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HomeMy WebLinkAboutPERMA ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF V~TAL STATISTICS MARRIAGE OFFICER RECORDS MAI~AGEMEIxrT OFFICER FREEDOM OF I~FOR, MATION OFFICER Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 southoldmwn.northfork.ne~ OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD OF 2002 WAS~ ~AI~OPTED ~ dEETING OF THE SOUTHOLD TOWN BOARD ON DECEMBER 3, 2002: RESOLVED tha~ the Town Board of the Town of Southold hereby authorizes and directs Supervisor Joshua Y. Horton to execute an acknowledge of receipt and understaading of chan~es made to the PERMA by-laws, Pro~ram A~reement and Coverage Documents as approvec[ by the PERMA Board of Directors, said acknowledgement subject to the approval of the Town Attorney. Elizabeth A. Neville Southold Town Clerk RESOLUTION DECEMBER 3, 2002 V-804 :RESOLVED that the Town Board of the Town of Southold hereby authorizes and directs Supervisor Joshua Y. ttorton to execute an acknowledge of receipt and understandine of changes made to the PERMA by-laws~ Program Agreement and Coverage Documents as approved by the PEP, MA Board of Directors, said acknowledgement subject to the approval of the Town Attorney. INFORMATION PAGE PUBLIC EMPLOYER RISK MANAGEMENT ASSOCIATION III Winners Circle COVERAGE NUMBER Albany, New York 12205 WC 1000744-01 RENEWAL PRIOR COVERAGE NUMBER 1. NAMED MEMBER AND MAILING ADDRESS LEGAL ENTITY Town of Southold Other - Town P.O. Box 1179 South~ld, NY 11971 OTHER ~A/ORKpLAcEs NOT SHOWN ABOVE AGENCY/BROKER 0002250-Maran, DeBaun, Cruise & Simonson ISSUING OFFICE ISSUE DATE PO Box 9300 11/23/1996 ID NUMBER Frorh 01/O1/1997 12:01 A.M. to 01/01/1998 12:01 A.M, Standard Time at the Member's mailing address. A. Workers Compensation Coverage: Part One of the coverage document applies to the Workers Compensation Law of the states listed here: NY B. Employers Liability Coverage: Part Two of the coverage document ~app/ies to work in each state ;isted in item 3.A The limits of our liability under Part Two are:$ 6,000,000 per Occurrence. C. Other States Coverage: Part Three of the coverage document app]ies to the states listed here: all states coverage D. This coverage document incluc~es these endorsements and schedules: PERMA WC01 (0296), PERMA WC04 (0695), PERMA WC05 (0695), PERMA WC06 (0695) The premium for this coverage will be determined by our Manuals of Ru~es, Classifications, Rates and Rating Plans. All information required on the attached extension of Information Page is subject to verification and change by audit. DEPOSIT TOTAL ESTIMATEE PREMIUM $ 39,659 PREMIUM 8 158,635 THE PREMIUM ADJUSTMENT PERIOD FOR THIS COVERAGE IS ANNUAL. Countersigned By /~' ~" ~--~ CountorsignatureDate .... L; / ~ ' Signed for the above Company as provider for any section of this coverage by: ~~ ~ Vice-President/Treasurer Member Copy . PERMAWC01 (ED. 02-96} COVERAGE ;×tenson of I'NFORMAT. ION PAGE PREMIUM BASIS RATE PER iTOTAL ESTIMATED ~100 OF ESTIMATED NEW YORK CODE ANNUAL REMUNER- ANNUAL CLASSIFICATIONS OF OPERATIONS NUMBERS t3EMUNERATION ATION PREMIUM Attorneys 8820 55,08 A .4 .~ 24 Lifeg u~rds/Beaches- & B~th houses 901,5 :L 04 ~ 1 23 3.7~. 3,94 Bud ng Operatiohs, Custod a 9026 3_93,862 5. ~i5 :LO, 56 Home Health C~re~N0~prefessional )051 43, &93_ 5.43 2,36 Nutritio~ prog'rams )079 81, :L:L9 3.15 2,55 Parks Maintenance ]102 479', 227 ~. 4. :t9 20,0~3 · Street (~lean~ng )402 666,7,02 ?. 2:t 48, 06 ~nJcip~a! E~l~yees ")4l 0 258,406 5.3 8 3_3,90 treet or .Read Maintenance - Sub Surface ~507 37,523 ?. 4~5 2,79 Electri~ PO:vv~,~r ~o./Street Light Repair t539 3 9,683_ 2.9~8 1,18 Bus Drivers ~394 54,486 8. :L :J. 4,4 :]. Meter Read,rs/Messengers ]742 3 8,13 9 .8_~ 33 C~erica[- O~fi~e ~1.0 2,9 9 ?, :L 83 .4 ~ 13, :3. 8 ~e~¥,clilig'l ,oir RefuseTransfer Station ~5§O 231,506 X0.9~ 25,28 I~0li6e D,~Lpar:~ment 7'720 2,675,880 2.. 3~ 61,81 Au~m~bi'ie I~echanics ~3391 315,635 5.5 ~ 17, ~ 7 Experience 'Modifier: .89 2 03, :Ll' WC Assessment @ 13.9% 28,23: PERMA Discount: @ 31.50% (72,875' Expense Constant: 0900 161 TOTAL ESTIMATED PREMIUM: $ 3_58, 63 THIS SCHEDULE FORMS A PART OF THE COVERAGE DOCUMENT TO WHICH IT IS ATTACHED. :NAMED MEMBER: Town of Southold COVERAGE NUMBER:WC1000744-01 COVERAGE EFFECTIVE DATE: 01/01/1997 PERMA WCO1 (ED. 02-96) Member Copy P ERMA ': ~,'" '~ ,, ~ IPUBUC~EMPEOYER~'RISK-~MANAGEMENT ASSOCIATION I1~! W~ ~ners ,Ci~'cle Albany, New York 12205 WORKERS COMPENSATION & EMPLOYERS LIABILITY COVERAGE AGREEMENT ] r~ con~sideration crf the, payment of c0ntribution and subjectto the limi,ts of liaEi]iW, exclusions, conditior~s and ~0thgr 1Larrup,Of this agreeme~nt, the, P,~bl~ E~ploya.r,~fS~Management Assoc~a~on (PERMA) a~re, es ~rth the member or members, named m the declarations made a par~h~reof as~¢o[10.w,s:, ~. , . ~ENERAL SECTION A. T, he Agreement T~his agreement includes at its effective date the Declarations Page and all endorsements and schedules listed thereon. Iris an agreement between you (the member or members named i~ the Declarations Page) and us (PERMA). The only agreements relating to this coverag~ arestated in this agreement. The terms of this agreement may not be changed or waived except by endorsement issued by us to be part of this agreement. B. Who, Is Covered You are covered if you are named in the Declarations Page. C. Workers Compensation Law Workers Compensation Law means the Workers Compensation Law of the state of New York except as otherwise provided by endorsement. It includes any amendments to that law which are in effect during the agreement period. It does not include the provisions of any law that provides non-occupational disability benefits, and, except as provided by endorsement to this agreement, any federal workers compensation law or occupational disease law. D. Locations This agreemen~ covers all usual workplaces of the member-in the state of New York at or from which operations covered by this agreement are conducted, except as otherwise excluded herein. Coverage afforded by this agreement is extended to cover employees who are employed and regularly engaged ~ operations of the member in the state of New York, or who may be tern porarily outside this state in connection with operations within New York state, With regard to such employment, if the member or any ~njured employee is deemed subject to the law for damages or the workers compensation law of a state not named in this agreement, the laws of such state will apply and any loss, compensation, or other benefits will be payable under this agreement in accordance with such laws. PERMA WC04 (6/95) PART ONE - WORKERS COMPENSATION COVERAGE A. How This Coverage Applies This workers compensation coverage 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 the state of New York 3. Bodily injury by accident must occur during the agreement period. 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 agreement 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 atour expense any claim or proceeding against you for benefits payable by this coverage. We have the right to investigate and settle these claims or proceedings. We have no duty to defend a claim or proceeding that is not covered by this agreement. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this agreement. D. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this coverage, as part of any claim or proceeding we defend: 1. reasonable expenses incurred at our request, but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this coverage; 3, litigation costs taxed against you; PERMA WC04 {6/95) 2 © © - 4. rote'rest on.an award as required by-law un~t~l we offer ~he ampunt, due under this coverage.; and 5. expenses we incur. Other Insurance We will not pay more than our share of benefits and costs ceveredby this, agreement _ a~d other insurance or self-insurance the.member may maintaim Subject to a~¥ limits of liability that may apply, all shares will be equal until the loss is paid. If any coverage or self-insurance is exhausted, the shares of all remaining sources of recovery, including . . self-insur.an, ce, will .be equal until the loss is paid. F, Payments You Must Make You ar~ responsible for any payment in excess of the benefits regularly provided by the Workers Compensation Law including those required because: t. of your serious and willful misconduct; 2. you 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 aga~nat any employee. If we make any payments in excess of the benefits regularly provided by the Workers Compensation Law on your behalf, you will reimburse us p~omptly. G. Recovery From Others We have your rights, and the rights of persons entitled to the benefits of this coverage, to recover ou[ payments from anyone liable for the injury. You wil 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 or knowledge of the injury when you have notice or knowledge. 2. Your default, bankruptcy or insolvency will not relieve us of our obligations under this agreement after an injury occurs. 3. We are directly and primarily liable to any person entitled to the benefits payable by this agreement. Those persons may enforce our duties; so may an agency authorized by law. Enforcement may be against us or against you and us. PER. MA WC04 (6/95) 3 Jurisdiction over you ~s jurisdiction over us for the purposes of the Workers Compensation Law. We are bound by decisions against you under that law, subject to the provisions of this agreement that are not in conflict with that law. 5. This agreement conforms to the parts of the Workers Compensation Law that apply to: a. benefits payable by this agreement; b. payments into security or other special funds, and assessments payable by us under that law. 6. Terms of this agreement 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 agreement. PART TWO - EMPLOYERS LIABILITY COVERAGE A. How This Coverage Applies When employers lability coverage appears in the Declarations Page of this agreement, this employers' liability coverage 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 the state of New York. 3. Bodily injury by accident must occur during the agreement period. Bodily injury by disease' must be caused or aggravated by the conditions of your employment. The employee's last day of Iast exposure to the conditions causing or aggravating such bodily injury by disease must occur during the agreement period. If you are suec, the original suit and an,/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 wil pay all sums you legally must pay as damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers Liability coverage. The damages we will pay, where recovery is permitted by law, include damages: PERMA WC04 (6/9~) ~. © © for which youare liable to a third party by reason of a claim or suit aga'nst you by that third party to recover the damages claims against such third party as a result of injury to your employee; and 2. for Care and loss of' services;~and for cons:ec~uen~ia, bodily injupLto a spouse, child, parent,'brother or sister of the injured/employee. provided that these damages are n the d rect consequence of bodily injury that arises out of and in the course of the injured employee's employment by you; and 4, because o~ bodily injury to your employee that arises out o~: and in the course of employm~en~cla~,me.cl.,,against ~y~ou, ina capacity.other ~tb..an~ as~emp oyer. C. Exclusions This agreement does not cover: 1, liability assumed under a contract. This exclusion'does not apply to warranty that your work will be done in a workman-like manner; 2, punitive or exemplary damages; any obligation imposed by a workers compensation law, occupational disease law, unemployment compensation law, disability benefits law, no fault law, civil rights law, or any similar law, damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, or any personnel practices, policies, acts or omissions; 5. bodily injury to an employee while employed by you in violation of law; 6, bodily injury intentionally caused or aggravated by you; bodily injury occurring outside the state of New York. This exclusion does not apply to bodily injury sustained by your regular New York employees while temporarily outside the state of New York; and, except as is afforded by endorsement to this coverage: PERMA WC04 (6/95) 5 any obligation imposed by a workers compensation or occupational disease law including the Longshore and Harbor Workers Compensation Act (33 USC Sections 901-950), the Defense Base Act (42 USC Sections 1651-1654), the Non- Appropriated Fund Instrumentalities Act (5 USC Sections 8171-8173), the Outer Continental Shelf Lands Act (43 USC Sections 1331-1356}, the Federal Coal Mine Health and Safety Act {30 USC Sections 901-945), any other federal workers compensation law or other federal occupational disease law, or any amendments to these Acts or laws; 9. bodily injury to an employee of your subcontractor; 10. bodily injury to a master or member of the crew of any vessel; 11 bodily injury to any person whose work is not subject to the Workers Corn pensation Law; '~12 bodily ~njury to any person in work subject to the Federal Employers Liability Act (45 USC Sections 51-60), or any amendment to that Act; 13. damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 USC Sections 1801-1872), or any amendment to that Act; and 14. fines or oenalties imposed for violation of federal or state law. We will not pay any damages for bodily injury excluded from the coverage of this agreem 9nt including damages for which you are ~iable to a third party by reason of a Claim or suit against you by that third party. D. We Will Defend We have the right and duty to defend, at our expense, any claim, proceeding or suit against you for damages payable by this agreement. We have the right to investigate and settle these claims, proceedings and suits. We have no duty to defend a claim, proceeding or suit that is not covered by this agreement. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this agreement. E. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this agreement, as part of any claim, proceeding or suit we defend: 1. reasonable expenses incurred at our request, but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this coverage; 3. litigation costs taxed against you; PERMA WC04 (6/95) 6 interest on a judgment as required by law,until we offer the amount due under this coverage; and expenses we incur. F. Other Insurance We will ,not pay more than our share of damages and costs coveEed by this agreement and other insurance or self-insurance the member may maintain. Subject to any limits of liab lity that may apply, all shares will be equal until the loss is paid. If any coverage or~self-insurance~,is exhausted, the.shares of all rema,ining sourcesof recoverw including ~-tT-i~ur~ce~, Wiiibe equal until the loss iS paid. Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in Item 5 of the De.claratio~ns Page. They apply as explained beloW. Bodily Injury by Accident. The limit shown for?;bodily~,injury by accident - each accident~! is the most we will pay for all damages,cqvered by, this agreement because ~f bodily injury to0ne Or more employees in an,/one accident. ':,A disease, ~s not hod y njury by accident unless it results directly from bodily injury by accident~, ,Bodily njury by Disease. The limit shown for "bodily injury by disease - each employee;' is:the most we will pay for all damages because of bodily, injury by disease t~o any one employee. Bodily injury by disease does not include .disease that results d~rectly from a bodily injury by accident, 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this agreement. H. Recovery From Others We have. your rights to recover our payment from anyone liable for .an injury covered by this agreement. You will do everything necessary to pro~ect those dghts for us and to help us enforce them. L Actions Against Us There will be,no right of action aga!nst us under this agreement unless: 1. you have complied with all terms of this agreement; and 2. the amount you owe has been determined with our consent or by actual trial and final judgment. PERMA WC04 (6~95) 7 This agreement does not give anyone the right to add us as a defendant in an action against you to determine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obligations under this Part after an injury occurs while this agreement is in force for you. PART THREE - YOUR DUTIES IF INJURY OCCURS Tel! us at once if injury occurs that may be covered by this agreement. Your other duties are listed here. Provide for immediate medical and other services required by the Workers Compensation Law. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need. Promptly give us all notices, demands and legal papers related to the ~njury, claim, proceeding or suit. Cooperate with us'and assist us, as we may request, in the investigation, settlement or defense of any claim, proceeding or suit 5. Do nothing after an injury occurs that might interfere with our right to recover from others. 6, Do not voluntarily make payments, assume obligations or incur expenses, except at your own cost. PART FOUR - CONTRIBUTION A. Our Manuals All contribution for this coverage will be determined by our manuals of rules, rat~s, rating 01ans and classifications. We may change our manuals and apply the changes to this 'coverage if authorized by the PERMA Board of Directors. B. Variation of Manual Rates We may apply contribution rates to the coverage that are in excess of or less than manual rates. Variations of manual rates will be determined by us according to our appraisal of you and your business operations as a risk. PERMA WC04 (6/95) 8 © © C. Classifications The Declarations Page sh~ws the rate and contribution basis for certain business or work classifications. These classifications were 9ssigned based on an estimate of the exposures you would have dur ng the agreement period. If your actual exposures are not properly described by those classifications, we will assign proper classifications; rates and contribution basis by endorsement to this agreement. D. Remuneration Contribution for each work classification is determined by multiplying a rate times a codtribufJon basis. Remuneration is the most common contribution basis. The contr butt0~',basis nc ude~t~payro I and e other,:remunerat on paid, or payable ~during the a~qree~ent, penod for.the serv ces,ot~; · I ';,a.; ~our, ~ff ce. rs and ~nployees,,eng,a'ged,in work covered by ~his ogreement; and · ~2.~ , ,~}1 Other perspns engagedm wo~l~ that, could make,usJ~gble under ;PaFt One~(Workers ~ ~ ""-.; }2~mp~,tlc:n Cov~,e). Of th S a( roe ~o ~t f you do not ~ave payro I re~,ords for ~J~ese persohs the centract )nco ~or their sorvlc(;s a~d:mater a s ~aybe osed as the ~ontnbuben basra. Ih~s paragraph, 2 w~ not app g: d you gyve, us proof that we d~em s~fficient to establish that l~he employers of 'these persons have lawfully secu/red, their worker~ompens~ti,on; obligations. E. Contribution 'Payments You,wi!Lpay all contribution when due You w pay the contribution even if part or all of the, ~Vorkers. Compensat~on Law ~s not vahd. F, Final. Contribution, The cpntdbu:tio~ shown on the Declarations Page, schedules, and endorsements, where app [cable Ls ~n estimate. The final contribution will be determined at the .end of the agreement period by using the actual, not the estimated, contribution basis and the proper,classifications and rates that I,awfully apply to the business and work covered by this agreement. If the final contribution is more than the contribution you paid to us, you mus~: ~ay u~the balance. If it is less, we will refund or credit the balance to you. The final ~)ntribut~i~n wll not be less than the highest minimum contribution for the classif~!c~tiogs 9overed by this agreement. If this agreement is cancelled, final contribution will be determined in the following way unle,~s our manuals provide otherwise. If we c~nce ~ or you cance because you are no onger requ red by aw to have coverage, final contribution w~l be calculated pro rata based on the t~me th~s agreement was in force. Final contribution will not be less than the pro rata share of the minimum contribution. PERMA WC04 (6195) 9 If you cancel for any reason other than that you are no longer required by law to have coverage, final contribution will be more than pro rata; it wi!l be based on the time this agreement Was in force, and increased by our short rate ~ance!lation tabte and procedure. Final contribution will not be less than the minimum contribution. Records You will keep records of information needed to corn pute contributions. You will provide us with copies of those records when we ask for them. Audit You will let us examine and audit all your records that relate to this coverage, whether these records pertain to the current agreement period or to any previous agreement period. These records include ledgers, journals, registers, vouchers, contracts, tax -.reports, payroll and disbursement records, and programs for storing and retnewng data. tWe may conduct the audits during regular business hours during the agreement period and within three years after the agreement period ends. Information developed by audit will be used to determine final contribution. Insurance rate service orgamzations have the same n~ hts we have under this provision. PART FIVE - CONDITIONS Inspection We have the right, but are not obligated to inspect your workplaces at any time. Our inspections are not safety inspections. They relate onlyto the insurability of the facilities and the contributions to be charged We may give you reports on the conditioc s we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public, We do not warrant that your facilities are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organizations have the same rights we have under this provision. ';Renewal This agreement renews automatically and continues in full force after the expiration of the original period of coverage for succeeding periods of twelve months or such other period as stipulated by endorsement. The agreement may be terminated only under Paragraph D. Cancellation. You are liable for the contribution for each succeeding agreement period. Each renewal contribution is payable by you at the beginning of each new period when you are notified of the amount. PERMA WC04 (6/95) 10 C, Transfer Of Your Rights and Duties Your rights, or duties under this agreement may not be transferred without our written consent. ,Jr you die and we receiv~notice with n-30 days aft(~r your death,;we wi[[~cover your legal representative as irJs~r~d,' D. Cancellation. This agreement may be canceled only as follows: You may cancel this agreement if you secure benefits for your employees in another manner that complies with the Workers Compensation Law. You must mail or delive,r Written notice to us which specifies the date you propose cancellation to take effect. Notwithstanding the date you specify, sanceJlatien will not take effect until thirty days.after the date you mail or deliver notice to us an.d ten days after we file notice in the office of the Chair of the Workers Compensation Board. 2. We may cancel this agreement: When you furnish proof satisfactory to us that you are no longer required to secure compensation under the Workers Compansat~on Law. Cancellation does not take effnct until at least ten days after we file notice in ~he office of the Chair of the Workers Compensation Board. For nonpayment of contribution. We must mail or deliver written notice to you at least ten days before cancellation isto take effect. Mailing that notice to the member at the mailing address in the Declarations Page is sufficient to prove notice. The agreement will end on the day and hour stated in the cancellation notice. Contribution payments received by us after cancellation is effective will not reinstate the agreement. Such payments will be credited to your account to cover any balance due on the final contribution. Any of these provisions that conflicts with a law that controls the cancellation of the coverage in this agreement is changed by this statement to comply with that law. E. Sole Representative The member first identified in Item 1 of the Declarations Page shall act on.behalf of al members to change the agreement, receive return contributions, and g~ve or receive notice of capcellation. PERMA WC04 (6195) 1 1 F. Declarations By acceptance of this agreement, the member agrees that the statements in the declarations and any other related application documents are its agreements and representations, and that this agreement ~s issued in reliance upon the truth of such representations and that this agreement em oodles all agreements existing between the member and PERMA and any of its agents relating to this coverage document. In witness whereof, PERMA has caused this agreement to be executed and attested, but this agreement shall not be valid unless countersigned by a duly authorized representative of PERMA PERM~ WC04 ¢/95) 1 2 PERMA Public Employers Risk Management Association III Winners Circle Albany~ New York 12205 FOREIGN VOLUNTARY COMPENSATION AND. EMPLOYERS [,lABILITY COVERAGE ENDORSEMENT This endorsement adds Voluntary Compensation C~verage to the agreement. A. How This Coverage Applies This coverage applies to bodily injury by accident or bodily injury by disease. E3odily injury includes resulting death. The bodily injury must be sustained by an. employee included in the group of employees described in the Schedule. The bodily injury must arise~out of and in the course of employment necessary or incidental to work in New York State. The bodily injury must occur in the United States of America, its territories or possessions, or Canada, and may occur elsewhere if the employee ~s a United States or Canadian citizen temporarily away from those places. 4. Bodily injury by accident must occur during the agreement period. 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 agreement period. B. We Will .Pay We will pay an amount equal to the benefits that would be required of you if you and your employees described in the Schedule were subject to the New York Workers Compensation Law. We will pay those amounts to the persons who would be entitled to them under the law. PERMA WC05 (6/95) 1 Exclusions This agreement does not cover: Bodily injury arising from any direct or indirect consequence of war, invasion, act of foreign enemy, hostilities (whether war is declared or not), civil war, rebellion, revolution, insurrection or military or usurped power. No current or subsequent endorsement to this agreement will override or waive this limitation. Any obligation imposed by a workers compensation or occupational disease law, or any similar law. 3. Bodily injury intentionally caused or aggravated by you. Before We Pay Before we pay benefits to the persons entitled to them, they must: 1. Release you and us, in writing, of all responsibility for injury or death. ~ 2. Transfer to us their right to recover from others who may be responsible for ~'~ :~ .injUry or death. Cooperate with us and do everything necessary to enable us to enforce the right to recover from Others. If the persons entitled to the benefits of this coverage fail to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. E. Recovery From Others If we make a recovery from others, we will keep an amount equal to our expenses of recovery and the benefits we paid. We will pay the balance to the persons entitled to it. If the persons entitled to the benefits of this coverage make a recovery from others, they must reimburse us for the benefits we paid them. ~'Employers Liability Coverage Part Two (Employers Liability Coverage) applies to bodily injury covered by this endorsement. This coverage does not apply to any suit brought on or any judgment rendered by any court outside the United States of America, its territories or possessions, or Canada or to an action on such judgment wherever brought. SCHEDULE All employees of the member or members hired ~vithin New York State while they are traveling or temporarily residing outside the United States of America, its territories or possessions, or Canada for a period no longer than ninety days. PERMA WC05 (6/95~ © © P E t~ ~A Public Employers Risk Management Association III Winners Circle Albany, New York 12205 ENDEMIC DISEASE AND REPATRIATION ENDORSEMENT Endemic Disease This endorsement changes the Foreign Voluntary Compensation and Employers Liability Coverage Endorsement. The word "disease" as used in that endorsement includes any endemic diseases. The coverage applies as if endemic diseases were included in the provisions of the New York Workers Compensation Law. Repatriation We agree to reimburse the employer for such additional expenses as reasonably may be incurred over and above normal transportation costs for repatriation of injured, sick or deceased employees as a result of bodily injury covered by this agreement from locations of operations outside the country to a destination in the United States of America, if in the case of injury, the injury makes repatriation necessary in the opinion of competent medical authorities. Our reimbursement shall be limited as follows: To the amount by which expenses exceed the normal coat of returning the employee ~f in good health, or In the event of death, to the amount by which such expenses'exceed the normal cost of returning the employee if alive and in good health, but In no event shall our reimbursement exceed 9150,000 as respects any one such employee whether dead or alive. PERMA WC06 (6/95} I Joshua Y- Horton representing the Town of Southold (Please print Name) (Town, City, V~ffiag~ etc~) Please Print have received and understand all changes made to the PERMA By4aws, Program Agreement and Coverage'Documents as approved by the PERMA Boarc[ of Dkectors at the October 16, 2002 Board meeting. Supervisor, Town of Southold TITLE (Please Print) Return signed form to PERMA by January 15, 2003 using the enclosed self-address stamped envelope e**e ACCOIJ/VI'ING & FINANCE DEPT. John A. Cushman, Town Comptroller Telephone (631) 765--4333 Fax (631~ 765-1366 E-mail: accounting@town.southold.ny.us TOWN I-I.ALL ANNEX Feather Hill, Building 10 620 Traveler Street P.O. Box 1179 Southold, NY 11971-0959 TOWN OF SOUTHOLD Ol~ICE OF THE SUPERVISOR To: Town Board From: John Cushman~ Date: November 27, 2J~02 Re: PERMA changes Please consider the follOwing resolution authorizing the Supervisor to execute an acknowledgement of receipt and understanding of changes from PERMA, our worker's compensation carrier: RESOLVED that the Town Board of the Town of Southold hereby authorizes and directs Supervisor Joshua Y. Horton to execute an acknowledge of receipt and understanding of changes made to the PERMA by-laws, Program Agreement and Coverage Documents as approved by the PERMA Board of Directors, said acknowledgement subject to the approval of the Town Attorney. Public Employei' Risk Management Association. Inc. 9 Comell Road, Lathara, NY 12110 Telephone (518) 220-111 I, Toll-free in US (888) 737-6269 Fax (877~ 737-6232 P ~ P, M A November 18, 2002 262002 IMPORTANT ANNOUNCEMENTS (1) CHANGES TO BYLAWS (2) CHANGES TO PROGRAM AGREEMENT (3) CHANGES TO COVERAGE AGREEMENTS Dear PERMA Member: At a meeting of the Board of Directors on October 16th, several minor technical changes were made to the PERMA bylaws, program agreement and coverage a~eement. While the Board is empowered to make such changes, the membership must be notified. The changes are described in greater detail in the enclosed materials. We ask that you review them and acknowledge your notification of such changes. (1) Changes to the PERMA Bylaws The Board approved several changes to the Byla~vs, which do not materially affect price or service. These changes are summarized on an attached sheet for your review. According to the Bylaws, changes may be made by either the membership (at the annual member meeting) or by the Board of Directors. I/the Board of Directors makes the changes, they are subject to being rescinded by the membership at the next annual or special meeting. If any member has concerns about the changes, please contact Kevin Hume. Executive Vice President or Karen Leffler, Vice Preside~at, Membership Services. (2) Changes to the PERMA Program Agreement The Board approved changes re the Program Agreement, which do nor materially affect price or service. These changes are summarized on an attached sheet for your review, tfany member has concerns about the changes, please contact Kevin Hume, Executive Vice President or Karen Lefller, Vice President, Membership Services. (3) Changes to the PEI*aMA Coverage Agreements The Board approved changes to the Volunteer Firefighters' Benefit Law. Volunteer Ambulance Workers' Benefit Law, and Workers' Compensation and Employers Liability Coverage Agreements. which do not materially affect price or service. These changes are summarized on an attached sheet for your rewe~v. If any member has concerns about the changes, please contact Kevin Hume, Executive Vice President er Karen Leffier, Vice President, Membership Services. Providing a safety net for the public employers and employees of Neu, York Receipt of Notification of Changes After you have reviewed the changes as approved bythe Board of Directors, please sign the enclosed form and ream it to us in the enclosed postage-paid cmvelope, l_fyou have concerns regarding any of the changes, please contact Kevin Hume, or Karen Leffler. Sincerely, Brent A. Wilkes President Providing a safety net for the public employers and employees of New PERMA By-Laws Summary.of Changes Article IV, paragraph 1 (b) (resignation of membership) This section has been revised to conform to the Coverage and Program Agreements regarding the requirement for a member to non-renew coverage with ~PERMA. The paragraph nov( states tha~ written notice o,f intem/on~m non- renew coverage must be delivered b2r certified mail to the PEKMA office 30 days prior to the effective date of c0verage. Article IV, paragraph I (O (termination of membership by PERMA) This section has been revised to clarify the provisions for termination of membership byPERMA. The paragraph now provides that for reasons other than nonpayment of contribution, term/nation requires two-thirds vote of the Board of Directors. The revision also provides that termination for nonpayment of contribution must be authorized by the President, or in his absence, the Executive Vice President. Article IV, paragraph 1 (~d) (obligations surviving resignation or termination) This section has been revised to clarify that the surviving obligation refers to payroll audits. Article IV, paragraph 2 (a) and globally The term "Director of Membership Services" has been changed to "Vice President, Membership Services" Article V, paragraph 2 (a) through 2 (d) CBoard of Directors term of office) Sub-paragraphs (a) through (d) have been removed since the transition from a two-year term to a three-year term for the Board of Directors has been satisfied. 6. Article VII, paragraph 1 (officers) and globally The term "Comptroller" has been changed to "Vice President. Finance". PERMA Program Agreement Snmmary of Changes Paragraph 13 (c) (termination of membership) This section has been revised to clarify the requirement for a member to non- renew coverage with PERMA, namely by giving written notice 30 days prior to the renewal effective date. Paragraph 14 (notice to parties of cancellation) This section has been revised to conform to changes made to paragraph 13 (c) as discussed above. PERMA Coverage Agreements Summary of Changes Part Five - Conditions, Paragraph B - (Renewal) This section has been revised to clarify the requirement for PERMA to non-renew coverage of a member, namely by giving written notice 60 days prior to the renewal effective date. Part Five - Conditions, Paragraph D (Cancellation), Sub-Paragraph 3. This section has been revised to clarify the requirements of delivery of notice of cancellation by a member, namely via certified mail: This section has also been revised to clarify when cancellation will be effective after notice of cancellation from member is received by PERMA.