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HomeMy WebLinkAboutWorkers Compensation CoverWORKERS COMPENSATION AND EMPLOYERS LIABILITY COVERAGE DOCUMENT INFORMATION PAGE PUBLIC EMPLOYER RISK MANAGEMENT ASSOCIATION, INC. 9 Cornell Road COVERAGE NUMBER Latham, New York 12110 .-.~- WC 1000744-07 - PRIOR COVERAGE NUMBER ..... ~ 1. NAMED MEMBER AND MAILING ADDRESS LEGAL ENTITY ' Town of Southold Other - Town P.O. Box 1179 Southold, NY 11971 OTHER WORKPLACES NOT SHOWN ABOVE AGENCY/BROKER 0002250-Maran Associates ISSUING OFFICE ISSUE DATE PO Box 9300 11/06/2002 ID NUMBER From 01/01/2003 12:01 A.M. to 01/01/2004 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 ef the states listed here: NY B. Employers Liability Coverage: Part Two of the coverage document applies to work in each state listed in item 3,A '['he limits of our liability under Part Two are:Unlimited per Occurrence. C. Other States Coverage: Part Three of the coverage document applies to the states listed here: all states coverag( except the monopolistic state fund states of Nevada, North Dakota, Ohio, Washington, West Virginia and Wyom n! and those states listed in item 3.A. of the information page. D. "['his covera§e document includes these endorsements and schedules: PERMA WC01 (0296), PERMA WC18 (0299), PERMA WC04 (1198), PERMA WC05 (1198), PERMA WC06 (119B), PERMA WC13 (119B), PERMA WC11 (1198), PERMA WC12 (1198) The contribution for this coverage will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. Al information required on the attached extension of Information Page is subject to verification and change by audit. DEPOSIT TOTAL ESTIMATED CONTRIBUTIOI~ ~ 73,770 CONTRIBUTION $ 295,078 THE CONTRIBUTION ADJUSTMENT PERIOD FOR THIS COVERAGE IS ANNUAL. Countersigned By _~'~~ Countersignature Date 11/06/2002 Signed for the above Company as provider for any section of this coverage by: President PERMA WC01 (ED. 02-96) Member Copy WORKERS COMPENSATION AND EMPLOYERS LIABILITY COVERAGE DOCUMENT Extension of INFORMATION PAGE CONTRIBUTION BASIS RATE PER TOTAL ESTIMATED 8100 OF ESTIMATED NEW YORK CODE ANNUAL REMUNER- ANNUAL CLASSIFICATIONS OF OPERATIONS NUMBERS REMUNERATION ATION CONTRIBUTION Building ,Operations, Custodial 9026 22 9, 04 6 S. 68 :13,0:10 Recycling or RefuseTransfer Station 7590 291,064 9.72 28,29:11 Bus Driw.~rs 8394 87,454 ? .37 6,445 Volunteer Clerical 8810V YS, 725 .34 641 Attorneys 8820 124,711 .26 324 Parks Maintenance 9102 702,483 3.91 27,4671 Harbor Patrol 7720F 166,581 4.33 7,213 Nutrition Programs 9079 112,019 3.22 3,607 Street Cleaning 9402 879,026 6.09 53,533 Municipal Employees 9410 490,987 2.15 10,556 Street or Road Maintenance - Sub Surface 5507 48,633 8.65 4,207 Electric Power Co./Street Light Repair 7539 50,154 2.94 1,475 Waste Water Treatment Plant 7580 48,884 5.65 2, ?62 Police Department 7720 4~ 273,745 2.25 96, :159 Automobile Mechanics 8391 512,751 5.60 28,7:14 Recreation & Summer Camp Programs 9063 12,680 1.83 232 Public Health Nursing 8854 :1:1:1,293 3.36 3,7391 Clerical Office 8810 3,704,008 .34 12,594 Lifeguards/Beaches & Bathhouses 9015 62,472 3.26 2,037 All Volunteers 9999V TF ANY .00 0 Experience Modifier: 1.02 308,477 WC Assessment @ 13% 40,102 PERMA Discount: @ 15.40% (53,681~ Expense Constant: 0900 18 ( TOTAL ESTIMATED CONTRIBUTIONi $ 295,078 THIS SCHEDULE FORMS A PART OF THE COVERAGE DOCUMENT TO WHICH IT IS ATTACHED. NAMED MEMBER: Town of Southold COVERAGE NUMBER: WC1000744-07 COVERAGE EFFECTIVE DATE: 01/01/2003 PERMA WC01 (ED. 02-96) Member Copy Public Employer Risk Management Association 9 Cornell Road Latham, New York 12110 Medical Coverage for Volunteers Endorsement It is hereby understood and agreed that, effective 01/01/2003, to expiration of ,01/01/2004, this agreement is subject to the following endorsement. At your discretion, you may elect, in accordance with the New York Workers' Compensation Law, to make a volunteer subject to the law, but only with respect to payment of medical expenses for work-related injury, and subject to the following limitations. The iniured volunteer will be reimbursed directly for medical expenses that they would (a) be eligible to have paid under Workers' Compensation Benefits Law and (b) of which they have incurred ("out of pocket" expenses). :2. Coverage does not apply to any volunteer whose injury makes them eligible for Volunteer Firefighters' Benefits Law or Volunteer Ambulance Workers Benefits Law. 3. This coverage will not reimburse the volunteer for medical bills that are otherwise reimbursable under any other insurance coverage. 4. If the named insured is eligible for experience rating, losses paid under this endorsement will be applied in the same manner as losses of paid employees. 5. In no event will reimbursements claimed under this coverage endorsement exceed $5,000 for any one occurrence. If we make a recovery from others, we will keep an amount equal to our expense 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. 7'. Before we pay benefits to the persons entitled to them, they must: A. Transfer to us the right to recover from others who may be responsible for injury or death to the extent that we render payment. B. Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If the person entitled to the benefits of this coverage fails 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. PERNIA WC18 (ED. 02-99) PUBLIC EMPLOYER RISK MANAGEMENT ASSOCIATION 9 Cornell Road Latham, New York 12110 WORKERS' COMPENSATION & EMPLOYERS LIABILITY COVERAGE AGREEMENT In consideration of the payment of contribution and subject to the limits of liability, exclusions, conditions and other terms of this agreement, the Public Employer Risk Management Association (PERMA) agrees with the member or members, named in the declarations made a par[ hereof, as follows: GENERAL SECTION A. The Agreement This agreement includes at its effective date the Declarations Page and all endorsements and schedules listed thereon. It is an agreement between you (the member or members named in the Declarations Page) and us (PERMA). The only agreements relating to this coverage are stated 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 an employer 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 agreement 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 in operations of the member in the State of New York, or who may be temporarily outside this state in connection with operations within New York State. With regard to such employment, if the member or any injured 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, PERNIA WC04 (ED, t0-02) compensation, or other benefits will be payable under this agreement in accordance with such laws. Definitions For purposes of this Coverage Agreement, the following definitions apply: "Injury" means injury, sickness or disease as defined by the Workers Compensation Law of the State of New York, sustained by a person, including death resulting from any of these at any time, but only if: (i) the "injury" arises out of and in the course of the injured employee's employment by you; (ii) the injured employee's employment is necessary or incidental to your work in the State of New York; and the "injury' occurs during the agreement period; except that, if the employee's "injury" is a sickness or disease, that sickness or disease is caused or aggravated by the conditions of your employment and the employee's last day of last exposure to the conditions causing or aggravating such disease occurs during the agreement period. "Occurrence" means an event, including continuous or repeated exposure to substantially the same general harmful conditions, which event causes "injury" to one or more employees. "Damages" means money damages you are legally obligated to pay in your capacity as employer or otherwise. Where permitted by law, "damages" includes damages: (i) for which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against such third party as a result of injury to your employee; (ii) for care and loss of services; and (iii) for consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee. PART ONE- WORKERS COMPENSATION COVERAGE How This Coverage Applies We will pay promptly when due the benefits required of you by the Workers Compensation Law because of "injury" to your employees. PERMA WC04 (ED. 10-02) We Will Defend We have the right and duty to defend at our 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. 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; 4. interest on an award as required by law until we offer the amount due under this coverage; and 5. expenses we incur. Other Insurance We will not pay more than our share of benefits and costs covered by this agreement and other insurance or self-insurance the member may maintain. Subject to any 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-insurance, will be equal until the loss is paid. Payments You Must Make You are responsible for any payment in excess of the benefits regularly provided by the Workers Compensation Law including those required because: 1. 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 against 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 promptly. PERMA WC04 (ED. 10-02) 3 Recovery From Others We have your dghts, and the rights of persons entitled to the benefits of this coverage, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. 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 wilt not relieve us of our obligations under this agreement after an injury occurs. 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. Jurisdiction over you is jurisdiction over us for the purposes of the Workers Compensation Law. We are bound by decisions against you under that taw, 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 How This Coverage Applies We will pay all sums you legally must pay to third parties as "damages" because of "injury" to your employees caused by an "occurrence" during the agreement period, provided the original suit against you and any related legal actions for "damages" for "injury" is brought within the United States of America, its territories or possessions, or Canada. PERMA WC04 (ED. 10-02) B. I=xclusions '~Fhis agreement does not cover: 1. liability assumed under a contract. This exclusion does not apply to a 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. "injury" to an employee while employed by you in violation of law; 6. "injury" intentionally caused or aggravated by you; o "injury" occurring outside the State of New York. This exclusion does not apply to "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: 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 taw or other federal occupational disease law, or any amendments to these Acts or laws; 9. "injury" to an employee of your subcontractor; 10. "injury" to a master or member of the crew of any vessel; 11. "injury" to any person whose work is not subject to the Workers Compensation Law; 1;.>. "injury" to any person in work subject to the Federal Employers Liability Act (45 USC Sections 51-60), any other federal laws obligating an employer to pay damages to any employee due to injury arising out of or in the course of employment, or any amendment to that Act or those laws; PERMA WC04 (ED. 10-02) 13. "damages" payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 USC Sections 1801-1872) and under any other federal taw awarding damages for_violation of these laws or regulations issued thereunder, or any amendment to that Act or those laws; 14. fines or penalties imposed for violation of federal or state law. We will not pay any "damages" for "injury" excluded from the coverage of this agreement including ,'damages* for which you are liable to a third party by reason of a claim or suit against you by that third party. We Will Defend We have the dght 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. 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 toss 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; 4. interest on a judgment as required by law until we offer the amount due under this coverage; and 5. expenses weincur. Other Insurance We will not pay more than our share of damages and costs covered by this agreement and other insurance or self-insurance the member may maintain. Subject to any 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 ail remaining sources of recovery, including self-insurance, will be equal until the loss is paid. PERMA WC04 (ED. 10-02) F. Limits of Liability Our limits of liability are shown in Item 3. B. of the Declarations Page. They apply as explained below: 1. Per Occurrence. The limit shown is the most we will pay for all "damages" you are legally obligated to pay for all "injuries" arising from a single "occurrence," irrespective of the number of employees injured by said "occurrence." 2. We will not pay any claims for "damages" after we have paid the applicable limit of our liability under this agreement. G. Recovery From Others We have your dghts to recover our payment from anyone liable for an injury covered by this agreement. You will do everything necessary to protect those dghts for use and to help us enforce them. H. Actions Against Us 'There will be no right of action against 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. 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 Tell 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. Promptty give us all notices, demands and legal papers related to the injury, 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. PERMA WC04 (ED. 10-02) 5. Do nothing after an injury occurs that might interfere with our right to recover from others. Do not voluntarily make payments, assume obligations or incur expenses, except. at your own cost. A= PART FOUR - CONTRIBUTION Our Manuals All contribution for this coverage will be determined by our manuals of rules, rates, rating plans and classificationsl We may change our manuals and apply the changes to this coverage if authorized by the PERMA Board of Directors. 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. Classifications The Declarations Page shows the rate and contribution basis for certain business or work classifications. These classifications were assigned based on an estimate of the exposures you would have during 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. Remuneration Contribution for each work classification is determined by multiplying a rate times a contribution basis. Remuneration is the most common contribution basis. The contribution basis includes payrotl and all other remuneration paid or payable during the agreement period for the services of: 1. all your officers and employees engaged in work covered by this agreement; and all other persons engaged in work that could make us liable under Part One (Workers Compensation Coverage) of this agreement. ~f you do not have payroll records for these persons, the contract price for their services and materials may be used as the contribution basis. This paragraph 2 will not apply if you give us proof that we deem sufficient to establish that the employers of these persons have lawfully secured their workers compensation obligations. PERMA WC04 (ED. 10-02) E. Contribution Payments F= You will pay all contributions when due. You will pay the contributions even if part or all of the Workers Compensation Law is not valid. Final Contribution The contribution shown on the Declarations Page, schedules, and endorsements, where applicable, is an 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 lawfully apply to the business and work covered by this agreement. If the final contribution is more than the contribution you paid to us, you must pay us the balance. If it is less, we will refund or credit the balance to you. The final contribution will not be less than the highest minimum contribution for the classifications covered by this agreement. If this agreement is cancelled, final contribution will be determined pursuant to Part Five - Conditions, Paragraph D. Cancellation. Records You will keep records of information needed to compute 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 retrieving data. We 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 organizations have the same rights 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 only to the coverage eligibility of the facilities and the contributions to be charged. We may give you repor[s on the conditions 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. PERMA WC04 (ED. 10-02) 9 B. 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, unless either party shall provide the other with written notice of its intent not to renew this agreement satisfying the requirements of written notice as outlined under Paragraph D. Cancellation. Any notice of intent not to renew provided by the member less than 30 days pdor to the renewal date shall be ineffective as a notice of non-renewal under this section but shall be deemed, to the extent otherwise valid, a notice of termination by member under Paragraph D. Cancellation, subparagraph 3. 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. C. Transfer Of Your Rights and Duties Your rights or duties under this agreement may not be transferred without our written consent. If you die and we receive notice within 30 days after your death, we will cover your legal representative as a covered party if the death resulted from a compensable injury under the Workers Compensation Law. D. Cancellation This agreement may be terminated other than at its renewal date as follows: By PERMA for the member's failure or refusal to make any payments set forth herein, which termination shall be effective 10 days following written notice by PERMA to the member, unless the member shall have made such payment prior to the expiration of said 10 days. 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. Mailing notice to the member at the mailing address in the Declarations Page is sufficient to prove notice. By PERMA for other cause, including but not limited to the member's failure to comply with the terms of the PERMA Workers Compensation Program Agreement, the terms of the member's workers compensation and/or employer's liability coverage agreement with PERMA, or the rutes, regulations or by-laws of PERMA, on 60 days' advance written notice to the member. Mailing notice to the member at the malting address in the Declarations Page is sufficient to prove notice. By member if you secure benefits for your employees in another manner that complies with the Workers Compensation Law. You must deliver written notice via certified mail to us which specifies the date you propose cancellation to take effect. Notwithstanding the date you specify, cancellation will not take effect until thirty days after the date notice is received by PERMA PERMA WC04 (ED. 10-02) including ten days for filing of notification in the office of the Chair of the Workers Compensation Board. In the event coverage is terminated pursuant to subparagraph 1. or 3. of this Paragraph, the member shall pay any and all contribution owed for the pedod preceeding termination, computed using the New York Compensation Insurance Rating Board Short Rate Cancellation Table, including the procedure accompanying such Table. The final contribution will not be less than the m~nimum contribution. tn the event coverage is otherwise canceled, final contribution will be calculated pro rata based on the time this agreement is in force. Final contribution then will not be less than the pro rata share of the minimum 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 all members to change the agreement, receive return contributions, and give or receive notice of cancellation. 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 is issued in reliance upon the truth of such representations and that this agreement embodies 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. PERMA WC04 (ED. '10-02) 'J'i Public Employers Risk Management Association 9 Cornell Road Latham, New York 12110 FOREIGN VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT In consideration of the payment of additional contribution and in reliance upon the statements in the declarations and any other related application documents and subject to the limit of liability, ,exclusions, conditions and other terms of this agreer~lent, this endorsement adds Foreign Voluntary Compensation Coverage to the agreement, Part One - Workers Compensation Coverage is modified as follows. A. How This Coverage Applies is replaced by the following. We will pay an amount equal to the benefits that would be required of you because of "injury" to your employees caused by an "occurrence" during the agreement Period 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. F. Recovery From Others is replaced by the following: ~f 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. H. Before We Pay is added: 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. 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. PERMA WC05 {ED. 11-98) I Part Two - Employers Liability Coverage is modified as follows: A. How This Coverage Applies is modified as follows. We will pay all sums you legally must pay to third parties as "damages" because of "injury" to your employees caused by an "occurrence" during the agreement period, provided the originally suit against you and any related legal actions for "damages" for "injury" is brought within the United States of America, its territories or possessions, or Canada. The "injury" must be sustained by an employee included in the group of employees described in the Schedule. The "injury" must occur in the United States of America, its territories or possessions, or Canada, and may occur elsewhere if the employee is a United States or Canadian citizen temporarily away from those places. Exclusions is changed by adding exclusion 17. This agreement does not cover: 17. 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. G. Recovery From Others is replaced by the following: 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. Before We Pay is added: 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. 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. SCHEDULE All employees of the member or members hired within 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 (ED. 11-98) 2 Public Employers Risk Management Association 9 Cornell Road Latham, New York 12110 ENDEMIC DISEASE AND REPATRIATION ENDORSEMENT A. Endemic Disease This endorsement changes the Foreign Voluntary Compensation and Employers Liability Coverage Endorsement and the general coverage agreement. The word "injury" 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. B. 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 "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 make repatriation necessary in the opinion of competent medical authorities. Our reimbursement shall be limited as follows: 1. To the amount by which expenses exceed the normal cost of returning the employee if in good health, or 2. 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 3. In no event shall our reimbursement exceed $150,000 as respects any one such employee whether dead or alive. PERMA WC06 (ED. 11-98) Public Employer Risk Management Association 9 Cornell Road Latham, New York 12110 Scheduled Volunteers Coverage Endorsement COVERAGE # 1000744-07 It is hereby understood and agreed that, effective as of 01/01/2003, to expiration of 01/01/2004, this agreement is subject to the following endorsement. In consideration of the additional contributions payable, you have elected, in accordance with the New York Workers Compensation Law, to make the class or classes of volunteer workers listed in the schedule below subject to the law, but only with respect to payment of medical expenses for work-related injury. Schedule: 8810V Volunteer Clerical 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. 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 the right to recover from others who may be responsible for injury or death. 3. 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, PERMA WC13 (ED. 11-98) Public Employers Risk Management Association 9 Cornell Road Latham, New York 12110 U.S. LONGSHORE AND HARBOR WORKERS COMPENSATION ACT COVERAGE ENDORSEMENT In consideration of the payment of additional contribution and in reliance upon the statements in the declarations and any other related application documents and subject to the limit of liability, exclusions (except exclusion 8), conditions and other terms of this agreement, this endorsement applies only to work subject to the Longshore and Harbor Workers Compensation Act in the State of New York. General Section C. Workers Compensation Law is replaced by the following: C. Workers Compensation Law Workers Compensation Law means the Workers Compensation Law and occupational disease law of the State of New York and the Longshore and Harbor Workers Compensation Act (33 USC Sections 901-950). It includes any amendments to those laws that are in effect during the agreement period. It does not include any other federal workers compensation law, other federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. Part Two {Employers Liability Coverage), B. Exclusions, exclusion 8 does not apply to work subject to the Longshore and Harbor Workers Compensation Act. This enrdorsement does not apply to work subject to the Defense Base Act, the Outer Continental Shelf Lands Act, or the Nonappropriated Fund Instrumentalities Act. PERMA WC11 (ED. 11-98) Public Employers Risk Management Association 9 Cornell Road Latham, New York 12110 MARITIME COVERAGE ENDORSEMENT In consideration of the payment of additional contribution and in reliance upon the statements in the declarations and any other related application documents and subject to the limit of liability, exclusions (except exclusion 10), conditions and other terms of this agreement, this endorsement changes how coverage provided by Part Two (Employers Liability Coverage) applies to "injury" to a master or member of the crew of any vessel. A. How This Coverage Applies We will pay all sums you legally must pay to third parties as "damages" because of "injury" to your employees cause by an "occurrence" during the agreement period, provided the "injury" occurred in the territorial limits of, or iin the operation of a vessel sailing directly between the ports of, the continental United States of America, Alaska, Hawaii or Canada and the original suit against you and any related legal actions for "damages" or "'injury" is brought within the United States of America, its territories or possessions, or Canada. "Injury" by disease will be deemed to occur in the state of the vessel's home port. I;xclusions is changed by removing exclusion 10 and by adding exclusions 15 and 16. :ThiS agreement does not cover: 15. "injury" covered by a Protection and Indemnity Policy or similar coverage issued to the member or for its benefit. This exclusion applies even if the other coverage does not apply because of an other insurance clause, deductible or limitation of liability clause, or any similar clause. 1~ 6. The member's duty to provide transportation, wages, maintenance and cure. This exclusion does not apply if a separate contribution entry is shown in the schedule. We Will Defend is changed by adding the following statement: We will treat a suit or other action in rem against a vessel owned or chartered by the member as a suit against the member. PERMA WC12 (ED. 11-98) Exclusions is changed by removing exclusion 10 and by adding exclusions This agreement does not cover: 15. bodily injury covered by a Protection and indemnity Policy or similar policy issued to the member or for its benefit. This exclusion applies even if the other policy does not apply because of an other insurance clause, deductible or limitation of liability clause, or any similar clause. 16. The member's duty to provide transportation, wages, maintenance and cure. This exclusion does not apply if a separate contribution entry is shown in the schedule. We Will Defend is changed by adding the following statement: We will treat a suit or other action in rem against a vessel owned or chartered by the member as a suit against the member. Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in the Declarations. 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 covered by this agreement because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. Bodily Injury 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 to any one employee. Bodily injury by disease will be deemed to occur in the state of the vessel's home port. Bodily injury by disease does not include disease that results directly from a bodily injury by accident. We will not pay any claims for damages after we have paid the applicable limit of our liability under this agreement. Schedule PERMA WC12 (6/95)