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HomeMy WebLinkAbout2009 Worker's CompensationAGENDA 1. Package Renewal-----I recommend to renew with Houston Casualty/Burham & Flower Group. 2. Worker's Compensation-----I recommend to replace the IPEP policy with Bituminous/Bliss McKnight. I recommend this because Bliss McKnight's risk management program. Proposal of Insurance for: City of Jeffersonville 07/15/09-07/15/10 Proposed July 7, 2009 by: Edward C Cooper Peggy Fawcett Maverick Insurance 826 West Main Street New Albany, IN 47150 www.maverick-insurance.com -- --- WORKERS' COMPENSATION SUMMARY Named Insured: City of Jeffersonville Insurer: Bituminous Policy Term: 07/15/09 to 07/15/09 Workers' Com ensation -Part Statutory Limits IN Other;,States -Part III Other States Coverage (except monopolistic states) The estimated annual payroll used for rating was provided by City of Jeffersonville. At the end of the policy term, the premium will be adjusted based on the actual payroll. This adjustment could result in an additional or return premium. For officers who choose to exclude themselves from workers' compensation coverage -many health insurance plans exclude on-the-job injuries. Please contact your agent to confirm your health insurance coverage. Endorsements - -- -- _ _ - _ - _ -.-1 WORKERS' COMPENSATION DEFINITi~JNS - -_ _ _ _ _~ Workers' Compensation: Obligates the insurer to pay all compensation and other benefits required of the insured by the workers' compensation law or occupational disease law of any state listed in the policy. The coverage applies to bodily injury by accident and by disease, and benefits are paid to the employee without regard to fault. Employers Liability: Protects employers for their legal liability for bodily injury by accident or disease to an employee arising out of and in the course of the employee's employment when not covered under the work comp law. Before benefits are paid under this coverage, the employee must prove the employer is liable for the injury. Experience Modification Factor: The experience mod factor is based on the insured's loss experience, and is used to increase/decrease the manual insurance rates. Monopolistic States: There are five states that require all workers' compensation insurance to be placed with their state funds. No private insurer is allowed to write workers' compensation coverage in a monopolistic state. These states are: North Dakota, Ohio, Washington, Wyoming, and West Virginia. Other States Insurance: Provides workers' compensation coverage if the insured expands operations into other states not declared at the time the policy is issued or renewed. If the insured elects this coverage and operations begin in a state listed under other states, the insurer provides the same coverage as if the state was declared in the policy at the time of policy issuance. United States Longshore and Harbor Workers: A federal act similar to the state workers' compensation act. The federal act was designed to provide workers' compensation benefits to employees who work in maritime employment upon the navigable waters of the United States and who are usually considered outside the scope of state work comp laws. When the USL&H endorsement is added to the standard policy it applies to work done in the states scheduled on the policy and extends the definition of the workers' compensation law to include the USL&H. Voluntary Compensation Endorsement: Workers' compensation laws of most states exempt some types of employment from work comp benefits. This endorsement amends the standard policy to provide coverage for employees with exempted occupations from the workers' compensation act. When the endorsement is added it does not make employees subject to the workers' compensation law, but it obligates the insurance company to pay on behalf of the insured, an amount equal to the compensation benefits that would be payable to those employees if they were subject to the workers' compensation law of that state. PREMIUM COMPARISON SUMMARY Named Insured: City of Jeffersonville Policy Term: 07/15/09-07/15/10 PROPOSAL INFORMATION Named Insured: City of Jeffersonville Policy Term: 07/15/09-07/15/10 • The abbreviated outlines of coverage used throughout this proposal are not intended to express any legal opinion as to the nature of coverage. They are only visuals to a basic understanding of coverages proposed. • Please be advised that no insurance coverage has yet been procured. All coverage summaries are for proposal purposes only. • Please refer to the actual policies for specific terms, conditions, limitations, and exclusions that will govern in the event of a loss. Specimen copies of all policies are available for review prior to the binding of coverage, upon request. • This proposal is based upon exposures to loss made known to our agency. If there are other areas that need to be evaluated prior to binding coverage, please bring these areas to our attention. Should any of your exposures change after coverage is bound, please let us know immediately so proper coverages) can be discussed. • We suggest that you carefully review your property values for adequacy and consider any coinsurance provisions. We are pleased to assist you with your own final determination of the values you decide to insure. • Higher limits of liability may be available. Please let us know if you would like a quote for higher limits. • This proposal may include quotations for auditable policies, such as general liability and workers' compensation. You are responsible for providing us with the estimated premium basis used for rating. Auditable policies are typically adjusted at the end of the policy term based on the estimated vs. actual premium basis. This adjustment could result in additional premium due. • Any exclusions shown in this proposal are highlighted for discussion purposes only. The policy is not necessarily limited to only those exclusions. Please refer to the actual policy for all policy exclusions. • Timely payment of your insurance premium is critical. Please note the due dates on the invoices you receive and remit payments promptly. Late notices and/or notices of cancellation for non-payment from your insurance company or premium finance company can result in substantial late charges, and in some cases, a refusal to continue coverage. • In addition to the fees and/or commissions received by' Maverick Insurance for the placement of your insurance coverages, we may also, where allowed by applicable law, receive contingent payments, overrides, bonus commissions, and/or administrative expense reimbursements from some insurers or other third parties. These payments are based on factors which are not client-specific, such as aggregate loss experience, or the size or performance of an overall book of business placed with the insurer. MAVERICK INSURANCE SERVICE TEAM FOR CITY OF JEFFERSONVILLE .Office Phone Maverick Insurance (NA) 826 West Main Street 812-941-4110 New Albany, IN 47150 _ Name_ Title Direct Phone e er Coo er Vice President Sales 812-941-4110 e Fawcett Account Mana er 812-941-4125 MISSION STATEMENT Fax 812-944-8010 E-Mail maverick-insurance.com maverick-insurance.com Maverick Insurance is dedicated to delivering the best insurance and risk management services to individual and business clients in our marketing territory. We will: • Provide prompt responses to our customers' inquiries • Continually develop and enhance our portfolio of products and services • Advance our capabilities through training and professional development programs for our people Maverick Insurance will work aggressively to accomplish its stated mission in order to achieve above average growth and customer satisfaction. +~ ;r'~' `,~., .~ ~~ ~~ . y, `'~ ~~ V Public Entity Insurance Proposal for: City of Jeffersonville Presented by: Pepper Cooper Maverick Insurance 826 W. Main St. New Albany, IN 47150 Phone: 812-941-4110 Fax: 812-944-8010 Bu~r~~ham:Flo~ver INSURANCE ti SOUP oa sr~wc~o a, a erase ~reac Municipal Insurance . ,~ ` ~~~~~~~ Alliance ~:. Randall W. Teltoe, CPCU, CIC, CRM Ph - 317-878-5035 rteltoe@bfgroup.com u a~n over I N S U R A N C E G R O U P ou serve o r~ e ~e~ue you, `4 Cyndi Trompeter Customer Service Representative Extension 3141 ctrompeter@bfgroup. com ~u sewve ot~ue~s ~e serve tau, Janet Daniels Randy Teltoe Don Dickerson Deparhnent Manager Account Manager Account Manager Extension 3120 317.878.5035 888.748.7966 ext. 3104 jdaniels@bfgroup.com rteltoe@bfgroup.com ddickerson@bfgroup.com Linda Fry Customer Service Representative Extension 3122 Ifry@bfgroup.com Jean Tomsic Processing Assistant Heather Reetz Processing Specialist Margaret Phillipson Processing Specialist Burnham & Flower Insurance Group > Customer Service B~Z~~~Floti 315 S. Kalamazoo Mall INSURANCE Q R o v P Kalamazoo, M1 49007 888.748.7966 ~~ Risk CoMn~ Midwest Risk Control Risk Control Administration 1700 Opdyke Court Auburn Hills, Michigan 48326 800.878.9878 Midwest Claims Service Claims Administration 1700 Opdyke Court Auburn Hills, Michigan 48326 800.878.9878 24 Hour Telephone: 800.225.6561 claims@midwestclaims.com 4 :, ^ THE MIIINIGIPAL INSURANCE ALLIANCE Set your home page to www.municipalalliance.com to visit The Alliance web site, available to you 24 hours each day, 7 days each week. Visit the site to learn about upcoming events such as annual conventions, important meetings and helpful workshops; learn about the board members who represent you; find contact information for all of the municipal coverage professionals who are eager to serve your needs. p• bbd _ ~ X r'lr N r. Hiwr lade W _.._._.. g ~._ InvRF. W6~._ 2S awe.., uW yjr.lz ~`JrY/i..iw ~RMa¢dpa^iM tl~ ~~ CI Pf4M9 ~wr sF.r Merw.n..d..s Qjn t«navta~.. U~+ ~ r.«ra.tu+»;FCOxt p}eoednwraK 41 ^... s...+.. r.. a, ~ tom. yjww:-a,..r.rt.,u.o.mR,., ~rm,+aFanRavnan+... tlwrw !. glwiayrta,.w.,.au w.wo.,. ' ~j1Y.RgY.RN>•YW 44p N.w_.. ~,l~..w 1w.W.oW FM.aMH ~j snMNleMG.A. p~.eM..sl twr.. Rxv Wwa... g]./uv.n nr ~n!rWle!wvhq bane, dof p~ .. ;j s.F..a a F,Fdq war~nnF~ a it "wm'iW+od QJ4.MRVI~RryY.wM.WR+kR... ~MR.Wn VtanaFwlrM/r 9d.FN. n... vWyIN..M M.1yw'.M~ ~ib.r:rb~vlpaAn Mwr... ~IYfir~wMwiNRrtar.up... ~}M.fte M+Wdad '_ ffbFtrr^hx.M.a a)YS'°"iRxb .• .- Jx ~ ~l ~6e~RR~ .RW111 ~''i~ M.. Alliance fnR ewnbpal IFaiugn4 rtliwruR N MR NRnI R.xweonmrxdnaRp~yR nO~Me gMR11R ~ MUNICIPAL IM84flANCE ALLIANCE . antl Y Uu dYRR nwtaf arddnp forRRYii'q wnt' FRrcfn ~ Ny~~ ~ vw RmFdd diMR9 rrhlROfRI wd+ptl. I I i TM IIYnRrOY IMtA110R AFUIq dIPR1f tl1RMRf e-Y ibRlNRlr+d OD M PERM AI .RliibN OOdA W oNrMgali WOi{T RIA R/ORap RVrrpdWS wqr Arb,Agfftl a~F. ~FM dMMroR NwRMf tlM~UdSN fAYNM~W OlidDaYGK- WI IMMr19lRN~R MMb/. OP00HM.t~RAiiRbl~IRd[tl1RIWAtM ~nY~~RHYtlIY. ~~. • d maNl7Rt wdI W RRWMsd fR[IOYYHAMwR cWRpM9. • El iiNml w WOM. •. H VrRpORUFRR UW fOM d.IIM M~1b.Rd MIIKpYO~.. • 9r4Yd MR61~RP #YO ONOORf apgVi~9. • C4~uMrW+f MkRrO. • C.MG9bAtD^9'bMt R'*MRbRIP. • CWOOIn /d01R[NNMt [YRt FT'dFd~. • tpRY dORrIb i10'r1fINfR/f1Rr1II.NRrROtRt1Y WlebYt iRM1ltd. • Gwn dlM bff m'Ma/04GM6MrM RORr~1R{pld p/Rrr4t0YKfOtln fD~MrGNrmNMOPMd1itWM11YR'1 MkR ia#C• • Lue+erterRU wnRn an dnerRU~dnoMm. . RglR. iuNtlwFaMY1~P+Aont dOeC tlN/R. f010WRq wJue aMQMeRI a. ^THE ~~~ MUNICIPAL INSURANCE AlL1ANCE A Subsidiary of HCC Insurance Holdings, Inc. MUNICIPAL INSURANCE ALLIANCE RISK CONTROL SERVICES The Municipal Insurance Alliance provides a variety of risk control services to its insured public entities throughout Michigan, Ohio, Indiana and Illinois. These services are provided by experienced risk control personnel located in each state who utilize proven risk control techniques and procedures. These techniques and procedures are continuously updated by conferring with Alliance appointed counsel and Midwest Claims Service, Inc.* Through these efforts, Alliance insureds are provided the most up to date information on statutes, case law and claims experience. These efforts are done as a service to Alliance insureds to help them avoid, reduce and/or transfer potential liability exposures. Some of the risk control services provided to Alliance insureds include: 1. Risk Control Profiles; 2. Risk Control Recommendations; 3. Special Events and Contract Reviews; 4. Resource Materials; 5. Technical Assistance; 6. Risk Control Seminars. - RISK CONTROL PROFILES -The Risk Control Department has field representatives who visit and survey insured public entities to identify existing and/or potential liability exposures. While at the site, the field representative meets with officials and department heads to discuss and review the operations of the entity. The Risk Control Department field representative will survey and analyze any potential problem areas that exist within the entity. These issues will then be discussed with officials and department heads during the on-site survey. - RISK CONTROL RECOMMENDATIONS -After the information is gathered during the Risk Control survey, letters of recommendation are developed and provided to the entity's officials and department heads. Often included with these recommendations is resource material to help the insured entity implement the recommendation(s). These efforts will help the insured entity manage their liability exposures. .~. - SPECIAL EVENTS AND CONTRACT REVIEWS -The Risk Control Department Representatives will review special event applications along with site plans to help insured entities identify potential liability exposures inherent with these types of events. Recommendations will then be made to help the Alliance insured manage these exposures. In addition, the Risk Control Department Representatives will review contractual language from a risk control perspective and provide suggestions to help reduce potential liability exposures. These suggestions can then be reviewed by the entity attorney before the contract is signed or revised. - RESOURCE MATERIAL -The Risk Control Department has a large quantity of resource material available to assist public entities in developing sound risk control programs. Specific information is available to assist human resource departments, park and recreation departments, public works departments, emergency medical services, fire departments, jails and police departments. In addition, the department has sample manuals, risk control guidelines and model policies and procedures. The Risk Control Department Representatives continuously update and make available these resources for Alliance insureds. - TECHNICAL ASSISTANCE -The Risk Control Department Representatives also provide assistance to Alliance insureds with liability related questions and issues. They are also available to meet with your safety committee to provide guidance and advice. The Risk Control Department Representatives are continuously trained and updated on the latest information that could potentially affect public entities. Their many years of experience, education and training are offered to Alliance insureds as a valuable service. - RISK CONTROL SEMINARS -The Risk Control Department assists, sponsors and presents seminars to Alliance insureds. Some topics include: 1. Sexual Harassment in the Workplace; 2. Other Forms of Discrimination, including ADA and Whistleblowers; 3. Law Enforcement Liability; 4. Governmentallmmunity. Other seminars can be tailored to meet the needs of the public entity. In conclusion, the Alliance Risk Control Department Representatives are available to provide risk control advice and guidance at no additional cost to Alliance insureds. If you have any questions in regards to any of the risk control services that are provided, please contact your local Alliance Risk Control Representative or the Alliance Risk Control Department. * Midwest Claims Service, Inc. is a subsidiary of HCC Insurance Holdings, Inc. and is the claims administrator for the Alliance program. Information regarding Midwest and appointed counsel is on their web page at www.midwestclaims.com. .« ti ~ ~~v~rrs~, , , • We will promptly respond to your phone calls and emails. • We will expedite any changes in coverage. • We have staff on-site with expertise in the following areas: o Property & Casualty o Workers compensation o Bonds • We will happily review your coverage at any time-we recommend review on an annual basis. • We have the ability to review contracts or certificates you receive from other entities. • We are willing and able to meet with you and your team to fully review coverage. ~~1~Cl~lahll~~'I~~V~" 1 N~ U R A N C E l3 O U P as ar.~ve o e a'~ae ~rpos, .w MUNICIPAL INSURANCE ALLIANCE OF INDIANA Date: 07/06/2009 Quote for: City of Jeffersonville Policy Term: 08/06/2009 to 08/06/2010 Company: U.S. Specialty Insurance Company General Liability Subject to $1,000,000 occurrence/$3,000,000 aggregate Cemetery Professional - No Coverage Subject to $0 deductible including loss and loss adjustment expense Medical Payment $10,000 Damage to Premises Rented to You $150,000 Sewer Backup Liability -Included Employee Benefits Claims Made Form - Retro Date 08/06/2005 Subject to $1,000,000 occurrence/$3,000,000 aggregate subject to $1,000 deductible Fireworks Liability: Subject to Receipt of Special Events Application and Risk Control review prior to binding coverage. (Additional Premium will apply) Wrongful Acts Liabilitv -Claims Made Coverage Form Subject to $1,000,000 occurrence/$1,000,000 aggregate Subject to $10,000 deductible including loss and loss adjustment expense Claims Made Retroactive Date 08/06/1997 Law Enforcement Liabilitv- Occurrence Coverage Form Subject to $1,000,000 occurrence/$1,000,000 aggregate Subject to $10,000 deductible including loss and loss adjustment expense Excess Liabilitv (Coverage applies to General Liability, Employee Benefits, Wrongful Acts, Law Enforcement, and Auto Liability) Subject to $4,000,000 occurrence/$4,000,000 aggregate Subject to $10,000 SIR Excludes Uninsured Motorist and Underinsured Motorist Pro e Total Building & Contents Limit 90% Coinsurance Subject to $2,500 Deductible Blanket Basis-Agreed Amount Replacement Cost Special Form Accounts Receivable Animal Mortality Backup Up of Sewer or Drains Building Ordinance or Law Business Income Extra Expense Communication Towers Debris Removal $58,971,384 $250,000 ($10,000 in transit) $40,000 any one occurrence $25,000 any one occurrence $250,000 Undamaged portion/or demolition 10% of reported values (increased cost of construction) $100,000 any one occurrence $500,000 any one occurrence $100,000 any one occurrence 25% of direct physical loss or damage to covered property :~ EDP Coverage Electrical Utility Service Interruption Equipment & Mechanical Breakdown Fine Arts Grounds Maintenance Equipment Newly Acquired or Constructed Prop.-Bldg. Newly Acquired or Constructed Prop-Conts. Outdoor Property any one occurrence Personal Effects -Prop. Of Others Property in Transit Property off Premises VP&R-Cost to Research Blanket Portable Equipment Earthquake Coverage Flood Coverage (Any location in the following flood zone is excluded: and V1-V30) $500,000 any one occurrence -In transit -Subject to $10,000 limit -Mechanical Breakdown -Subject to $10,000 limit $25,000 any one occurrence Included $5,000 any one item/$25,000 any one occurrence $100,000 any one occurrence $1,000,000 for 180 days at each building $250,000 at each building $10,000 for loss to trees, shrubs, plants, lawns,(excluding golf course greens) outdoor fences, signs-other than attached to bldg., guardrails, traffic lights, and road signs. Limited Perils. $5,000 occurrence -all other outdoor property- Limited Perils $1,000 for personal property of any one employee or volunteer $50,000 any one occurrence $15,000 any one occurrence for property of others $25,000 any one conveyance $100,000 any one occurrence $250,000 any one occurrence $1,017,740 $5,000,000 Subject to $50,000 Ded $5,000,000 Subject to $50,000 Ded Flood Zones A, AO, AH, Al-A30, A99, V Automobile Based on 296 vehicles -schedule on file with company Subject to Liability limit - $1,000,000 Subject to $2,500 deductible including loss & loss adjustment expense $1,000,000 Uninsured/Underinsured Motorist coverage limit -subject to signed UM/UIM form Hired and Non-Owned Automobile Liability Physical Damage - Per Schedule on file with company Hired Auto Physical Damage Coverage -Limit $100,000 -Subject to deductibles per schedule on file with company Physical Damage to Volunteers' or Employees' Personal Auto Medical Payments - $5,000 limit Inland Marine Total Limit-Per Schedule on file with company $9,570,370 Misc. Prop. & Equip. included in limit $759,577 Contractors Equipment Leased/Rented from Others Less Than 90 Days-included in Total Limit $50,000 Valuation: RC Subject to $ 2,500 Deductible EDP Limited to coverage provided under Property Extensions Crime Coverage form: Subject to $1,000 deductible B. Forgery or Alteration $ 500,000 C. Theft, Disappearance and Destruction: In/Out $ 500,000 Tax Time Limit $ 500,000 ~ 4 ~e F. Computer Fraud $500,000 O. Employee Dishonesty -Per Loss $500,000 Includes Faithful Performance PACKAGE/BOILER ANNUAL PREMIUM: $ 310,182 NOTE: Mold, Fungi & Bacteria Exclusion included NOTE: All SIR Includes Loss, Loss Adjustment Expense and Supplementary Payments ***MINE SUBSIDENCE COVERAGE IS AVAILABLE. IF QUOTE IS DESIRED, PLEASE ADVISE. Limited Terrorism coverage and pricing subject to the Terrorism Risk Insurance Program Reauthorization Act of 2007. TRIPRA DOES NOT APPLY TO AUTOMOBILE, EMPLOYEE BENEFITS, WRONGFUL ACTS OR LAW ENFORCEMENT U.S. SPECIALTY INSURANCE COMPANY, ADDITIONAL PREMIUM FOR LIMITED TERRORISM COVERAGE (NOT INCLUDED IN ABOVE PACKAGE QUOTE): CASUALTY LIMITED TERRORISM COVERAGE (ACT OF 2007): $ 930 PROPERTY LIMITED TERRORISM COVERAGE (ACT OF 2007): $ 1,179 Optional Quotes and Premiums: None Special Conditions: Subject To Vin Numbers on Vehicle# 459 Rockford Flatbed Trailer and Vehicle #462 Goldstar Flatbed Trailer QUOTE GOOD FOR 30 DAYS ONLY. ENTIRE QUOTE SUBJECT TO THE TERMS AND CONDITIONS OF THE POLICY. • Additional Forms To Be Signed and Returned • Bind Request • Uninsured & Underinsured Motorists Coverage Form • Policyholder Disclosure Notice of Terrorism Insurance Coverage Form ** Please Note - if these forms are not returned, it wlll delay the issuance of your policy. ** City of Jeffersonville Indiana v h POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE You are hereby notified that under the Terrorism Risk Insurance Act, as amended, that you have a right to purchase insurance coverage for losses resulting from acts of terrorism, as defined in Section 102(1) of the Act: The term 'act of terrorism' means any act that is certified by the Secretary of the Treasury-in concurrence with the Secretary of State, and the Attorney General of the United States-to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of certain air carrier or vessels or the premises of a United States mission; and to have been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. However, the actual coverage provided by your Policy for acts of terrorism, as is true for all coverages, is limited by terms, conditions, exclusions, limits, other provisions of your policy, any endorsements to the policy and generally applicable rules of law. YOU SHOULD KNOW THAT WHERE COVERAGE IS PROVIDED BY THIS POLICY FOR LOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM, SUCH LOSSES MAY BE PARTIALLY REIMBURSED BY THE UNITED STATES GOVERNMENT UNDER A FORMULA ESTABLISHED BY FEDERAL LAW. HOWEVER, YOUR POLICY MAY CONTAIN OTHER EXCLUSIONS WHICH MIGHT AFFECT YOUR COVERAGE, SUCH AS AN EXCLUSION FOR NUCLEAR EVENTS. UNDER THE FORMULA, THE UNITED STATES GOVERNMENT GENERALLY REIMBURSES 85% OF COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE PAID BY THE INSURANCE COMPANY PROVIDING THE COVERAGE. THE PREMIUM CHARGED FOR THIS COVERAGE IS PROVIDED BELOW AND DOES NOT INCLUDE ANY CHARGES FOR THE PORTION OF LOSS THAT MAY BE COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT. YOU SHOULD ALSO KNOW THAT THE TERRORISM RISK INSURANCE ACT, AS AMENDED, CONTAINS A $100 BILLION CAP THAT LIMITS U.S. GOVERNMENT REIMBURSEMENT AS WELL AS INSURERS' LIABILITY FOR LOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM WHEN THE AMOUNT OF SUCH LOSSES IN ANY ONE CALENDAR YEAR EXCEEDS $100 BILLION. IF THE AGGREGATE INSURED LOSSES FOR ALL INSURERS EXCEED $100 BILLION, YOUR COVERAGE MAY BE REDUCED. ACCEPTANCE OR REJECTION OF TERRORISM INSURANCE COVERAGE LISTED BELOW IS THE ADDITIONAL PREMIUM TO PURCHASE TERRORISM COVERAGE, WHICH IS IN ADDITION TO THE PREMIUM WE HAVE QUOTED OTHERWISE. AT THE TIME OF BINDING YOUR NEW OR RENEWAL COVERAGE, THE FOLLOWING STATEMENT MUST BE COMPLETED AND SIGNED BY THE POLICYHOLDER. ACCEPTANCE of Terrorism Coverage I hereby elect to purchase Casualty Terrorism Coverage for a prospective premium of $ 930 (Please check the box to the left and initial if this is your election) I hereby elect to purchase Property Terrorism Coverage for a prospective premium of $ 1179 (Please check the box to the left and initial if this is your election) REJECTION of Terrorism Coverage I hereby decline to purchase Casualty terrorism coverage for certified acts of Terrorism. I understand that I will have no coverage for any losses resulting from certified acts of terrorism. (Please check the box to the left and initial if this is your election) hereby decline to purchase Property terrorism coverage for certified acts of Terrorism. I understand that I will have no coverage for any losses resulting from certified acts of terrorism. (Please check the box to the left and initial if this is your election) Policyholder/Applicant's Signature US Specialty Insurance Company Insurance Company PKG80310163 Print Name Date 01/08 Policy Number CITY OF JEFFERSONVILLE Insured Name a HCC INSURANCE COMPANY ENDORSEMENT NO. ATTACHED TO AND ENDORSEMENT EFFECTIVE FORMING A PART OF (Standard Time) INSURED AGENCY AND CODE POLICY NUMBER MO. DAY YR. 12:01 NOON A.M. 08 06 09 X City of Jeffersonville 99900 In consideration for the premium charged, it is hereby understood and agreed the following change (s) are made to the AUTOMOBILE section of this policy REJECTION OR REDUCTION OF UNINSURED 8~ UNDERINSURED MOTORISTS COVERAGE Indiana Law now requires that we write Uninsured & Underinsured Motorists Coverage equal to the Bodily Injury Limits of your automobile policy unless you, the insured, state that you want lesser limits or that you do not want this protection. Uninsured & Underinsured Motorists Coverage, therefore, has been/will be included in your policy equal to your Bodily Injury Liability limits. If you want lesser coverage, or want to reject entirely, it will be necessary for you to complete this form and return it to the company. Uninsured & Underinsured Motorists Coverage protects you and your family within the same terms and limits of the policy, if you suffer bodily injury or death for which an uninsured or underinsured motorist is legally liable. X I (We) do not want Uninsured & Underinsured Motorists Coverage equal to the limits on my (our) automobile policy, and desire $1,000.000/$1,000.000 Limits. I (We) reject Uninsured & Underinsured Motorists Coverage in its entirety. Effective Date: 08/06/2009 Named Insured: City of Jeffersonville Agency Name: Municipal Insurance Alliance Policy Number: PKG80310163 Insured's Signature: Date: ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED C~-~m ~~~ AUTHORIZED REPRESENTATIVE DATE 4v I v . ~ City of Jeffersonville Indiana Premium Summary General Liability Included Employee Benefits Liability Included Wrongful Acts Liability Included Law Enforcement Liability Included Umbrella Included Property Included Automobile Included Inland Marine Included Crime Included Premium (subtotal): $310,182 Terrorism $2,109 Insurance and Risk Management $62,458 Total Premium: $374,749 Exposure Development: Current LR G d Prior Year 08'09 ~9~~ ~ Lst Prior LR-_-_~ ~ 3 ~ ? 2nd Prior LR ----' "`-- ICRB Mod ~~ --- 3rd Prior LR ~ ~ ~/ 9 ~ Q ?d/ Payroll ~ ~~~1~'--rs.~~ ---1-~- i A.) Member Provided ~ ~ ~ ~y°~ B.) Broker Provided STD Prem. ~~ .~~ / C.) Last Audit+ % /d 0 D.) Current Term IPEP Mod ~_ ~ E.) Pre-Audit C ~~ / ~a~~ ~' / Contribution ~.J r~-~ -'-~ /~ gy. Date: ~ / ~ - Remarks ~~~ ~ ~~ ~~~~9 (Rev. 8-03) Indiana Public Employers' Plan Kokomo, IN WORKERS COMPENSATION AND EMPLOYERS LIABILITY SUBSCRIBED COVERAGE INFORMATION PAGE CARRIER CODE: Item 1. Name and Jeffersonville; City of NUMBER 066-010 Address of 500 Quartermaster Ct. Insured Jeffersonville, IN 47130 Form of Business: City RISK ID# 130100791 FEDERAL ID# 35-6001067 Locations-All usual workplaces of the insured at or from which operations covered by this subscription are conducted are located at the above address unless otherwise stated herein: See Attached Schedule for Location(s) Item 2. Coverage Period: From 07/15/2009 - 07/15/2010 12:01 A.M. standard time at the member's mailing address. Item 3. A. Workers Compensation Coverage: Part One of the subscription applies to the Workers Compensation Law of the States listed here: Indiana B. Employer Liability Coverage: Part two of the subscription applies to work in each state listed in Item 3.A. The limits of our liability under Part Two aze: Bodily Injury by Accident $ 1,000.000 each accident Bodily Injury by Disease $ 1,000,000 each employee Bodily Injury by Disease $ 1.000.000 coverage limit C. Other States Coverage: Part Three of the subscription applies to the states, if any, listed here: D. This coverage includes these endorsements and schedules: Item 4. T'he contribution for this coverage will be determined by our Manuals and Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit: ** See Attached Schedule for Classifications** Total Estimated Standard Contribution Subject to Minimum Contribution of Estimated Coverage Total Dated Issued: 05/14/2009 Countersignature Date ~\~`~ awl Attorney-in-fact: Downey Insurance PO Box 1247 Kokomo, IN 46901 195,877 1,000 195,877 By <~ 1 ~-- Doc # 2146658 Name of Particip; Certificate #: Coverage Period: • Jeffersonville; City of 0066-0102 07/15/2009 - 07/15/2010 _-- _ ~ C<H~;ll UL~~ U F OPER~TI OBI S MANUAL CONTRIBUTION CALCULATION FOR 2008 ESTIMATED PAYROLL POLICY PERIOD: 07/15/2009 - 07/15/2010 SEE NEXT PAGE FOR TOTAL CONTRIBUTION SUMMARY Doc # 2146658 Name of Particip; Certificate #: Coverage Period: Jeffersonville; City of 0066-0102 07/15/2009 - 07/15/2010 SCH~~DULE OF OPERATIONS CONTRIBUTION SUMMARY FOR 2008 ESTIMATED PAYROLL PERIOD: 07/15/2009 - 07/15/2010 BOTH DAYS AT 12:01 AM STANDARD TIME Indiana: 07/15/2009 - 07/15/2010 Total Contribution Subject to Experience Rating Experience Modification 0 77 Total Contribution Adjusted by Experience Modification Indiana Contribution Total Contribution Subject to Schedule Debit/Credit Schedule DebidCredit Total Contribution Adjusted by Application of Modification(s) Total Estimated Annual Contribution Subject to Minimum Contribution of Estimated Coverage Total 1.00 254,387 -58,510 195,877 195,877 0 195, 877 195,877 1,000 195,877 Doc # 2146658 ;::jai:*~** ::,~ ~* BITUMINOUS . ,;I.II*'**** InsuranceCompaniesQUOTEPROPOSAL Item 1. Named Insured and Mailing Address CITY OF JEFFERSONVILLE 500 Q UARTER MASTER CT. JEFFERSONVILLE IN 47130 This proposal does not bind coverage or obligate the company. to the follawing stipulations. Producer Name and Address BLISS-MCKNIGHT OF INDIANA, INC. POBOX157 BLOOMINGTON IL 61702-0157 Producer No. 0002785 This quote is valid f 3 0 days and subject O Item 2. Policy Period From: 0 7 -15 - 2 0 0 9 To: 0 7 -15 0 at 12:01 AM., Standard Time at your ss shown above, Item 3. Business Description: Form of Business: GOVERNMENT ENTITY O Assn No.: Item 4. In return for the payment of the premi ~ ubl o all the terms of this policy, we agree with you to provide the insurance as stated in this po This quote consists of the following coverage parts for ch a premium is indicated. Where no premium is shown, there is no coverage. This premium may be ct to adjustment. Coverage Part(s) Premium Workers Compensation $ 19 3 , 5 0 2.0 0 Total Quote Premium $ 19 3, 5 0 2. 0 0 GV-3000 (01 / 00) Printed: 07-O1-09 WORI~RS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY ~~;I;* * * * FORM PROPOSAL ~,~ ' r `* * BITUMINOUS ?III***** Insurance Companies 1. The Insured/Mailing address ^ Individual ^ Partnership ^ Corporation or GOVERNMENT ENTITY CITY OF JEFFERSONVILLE 500 QUARTER MASTER CT. JEFFERSONVILLE IN 47130 2. Proposed Policy Period: The policy period is from 0 7 -15 - 2 0 0 9 to 0 7 -15 - 2 0 12:01 A.M. Standard time. at the Insured's mailing addres 3. Coverage: O A. Workers compensation Insurance: Part One of the policy applies to th compensation Law of the states listed here: , INDIANA 0 B. Employers liability Insurance; Part Two of the policy app ~ o ~ each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Acci 1, 0 0 0 , 0 0 0 each accident Bodily Injury by Di $ 1, 0 0 0 , 0 0 0 each employee Bodily Injury by Dise $ 1, 0 0 0 , 0 0 0 policy limit C. Other States insurance: Part Three oft icy applies to the states, If any, listed here: ALL STATES EXCEPT HAW HAMPSHIRE, NEW JERSEY, NORTH DAKOTA, OHIO, WASHINGTON, W O AND THE STATES LISTED IN ITEM 3-A. D. This policy inclu ments and schedules: See schedule of forms and endorsements. 4. Premium: The premi 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. Rate Per Premium Basis Estimated Annual $100 of Total estimated Code Premium Remuneration Annual Remuneration No. Classifications , See attached schedule $ 19 3 , 5 0 2 . 0 0 Total Estimated Annual Premium Deposit Premium $ 19 3 , 5 0 2 . 0 0 Minimum Premium $ 1, 0 0 0. 0 0 Premium Adjustment Period: ANNUAL WORKERS' COMPENSATION SCHEDULE NAME EFFECTIVE DATE POLICY NUMBER CITY OF JEFFERSONVILLE 07-15-09 ESTIMATED ESTIMATED CLASSIFICATION CODE P ~ ~$ TOTAL ANNUAL ANNUAL 10 0 REMUNERATION PREMIUMS INDIANA Rating Group 0001-01 STREET OR ROAD 5506 5.68 549,820 $ 31,230.00 CONSTRUCTION: PAVING OR REPAVING & DRIVERS. ROSTERED 7698 .78 1 $ 0.00 VOLUNTEERS-MEDICAL ONLY O & DRIVERS. FIREFIGHTERS-MEDICAL 7699 2.4 3,308,310 $ 81,384.00 ONLY & DRIVERS. POLICE OFFICERS-MEDICAL 77 1.62 3,297,729 $ 53,423.00 ONLY & DRIVERS. AUTOMOBILE SERVICE OR ~ O 8380 2.25 147,462 $ 3,318.00 REPAIR CENTER & DRIVERS. ENGINEER OR O 8601 .44 158,578 $ 698.00 ARCHITECT-CONSULTING CLERICAL OFFICE O 8810 .20 1,951,513 $ 3,903.00 EMPLOYEES NOC ATTORNEY-ALL EMP ES & 8820 .13 38,142 $ 50.00 CLERICAL, MESSENG DRIVERS HOSPITAL-VETERINARY S 8831 1.27 213,358 $ 2,710.00 DRIVERS PARK NOC-ALL EMPLOYEES & 9102 2.55 839,625 $ 21,410.00 DRIVERS SEWER CLEANING & DRIVERS 9902 4.03 513,608 $ 20,698.00 ASHES, GARBAGE, OR 9403 5.31 459,220 $ 24,385.00 REPOSE COLLECTION & DRIVERS WORKERS' COMPENSATION SCHEDULE NAME EFFECTIVE DATE POLICY NUMBER CITY OF JEFFERSONVILLE 07-15-09 ~~ PER ESTIMATED ESTIMATED CLASSIFICATION CODE TOTAL ANNUAL ANNUAL $~~ REMUNERATION PREMIUMS MUNICIPAL, TOWNSHIP 9410 1.89 209,695 $ 3,962.00 COUNTY OR STATE EMPLOYEE NOC. O O O O 0 O TOTAL CLASS PREMIUM S 247,171.00 INCREASE LIMITS 0 9812 S 6,921.00 TOTAL SUBJECT P UM S 254,092.00 EXPERIENCE PREMI 9898 S -58,441.00 TOTAL MODIFIED PREMI S 195,651.00 SCHEDULE MODIFICATION 1.10 9889 S 19,565.00 STANDARD TOTAL S 215,216.00 PREMIUM DISCOUNT .884 0063 S -29,965.00 EXPENSE CONSTANT 0900 $ 200.00 TERRORISM .O1 9740 $ 1,169.00 CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) Ol' 9741 S 1,169.00 TOTAL ESTIMATED PREMIUM SECOND INJURY FUND $ 192,789.00 SURCHARGE 1.0037 0935 FINAL TOTAL $ 713.00 S 193,502.00 H~~~~,~y, ~LISS•MC ICiHTo Proactive Risk Control Programs Bliss McKnight Risk Management Services work in tandem with Bituminous insurance Loss Control Specialists to provide proactive risk control programs which focus on customer needs. Because no two customers face exactly the same challenges, we offer a wide range of risk control service. Risk Control Consultation Controlling loss exposures contributes. to lower overall expenses. The goal of Bliss McKnightJBituminous risk control is to assist customers in nuuiing safer operations. Risk control assistance may take any of the following forms: • Site visits • Safety management development • Special programs for confined space, hazard communication, lock-out/tag-out and motor vehicle accident prevention • Training for management, supervisors and employees • Accident and incident investigation procedures • Self inspection programs • Safety committees • Subcontractor controls • Driver supervision and driver training Training Assistance We work directly with our customers to identify and tailor management, supervisory and employee training sessions. Risk control staff assists in the selection, design and/or delivery that best supports your goals. We maintain an in-house video library of more than 300 titles of concern and interest. If our library cannot meet specific needs, our risk control consultants can assist in locating suitable materials from other sources. For remote. sites, our consultants have access to portable Television/Video-Player equipment. Safety News Briefs Here's a way to keep current with emerging issues of concern. Visit and bookmark our Safety News Briefs. These selected news briefs cover topics specific to our target industries: worker safety, public liability, property protection and more. Information provided is produced by ISO Services' Engineering and Safety group and shown here by permission. Many briefs provide links to additional sources of information. Safety Materials Safety Talks Beef up your safety meetings and "tool box talks" with timely and thought-provoking topics and training aids. Available through Bliss McKnightlgituminous risk control are more than 300 Safety Talks (English and English/Spanish) that cover construction, general safety and health topics. Posters Are you reinforcing your safety awareness program with Bituminous safety posters? Our risk control consultants can assist in selecting specific posters to support your efforts. Topics stay fresh and current through our quarterly poster mailings. "Today's Supervisor"® Complimentary copies of the National Safety Council's monthly publication are useful to many customers. Articles written from a management/supervisory perspective cover a broad range of safety topics. Our risk control can assist in determining who could benefit from this publication. Accident Investigation Unfortunately, even the best-managed operations can have accidents. A key part of any safety program is an effective process to respond to accidents or incidents. These steps may include: • Identification of qualified medical facilities • Procedures for prompt and thorough investigation • Procedures for prompt reporting of accidents or incidents • Return to work or transitional work procedures This safety program is a team effort involving our customers, our risk control consultants and our claims representatives. Loss Information Reports A review of their own loss history leads many customers to more effective management of their operations. Our risk control consultants will help you develop a schedule for receipt of Loss Summary and Loss Analysis reports which can be on a monthly, quarterly or annual basis. Reviewing reports with customers allows our risk control consultants to better assist you in your loss control measures. Loss Summary -reports provide information on each incident: people involved, amount of loss, a brief description of what occurred. Loss. Analysis -reports show loss trends and provide profiles by type of loss. The report recaps both percentages of incidents and percentage of loss costs. For workers compensation a loss analysis provides information based on part of body injured. An automobile and workers compensation loss analysis report includes a list of incidents arranged by driver or employee name. Identifying individuals involved in multiple incidents highlights the potential need for retraining or program adjustment.