HomeMy WebLinkAbout2008 Invoice Workers Compensation & Employers Liability Renewal', Maverick Insurance (NA)
826 West Main Street
New Albany,IN 47150
~I Phone:812-941-4110 812-944-8010
City of Jeffersonville
500 Quartermaster Ck
Jeffersonville, IN 47130-3672
INVOICE# 21695 '` wP~a~e1
JEFFE-0-3001 PF 06/10/08
07/15/08
a ~ eoecY r~~iscSiPG ~ ~,;.1 .. 1.; ~ itLnt,
DAIS/08 00660101 0]/15/08-09 WC Renewal S 125,94800
Invoice Balanc . $ 125 948 00
CIiV OF JEFFERSONVILLE
JUN 2 fi 7nnq
CLERK~iREASUP,ER
RFC
l,~i ,
Payment is due by July 1, 2008. Please make check payable to
Maverick, Ins. Thank you, PFawcett
Indiana Public Employers' Plan
Kokomo, IN
WORKERS COMPENSATION AND EMPLOYERS LIABILITY
SUBSCRIBED COVERAGE
INFORMATION PAGE
CARRIER CODE:
Item 1. Name and Jeffersonvilley City of NUMBER
Address of 500 Quartermaster Ct. 0066-0101
Inamed Jeffersonville, IN 47130
RISK ID# 130100791 FEDERAL ID# 35-6001067
Forzn of Business: City
Locations-All usual workplaces of the insured at or from which operations covered by [his subscription are conducted aze located a[
the above address unless otherwise stated herein: See Attached Schedule for Location(s)
Item 2. Coverage Period: Fmm 07/15/2008 - 07/15/2009 12:01 A.M. standard time at tha member's mailing addmse.
Item 3.
q. Workers Compensation Coverage: Part One of the subscnption applies to the Workers Compensaton Law of [he
Stales listed here: Indiana
g. Employer Liability Coverage: Part two of [he subscription applies ro 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 $ 1000.000 each employee
Bodily lnjuryby Disease $ 1.000.000 coverage limit
C. Other States Coverage: Part Three of the subscription applies to the states, if any, listed here
p. This coverage includes these endorsements and schedules.
Item 6. The contribution for this wvemge will be determined by our Manuals and Rules, Classifications, Rates and Rahng Plans.
All inforrna[iov required below is subject m verification and ohange by audit:
** See Attached Schedule (or Classifications**
Total Estimated Standard Contribution
Subject to Minimum Contribution of
Estimated Coverage Total
Dated Issued: 05/29/2008
Attorney-in-fact: Downey Insurance
Kokomo, M 46901
125,948
1,000
125,948
Coumersignamre Dale 9 O BY1~%~'Yi"'"' ~ ~ ;~-
~-
Doc# 2119123
tYame of Participant: Jeffersonville; City of
Certificate #: 0066-0101
Coverage Period: 07/15/2008 - 07/15/2009
SCHEDULE OF OPERATIONS
MANUAL CONTRIBUTION CALCULATION
FOR 2008 ESTIMATED PAYROLL
POLICY PERIOD: 07/15/2008 - 07/15/2009
PaYrull Class ffi37~e~ -?~i Estr" ~ olt ^RatL~ Manua{Frr~=''
5506 -Streets 500,922 5.66 28,352
7711-Volunteer Firemen 3,044,655 2.60 79,161
8380-Auto Service 162,335 2.39 3,880
7725 -Police Medical 7,032,584 1.43 43,366
8601 -Surveyor 76,603 O.SO 383
8610-Clerical Office Employ 1,78fi,532 0.21 3,752
8820-Attorney 106,572 0.14 149
8831 -Hospital Ve[ 198,752 1.33 2,fi43
9102 -Parks NOC 668,330 2.40 16,040
9402-Sewer Cleaning 590,293 3.87 22,844'
9403-Garbage 409,612 5.77 23,fi35
9410 -Municipal Employees 143,247 2.13 3,051
7698 - Rostered Volunteers I 49,500.00 495
TOTALS $ 10,720,438 $ 227,751
SEE NEXT PAGE FOR TOTAL CONTRIBUTION SUMMARY
Doc # 2119123
Name oC Participant: Jeffersonville; City of
Certificate #: 0066-0101
Coverage Period: 07/15/2008-07/15/2009
CONTRIBUTION SUMMARY
FOR 2008 ESTIMATED PAYROLL
PERIOD: 07/15/2008 - 07/15/2009 BOTH DAYS AT
12:01 AM STANDARD TIME
Indiana: 07/15/2008 - 07/15/2009
ToffiI Contribution Subject to Expedence Rating 227,751
Experience Modification 0.79 -47,828
Total Contribution Adjusted by Experience Mod~ca[ion 179,923
Indiana Contribution
Total Conmbution Subject to Schedule Debit/Credit 179,923
Schedule DebidCredit 0.70 -53,975
Total Contribution Adjusted by Application of ModiScation(s) 125,948
Total Estimated Annual Contibution 125,948
Subject to Minimum Conh'ibu[ion of 1,000
Estimated Coverage Total 125,948
Doc # 2119123