HomeMy WebLinkAboutIndiana Public Employers' PlanIndiana Public Employers' Plan
Kokomo IN
WORKERS COMPENSATION AND EMPLOYERS LIABILITY
SUBSCRIBED COVERAGE
INFORMATION PAGE
CARRIER CODE:
Item 1. Name and Jeffersonville; City of
address of 501 East Court Avenue
insured
Jeffersonville, IN 47130
Form of Business: City
RISK ID# 130100791
NUMBER
clo3_5 0664
PREVIOUS NUMBER
~VC 102-5IN0664 ]
FEDERAL ID# 35-6001067
Locations--All usual workplaces Of file 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/I5/2003 to 07/15/2004 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. Employers 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 are: 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. The 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
Plus Expense Constant
Total Estimated Annual Contribution
Subject to Minimum Contribution of
Estimated Coverage Total
$188,053.00
$o.oo
$188,053.00
$75o.oo
$188,053.00
Date Issued: 05/05/2004
Countersignamre Date
Attorney-in-fact: Downey Insurance, Inc.
Kokomo, IN 46901
~ame o~_~!~]pa~ Jeffersonvii[e; City of
~ertifi~te g: WClO3-51N0664 005
~erage ~emo 07/15/2003 - 07/15/2004
PAYROLL
CLASS
5506
7~98
7699
7725
8380
8601
8810
8820
8831
9102
9402
9403
9410
DESCRIPTION
STREET OR ROAD CONSTRUCTION:
ROSTERED VOLUNTEERS (Group Rate)
FIREMEN - MED ONLY
POLICE MED ONLY
AUTOMOBILE SERVICE
ARCHITECT OH ENGINEER - CONSULTING
CLERICAL OFFICE EMPLOYEES NOC
ATTOP~EY -ALL EMPLOYEES & CLERICAL
HOSPITAL - VETERINARY - & DRIVERS
PARKS NOC
SEWER CLEA~ING & DRIVERS
GARBAGE ASHES OR REFUSE COLLECTION
MUNICIPAL TOWNSHIP COUNTY OR
ESTIMATED
PAYROLL
MkNUAL
RATE CONTRIBUTION
513,232.00 5.08
26,072~
0.00 500.00 ~'~0 __~/~__
2,181,189.00 3.74 81,57~
2,827,137.00 1.07 30,250
160,366.00 2.31 3,704
54,611.00 0.78 426
1,377,970.00 0.24 3,307
125,277.00 0.19 238
173,982.00 1.17 2,036
497,998.00 3.27 16,285
378,145.00 5.42 20,495
369,447.00 9.30 34,359
199,374.00 1.84 3,668
TOTALS $8,858,728.00
$222,416
See NEXT PAGE FOR TOTAL CONTRIBUTION SUMMARY
~ame ~0~ p~t~¢]p~fft:: Jeffersonville; City of
WC103-51N0664 005
C~er~ ~iOd!~ 07/15/2003 - 07/15/2004
Indiana: 07/15'2003 TO 07/15/2004
Total Contribution Subject to Experience Rating
Additional Contribution for Increased Limits
Adjustment to Minimum Add. Contribution for Increased Limits
Total Contribution Subject to Experience Rating
Experience Modification
Total Contribution Adjusted by Experience Modification
0.8900
222,416
0
0
222,416
-24,468
197,950
Indiana Contribution
Total Contribution Subject to Schedule Debit/Credit
Schedule Debit/Credit
Contribution Adjusted by Application of Modification(s)
Total Estimated Standard Contribution
Plus Expense Constant
Total Estimated Ar~nua] Contribution
Subject to Minimum Contribution of
Estimated Coverage Total
0.9500
197,950
-9,898
188,053
188,053
0
188,053
750
188,053
ROSTERED VOLUNTEER SCHEDULE
(Authority Contained In Public Law 51-1993
Governmental Unit:
Department:
--- Name of Volunteer:
Address:
Phone:
Home:
--- Name of Volunteer:
Address:
Phone:
Home:
Name of Volunteer:
Address:
Phone:
Name of Volunteer:
Address:
Phone:
Home:
--- Name of Volunteer:
Address:
Phone:
Home:
--- Name of
Address:
Phone:
Volunteer:
(IC 22-3-2-2-1)
Work:
Work:
Work:
Work:
Work:
Work:
This Form Provided by Indiana Public Employers' Plan, Inc.