any other federal workers or
workmen's compensation law or other federal
occupational disease law, or any amendments to
these laws;
9. Bodily injury to any person in work subject to the Federal Employers' Liability Act (45 U.S.C.
Sections 51 et seq.), any other federal laws
obligating an employer to pay damages to an
employee due to bodily injury arising out of or in
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