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Home My WebLink AboutWorkers Compensation Change Form i l ' IIIQi * * ** C BITUMINOUS . . , iIIII li litti * * ** Ineerance Casale WORKERS COMPENSATION CHANGE FORM THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ R CAREFULLY. THE POLICY IS AMENDED AS FOLLOWS: WC -AMEND EXPOSURE THE FOLLOWING CLASS CODE HAS CHANGED FROM: STATE: INDIANA RATING GROUP: 0001-01 CLASS CODE: 5506 (STREET OR ROAD CONSTRUCTION: PAVING OR REPAVING &) ANNUAL PREMIUM BASIS: $646.440.00 PRO RATA FACTOR: 1.00 RATE: 5.34 ANNUAL CLASSIFICATION PREMIUM: $34,520.00 TO: STATE: INDIANA RATING GROUP: 0001 -01 CLASS CODE: 5506 (STREET OR ROAD CONSTRUCTION: PAVING OR REPAVING &) ANNUAL PREMIUM BASIS: $540,876.00 PRO RATA FACTOR: 1.00 RATE: 5.34 ANNUAL CLASSIFICATION PREMIUM: $28,883.00 THE FOLLOWING CLASS CODE HAS CHANGED FROM: STATE: INDIANA RATING GROUP: 0001 -01 CLASS CODE: 7580 (SEWAGE DISPOSAL PLANT OPERATIOII & DRIVERS) ANNUAL PREMIUM BASIS: $1,066,290.00 PRO RATA FACTOR: 1.00 RATE: 2.19 ANNUAL CLASSIFICATION PREMIUM: $23,352.00 TO: Coverage Parts Affected I • This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. All other terms and conditions of this Policy remain unchanged. (The information below is required to be completed only when this endorsement is issued subsequent to the policy effective dste ) Endorsement Effective Date 07 - - , this endorsement tomes part of Policy Number WC 3 557 468 Insured Name: CITY OF JEFFERSONVILLE Policy Effective Date: 07 -15 -11 ADD' L PREMIUM: $ 31, 253.00 Policy Expiration Date: 07 NCCI Carrier Code: 10138 BITUMINOUS CASUALTY CORPO ci,r.„‘ RATION Endorsement No.: 001 ,_ / i, Page 1 AUTHORIZED REPRESENTATIVE: - /� ` Authonzcd Representative Signature • WC8906008(07 -01) Insured 's Copy III * ** * l i * BITUMINOUS Inman*. Colman d o1116b * * * * WORKERS COMPENSATION CHANGE FORM THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ FT CAREFULLY. STATE: INDIANA RATING GROUP: 0001.01 CLASS CODE: 7580 (SEWAGE DISPOSAL PLANT OPERATION & DRIVERS) ANNUAL PREMIUM BASIS: $1,141,076.00 PRO RATA FACTOR: 1.00 RATE: 2.19 ANNUAL CLASSIFICATION PREMIUM: $24,990.00 THE FOLLOWING CLASS CODE HAS CHANGED FROM: STATE: INDIANA RATING GROUP: 0001 -01 CLASS CODE: 7699 (FIREFIGHTERS - MEDICAL ONLY & DRIVERS.) ANNUAL PREMIUM BASIS: $3.910.593.00 PRO RATA FACTOR: 1.00 RATE: 2.91 ANNUAL CLASSIFICATION PREMIUM: $113,798.00 TO: STATE: INDIANA RATING GROUP: 0001 -01 CLASS CODE: 7699 (FIREFIGHTERS- MEDICAL ONLY & DRIVERS.) ANNUAL PREMIUM BASIS: $4,311,890.00 PRO RATA FACTOR: 1.00 RATE: 2.91 ANNUAL CLASSIFICATION PREMIUM: $125.476.00 THE FOLLOWING CLASS CODE HAS CHANGED FROM: STATE: INDIANA RATING GROUP: 0001 -01 CLASS CODE: 7725 (POLICE OFFICERS-MEDICAL ONLY & DRIVERS.) ANNUAL PREMIUM BASIS: 13,798.897.00 PRO RATA FACTOR: 1.00 RATE: 2.01 ANNUAL CLASSIFICATION PREMIUM: $76,358.00 Coverage Parts Affected t This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. All other terms and conditions of this Policy remain unchanged. (The information below Is required to be completed only when Mrs endorsement is issued subsequent to the policy emecbve date.) Endorsement Effective Date 07.15 -11 , this endorsement forms part of Policy Number WC 3 557 468 Insured Name: CITY OF JEFFERSONVILLE Policy Effective Date: 07 -15 -11 ADD'. PREMIUM: $ 31,253.00 Policy Expiration Date: 07-15-12 NCCICanierCode: 10138 BITUMINOUS CASUALTY CORPORATION Endorsement No.: 001 Page 2 AUTHORIZED REPRESENTATIVE: Authoriz d.Aepresenta' Signature WC8906006(07.01) Insured's Copy I* ** ** IF # BITUMINOUS .i. II I�I Iii�F ** Imurncs Companies WORKERS COMPENSATION CHANGE FORM THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ R CAREFULLY. T0: STATE: INDIANA RATING GROUP: 0001 -01 CLASS CODE: 7725 (POLICE OFFICERS- MEDICAL ONLY & DRIVERS.) ANNUAL PREMIUM BASIS: *3.947,537.00 PRO RATA FACTOR: 1.00 RATE: 2.01 ANNUAL CLASSIFICATION PREMIUM: *79.345.00 THE FOLLOWING CLASS CODE HAS CHANGED FROM: STATE: INDIANA RATING GROUP: 0001 -01 CLASS CODE: 8380 (AUTOMOBILE - SERVICE OR REPAIR CENTER & DRIVERS) ANNUAL PREMIUM BASIS: *151,813.00 PRO RATA FACTOR: 1.00 RATE: 2.32 ANNUAL CLASSIFICATION PREMIUM: *3,522.00 TO: STATE: INDIANA RATING GROUP: 0001 -01 CLASS CODE: 8380 (AUTOMOBILE - SERVICE OR REPAIR CENTER & DRIVERS) ANNUAL PREMIUM BASIS: $293,746.00 PRO RATA FACTOR: 1.00 RATE: 2.32 ANNUAL CLASSIFICATION PREMIUM: *6.815.00 THE FOLLOWING CLASS CODE I5 DELETED FROM THIS POLICY: STATE: INDIANA RATING GROUP: 0001 -01 CLASS CODE: 8602 (SURVEYORS, TIMBER CRUISERS, OIL OR GAS GEOLOGISTS OR SCOUTS, & DRIVERS) Coverage Parts Affected This endorsement changes the policy to which it is attached and is effective on the date issued unless othenvise stated. All other terms and conditions of this Policy remain unchanged. (The information below m requited to be completed only %Olen this endorsement is issued subsequent to the pdicy effective date.) Endorsement Effective Date 07 -15 -11 , this endorsement forms part of Policy Number WC 3 557 468 Insured Name: CITY OF JEFFERSONVILLE Policy Effective Date: 07 -15 -11 ADD'L PREMIUM: $ 31,253.00 Policy Expiration Date: 07.15.12 NCCI Carrier Code: 10138 BITUMINOUS CASUAL CORPORATION d i I I OF Endorsement No.: 001 Page 3 0 e t AUTHORIZED REPRESENTATIVE: Ei2 A i i tor' - • .. • - . ive Signature WC890600B(07 -01) Insured's Copy i1 * * * * l4 BITUMINOUS niumfacw . WORKERS COMPENSATION CHANGE FORM THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ANNUAL PREMIUM BASIS: $124.836.00 PRO RATA FACTOR: 1.00 RATE: .44 ANNUAL CLASSIFICATION PREMIUM: $549.00 THE FOLLOWING CLASS CODE HAS CHANGED FROM: STATE: INDIANA RATING GROUP: 0001 -01 CLASS CODE: 8810 (CLERICAL OFFICE EMPLOYEES NOC) ANNUAL PREMIUM BASIS: $2,209,700.00 PRO RATA FACTOR: 1.00 RATE: .17 ANNUAL CLASSIFICATION PREMIUM: $3,756.00 TO: STATE: INDIANA RATING GROUP: 0001 -01 CLASS CODE: 8810 (CLERICAL OFFICE EMPLOYEES NOC) ANNUAL PREMIUM BASIS: $2,438,571.00 PRO RATA FACTOR: 1.00 RATE: .17 ANNUAL CLASSIFICATION PREMIUM: $4,146.00 THE FOLLOWING CLASS CODE HAS CHANGED FROM: STATE: INDIANA RATING GROUP: 0001 -01 CLASS CODE: 8831 (HOSPITAL - VETERINARY & DRIVERS) ANNUAL PREMIUM BASIS: $225,771.00 PRO RATA FACTOR: 1.00 RATE: 1.26 ANNUAL CLASSIFICATION PREMIUM: $2,845.00 TO: STATE: INDIANA RATING GROUP: 0001 -01 Coverage Parts Affected This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. All other terms and conditions of this Policy remain unchanged. (The infolmsbon below is requited to be completed only omen this endosement is issued subsequent to the policy effective date.) Endorsement Effective Date 07-15-11 , this endorsement forms pan of Policy Number WC 3 557 468 Insured Name: CITY OF JEFFERSONVILLE Policy Effective Date: 07 -15 -11 ADO'L PREMIUM: $ 31,253.00 Policy Expiration Date: 07.15.12 NCCI Carrier Code: 10138 BITUMINOUS CASUALT ORPORATION Endorsement No.: 001 . / -f-}71:60y Page 4 AUTHORIZED REPRESENTATIVE: _ Au • - • esentative Signature WC8906008(07 -01) Insured's Copy * *y. ** * BITUMINOUS II IIh * Imurance Compenes I .I II III ** WORKERS COMPENSATION CHANGE FORM THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ R CAREFULLY. CLASS CODE: 8831 (HOSPITAL- VETERINARY & DRIVERS) ANNUAL PREMIUM BASIS: $246,349.00 PRO RATA FACTOR: 1.00 RATE: 1.26 ANNUAL CLASSIFICATION PREMIUM: 13,104.00 THE FOLLOWING CLASS CODE HAS CHANGED FROM: STATE: INDIANA RATING GROUP: 0001 -01 CLASS CODE: 9102 (PARK NOC -ALL EMPLOYEES & DRIVERS) ANNUAL PREMIUM BASIS: $774,528.00 PRO RATA FACTOR: 1.00 RATE: 2.59 ANNUAL CLASSIFICATION PREMIUM: 120,060.00 TO: STATE: INDIANA RATING GROUP: 0001 -01 CLASS CODE: 9102 (PARK NOC -ALL EMPLOYEES & DRIVERS) ANNUAL PREMIUM BASIS: $879,513.00 PRO RATA FACTOR: 1.00 RATE: 2.59 ANNUAL CLASSIFICATION PREMIUM: $22,779.00 THE FOLLOWING CLASS CODE HAS CHANGED FROM: STATE: INDIANA RATING GROUP: OD01 -01 CLASS CODE: 9102U (PARK NOC -ALL EMPLOYEES & DRIVERS- USL &H) ANNUAL PREMIUM BASIS: IF ANY PRO RATA FACTOR: 1.00 RATE: 4.25 ANNUAL CLASSIFICATION PREMIUM: $0.00 TO: Coverage Parts Affected This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. All other terms and conditions of this Policy remain unchanged. (The information below is required to be completed only when res endorsement is issued subsequent to the policy effective dale.) Endorsement Effective Date 07-15-11 , this endorsement forms part of Policy Number WC 3 557 468 InsuredName: CITY OF JEFFERSONVILLE Policy Effective Date: 07 -15 -11 ADD' I. PREMIUM: $ 31.253.00 Policy Expiration Date: 07-15-12 NCCICarderCode: 10138 BITUMINOUS CASUALTY CORPORATION EndorsementNo.: 001 Page 5 AUTHORIZED REPRESENTATIVE: (� :Wig ature WC890600B(07 -0t) Insured' Copy ,u* 11 II* * I L BITUMINOUS 11111111 ** * ei wan WORKERS COMPENSATION CHANGE FORM THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ fl CAREFULLY. STATE: INDIANA RATING GROUP: 0001 - CLASS CODE: 91020 (PARK NOC -ALL EMPLOYEES & DRIVERS- USL &H) ANNUAL PREMIUM BASIS: $10,000.00 PRO RATA FACTOR: 1.00 RATE: 4.25 ANNUAL CLASSIFICATION PREMIUM: $425.00 THE FOLLOWING CLASS CODE HAS CHANGED FROM: STATE: INDIANA RATING GROUP: 0001 -01 CLASS CODE: 9402 (SEWER CLEANING & DRIVERS) ANNUAL PREMIUM BASIS: $706,371.00 PRO RATA FACTOR: 1.00 RATE: 5.22 ANNUAL CLASSIFICATION PREMIUM: $36,873.00 TO: STATE: INDIANA RATING GROUP: 0001-01 CLASS CODE: 9402 (SEWER CLEANING & DRIVERS) ANNUAL PREMIUM BASIS: $639,172.00 PRO RATA FACTOR: 1.00 RATE: 5.22 ANNUAL CLASSIFICATION PREMIUM: $33,365.00 THE FOLLOWING CLASS CODE HAS CHANGED FROM: STATE: INDIANA RATING GROUP: 0001-01 CLASS CODE: 9403 (ASHES. GARBAGE. OR REFUSE COLLECTION & DRIVERS) ANNUAL PREMIUM BASIS: $537.751.00 PRO RATA FACTOR: 1.00 RATE: 5.53 ANNUAL CLASSIFICATION PREMIUM: $29,738.00 Coverage Parts Affected This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. All other terms and conditions of this Policy remain unchanged. (The information below is !squired to be completed only wtwn this ondolsement is Issued subsequent to be policy effective date.) Endorsement Effective Date 07-15-11 , this endorsement forms pan of Policy Number WC 3 557 468 Insured Name: CITY OF JEFFERSONVILLE Policy Effective Date: 07 - 15- ]1 ADD'L PREMIUM: $ 31,253.00 Policy Expiration Date: 07-15-12 NCCICarrierCode: 10138 BITUMINOUS CASUALTY CORPORATION Endorsement No.: 001 Page 6 AUTHORIZED REPRESENTATIVE: � `' � Auth • — - -- — sentative Signature WC 89 06 00B (07.01) 'inured' s Copy * * * BITUMINOUS Lt** Insurance Companies �idllll1J *** ortpam WORKERS COMPENSATION CHANGE FORM THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TO: STATE: INDIANA RATING GROUP: 0001-01 CLASS CODE: 94D3 (ASHES, GARBAGE, OR REFUSE COLLECTION & DRIVERS) ANNUAL PREMIUM BASIS: $609,507.00 PRO RATA FACTOR: 1.00 RATE: 5.53 ANNUAL CLASSIFICATION PREMIUM: 333,706.00 THE FOLLOWING CLASS CODE HAS CHANGED FROM: STATE: INDIANA RATING GROUP: 0001-01 CLASS CODE: 9410 (MUNICIPAL. TOWNSHIP, COUNTY OR STATE EMPLOYEE NOC.) ANNUAL PREMIUM BASIS: 3192,777.00 PRO RATA FACTOR: 1.00 RATE: 2.19 ANNUAL CLASSIFICATION PREMIUM: 34,222.00 TO: STATE: INDIANA RATING GROUP: 0001-01 CLASS CODE: 9410 (MUNICIPAL. TOWNSHIP, COUNTY OR STATE EMPLOYEE NOC.) ANNUAL PREMIUM BASIS: 3574,724.00 PRO RATA FACTOR: 1.00 RATE: 2.19 ANNUAL CLASSIFICATION PREMIUM: $12,586.00 Coverage Parts Affected This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. All other terms and conditions of this Policy remain unchanged. The inrametion below L• required to be completed only when this endorsement Is Issued subsequent to the pricy ottecbve date.) Endorsement Effective Date 07 - 15.11 ,this endorsement forms part of Policy Number WC 3 557 468 InsuredName: CITY OF JEFFERSONVILLE Policy Effective Date: 07 -15 -11 ADD PREMIUM: $ 31.253.00 Policy Expiration Date: 07 NCCI Carrier Code: 10138 BITUMINOUS CASUALTY CO "(RATION Endorsement No.: 001 toe Page 7 AUTHORIZED REPRESENTATIVE: r Au r • n 1_W e Signature WC 89 06 008 (07 -01) Insured's Copy ir e* * * • E It BITUMINOUS r ***** flumes Companies WORKERS COMPENSATION CHANGE FORM THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THE FOLLOWING RATING PLAN IS AMENDED: PREMIUM DISCOUNT(00631 STATE: 111 AMOUNT: 12.10% TO 12.20% THE FOLLOWING FORM(S) HAS BEEN AMENDED: GO%- 2278WK 12-92 WORK COMP SCHEDULE OF NAMED INSUREDS WC2308 05-93 WORKERS COMPENSATION SCHEDULE Coverage Parts Affected This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. All other terms and conditions of this Policy remain unchanged. (The information heave a required to be oomplesed say when this endorsement is issued subsequent to the policy Weave date.) Endorsement Effective Date 07-15.11 . this endorsement forms part of Policy Number WC 3 557 468 Insured Name: CITY OF JEFFERSONVILLE Policy Effective Date: 07-15-11 ADD' L PREMIUM: S 31.253.00 Policy Expiration Date: 07-15-12 NCCI Carrier Code: 10138 BITUMINOUS CASUALTY CORP''ATION Endorsement No.: 001 � %� Page 8 AUTHORIZED REPRESENTATIVE: Author , presentative Signature WC890600B(07 -01) Insured 's Copy SCHEDULE OF NAMED INSUREDS NAMED INSURED POLICY NUMBER CITY OF JEFFERSONVILLE WC 3 657 468 0001-01 CITY OF JEFFERSONVILLE 500 QUARTERMASTER CT JEFFERSONVILLE IN 47130 FEIN: 35 NAIC Code: 92112 0001 -01 CITY OF JEFFERSONVILLE 501 EAST COURT AVENUE JEFFERSONVILLE IN 47130 FEIN: 35-6001067 NAIL Code: 92112 GOX-2278WK (12/92) SCHEDULE OF FORMS AND ENDORSEMENTS NAMED INSURED POLICY NUMBER CITY OF JEFFERSONVILLE WC 3 557 468 WC 89 06 00B (07/01) WORKERS COMPENSATION CHANGE FORM WC 89 06 OOB (07/01) WORKERS COMPENSATION CHANGE FORM WC 89 06 008 (07/01) WORKERS COMPENSATION CHANGE FORM WC 89 06 00B (07/01) WORKERS COMPENSATION CHANGE FORM WC 89 06 008 (07/01) WORKERS COMPENSATION CHANGE FORM WC 89 06 008 (07/01) WORKERS COMPENSATION CHANGE FORM WC 89 06 008 (07/01) WORKERS COMPENSATION CHANGE FORM WC 89 06 008 (07/01) WORKERS COMPENSATION CHANGE FORM GOX•2278WK (12/92) SCHEDULE OF NAMED INSUREDS GOX 2279 (12/92) SCHEDULE OF FORMS AND ENDORSEMENTS WC 2308 (05/93) WORKERS COMPENSATION SCHEDULE WC 2308 (05/93) WORKERS COMPENSATION SCHEDULE GOX -2279 (12/92) WORKERS COMPENSATION SCHEDULE NAME POLICY EFFECTIVE DATE POLICY NUMBER CITY OF JEFFERSONVILLE 1 07 -15 -11 WC 3 557 468 ESTIMATED ESTIMATED RATE PER TOTALANNUAL ANNUAL CLASSIFICATION CODE S1OO REMUNERATION PREMIUMS INDIANA Rating Group 0001 -01 STREET OR ROAD 5506 5.34 540,876 $ 28,883.00 CONSTRUCTION: PAVING OR REPAVING & DRIVERS. SEWAGE DISPOSAL PLANT 7580 2.19 1,141.076 $ 24,990.00 OPERATION & DRIVERS ROSTERED 7698 1.25 1 $ 0.00 VOLUNTEERS-MEDICAL ONLY & DRIVERS. FIREFIGHTERS- MEDICAL 7699 2.91 4,311,890 $ 125,476.00 ONLY & DRIVERS. POLICE OFFICERS - MEDICAL 7725 2.01 3.947,537 $ 79,345.00 ONLY & DRIVERS. AUTOMOBILE - SERVICE OR 8380 2.32 293,746 $ 6,815.00 REPAIR CENTER & DRIVERS CLERICAL OFFICE 8810 .17 2,438,571 $ 4,146.00 EMPLOYEES NOC ATTORNEY -ALL EMPLOYEES & 8820 .13 IF ANY S 0.00 CLERICAL, MESSENGERS DRIVERS HOSPITAL-VETERINARY & 8831 1.26 246.349 $ 3,104.00 DRIVERS PARK NOC-ALL EMPLOYEES & 9102 2.59 879.513 $ 22,779.00 DRIVERS PARK NOC -ALL EMPLOYEES & 9102U 4.25 10,000 $ 425.00 DRIVERS -USL &H SEWER CLEANING & DRIVERS 9402 5.22 639,172 $ 33,365.00 WC -2308 (5193) WORKERS COMPENSATION SCHEDULE i. NAME POLICY EFFECTIVE DATE POLICY NUMBER CITY OF JEFFERSONVILLE 07 WC 3 557 468 ESTIMATED ESTIMATED RATE PER TOTAL ANNUAL ANNUAL CLASSIFICATION CODE S100 REMUNERATION PREMIUMS ASHES. GARBAGE, OR 9403 5.53 609.507 $ 33,706.00 REFUSE COLLECTION & DRIVERS MUNICIPAL, TOWNSHIP 9410 2.19 574,724 $ 12,586.00 COUNTY OR STATE EMPLOYEE NOC. TOTAL CLASS PREMIUM $ 375.620.00 INCREASE LIMITS 1.028 9812 $ 10,517.00 TOTAL SUBJECT PREMIUM $ 386,137.00 EXPERIENCE PREMIUM 1.33 9898 $ 127.425.00 TOTAL MODIFIED PREMIUM $ 513.562.00 STANDARD TOTAL $ 513,562.00 PREMIUM DISCOUNT .878 0063 $ -62,655.00 EXPENSE CONSTANT 0900 $ 200.00 TERRORISM .01 9740 S 1.563.00 CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) .01 9741 $ 1,563.00 TOTAL ESTIMATED PREMIUM $ 454.233.00 SECOND INJURY FUND SURCHARGE 1.0075 0935 $ 3,407.00 FINAL TOTAL $ 457,640.00 WC -2308 (5/93)