Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
PROOF OF INSURANCE (2014) CLOSED
2 CERTIFICATE OF LIABILITY INSURANCE DA 9/26/2013 ) THIS CERTIFICATE IS ISSUED AS ..A ...MATTE... _....... ..- - --...... _ .......... .... ..- R OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT. If the certif'icateholder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). _ ..w ............. . PRODUCER CONTACT NAME;'. Willis of Illinois, Inc. PHONE "" (877 945 378C,mrrL (888IT 467 2378 c/o 26 Cent u Blvd. (A/r,,N Exit __ „•, ) 7 P.O. Box 305 91 ADDRI SS Nashville TN 37230 - 5191 _._. .............................. ' INSURERS AFFORDING COVERAGE _ NAIC # INSURERA:Travelers Indemnity Company of CT 25682 ........... ___ . _____. ----- .... -- INSURED INSURER B: Travelers Property Casualty Company of America 25674 Bucknam Infrastructure Group, Inc. INSURER C: Continental Casualty Company 20443 3548 Seagate Way, Suite 230 INSURER D: Oceanside, CA 92056 INSURER E COVERAGES CERTIFICATE TE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, R f FF LI Y EXP W��T E OF INSURANCE �� POLICY NUMBER—,,,, MM1D[�IYYYY LIMITS �� .... TMP.... a J.NS. ! lMM(�?�) .. .. .......... ... ........... GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 vrXG ifiiiFRTF A X COMMERCIAL GENERAL LIABILITY X X 6806A55628A 9/1612013 9/16/2014 PREMISES Ea occurrence) $ 1,000,00 CLAIMS -MADE 6_X .I OCCUR MED EXP (Any one person) $ 10,00 PERSONAL & ADV INJURY -- GENER__AL AGGREGATE . $ ... 2,000,00 I GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2 000 , ,00 PRO- — � LOC $ ......, .� AUTOMOBILE LIABILITY COMBINED SINGLE LIMU (Ea accident) $ A ANY AUTO 6806A55628A 9/1612013 9/16/2014 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) .........$.. $ ... .... ED _ ... .._......AGE �X...„ HIRED AUTOS X.. AUTOS PRU AEfChGENT . ............................ ,...... CSL incl in GL $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ I— .................,.,.... .. DED $ $ ..,RETENTION _ ........ ..... . ... WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS' LIABILITY TQRY MMIT$,,,,, - -- FR._„ Y / N - -- - B ANY PROPRIETOR /PARTNER /EXECUTIVE UB3790T99A 9/16/2013 9/16/2014 L. EACH ACCIDENT 1,000,00 _E _ OFFICERIMEMBER EXCLUDED? �.) N/A _$ (Mandatory in NH) E,L. DISEASE - EA EMPLOYEE $ 1,000,0.0__' If yes, describe under DESCRIPTION OF OPERATIONS below E.L, DISEASE - POLICY LIMIT .. ......................... $ 1,000,00 C Professional Liab. MCH288359767 9/1612013 9/16/2014 Per Cla Im/Agg 1 000..00.... , ( is required) DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES Attach ACORD 101, Additional Remarks Schedule, if more space Re: Final El Segundo PMP City of El Segundo, its officials and employees are named as Additional Insureds with respects to General Liability. General Liability policy shall be Primary with any other insurance in force for or which may be purchased by Additional Insureds. Waiver of Subrogation applies in favor of Additional Insureds with respects to General Liability. CERTIFICATE HOLDER CANCELLATION ..... — — .... ..__........ j � SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED ' BEFORE J f tH�E EXPIRATION DATE THEREOF, NOTICE WILL ARDANCE WITH THE POLICY PROVISIONS. BE DELIVERED IN � al City f El Segundo THORIZED REPRESENTATNE ty g U�*' Attention: Katsouleas P.E. 350 Main Street EI . ,_ _._ —.. ....._ __......._ __.._ f _. gunr4w CA 0245- 0000.1�s. , .. ` .............. „. c _ O 1988 2010 ACORD CORPORATION. All rights reserved.. �o ACORD 25 (2010105) The ACORD name and lo$a are registered marks of ACORD COMMERCIAL GENERAL LIABILITY POLICY NO 6806A55628A THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED (ARCHITECTS, ENGINEERS AND SURVEYORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. The following is added to WHO IS AN INSURED (Section II): Any person or organization that you agree in a "contract or agreement requiring insurance" to include as an additional insured on this Coverage Part, but only with respect to liability for "bodily injury", "property damage" or "personal injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: a. In the performance of your ongoing operations; b. In connection with premises owned by or rented to you; or c. In connection with "your work" and included within the "products- completed operations hazard ". Such person or organization does not qualify as an additional insured for "bodily injury", "property damage" or "personal injury" for which that person or organization has assumed liability in a contract or agreement. The insurance provided to such additional insured is limited as follows: d. This insurance does not apply on any basis to any person or organization for which coverage as an additional insured specifically is added by another endorsement to this Coverage Part. This insurance does not apply to the rendering of or failure to render any "professional services ". f. The limits of insurance afforded to the additional insured shall be the limits which you agreed in that "contract or agreement requiring insurance" to provide for that additional insured, or the limits shown in the Declarations for this Coverage Part, whichever are less. This endorsement does not increase the limits of insurance stated in the LIMITS OF INSURANCE (Section III) for this Coverage Part. B. The following is added to Paragraph a. of 4. Other Insurance in COMMERCIAL GENERAL LIABILITY CONDITIONS (Section IV): However, if you specifically agree in a "contract or agreement requiring insurance" that the insurance provided to an additional insured under this Coverage Part must apply on a primary basis, or a primary and non- contributory basis, this insurance is primary to other insurance that is available to such additional insured which covers such additional insured as a named insured, and we will not share with the other insurance, provided that: (1) The "bodily injury" or "property damage" for which coverage is sought occurs; and (2) The "personal injury" for which coverage is sought arises out of an offense committed; after you have entered into that "contract or agreement requiring insurance ". But this insurance still is excess over valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to the insured when the insured is an additional insured under any other insurance. C. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us in COMMERCIAL GENERAL LIABILITY CONDITIONS (Section IV): We waive any rights of recovery we may have against any person or organization because of payments we make for "bodily injury", "property damage" or "personal injury" arising out of "your work" performed by you, or on your behalf, under a "contract or agreement requiring insurance" with that person or organization. We waive these rights only where you have agreed to do so as part of the "contract or .agreement requiring insurance" with such person or organization entered into by you before, and in effect when, the "bodily CG D3 81 09 07 0 2007 The Travelers Companies, Inc. Page 1 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. injury" or "property damage" occurs, or the "personal injury" offense is committed. The following definition is added to DEFINITIONS (Section V): "Contract or agreement requiring insurance" means that part of any contract or agreement under which you are required to include a person or organization as an additional insured on this Coverage Part, provided that the "bodily injury" and "property damage" occurs, and the COMMERCIAL GENERAL LIABILITY "personal injury" is caused by an offense committed: a. After you have entered into that contract or agreement; b. While that part of the contract or agreement is in effect; and c. Before the end of the policy period. CG D3 81 09 07 © 2007 The Travelers Companies, Inc. Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. SAFETY SERVICES Notice to policy recl lent; If you are not the person directly responsible for the accident prevention activities for your company, please direct this Safety Services notice to the person that is directly responsible for them. SAFETY IS OUR CONCERN Thank you for purchasing your insurance from one of the writing companies owned or managed by The Travelers Companies, Inc. We appreciate your business and welcome the opportunity to be of service. An important part of that service concerns safety and accident prevention. Travelers Risk Control department has the experience, resources and capabilities to provide a range of safety services, including site surveys, phone consultations, as well as provide access to numerous safety - related materials. We have experience in a variety of industries, some of which include manufacturing, wholesale and retail businesses, service organizations, technology - related business, oil and gas -based business, and the public sector. Following are some examples of available safety services: Accident Prevention — Our staff can help you identify present and potential hazards in your operations, premises and equipment, and recommend measures for reducing or eliminating these hazards. Analysis of Accident Causes — Although you investigate and keep records of accidents, we are available to assist if needed. Safety Consultations — Our Consultants can help you with special problems such as ergonomics and human factors. Industrial Hygiene /Health Services — We have the facilities and resources to answer your questions concerning job related industrial hygiene /health issues and to measure exposure to industrial hygiene hazards. Safety Literature and Diaital Media — We can provide you with top -notch safety - related literature, CDs, DVDs, and videos to assist in your loss control efforts. Also, we can direct you to several vendors who are able to provide additional safety materials, including brochures, pamphlets and digital media. Safety Training — We offer face -to -face classroom courses, as well as distance learning programs that explore the risks our policyholders face and ways for them to control losses. Return -To -Work Coordination — We can assist you with several aspects of the post injury management process. Internet Website — Visit our Risk Control website for access to our safety newsletters and other safety literature at: http: / /www.travelers.com /riskcontrol This website also has links to other safety - related Internet sites. Please note: For ALL loss control assistance requests, please contact your local office directly, which is listed on one of the following pages. These services are available upon request. See the remainder of this document for the Travelers' Risk Control office nearest you. These phone numbers should not be used for questions regarding our golic or claims. WUNT3B13 © 2012 The Travelers Indemnity Company. All rights reserved, Page 1 of 5 SAFETY IS YOUR CONCERN U.S. employers spend billions of dollars each year on the direct and indirect costs of work - related accidents. Dollar figures can't begin to reflect the pain and suffering of an injured worker and his or her family. But they do give some indication of the multiple consequences of a job - related accident... loss of time, interrupted production, damaged materials and equipment, the expense of retraining or replacing an injured worker, possible legal action from government regulatory agencies, and increased insurance costs. It makes good sense for both employers and their employees to actively participate in a sound accident prevention program. The success of such a program depends to a large extent on your commitment to safety procedures and accident prevention techniques. Safety is a management concern. Maybe we can help. You may want to consider the following "Safety Checkpoints" as you evaluate your organization's safety activities: SELF - INSPECTION PROGRAM: • Do you conduct periodic surveys of premises ?... equipment ?... operations? WUNT3B13 © 2012 The Travelers Indemnity Company. All rights reserved. SELF - INSPECTION PROGRAM (continued): • Do you analyze each job to find inherent hazards? • If you discover hazards, do you follow up with immediate corrective action? • Do you monitor such action to make sure it is implemented and effective? ACCIDENT INVESTIGATION: • Do you investigate each accident? ... determine the cause? • Do you take immediate steps to prevent a recurrence? • Do you keep records of accident investigations and follow -up measures? • Do you complete accident statistics and analyze trends? EDUCATION AND TRAINING: • Do you take the time to train each of your employees to perform tasks safely? • Do more - experienced employees receive training to correct bad habits that have developed over time? • Do all employees understand that safety is an important part of their jobs? Page 2 of 5 WUNT3B13 Page 3 of 5 © 2012 The Travelers Indemnity Company. All rights reserved. Please call these numbers FOR SAFETY SERVICES ONLY For all other vin uiries please gpnta t your agent, underwriter or claim representative ALABAMA CALIFORNIA HAWAII Birmingham San Diego Orange, CA 3000 Riverchase Galleria 9325 Sky Park Court, Ste. 220 333 City Blvd. W Ste. 600 San Diego, CA 92123 Suite 1100 Birmingham, AL 35244 (714) 612 -0682 Orange, CA 92868 (678) 317 -7708 (714) 620 -0682 Claims: 1- 800 - 238 -6214 ALASKA CALIFORNIA IDAHO Portland, OR Walnut Creek Portland, OR 4000 SW Kruse Place, Suite 100 225 Lennon Lane, Ste. 105 4000 SW Kruse Place, Suite 100 Lake Oswego, OR 97035 P.O. Box 8090 Lake Oswego, OR 97035 (503) 534 -4276 Walnut Creek, CA 94596 -8090 (503) 534 -4276 Risk Control: (925) 945 -4171 Claims: (800) 842 -7354 ARIZONA COLORADO ILLINOIS Phoenix Denver Chicago 2401 W Peoria Ave., Suite 130 6060 S. Willow Dr. #300 200 North LaSalle Street Phoenix, AZ 85029 Greenwood Village, CO 80111 Suite 2200 (720) 200 -8355 (720) 200 -8355 Chicago, IL 60601 Claims: 720 - 200 -8100 (630) 961 -8074 Claims: 800 - 842 -6172 ARKANSAS CONNECTICUT ILLINOIS Richardson, TX Hartford Naperville 1301 E. Collins Blvd 300 Windsor Street 215 Shuman Boulevard Richardson, TX 75081 Hartford, CT 06120 P.O. Box 3208 (214) 570 -6675 (860) 954 -3741 Naperville, IL 60566 Claims: (860) 954 -5190 (630) 961 -8074 Claims: 800 - 842 -6172 CALIFORNIA DELAWARE INDIANA Diamond Bar Washington, DC Indianapolis 21688 Gateway Center Drive 10 Sentry Parkway, Suite 300 Suite 300 P.O. Box 6512 Blue Bell, PA 19422 6081 East 82nd Street Diamond Bar, CA 91765 -8512 (215) 274 -1610 Indianapolis, IN 46250 Risk Control: (714) 620 -0682 Claims: 1- 800 - 368 -3562 (317) 845 -1479 Claims: (909) 612 -3000 Claims: 800 - 238 -6210 CALIFORNIA DISTRICT OF COLUMBIA IOWA Glendale Washington, DC Des Moines 700 N. Central Avenue, 4th Floor 14200 Park Meadow Dr. 7101 Vista Dr. P.O. Box 1840 Chantilly, VA 20151 West Des Moines, IA 50266 -9313 Glendale, CA 91209 (571) 287 -6232 (651) 310 -4422 Risk Control: (714) 620 -0682 Claims: 1- 800 - 368 -3562 Claims: 800 - 255 -5072 Claims: (909) 612 -3000 CALIFORNIA FLORIDA KANSAS Los Angeles Orlando Kansas City 888 South Figueroa St., Ste. 500 2420 Lakemont Dr 7465 West 132nd Los Angeles, CA 90017 Orlando, FL 32814 Overland Park, KS 66213 (714) 620 -0682 (407) 388 -3307 (913) 685 -5109 Risk Control: (714) 620 -0682 Claims: 407 - 388 -2400 Claims: (909) 612 -3000 CALIFORNIA GEORGIA KENTUCKY Sacramento Atlanta Louisville 11070 White Rock Road, Suite 130 1000 Windward Concourse Suite 150 Rancho Cordova, CA 95670 Alpharetta, GA 30005 303 N Hurstbourne Pkwy Risk Control: (916) 852 -5245 (678) 317 -7708 Louisville, KY 40222 Claims: (800) 727 -3995 Claims: 800 - 238 -6214 (502) 429 -7390 Claims: 800 - 238 -6210 WUNT3B13 Page 3 of 5 © 2012 The Travelers Indemnity Company. All rights reserved. Please call these numbers FOR SAFETY SERVICES ONLY For all other i ng uiries please contact you r agent, underwriter or claim rep, resent tine LOUISIANA New Orleans 3838 N. Causeway, Suite 2700 Metairie, LA 70002 P.O. Box 61479 New Orleans, LA 70161 -1479 (504) 832 -7562 Claims: 800 - 842 -2556 MAINE Portland, ME 207 Larrabee Road, Suite 3 Westbrook, ME 04092 (207) 857 -2021 MARYLAND Washington, DC 14200 Park Meadow Dr. Chantilly, VA 20151 (571) 287 -6232 Claims: 1- 800 - 368 -3562 MASSACHUSETTS Boston 100 Summer Street, Suite 201A Boston, MA 02110 (781) 817 -8370 Claims: 800 - 832 -7839 MASSACHUSETTS Hudson 1 Cabot Road Suite 250 Hudson, MA 01749 (781) 817 -8370 Claims: 800 - 832 -7839 MASSACHUSETTS Braintree 350 Granite Street Suite 1201 Braintree, MA 02184 (781) 817 -8370 Claims: 800 - 832 -7839 MICHIGAN Grand Rapids 3777 Sparks Ave. SE, Ste. 200 P.O. Box 3010 Grand Rapids, MI 49501 -0323 (248) 312 -7301 Claims: 800 - 238 -6210 MICHIGAN Troy 1301 W. Long Lake Rd., Ste. 300 Troy, MI 48098 (248) 312 -7301 Claims: 800 - 238 -6210 MINNESOTA St. Paul 385 Washington St., MC 104P St. Paul, MN 55102 (651) 310 -4422 Claims: 800 - 842 -3073 MISSISSIPPI Jackson 1080 River Oaks Dr Ste B -200 Flowood, MS 39232 (601) 936 -8212 Claims: 1- 800 - 342 -4064 MISSOURI Maryland Heights 940 West Port Plaza, Suite 450 Maryland Heights, MO 63146 (913) 685 -5109 Claims: 800 - 842 -9621 Kansas City 7465 West 132nd Overland Park, KS 66213 (913) 685 -5109 Claims: 800 - 255 -5072 Missouri Workers' Compensation Plan (MWCP) 1000 Walnut Street Kansas City, MO 64199 (816) 391 -1123 MONTANA Portland, OR 4000 SW Kruse Place, Suite 100 Lake Oswego, OR 97035 (503) 534 -4276 NEBRASKA Omaha 11516 Miracle Hills Dr., St. 400 Omaha, NE 68154 (651) 310 -4422 Claims: 800 - 255 -5072 NEVADA Las Vegas 1850 E Flamingo, Suite 202 Las Vegas, NV 89119 (702) 669 -4746 Claims: 702 - 479 -4200 NEW HAMPSHIRE Portland, ME 207 Larrabee Road, Suite 3 Westbrook, ME 04092 (207) 857 -2021 NEW JERSEY Morristown 445 South Street Morristown, NJ 07960 (973) 631 -7015 Claims: 1- 800 - 842 -2475 NEW JERSEY Marlton Lake Center Exec Park Building 30 Suite 110 Marlton, NJ 08053 (856) 703 -2323 Claims: 800 - 842 -2475 NEW MEXICO Phoenix 2401 W Peoria Ave., Suite 130 Phoenix, AZ 85029 (720) 200 -8355 Claims: 602 - 861 -8600 NEW YORK Albany 900 Watervliet- Shaker Road Albany, NY 12205 (315) 424 -7231 Claims: 800 - 842 -2475 NEW YORK Buffalo 60 Lakefront Blvd. P.O. Box 242 Buffalo, NY 14240 -0242 (315) 424 -7231 Claims: 800 - 842 -2475 NEW YORK Jericho -Long Island Two Jericho Plaza Jericho, NY 11753 (516) 933 -3932 Claims: 800 - 842 -2475 NEW YORK New York 485 Lexington Ave. New York, NY 10017 -2630 (516) 933 -3932 Claims: 1- 800 - 842 -2475 WUNT3B13 Page 4 of 5 © 2012 The Travelers Indemnity Company. All rights reserved. Please call these numbers FOR SAFETY SERVICES ONLY Ftar all other "in uiries Please contact your agent, underwriter or claim re resentative NEW YORK PENNSYLVANIA UTAH Rochester Philadelphia Denver, CO 75 Town Centre Drive 10 Sentry Parkway, Suite 300 6060 S. Willow Drive #300 P.O. Box 23235 Blue Bell, PA 19422 Greenwood Village, CO 80111 Rochester, NY 14692 -3235 (215) 274 -1610 (720) 200 -8306 (315) 424 -7231 Claims: 800 - 832 -0606 Claims: 800 - 453 -3025 Claims: 1- 800 - 842 -2475 NEW YORK Syracuse 440 South Warren Street P.O. Box 4963 Syracuse, NY 13221 -4963 (315) 424 -7231 Claims: 800 - 842 -2475 NORTH CAROLINA Charlotte 11440 Carmel Commons Blvd P.O. Box 473500 Charlotte, NC 28247 -3500 (704) 540 -3438 Claims: (704) 544 -3500 NORTH CAROLINA Raleigh 4504 Emperor Blvd. Durham, NC 27703 (919) 474 -4811 Claims: (704) 544 -3500 NORTH DAKOTA St. Paul, MN 385 Washington St., MC 104P St. Paul, MN 55102 (651) 310 -4422 Claims: 800 - 842 -3073 OHIO Cincinnati 895 Central Ave., Ste. 800 Cincinnati, OH 45202 (317) 845 -1479 Claims: 800 - 238 -6210 OHIO Cleveland Skylight Office Tower 1660 W. 2nd St., Ste. 500 Cleveland, OH 44113 -1454 (317) 845 -1479 Claims: 800 - 238 -6210 PENNSYLVANIA Pittsburgh 800 Two Chatham Center Pittsburgh, PA 15219 -2505 (412) 338 -3082 Claims: (412) 338 -3000 PENNSYLVANIA Reading 1105 Berkshire Blvd. P.O. Box 13426 Wyomissing, PA 19612 -3426 (215) 274 -1610 Claims: 800 - 832 -0606 RHODE ISLAND Braintree 350 Granite Street Suite 1201 Braintree, MA 02184 (781) 817 -8370 Claims: 800 - 832 -7839 SOUTH CAROLINA Charlotte 11440 Carmel Commons Blvd. P.O. Box 473500 Charlotte, NC 28247 -3500 (704) 540 -3438 Claims: 704 - 544 -3500 SOUTH DAKOTA St. Paul, MN 385 Washington St. St. Paul, MN 55102 (651) 310 -4422 Claims: 800 - 842 -3073 TENNESSEE Franklin 6640 Carothers Pkwy, Suite 300 Franklin, TN 37067 (615) 660 -6036 Claims: (615) 660 -6000 VERMONT Hartford, CT 300 Windsor Street Hartford, CT 06120 (860) 954 -5190 VIRGINIA Richmond 300 Arboretum Place P.O. Box 26426 Richmond, VA 23260 -6426 (804) 330 -6063 Claims: (804) 330 -6000 Washington, DC 14200 Park Meadow Dr. Chantilly, VA 20151 (571) 287 -6232 Claims: 800 - 368 -3562 WASHINGTON Seattle 1501 4th Avenue, Suite 400 Seattle, WA 98101 (206) 464 -3463 WEST VIRGINIA Pittsburgh, PA 800 Two Chatham Center Pittsburgh, PA 15219 -2502 (412) 338 -3082 Claims: (443) 353 -1000 WISCONSIN Milwaukee 13935 Bishops Drive, Suite 200 Brookfield, WI 53005 (262) 825 -9203 Claims: 800 - 842 -6172 OKLAHOMA TEXAS WYOMING Tulsa Dallas Denver, CO 9820 East 41st St., Suite 401 1301 E Collins Blvd., Suite 300 6060 S. Willow Drive #300 P.O Box 3510 Richardson, TX 75081 Greenwood Village, CO 80111 Tulsa, OK 74101 (214) 570 -6675 (720) 200 -8306 (918) 624 -2730 Claims: 214 - 570 -6000 OREGON TEXAS Portland Houston 4000 SW Kruse Place, Suite 100 4650 Westway Park Blvd., Suite 350 Lake Oswego, OR 97035 Houston, TX 77041 (503) 534 -4276 (281) 606 -8534 Claims: 800 - 698 -6883 Claims: 800 - 235 -3610 WUNT3B13 Page 5 of 5 © 2012 The Travelers Indemnity Company. All rights reserved. Important Notice to Policy Holders in California Your policy contains the following form: WC 04 03 17 00 — Employee Insured by General Employer If, in the conduct of your business in California, you have employees provided to you pursuant to an agreement with another employer (the "General Employer "), this endorsement is intended to prevent your workers' compen- sation policy from responding to work related injuries to such employees in the event the General Employer's workers' compensation carrier becomes insolvent. Such an agreement may exist, for example, if you hire temporary employees through an agency, or contract with an employee leasing company. In order for exclusion WC 04 03 17 00 to be effective, you must countersign the form. Sign and return the form if you want to avoid this exposure under your policy, if you have a valid and enforceable agreement with the General Employer in which the General Employer has agreed to obtain workers' compensation coverage for the employees, and if the General Employer has obtained such workers' compensation coverage. With this exclusion in place on your policy, an injured employee you hired through a temporary agency or under contract with an employee leasing company would submit the claim to the California Insurance Guarantee Association (CIGA) in the event the temporary agency's or employee leasing company's workers' compensation carrier becomes insolvent. Without the signed exclusion, CIGA may not pay such claims, resulting in increased exposure under your policy. Signed forms should be sent to your agent or broker. WUNN1 B08 Page 1 of 1 TRAVELERS!' ONE TOWER SQUARE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY HARTFORD, CT 06183 ENDORSEMENT WC 04 03 17 (00) POLICY NUMBER: (XJUB- 3790T99 -A -13) ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Employee Insured by General Employer Excluded The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: NO LIABILITY FOR Any liability you may have as the special employer of an employee who is not EMPLOYEE INSURED BY on your payroll at the time of injury, based upon your representation that: (1) GENERAL EMPLOYER you have entered into a valid and enforceable agreement pursuant to Labor Code Section 3602 (d) with the employee's general employer under which the general employer agrees to secure the payment of compensation for such employee and (2) the general employer has obtained workers' compensation coverage for the employee. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). By signature below, you affirm that, with respect to any employee who is also the employee of a general employer, (1) you have entered into a valid and enforceable agreement pursuant to Labor Code Section 3602(d) with the employee's general employer under which the general employer agrees to secure the payment of compensation for such employee and (2) the general employer has obtained workers' compensation coverage for the employee. Countersigned By This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Insurance Company Countersigned by POLICYHOLDER NOTICE SHORT RATE CANCELATION CALIFORNIA INSURANCE CODE SECTION 481 CA Insurance Code Section 481 requires that where an insurance policy includes a provision to refund premium on anything other than a pro rata basis, including the assessment of cancellation fees, the insurer must disclose that fact to the policyholder in writing prior to, or concurrent with, the proposal or quote prior to each renewal. The disclosure must include the actual or maximum fees or penalties to be applied. The WCIRB also created a Short Rate Cancelation Endorsement which complements the disclosure requirement. This requirement applies to in- surance policies issued or renewed on or after January 1, 2012. In order to respond to this insurance code requirement we have created this Policyholder Notice to disclose our use of short rate calculations as described in the California Short Rate Cancelation Endorsement included in the policy. W04N2H12 Page 1 of 1 TRAVELERSJ� Report Claims Immediately by Calling* 1- 800 - 238 -6225 Speak directly with a claim professional 24 hours a day, 365 days a year `Unless Your Policy Requires Written Notice or Reporting WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY A Custom Insurance Policy Prepared for: BUCKNAM INFRASTRUCTURE GROUP, INC. 3548 SEAGATE WAY SUITE 230 OCEANSIDE CA 92056 TRAVELERS ONE TOWER SQUARE HARTFORD, CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) POLICYNUMBER: (XJUB- 3790T99 -A -13) RENEWAL OF (XJUB- 3790T99 -A -12) INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA 1. INSURED: PRODUCER: NCCI CO CODE: 13 57 9 BUCKNAM INFRASTRUCTURE GROUP, WILLIS OF ILLINOIS INC INC. 233 SO WACKER DR STE 2000 3548 SEAGATE WAY CHICAGO IL 60606 SUITE 230 OCEANSIDE CA 92056 Insured is A CORPORATION Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 09 -16 -13 to 09 -16 -14 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: CA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 1000000 Each Accident Bodily Injury by Disease: $ 1000000 Policy Limit Bodily Injury by Disease: $ 1000000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: AL AR AZ CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI WV D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 09 -19 -13 EC OFFICE: SPECIALIST A &E 21X PRODUCER: WILLIS OF ILLINOIS INC CSN36 DIRECT BILL TRAVELERS ..1 ONE TOWER SQUARE HARTFORD, CT 06183 CLASSIFICATION SCHEDULE: CLASSIFICATIONS SIC -CODE: 8711 CODE NO WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (XJUB- 3790T99 -A -13) PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL REMUNERATION REMUNERATION PREMIUM SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S) STANDARD TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 3864 PREMIUM DISCOUNT NONE 0900 -04 EXPENSE CONSTANT 185 TERRORISM 108 TOTAL ESTIMATED PREMIUM 4157 TAXES AND SURCHARGES 201 DEPOSIT AMOUNT DUE 4358 Minimum Premium: $ 500 OTHER MINIMUMS ARE INDICATED ON THE APPLICABLE SCHEDULE(S) DATE OF ISSUE: 09 -19 -13 EC OFFICE: SPECIALIST A &E 21X PRODUCER: WILLIS OF ILLINOIS INC CSN36 Welt e goo) ;T-1 itei�l:4 olffAmp lM TRAVELERS!' ONE TOWER SQUARE HARTFORD, CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE - SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (XJUB- 3790T99 -A -13) INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA INSURED'S NAME: BUCKNAM INFRASTRUCTURE GROUP, INC. CLASSIFICATION LOCATION 001 01 FEIN 452723662 ENTITY CD 001 BUCKNAM INFRASTRUCTURE GROUP, INC. 3548 SEAGATE WAY SUITE 230 OCEANSIDE, CA 92056 BLANKET WAIVER SEE ENDT WC990601 A WAIVER CALCULATION IS BASED ON CLASS CODE(S) PREMIUM X RATE PREMIUM BASIS ESTIMATED TOTAL ANNUAL CODE REMUNERATION 0930 3614 110 13579 -CA RATES ESTIMATED PER $100 OF ANNUAL REMUNERATION PREMIUM .03 108 DATE OF ISSUE: 09 -19 -13 EC SCHEDULE NO: 1 OF MORE TRAVELERS ONE TOWER SQUARE HARTFORD, CT 06183 CLASSIFICATION LOCATION 001 01 (CONT'D) ENGINEERS-CONSULTING- MECHANICAL, CIVIL, ELECTRICAL AND MINING ENGINEERS AND ARCHITECTS -NOT ENGAGED IN ACTUAL CONSTRUCTION OR OPERATION- INCLUDING OUTSIDE SALESPERSONS AND CLERICAL OFFICE EMPLOYEES. CA MANUAL PREMIUM $ 3614 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE - SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (XJUB- 3790T99 -A -13) PREMIUM BASIS ESTIMATED TOTAL ANNUAL CODE REMUNERATION 8601 361363 BALANCE TO WAIVER MINIMUM PREMIUM $ EXPERIENCE MODIFICATION: NONE MODIFIED PREMIUM TOTAL ESTIMATED ANNUAL STANDARD PREMIUM EXPENSE CONSTANT(0900) TERRORISM (9740) 2.00% CIGA SURCHARGE 2.83% USER / FRAUD / UEBT / SIBT / OSH / LEC TOTAL ESTIMATED PREMIUM DEPOSIT AMOUNT DUE RATES ESTIMATED PER $100 OF ANNUAL REMUNERATION PREMIUM 1.00 3614 142 NONE 3864 185 108 83 118 4358 4358 DATE OF ISSUE: 09 -19 -13 EC SCHEDULE NO: 2 OF LAST TRAVELERS WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD, CT 06183 ENDORSEMENT WC 00 00 01 (A) POLICY NUMBER: (XJUB- 3790T99 -A -13) LISTING OF ENDORSEMENTS EXTENSION OF INFO PAGE We agree that the following listed endorsements form a part of this policy on its effective date, WC 00 00 01 A - 001 WC 00 00 01 A - 001 WC 00 00 01 A - 001 WC 00 00 01 A - 001 WC 04 03 17 00 - 001 WC 00 04 22 A - 001 WC 99 03 F3 00 - 001 WC 99 03 76 A - 001 WC 99 03 99 00 - 001 WC 00 04 21 C - 001 WC 04 03 01 B - 001 WC 04 03 60 A - 001 WC 04 04 22 00 - 001 WC 04 06 01 A - 001 INFORMATION PAGE INFORMATION PAGE 2 EXTENSION OF INFORMATION PAGE - SCHEDULE ENDORSEMENT LISTING ENDT AGRMNT LIMITING & RESTRICTING INS TERRORISM - REAUTHORIZATION ACT DISCLOSURE CA LIMITS OF LIABILITY ENDT WAIVER OF OUR RIGHTS TO RECOVER -CA CA WORKERS' COMP NOTICE OF NON- RENEWAL CATASTROPHE (O /T CERT. ACTS OF TERR)ENDT POLICY AMENDATORY ENDORSEMENT- CALIFORNIA CA- EMPLOYERS LIAB COV AMENDATORY ENDT CALIFORNIA SHORT -RATE CANCELATION ENDT CA CANCELATION ENDT DATE OF ISSUE: 09 -19 -13 ST ASSIGN: Page 1 of LAST WC 00 00 00 ( B) (Ed. 7 -11) The Travelers Insurance Companies (Each a Stock Insurance Company) Hartford, Connecticut WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows: GENERAL SECTION A. The Policy This policy includes at its effective date the Informa- tion Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Information Page) and us (the insurer named on the Information Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy. B. Who Is Insured You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a part- nership, and if you are one of its partners, you are insured, but only in your capacity as an employer of the partnership's employees. C. Workers Compensation Law Workers Compensation Law means the workers or workmen's compensation law and occupational dis- ease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect during the policy pe- riod. It does not include any federal workers or work- men's compensation law, any federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D. State State means any state of the United States of America, and the District of Columbia. E. Locations This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A. states unless you have other insurance or are self - insured for such work- places. PART ONE — WORKERS COMPENSATION INSURANCE A. How This Insurance Applies This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. Bodily injury by accident must occur during the policy period. 2. Bodily injury by disease must be caused or aggra- vated by the conditions of your employment. The employee's last day of last exposure to the condi- tions causing or aggravating such bodily injury by disease must occur during the policy 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 at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to inves- tigate and settle these claims, proceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. D. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, 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 insurance. Page 1 of 6 © Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. 3. litigation costs taxed against you; 4. interest on a judgment as required bylaw until we offer the amount due under this insurance; and 5. expenses we incur. E. Other Insurance We will not pay more than our share of benefits and costs covered by this insurance and other insurance or self - insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self - insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid. F. Payments You Must Make You are responsible for any payments in excess of the benefits regularly provided by the workers compensa- tion law including those required because: 1. of your serious and willful misconduct; 2. you knowingly 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 in violation of the workers compensation law. 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. WC 00 00 00 ( B) (Ed. 7 -11) H. Statutory Provisions These statements apply where they are required by law. 1. As between an injured worker and us, we have notice of the injury when you have notice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our duties under this insurance after an injury occurs. 3. We are directly and primarily liable to any person entitled to the benefits payable by this insurance. Those persons may enforce our duties; so may an agency authorized by law. Enforcement may be against us or against you and us. 4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law. 5. This insurance conforms to the parts of the work- ers compensation law that apply to: a. benefits payable by this insurance; b. special taxes, payments into security or other special funds, and assessments payable by us under that law. 6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. G. Recovery From Others Nothing in these paragraphs relieves you of your We have your rights, and the rights of persons entitled duties under this policy. to the benefits of this insurance, to recover our pay- ments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. PART TWO — EMPLOYERS LIABILITY INSURANCE A. How This Insurance Applies This employers liability insurance 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 a state or territory listed in Item 3.A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggra- vated by the conditions of your employment. The employee's last day of last exposure to the condi- tions causing or aggravating such bodily injury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury by ac- cident or by disease must be brought in the United Page 2 of 6 © Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. States of America, its territories or possessions, or Canada. B. We Will Pay We will pay all sums that you legally must pay as damages because of bodily injury to your employees, provided the bodily injury is covered by this Employ- ers Liability Insurance. The damages we will pay, where recovery is permitted by law, include damages: 1. 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; 2. For care and loss of services; and 3. For consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee; provided that these damages are the direct conse- quence of bodily injury that arises out of and in the course of the injured employee's employment by you; and 4. Because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer. C. Exclusions This insurance does not cover: 1. Liability assumed under a contract. This exclu- sion does not apply to a warranty that your work will be done in a workmanlike manner; 2. Punitive or exemplary damages because of bodily injury to an employee employed in violation of law; 3. Bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive of- ficers; 4. Any obligation imposed by a workers compensa- tion, occupational disease, unemployment com- pensation, or disability benefits law, or any simi- lar law; 5. Bodily injury intentionally caused or aggravated by you; 6. Bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily WC 00 00 00 (B) (Ed. 7 -11) injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 7. Damages arising out of coercion, criticism, demo- tion, evaluation, reassignment, discipline, defa- mation, harassment, humiliation, discrimination against or termination of any employee, or any personnel practices, policies, acts or omissions. 8. Bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901 -950), the Nonappro- priated Fund Instrumentalities Act (5 USC Sec- tions 8171 - 8173), the Outer Continental Shelf Lands Act (43 USC Sections 1331- 1356a), the Defense Base Act (42 USC Sections 1651 - 1654), the Federal Coal Mine Safety and Health Act (30 USC Sections 801 -945), any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws. 9. Bodily injury to any person in work subject to the Federal Employers' Liability Act (45 USC Sec- tions 51 -60), any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws. 10. Bodily injury to a master or member of the crew of any vessel. 11. Fines or penalties imposed for violation of federal or state law. 12. Damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 USC Sec- tions 1801 -1872) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amend- ments to those laws. 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 insurance. We have the right to inves- tigate and settle these claims, proceedings and suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. Page 3 of 6 © Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. E. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, 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 limit of our liability under this insurance; 3. Litigation costs taxed against you; 4. Interest on a judgement as required by law until we offer the amount due under this insurance; and 5. expenses we incur. F. Other Insurance We will not pay more than our share of damages and costs covered by this insurance and other insurance or self - insurance. Subject to any limits of liability that apply, all shares will be equal until the loss is paid. If any insurance or self - insurance is exhausted, the shares of all remaining insurance and self - insurance will be equal until the loss is paid. G. Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.13. of the Information Page. They apply as explained below: 1. 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 insurance 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. WC 00 00 00 ( B) (Ed. 7 -11) Bodily Injury by Disease. The limit shown for "bodily injury by disease - policy limit" is the most we will pay for all damages covered by this insur- ance and arising out of bodily injury by disease, regardless of the number of employees who sus- tain 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 bod- ily injury by disease to any one employee. Bodily injury by disease does not include disease that results directly from a bodily injury by acci- dent. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability un- der this insurance. H. Recovery From Others We have your rights to recover our payment from anyone liable for an injury covered by this insurance. You will do everything necessary to protect those rights for us and to help us enforce them. I. Actions Against Us There will be no right of action against us under this insurance unless: 1. You have complied with all the terms of this pol- icy; and 2. The amount you owe has been determined with our consent or by actual trial and final judgement. This insurance does not give anyone the right to add us as a defendant in an action against you to deter- mine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obligations under this Part. PART THREE — OTHER STATES INSURANCE A. How This Insurance Applies 3. We will reimburse you for the benefits required by 1. This other states insurance applies only if one or the workers compensation law of that state if we more states are shown in Item 3.C. of the Infor- are not permitted to pay the benefits directly to mation Page. persons entitled to them. 2. If you begin work in any one of those states after the effective date of this policy and are not in- sured or are not self - insured for such work, all provisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page. 4. If you have work on the effective date of this pol- icy in any state not listed in Item 3.A. of the In- formation Page, coverage will not be afforded for that state unless we are notified within thirty days, B. Notice Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. Page 4 of 6 © Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. W0000000(B) (Ed. 7 -11) PART FOUR — YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this 4. Cooperate with us and assist us, as we may request, in policy. Your other duties are listed here. the investigation, settlement or defense of any claim, 1. Provide for immediate medical and other services proceeding or suit. required by the workers compensation law. 5. Do nothing after an injury occurs that would interfere 2. Give us or our agent the names and addresses of the with our right to recover from others. injured persons and of witnesses, and other informa- 6. Do not voluntarily make payments, assume obliga- tion we may need. tions or incur expenses, except at your own cost. 3. Promptly give us all notices, demands and legal papers related to the injury, claim, proceeding or suit. PART FIVE — PREMIUM A. Our Manuals D. Premium Payments All premium for this policy will be determined by our You will pay all premium when due. You will pay the manuals of rules, rates, rating plans and classifica- premium even if part or all of a workers compensation tions. We may change our manuals and apply the law is not valid. changes to this policy if authorized by law or a gov- E. Final Premium ernmental agency regulating this insurance. The premium shown on the Information Page, B. Classifications schedules, and endorsements is an estimate. The final Item 4 of the Information Page shows the rate and premium will be determined after this policy ends by premium basis for certain business or work classifica- using the actual, not the estimated, premium basis and tions. These classifications were assigned based on an the proper classifications and rates that lawfully apply estimate of the exposures you would have during the to the business and work covered by this policy. If the policy period. If your actual exposures are not properly final premium is more than the premium you paid to described by those classifications, we will assign us, you must pay us the balance. If it is less, we will proper classifications, rates and premium basis by refund the balance to you. The final premium will not endorsement to this policy. be less than the highest minimum premium for the C. Remuneration classifications covered by this policy. If this policy is canceled, final premium will be de- Premium for each work classification is determined by termined in the following way unless our manuals multiplying a rate times a premium basis. Remunera- o provide otherwise: tion is the most common premium basis. This pre- 1. If cancel, final premium will be calculated pro mium basis includes payroll and all other rmunera- rata based on the time this policy was in force. e paid or payable during the policy period for the Final premium will not be less than the pro rata services o£ se share of the minimum premium. 1. All your officers and employees engaged in work 2. If you cancel, final premium will be more than covered by this policy; and pro rata; it will be based on the time this policy 2. All other persons engaged in work that could was in force, and increased by our short -rate can - make us liable under Part One (Workers Com- cellation table and procedure. Final premium will pensation Insurance) of this policy. If you do not not be less than the minimum premium. have payroll records for these persons, the con- F. Records tract price for their services and materials may be You will keep records of information needed to used as the premium basis. This paragraph 2 will compute premium. You will provide us with copies of not apply if you give us proof that the employers those records when we ask for them. of these persons lawfully secured their workers G. Audit compensation obligations. You will let us examine and audit all your records that relate to this policy. These records include ledgers, journals, registers, vouchers, contracts, tax reports, Page 5 of 6 © Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. payroll and disbursement records, and programs for storing and retrieving data. We may conduct the au- dits during regular business hours during the policy period and within three years after the policy period A. Inspection WC 00 00 00 (B) (Ed. 7 -11) ends. Information developed by audit will be used to determine final premium. Insurance rate service or- ganizations have the same rights we have under this provision. PART SIX — CONDITIONS We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurability of the workplaces and the premiums to be charged. We may give you reports 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 em- ployees or the public. We do not warrant that your workplaces 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. B. Long Term Policy If the policy period is longer than one year and sixteen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. C. Transfer of Your Rights and Duties Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days after your death, we will cover your legal representa- tive as insured. D. Cancellation 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2. We may cancel this policy. We must mail or de- liver to you not less than ten days advance written notice stating when the cancellation is to take ef- fect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancellation notice. 4. Any of these provisions that conflict with a law that controls the cancellation of the insurance in this policy is changed by this statement to comply with the law. E. Sole Representative The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancellation. In witness whereof, the company has caused this policy to be signed by its President and Secretary at Hartford, Connecticut and countersigned on the Information page by a duly authorized agent of the company. 4' e. %�' Secretary © Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. 1-�I Le" President Page 6 of 6 TRAVELERS!' WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD, CT 06183 ENDORSEMENT WC 00 04 22 (A) POLICY NUMBER: (XJUB- 3790T99 -A -13) TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2007. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and /or state laws, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2007. "Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property or infrastructure. c. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian popula- tion of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss" means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insur- ance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2008, and ending on December 31, 2014, an amount equal to 20% of our direct earned premiums, over the calendar year immediately preceding the applica- ble Program Year. "Program Year" refers to each calendar year between January 1, 2008 and December 31, 2014, as applicable. Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a Program Year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. DATE OF ISSUE: 09 -19 -13 ST ASSIGN: Page 1 of 2 TRAVELERS" ONE TOWER SQUARE HARTFORD, CT 06183 Policyholder Disclosure Notice WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 00 04 22 (A) POLICY NUMBER: (XJUB- 3790T99 -A -13) 1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses exceed $100,000,000 in a Program Year, the United States Government would pay 85% of our Insured Losses that exceed our Insurer Deductible. 2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100,000,000,000. 3. The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in Item 4 of the Information Page or in the Schedule below. State Schedule Rate Premium This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Insured Insurance Company Policy No. Countersigned by Endorsement No. Premium $ DATE OF ISSUE: 09 -19 -13 ST ASSIGN: Page 2 of 2 TRAVELERS J� ONE TOWER SQUARE WORKERS COMPENSATION HARTFORD, CT 06183 AND EMPLOYERS LIABILITY INSURANCE POLICY ENDORSEMENT WC 99 03 F3 (00) POLICY NUMBER: (XJUB- 3790T99 -A -13) CALIFORNIA LIMITS OF LIABILITY ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. The limits of our liability under Part Two of the policy are: Bodily Injury by Accident $1,000,000 or the amount shown in Item 3.6. of the Information Page, whichever is greater, each accident Bodily Injury by Disease $1,000,000 or the amount shown in Item 3.B. of the Information Page, whichever is greater, policy limit Bodily Injury by Disease $1,000,000 or the amount shown in Item 3.B, of the Information Page, whichever is greater, each employee This change applies to the insurance this policy provides for California operations only. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Premium $ Insurance Company Countersigned by DATE OF ISSUE: 09 -19 -13 ST ASSIGN: Page 1 of 1 TRAVELERS!' AND COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD, CT 06183 ENDORSEMENT WC 99 03 76 ( A) — 001 POLICY NUMBER: (XLTUB- 3790T99 -A -13) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA (BLANKET WAIVER) We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. The additional premium for this endorsement shall be 3 .0 % of the California workers' compensation pre- mium. Schedule Person or Organization Job Description ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Insured Insurance Company Policy No. Countersigned by Endorsement No. Premium DATE OF ISSUE: 09 -19 -13 ST ASSIGN: Page 1 of 1 TRAVELERS J� WORKERS COMPENSATION AND ONE TOWER CT SQUARE 061 HARTFORD, CT 06183 EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 99 03 99 (00) POLICY NUMBER: (XJUB- 3790T99 -A -13) CALIFORNIA WORKERS' COMPENSATION NOTICE OF NON - RENEWAL Section 11664 of the California Insurance Code which becomes operative November 30, 1994 requires us in most instances to provide you with a notice of non - renewal. Except as specified in paragraphs 1 through 6 below, if we elect to non -renew your policy, we are required to deliver or mail to you a written notice stating the reason or reasons for the non - renewal of the policy. The notice is required to be sent to you no earlier than 120 days before the end of the policy period and no later than 30 days before the end of the policy period. If we fail to provide you the required notice, we are required to continue the coverage under the policy with no change in the premium rate until 60 days after we provide you with the required notice. We are not required to provide you with a notice of non - renewal in any of the following situations: 1. Your policy was transferred or renewed without a change in its terms or conditions or the rate on which the premium is based to another insurer or other insurers who are members of the same insurance group as us. 2. The policy was extended for 90 days or less and the required notice was given prior to the extension. 3. You obtained replacement coverage or agreed, in writing, within 60 days of the termination of the policy, to obtain that coverage. 4. The policy is for a period of no more than 60 days and you were notified at the time of issuance that it may not be renewed. 5. You requested a change in the terms or conditions or risks covered by the policy within 60 days prior to the end of the policy period. 6. We made a written offer to you at least 30 days, but not more than 120 days, prior to the end of the policy period to renew the policy at a changed premium rate. DATE OF ISSUE: 09 -19 -13 ST ASSIGN: Page 1 of 1 TRAVELERS, WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD, CT 06183 ENDORSEMENT WC 00 04 21 (C) POLICY NUMBER: (XJUB- 3790T99 -A -13) CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT This endorsement is notification that your insurance carrier is charging premium to cover the losses that may occur in the event of a Catastrophe (other than Certified Acts of Terrorism) as that term is defined below. Your policy provides coverage for workers compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism). This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 A), attached to this policy. For purposes of this endorsement, the following definitions apply: • Catastrophe (other than Certified Acts of Terrorism): Any single event, resulting from an Earthquake, Noncertified Act of Terrorism, or Catastrophic Industrial Accident, which results in aggregate workers com- pensation losses in excess of $50 million. • Earthquake: The shaking and vibration at the surface of the earth resulting from underground movement along a fault plane or from volcanic activity. • Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary of Treasury pursuant to the Terrorism Risk Insurance Act of 2002 (as amended) but that meets all of the follow- ing criteria: a. It is an act that is violent or dangerous to human life, property, or infrastructure; b. The act results in damage within the United States, or outside of the United States in the case of the premises of United States missions or air carriers or vessels as those terms are defined in the Terrorism Risk Insurance Act of 2002 (as amended); and c. It is an act that has been committed by an individual or individuals as part of an effort to coerce the civil- ian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. • Catastrophic Industrial Accident: A chemical release, large explosion, or small blast that is localized in nature and affects workers in a small perimeter the size of a building. The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism) is shown in Item 4 of the Information Page or in the Sched- ule below. State Schedule Rate Premium This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Insured Insurance Company Policy No. Countersigned by Endorsement No. Premium $ DATE OF ISSUE: 09 -19 -13 ST ASSIGN: Page 1 of 1 TRAVELERS!' WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD, CT 06183 ENDORSEMENT WC 04 03 01 (B) POLICY NUMBER: (XJUB- 3790T99 -A -13) POLICY AMENDATORY ENDORSEMENT - CALIFORNIA It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: 1. Minors Illegally Employed — Not Insured. This policy does not cover liability for additional compensation imposed on you under Section 4557, Division IV, Labor Code of the State of California, by reason of injury to an employee under sixteen years of age and illegally employed at the time of injury. 2. Punitive or Exemplary Damages — Uninsurable. This policy does not cover punitive or exemplary dam- ages where insurance of liability therefor is prohibited by law or contrary to public policy. 3. Increase in Indemnity Payment — Reimbursement. You are obligated to reimburse us for the amount of increase in indemnity payments made pursuant to Subdivision (d) of Section 4650 of the California Labor Code, if the late indemnity payment which gives rise to the increase in the amount of payment is due less than seven (7) days after we receive the completed claim form from you. You are obligated to reimburse us for any increase in indemnity payments not covered under this policy and will reimburse us for any increase in indemnity payment not covered under the policy when the aggregate total amount of the reimbursement payments paid in a policy year exceeds one hundred dollars ($100). If we notify you in writing, within 30 days of the payment, that you are obligated to reimburse us, we will bill you for the amount of increase in indemnity payment and collect it no later than the final audit. You will have 60 days, following notice of the obligation to reimburse, to appeal the decision of the insurer to the Depart- ment of Insurance. 4. Application of Policy. Part One, "Workers Compensation Insurance ", A, "How This Insurance Applies ", is amended to read as follows: This workers compensation insurance applies to bodily injury by accident or disease, including death result- ing therefrom. Bodily injury by accident must occur during the policy period. Bodily injury by disease must be caused or aggravated by the conditions of your employment. Your employee's exposure to those conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. Rate Changes. The premium and rates with respect to the insurance provided by this policy by reason of the designation of California in Item 3 of the Information Page are subject to change if ordered by the Insurance Commissioner of the State of California pursuant to Section 11737 of the California Insurance Code. 6. Long Term Policy. If this policy is written for a period longer than one year, all the provisions of this policy shall apply separately to each consecutive twelve -month period or, if the first or last consecutive period is less than twelve months, to such period of less than twelve months, in the same manner as if a separate pol- icy had been written for each consecutive period. 7. Statutory Provision. Your employee has a first lien upon any amount which becomes owing to you by us on account of this policy, and in the case of your legal incapacity or inability to receive the money and pay it to the claimant, we will pay it directly to the claimant. 8. Part Five, "Premium ", E, "Final Premium ", is amended to read as follows: The premium shown on the Information Page, schedules, and endorsements is an estimate. The final pre- mium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund DATE OF ISSUE: 09 -19 -13 ST ASSIGN: © 2011 Workers- Compensation Insurance Rating Bureau of California. All rights reserved. Page 1 of 2 TRAVELERS /�� WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD, CT 06183 ENDORSEMENT WC 04 03 01 ( B) POLICY NUMBER: (XJUB- 3790T99 -A -13) the balance to you. The final premium will not be less than the highest minimum premium for the classifica- tions covered by this policy. If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise: a. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. b. If you cancel, final premium may be more than pro rata; it will be based on the time this policy was in force, and may be increased by our short -rate cancelation table and procedure. Final premium will not be less than the pro rata share of the minimum premium. It is further agreed that this policy, including all endorsements forming a part thereof, constitutes the entire contract of insurance. No condition, provision, agreement, or understanding not set forth in this policy or such endorsements shall affect such contract or any rights, duties, or privileges arising therefrom. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Insured DATE OF ISSUE: 09 -19 -13 Policy No. Insurance Company ST ASSIGN: Countersigned by © 2011 Workers' Compensation Insurance Rating Bureau of California. All rights reserved. Endorsement No. Page 2 of 2 TRAVELERS /�, WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD, CT 06183 ENDORSEMENT WC 04 03 60 (A) POLICY NUMBER: (XJUB- 3790T99 -A -13) EMPLOYERS' LIABILITY COVERAGE AMENDATORY ENDORSEMENT - CALIFORNIA The insurance afforded by Part Two (Employers' Liability Insurance) by reason of designation of California in item 3 of the information page is subject to the following provisions: A. "How This Insurance Applies," is amended to read as follows: A. How This Insurance Applies This employers' liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury means a physical injury, including 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 California. 3. Bodily injury by accident must occur during the policy period. 4. 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 policy period. 5. If you are sued, the original suit and any 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. C. The "Exclusions" section is modified as follows (all other exclusions in the "Exclusions" section remain as is): 1. Exclusion 1 is amended to read as follows: 1. liability assumed under a contract. 2. Exclusion 2 is deleted. 3. Exclusion 7 is amended to read as follows: 7. damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, termination of employment, or any personnel practices, policies, acts or omissions. 4. The following exclusions are added: 1. bodily injury to any member of the flying crew of any aircraft. 2. bodily injury to an employee when you are deprived of statutory or common law defenses or are subject to penalty because of your failure to secure your obligations under the workers' compensation law(s) applicable to you or otherwise fail to comply with that law. DATE OF ISSUE: 09 -19 -13 ST ASSIGN: Page 1 of 1 TRAVELERS ONE TOWER SQUARE HARTFORD, CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 04 04 22 (00) POLICY NUMBER: (XJUB- 3790T99 -A -13) CALIFORNIA SHORT -RATE CANCELATION ENDORSEMENT It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: If you cancel the policy and a disclosure was provided in accordance with Section 481(c) of the California Insurance Code, final premium will be based on the time this policy was in force and increased by the short-rate cancelation table below: Short Rate Cancelation Table Days in Policy Period Short Rate Percentages Factors to Apply to Earned Premium for Period Pollc In Effect Days In Policy Period Short Rate Percentages Factors to Apply to Earned Premium for Period Policy in Effect Days in Policy Period Short Rate P Factors to Apply to Earned Premium for Period Policy in Effect 1 5% 18.2482 46 23% 1.8250 91 35% 1.4038 2 6 10.9489 47 23 1.7861 92 36 1.4283 3 7 8.5158 48 24 1.8250 93 36 1.4129 4 7 6.3869 49 24 1.7877 94 36 1.3979 5 8 5.8394 50 24 1.7520 95 37 1.4216 6 1 8 4.8662 51 24 17176 96 37 1.4068 7 9 4.6924 52 25 1.7548 97 37 1.3923 8 9 4.1058 53 25 17216 98 37 1.3781 9 10 4.0552 54 25 1.6899 99 38 1.4010 10 10 3.6496 55 26 1.7255 100 38 1.3870 11 11 3.6496 56 26 1.6947 101 38 1.3733 12 11 3.3455 57 26 1.6650 102 38 1.3598 13 12 3.3689 58 26 1.6362 103 39 1.3820 14 12 3.1283 59 27 1.6704 104 39 1.3688 15 13 3.1630 60 27 1.6425 105 39 1.3557 16 13 2.9653 61 27 1.6156 106 40 1,3774 17 14 3.0056 62 27 1.5895 107 40 1.3645 18 14 2.8386 63 28 1.6222 108 40 1.3519 19 15 2.8818 64 28 1.5969 1 109 40 1.3395 20 15 2.7377 65 28 1.5723 110 41 1.3605 21 16 2.7812 66 29 1.6038 111 41 1.3482 22 16 2.6547 67 29 1.5799 112 41 1.3362 23 17 2.6980 68 29 1.5566 113 41 1.3243 24 17 2.5856 69 29 1.5341 114 42 1.3447 25 17 2.4821 70 30 1.5643 115 42 1.3330 26 18 2.5270 71 30 1.5423 116 42 1.3215 27 18 2.4334 72 30 1.5208 1 117 43 1.3414 28 18 2.3465 73 30 1.5000 118 43 1.3301 29 18 2.2656 74 31 1.5291 119 43 1 1.3189 30 19 2.3117 75 31 1.5087 120 43 1.3079 31 19 2.2371 76 31 1.4888 121 44 1.3273 32 19 2.1672 77 32 1.5169 122 44 1.3164 33 20 2.2121 78 32 1.4974 123 44 1.3057 34 20 2.1471 79 32 1.4785 124 44 1.2951 35 20 2.0857 80 32 1.4600 125 45 1.3140 36 20 2.0278 81 33 1.4870 126 45 1.3036 37 21 2.0716 82 33 1.4689 127 45 1.2933 38 21 2.0171 83 33 1.4512 128 46 1.3117 39 21 1.9654 84 34 1.4774 129 46 1.3016 40 21 1.9162 85 34 1.4600 130 46 1.2916 41 22 1.9585 86 34 1.4430 131 46 1.2817 42 22 1.9119 87 34 1.4264 132 47 1.2996 43 22 1.8674 88 35 1.4517 133 47 1.2899 44 23 1.9079 89 35 1.4354 134 47 1.2802 45 23 1.8655 90 35 1.4194 135 47 1.2708 © 2011 Workers' Compensation Insurance Rating Bureau of California. All rights reserved DATE OF ISSUE: 09 -19 -13 ST ASSIGN: Page 1 of 3 TRAVELERS!' ONE TOWER SQUARE HARTFORD, CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 04 04 22 (00) POLICY NUMBER: (XJUB- 3790T99 -A -13) Days in _ _ Factors to Apply to Days in Factors to Apply to Days in Factors to Apply to Policy Short Rate Earned Premium for Policy Short Rate Earned Premium for Policy Short Rate Earned Premium for Period Percentages Period Polio In Effect Period Percenta es Period Polio in Effect Period Percentages Period Policy In Effect 136 48% 1.2882 181 60% 1.2099 226 70 % 1.1305 137 48 1.2788 182 60 1.2033 227 70 1.1255 138 48 1.2696 183 61 1.2167 228 70 1.1206 139 49 1.2867 184 61 1.2101 229 71 1.1317 140 49 1.2775 185 61 1.2035 230 71 1.1267 141 49 1.2684 186 61 1.1970 231 71 1.1219 142 49 1.2595 187 61 1.1906 232 71 1.1170 143 50 1.2762 188 62 1.2037 233 72 1.1279 144 50 1.2674 189 62 1..1974 234 72 1.1231 145 50 1.2586 190 62 '6.1910 235 72 1.1183 146 50 1.2500 191 62 11848 236 72 1.1136 147 51 1.2663 192 63 1.1977 237 72 1.1089 148 51 1.2578 193 63 1.1914 238 73 1.1195 149 51 1.2493 194 63 11853 239 73 1.1149 150 52 1.2653 195 63 1.1792 240 73 1.1102 151 52 1.2569 196 63 1.1732 241 73 1.1056 152 52 1.2487 197 64 11858 242 74 1.1161 153 52 1.2405 198 64 1,1798 243 74 1.1115 154 53 1.2562 199 64 1.1739 244 74 1.1070 155 53 1.2481 200 64 1.1680 245 74 1.1025 156 53 1.2401 201 65 1.1804 246 74 1.0980 157 54 1.2554 202 65 1.1745 247 75 1.1083 158 54 1.2475 203 65 1.1687 248 75 1.1038 159 54 1.2396 204 65 1.1630 249 75 1.0994 160 54 1.2319 205 65 11573 250 75 1.0950 161 55 1.2469 206 66 1.1694 251 76 1.1052 162 55 1.2392 207 66 1.1638 252 76 1.1008 163 55 1.2316 208 66 1.1582 253 76 1.0964 164 55 1.2241 209 66 1,1526 254 76 1.0921 165 56 1.2388 210 67 1.1645 255 76 1.0878 166 56 1.2313 211 67 1.1590 256 77 1.0979 167 56 1.2240 212 67 1.1535 257 77 1.0936 168 57 1.2384 213 67 1.1481 258 77 1.0893 169 57 1.2311 214 67 1.1428 259 77 1.0851 170 57 1.2238 215 68 1.1544 260 77 1.0810 171 57 1.2167 216 68 1.1491 261 78 1.0908 172 58 1.2308 217 68 1,1438 262 78 1.0866 173 58 1.2237 218 68 1.1385 263 78 1.0825 174 58 1.2167 219 69 11500 264 78 1.0784 175 58 1.2097 220 69 1A448 265 79 1.0881 176 59 1.2236 221 69 11.1396 266 79 1.0840 177 59 1.2167 222 69 1.1345 267 79 1.0800 178 59 1.2098 223 69 1.1294 268 79 1.0759 179 60 1.2235 224 I 70 1,1406 269 79 1.0719 180 60 11167 225 70 1,1356 270 80 1.0815 © 2011 Workers' Compensation Insurance Rating Bureau of California. All rights reserved DATE OF ISSUE: 09 -19 -13 ST ASSIGN: Page 2 of 3 TRAVELERSJM ONE TOWER SQUARE HARTFORD, CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 04 04 22 (00) POLICY NUMBER: (XJUB- 3790T99 -A -13) Days in Policy Period Short Rate Percenta es Factors to Apply to Earned Premium for Period Polie in Effect Days In Policy Period Short Rate Percenta es Factors to Apply to Earned Premium for Period Policy in Effect Days in Policy Period Short Rate Percentages Factors to Apply to Earned Premium for Period Polic in Effect 271 80% 1.0775 316 90% 1.0396 361 100% 1.0111 272 80 1.0735 317 90 1.0363 362 100 1.0083 273 80 1.0696 318 90 1.0330 363 100 1.0055 274 81 1.0790 319 90 1.0298 364 100 1.0027 275 81 1.0751 320 91 I 1.0380 365 100 1.0000 276 81 1.0712 321 91 1.0347 277 81 1,0673 322 91 1.0315 278 81 1.0635 323 91 1.0283 279 82 1.0728 324 92 1.0364 280 82 1,0689 325 92 1.0332 281 82 1.0651 326 92 1.0301 282 82 1.0614 327 92 1.0269 283 83 1.0705 328 92 1.0238 284 83 1,0667 329 93 1.0318 285 83 1.0630 330 93 1.0286 286 83 1.0593 331 93 1.0255 287 83 1.0556 332 93 1.0224 288 84 1.0646 333 94 1.0303 289 84 1.0609 334 94 1.0272 290 84 1.0572 335 94 1.0242 291 84 1.0536 336 94 1.0211 292 85 1,0625 337 94 1.0181 293 85 1.0589 338 95 1.0259 294 85 1.0553 339 95 1.0229 295 85 1.0517 340 95 1.0198 296 85 1.0481 341 95 1.0169 297 86 1.0569 342 95 1.0139 298 86 1.0534 343 96 1.0216 299 86 1.0498 344 96 1.0186 300 86 1.0463 345 96 1.0156 301 86 1.0429 346 96 1.0127 302 87 1.0515 347 97 1.0203 303 87 1.0480 348 97 1.0174 304 87 1.0446 349 97 1.0145 305 87 1.0411 350 97 1.0116 306 88 1.0497 351 97 1.0087 307 88 1.0462 352 98 1.0162 308 88 1.0429 353 98 1.0133 309 88 1.0395 354 98 1.0105 310 88 1.0361 355 98 1.0076 311 89 1.0445 356 99 1.0150 312 89 1.0412 357 99 1.0122 313 89 1,0379 358 99 1.0094 314 89 1.0346 359 99 1.0065 315 90 1 1.0429 360 1 99 11 1.0038 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Insured Insurance Company Policy No. Countersigned by © 2011 Workers' Compensation Insurance Rating Bureau of California. All rights reserved DATE OF ISSUE: 09 -19 -13 ST ASSIGN: Endorsement No. Premium $ Page 3 of 3 TRAVELERS J� WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD, CT 06183 ENDORSEMENT WC 04 06 01 (A) POLICY NUMBER: (XJUB- 3790T99 -A -13) CALIFORNIA CANCELATION ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the information page. The cancelation condition in Part Six (Conditions) of the policy is replaced by these conditions: CANCELATION 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation is to take effect. 2. We may cancel this policy for one or more of the following reasons: a. Non - payment of premium; b. Failure to report payroll; c. Failure to permit us to audit payroll as required by the terms of this policy or of a previous policy issued by us; d. Failure to pay any additional premium resulting from an audit of payroll required by the terms of this policy or any previous policy issued by us; e. Material misrepresentation made by you or your agent; f. Failure to cooperate with us in the investigation of a claim; g. Failure to comply with Federal or State safety orders; h. Failure to comply with written recommendations of our designated loss control representatives; i. The occurrence of a material change in the ownership of your business; j. The occurrence of any change in your business or operations that materially increases the hazard for frequency or severity of loss; k. The occurrence of any change in your business or operation that requires additional or different classification for premium calculation; I. The occurrence of any change in your business or operation which contemplates an activity excluded by our reinsurance treaties. 3. If we cancel your policy for any of the reasons listed in (a) through (f), we will give you 10 days advance written notice, stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. If we cancel your policy for any of the reasons listed in Items (g) through (1), we will give you 30 days advance written notice; however, we agree that in the event of cancelation and reissuance of a policy effective upon a material change in ownership or operations, notice will not be provided. 4. The policy period will end on the day and hour stated in the cancelation notice. DATE OF ISSUE: 09 -19 -13 ST ASSIGN; Page 1 of 1 TRAVELERSJ' Travelers Medical Provider Network (MPN) Plan — CALIFORNIA Necessary Action for MPN Implementation Dear Policyholder: As your workers compensation insurer, Travelers is pleased to include your Company in our California Medical Provider Network (MPN) plan. Travelers has an extensive MPN with physicians who understand workers com- pensation and are experienced in providing expert care for injured workers. Our program ensures that every covered employee that suffers a work - related injury or illness has access to prompt medical care and an im- proved likelihood of a safe return to work as soon as medically appropriate. MPN utilization can reduce overall workers compensation claim payouts by providing greater control over medical fees and obtaining more favor- able medical treatment outcomes. Your role is crucial to the success of the MPN program. Together, we can better manage your Workers Compensation claims within the MPN. The MPN is a standard product in all Travelers workers compensation policies, and all policyholders are expected to enroll. This information is being provided to you to help you understand the requirements for proper MPN implementation. The State Division of Workers' Compensation (DWC) regulates how an MPN is implemented. Sections § 9767.12 and § 9767.16 of Title 8, California Code of Regulations specify what notices are to be provided to employees, as well as when and how they are to be provided. Travelers has an Employer MPN Implementation Checklist (included in the MPN Enrollment Kit) that walks policyholders through the requirements of the enrollment and implementation process. The Employer Checklist, MPN Enrollment Kit, and all other Travelers MPN documents are located on www.travelers.com. Please type this web address into your browser to download the necessary forms: www.travelers.com /CAMPN If you have any questions regarding the MPN implementation process, or any of the MPN documents, you can speak with a Travelers MPN Enrollment Representative by calling (800) 287 -9682. Please listen for the prompts for Employers or Employer Representatives. A "Frequently Asked Questions" page is also available through the above web address. Look for the link called FAQ — MPN. In addition to following the notification requirements listed on the Employer MPN Implementation Checklist, we also recommend that you: • Make sure your management staff has instructions on how to access the MPN Medical Provider directory via http: / /www.mywcinfo.com. • Select an occupational medicine clinic, urgent care clinic, or, an acute care hospital from the MPN to serve as your designated initial injury treatment facility for each plant /location. Contact this facility and inform them that you are participating in the Travelers Medical Provider Network Plan. Update the State Posting Notices to include the name, address, and phone number of the facility. • Review your procedures for handling work - related injuries, your modified duty policy, and your safety committee operation with your management staff. We believe the MPN program will provide better overall workers compensation outcomes for you as an em- ployer. If you should have any questions regarding the Travelers MPN, please contact the Travelers MPN Team at (800) 287 -9682 or CAMPN @travelers.com. Sincerely, Travelers W04NIB09 Page 1 of 1 If Your Employee Is Injured At Work Prompt reporting of work - related injuries and illnesses and the use of Travelers national Medical Net- work Providers can achieve better outcomes and lower your overall workers compensation claim costs! Whenever an Employee suffers a work - related injury or illness, the Employer should: 1. Seek appropriate medical care for the Employee. 2. If the injury or illness is acute, the Employer should always send the Employee to the nearest medical emergency department. 3. If the injury or illness is not acute, the Employer may suggest that the Employee seek treatment from the nearest Medical Network Provider. Medical Network Providers understand work - related illnesses and injuries, are credentialed to help assure quality care, and cooperate to achieve a medically appropriate return to work for the Employee. Medical Network Providers (hospitals, initial care clinics, specialists, testing, therapy, etc.) are available in all 50 States and the District of Columbia. Even before an illness or injury occurs, it may be helpful for the Employer to build a relationship with a convenient Medical Network Clinic or Hospital that will provide initial treatment for ill or injured Employees. 4. The Employee's Supervisor should gather pertinent facts about the work - related illness or injury and may use the Worksheet For Workers' Compensation Telephone Reporting provided by Travelers as a guide. 5. As soon as possible, the Employer should report all work - related illnesses or injuries to Travelers by, • using Travelers business insurance online reporting web site at travelers.com • dialing our toll free number, 1- 800 - 238 -6225. If needed at that time, Travelers Customer Service Repre- sentative can provide the name of a convenient Medical Network Provider. Prompt reporting of work - related illnesses and injuries is key in helping to reduce total claim costs. At the conclusion of the phone call, the Travelers Customer Service Representative will provide a claim number that should be retained for the Employer's reference and also provided to the ill or injured Employee. The card below contains information that may be helpful in reporting work - related illnesses and injuries to Travelers and should be kept in a convenient location for use by the Employer when needed. OW TRAVELERS / J WC Claim Reporting • Promptly report your work - related injuries to Travelers: . Travelers.com • 800 - 238 -6225 • Learn about Travelers unique Claim Services and find a convenient medical network provider by logging on to Travelers.com. • To get to Travelers website, select Business Insurance from the home page. Then choose Workers' Compensation & Managed Care Claim Management from the menu of services in the left margin. Finally, click on Preferred Provider Network to search for a Medical Network Provider near you. WUNC61308 Page 1 of 1 WORKERS' COMPENSATION TELEPHONE REPORTING WORKSHEET THINGS TO REMEMBER WHEN COMPLETING THE INFORMATION BELOW: Call the Telephone Reporting Center to quickly and easily report all Workers' Compensation injuries. We will be asking you the following questions, so please have the information handy. We will produce and submit the necessary state forms. DO NOT DELAY IN CALLING IF YOU DO NOT HAVE ANSWERS TO ALL THE QUESTIONS. ACCOUNT /ACCIDENT INFORMATION CALLER'S PHONE NUMBER/EXTENSION CALLER'S TITLE CALLER'S NAME REPORTING STATE SUBSIDIARY NAME SUBSIDIARY S ADDRESS (STREET, CITY, STATE & ZIP) SUBSIDIARY'S MAILING ADDRESS (STREET, CITY, STATE & ZIP) ❑ SAME DID THE ACCIDENT OCCUR AT THE LOCATION ADDRESS? ❑ YES ❑ NO IF NO, ADDRESS WHERE ACCIDENT OCCURRED PARENT COMPANY /INSURED'S NAME LOCATION CODE POLICY SYMBOL AND NUMBER NATURE OF BUSINESS DATE OF INJURY TIME OF INJURY ACCIDENT DESCRIPTION EMPLOYEE INFORMATION INJURED EMPLOYEE'S SOCIAL SECURPY NUMBER EMPLOYEE'S NAME (FIRST, MI, LAST) GENDER ❑ MALE ❑ FEMALE DATE OF BIRTH EMPLOYEE'S MAILING ADDRESS EMPLOYEE'S HOME PHONE NUMBER EMPLOYEE'S HOME ADDRESS (IF DIFFERENT FROM MAILING) EMPLOYEE JOB INFORMATION EMPLOYMENT STATUS CODE INJURED WORKER TYPE REGULAR OCCUPATION ❑ FULL -TIME ❑ PART -TIME ❑ OTHER OCCUPATION WHEN INJURED EMPLOYEE'S WORK SCHEDULE REGULAR WORK HOURS HOURS /DAY DAYS /WEEK EMPLOYEE'S WAGE INFORMATION $ /HOUR OR $ /ANNUAL OR $ /WEEKLY OVERTIME: $ ADDITIONAL BENEFITS: $ DATE OF HIRE OR LENGTH OF EMPLOYMENT SUPERVISOR'S NAME SUPERVISOR'S PHONE NUMBER: BEST HOURS TO CONTACT ACCIDENT INFORMATION DATE CLAIM REPORTED TO EMPLOYER? DID EMPLOYEE LOSE ANY TIME FROM WORK? FISTHE EMPLOYEE BACK AT WORK? ❑ YES ❑ NO YES ❑ NO IF YES, DATE RETURNED TO WORK? RETURN TO WORK STATUS DATE EMPLOYEE LAST WORKED WAS INJURY FATAL? IF YES, DATE OF DEATH El LIGHT El MODIFIED El REGULAR ❑ YES E-1 NO CAUSE OF ACCIDENT (E.G., SLIP /FALL, LIFTING, CHEMICAL) EQUIPMENT, MATERIAL OR SUBSTANCE INVOLVED DO YOU QUESTION THE VALIDITY OF THE CLAIM? ❑ YES ❑ NO WITNESS INFORMATION /OTHERS INVOLVED NAME (FIRST, MI, LAST) ADDRESS PHONE NUMBER CONTINUED ON REVERSE SIDE WUNTCD05 INJURY INFORMATION PART OF BODY INJURED (E,G,, HEAD, NECK, ARM, LEG) NATURE OF INJURY (E.G, FRACTURE, SPRAIN, LACERATION PRIOR INJURY OR PRE - EXISTING CONDITION(S) (IF YES, DESCRIBE) ❑ YES ❑ NO TREATMENT ( "X" ALL THAT APPLY) TREATMENT AND DATE OF 1$t TREATMENT ❑ FIRSTAID- HOSPITALI NAME, ADDRESS, PHONE NUMBER, PHYSICIAN NAME, TREATMENT, DATE OF 1st TREATMENT, LENGTH OF STAY AMBULANCE USED? ❑ CLINIC — WAS EMPLOYEE TREATED IN AN EMERGENCY ROOM? WAS EMPLOYEE HOSPITALIZED OVERNIGHT AS AN IN- PATENT? ❑ YES ❑ NO ❑ YES ❑ NO ❑ PHYSICIAN — SEE WORKERS' COMPENSATION - FIRST REPORT OF INJURY - STATE SPECIFIC QUESTIONS FOR YOUR INDIVIDUAL STATE. CUSTOMER SPECIFIC INFORMATION ADDITIONAL COMMENTS & INFORMATION WUNTCD05 (Back) WORKERS' COMPENSATION — FIRST REPORT OF INJURY — STATE SPECIFIC QUESTIONS Alabama Employee's County: Return to work (Y /N): At what Occupation: At what Wage $: Return to work wage is per (Day, Week or Month): Employer's ID (U.C. Account) Number: What Specific Products does the business produce: Alaska - No Additional State Questions Arizona Last Day of Work after injury: Number of Days per Week Company usually Works: Department Number: If Validity of Claim is Doubted, state Reason: Has injured been employed for more than 12 months (Y /N): Was employee on overtime when injured (Y /N): Arkansas - No Additional State Questions California State Unemployment Insurance Account Number: Date employee was provided Employee Claim Form: Has your employee pre- designated a primary treating physician (Y /N): If Yes, Primary Treating Physicians First Name: Last Name: Street Address: City: State: Zip: Phone: If No, did your employee require medical treatment (Y /N): If Yes, Treating Physicians First Name: Last Name: Phone: If No, and employee requires medical treatment in the future, you can go to our website WWW.MYWCOMPINFO.COM to find a provider in the Medical Provider Network. Colorado Employer Federal ID Number Does Employer have a salary continuation program (Y /N) If "Yes" is this program registered with the state (Y /N) Connecticut - No Additional State Questions Delaware Employer's UC Reporting Number: Employees County: Returned to work (Y /N): If Yes, at same wage (Y /N): District of Columbia Employer ID Number: Returned to work (Y /N): If Yes, at what Time: AM /PM At what Wage $: Per (Day, Week or Month): Was injured hired in DC (Y /N): Was employee in his /her regular occupation when injured (Y /N): Was injured given Form #7 DCWC (Y /N): Piece or Time Worker (piece„ time or blank): Florida - No Additional State Questions Georgia Wage Rate at time of injury $: Per: First Date employee failed to work a full day: Did employee work the next day (Y /N): Return to work Wage $: Return to work wage is per (Day, Week or Month): Hawaii Was employee furnished meals or lodging (Y /N): Idaho - No Additional State Questions Illinois Has the injured worker signed a medical authorization (Y /N): If yes, inform them to please fax the signed medical authorization to the med auth customer service specialist at 1- 877 - 786 -5567. Indiana - No Additional State Questions Iowa - No Additional State Questions Kansas SIC Code: Was worker admitted to hospital (Y /N): If Yes, Date of Admission: Was worker treated in emergency room only (Y /N): Returned to work (Y /N): If employee has returned to work, was return to light duty (Y /N): Is further medical aid needed (Y /N): Is compensation now being paid (Y /N): If Yes, Date of first Initial Payment: Fatal (Y /N): If Yes, Name and Address of Dependents: Kentucky - No Additional State Questions Louisiana Employer's Federal ID Number: Employer's Unemployment Insurance Reporting Number: Returned to work (Y /N): If Yes, at same wage (Y /N): Last Full Day Paid: If occupational disease, Date of Initial Diagnosis: Parish (county) where injury occurred: Maine Employer's State Unemployment Insurance Account Number (UTAN): Federal Employer Insurance Number (FEIN): Maryland - No Additional State Questions Massachusetts Federal ID Number: Returned to work (Y /N): Did employee return to his /her regular occupation (Y /N): Describe nature of business or article manufactured (S= Service, W= Wholesale, R= Retail, M= Manufacturing): Date Reported as work related: Michigan Federal ID Number: Minnesota Date employer notified of lost time: NAICS Code Number: Mississippi - No Additional State Questions Missouri - No Additional State Questions Montana - No Additional State Questions Nebraska - No Additional State Questions Nevada How long employed by you in Nevada Years: Months: If Validity of Claim is Doubted, state Reason: New Hampshire Federal I.D. Number: Was the employee injured in his /her regular occupation (Y /N): Was injured hired in New Hampshire (Y /N): Number of Full -Time Employees: Number of Part-Time Employees: If leased or temporary worker, provide the Clients Business Name: Was accident caused by injured's failure to use safeguards or follow regulations (Y /N): Probable Length of Disability: Returned to work (Y /N): At what Occupation: Returned at Full Duty: Returned at Alternative /Light Duty: Initial treatment ( "X" all that apply) No medical treatment: Care provided by employer only (on- site): Emergency Care: Hospitalized: Outpatient: Clinic: Office Visit: Other - explain: Is there a managed care program (Y /N): WUNTDD10 Page 1 WORKERS' COMPENSATION — FIRST REPORT OF INJURY — STATE SPECIFIC QUESTIONS If Yes, Name of Provider: Is there a written safety program in force (Y /N): Is there an active safety committee (Y /N): Employees Legal First Name (please validate): New Jersey - No Additional State Questions New Mexico - No Additional State Questions New York Did you provide medical care (Y /N): If Yes, When: Returned to work (Y /N): If Yes, at what Weekly Wage $: Injured workers Work Week (indicate days regularly worked): Fatal (Y /N): If Yes, Name and Address of nearest relative: Relationship: North Carolina Regular Wages per Day $: Average Weekly Wages with Overtime $: Returned to work (Y /N): If Yes, at what Time: AM /PM If Yes, what Date: Return to work at what Wage $: Per (Day, Week or Month): Return to work at what Occupation: North Dakota - No Additional State Questions Ohio Time Accident Reported to employer: AM /PM: Has employee ever filed a previous application for this injury (Y /N): Has employee filed any other claims with the Bureau or Industrial Commission (YIN): If Yes, specify Claim Number and Body Parts: Employee's County: Current Employer's Risk Number: Oklahoma Was employment agreement made in Oklahoma (Y /N): SIC Number: Type of Ownership (P= Private, S =State Government, C= County Government, L =Local Government): Oregon Hospitalized overnight as inpatient (if emergency room only, answer N) (Y /N): Was accident caused by failure of machinery or product (Y /N): Did someone (not worker) cause accident (Y /N): Time worker left work: AM /PM: Pennsylvania Employee's County: Bureau Code: NAICS Code: Employers County: Are you aware of a'Panel of Physicians' for your Employer? (Y /N) Rhode Island Federal ID Number: First Full Day Lost from work: Unemployment Insurance Number: State of Hire: Was this injury previously an "Incident Only" with no medical treatment and no lost time (Y /N): If Yes, Date Employer first Notified of medical treatment or lost time: Category of Injury or Illness ( "X" all that apply): Injury: Illness: Occupational Disease: Repetitive Trauma: Occupational Hearing Loss: Unknown: South Carolina - No Additional State Questions South Dakota Federal ID Number: Number of employees: Body Part Injured Code (2 digits): Cause of Injury Code (2 digits): Nature of Injury Code (2 digits): Was employee hired for temporary employment (Y /N): Carrier Code: Tennessee - No Additional State Questions Texas - No Additional State Questions Utah - No Additional State Questions Vermont Federal ID Number: Was employee hired in Vermont (Y /N): Does the employer regularly employ 10 or more employees (Y /N): Returned to work (Y /N): If Yes, at what Weekly Wage $: Was injured paid in full for the date disability began (Y /N): Was employee injured at his /her regular occupation (Y /N): Fatal (Y /N): If Yes, Name, Address and Relationship of Nearest Relative: Last Date Paid in Full: Virginia Returned to work (Y /N): If Yes, at what Wage $: Federal Tax ID Number: Washington - No Additional State Questions West Virginia Has the employee been given "The Employees and Physicians Report of Injury Form" (Y /N) Wisconsin - No Additional State Questions Wyoming - No Additional State Questions U.S. Longshoreman (USDOL) - No Additional State Questions WUNTDD10 Page 2 TRAVELERSJ� PRIVACY NOTICE THE TRAVELERS INSURANCE COMPANIES PRIVACY POLICY Thank you for selecting THE TRAVELERS INSURANCE COMPANIES as your workers compensation insurer. At THE TRAVELERS INSURANCE COMPANIES a subsidiary of Travelers, we recognize that privacy is important to you. That is why we are committed to protecting your privacy through the adoption of the following privacy principles: Collection Of Information We collect, retain, and use information about you, or about participants, beneficiaries or claimants under your workers compensation coverage, only where we believe that it will help or is necessary to provide you products and services or otherwise conduct our business. We collect nonpublic personal financial information about you, or about participants, beneficiaries or claimants under your workers compensation coverage, from the following sources: • information we receive from you or through your agent or broker on applications or other forms; • information we receive from or about you in the process of adjusting claims; • information about your other transactions, including risk control and other consulting services, with us, our affiliates or other third parties; • information about your coverages and loss activity with other carriers; and • information we receive from a consumer reporting agency. Such information includes identifying information such as policyholder, participant, beneficiary or claimant name, address, and social security number; financial information such as income, payment history, or credit history; and, under certain circumstances, health information such as information about an illness, disability, or injury. It could also include information on claims with other insurance companies and us and the condition and mainte- nance of your property. Disclosure Of Information We usually do not disclose nonpublic personal information about you, or about participants, beneficiaries or claimants under your workers compensation coverage, without your consent. However, in some circumstances we may disclose information to others without your prior authorization. The most common disclosures are to the following persons: • our affiliated property and casualty insurance companies; • state insurance departments, for their regulation of our business; • other government authorities; • our agents and brokers as necessary to conduct our business; • organizations that perform underwriting and claims investigations; • another insurance company to which you have applied for a policy or submitted a claim; • insurance support agencies, law enforcement agencies and our reinsurers; and • any other third party, as permitted or required by law. Most importantly, THE TRAVELERS INSURANCE COMPANIES does not and will not disclose or sell nonpublic personal information about you, or about participants, beneficiaries or claimants under your workers compensation coverage, to anyone for marketing purposes. WUNNAB09 Page 1 of 2 Confidentiality And Security We restrict access to nonpublic personal information about you, or about participants, beneficiaries or claimants under your workers compensation coverage, to those who need it to serve your insurance needs and to maintain and improve customer service. We maintain physical, electronic, and procedural safeguards that comply with federal and state laws and regulations to guard your nonpublic personal information. Disclosure and Protection of Former Customers' Information We may disclose all the personal information we have collected, as described above. However, even if you no longer have a customer relationship with us, we will continue to follow our privacy policies and practices to protect your information. Changes In Privacy Policy We may choose to modify our policy regarding the treatment of personal information at any time. Before we do so, we will notify you and provide an updated privacy notice. WUNNAB09 Page 2 of 2 IMPORTANT NOTICE - INDEPENDENT AGENT AND BROKER COMPENSATION NO COVERAGE IS PROVIDED BY THIS NOTICE. THIS NOTICE DOES NOT AMEND ANY PROVISION OF YOUR POLICY. YOU SHOULD REVIEW YOUR ENTIRE POLICY CAREFULLY FOR COMPLETE INFORMATION ON THE COVERAGES PROVIDED AND TO DETERMINE YOUR RIGHTS AND DUTIES UNDER YOUR POLICY. PLEASE CONTACT YOUR AGENT OR BROKER IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR ITS CONTENTS. IF THERE IS ANY CONFLICT BETWEEN YOUR POLICY AND THIS NOTICE, THE PROVISIONS OF YOUR POLICY PREVAIL. For information about how Travelers compensates independent agents and brokers, please visit www.travelers.com, call our toll -free telephone number 1- 866 - 904 -8348, or request a written copy from Marketing at One Tower Square, 2GSA, Hartford, CT 06183. WUNNDD08 PN T4 54 01 08 Page 1 of 1 IMPORTANT Policy Audit Information Dear Policyholder: This policy is issued with an estimated premium based upon information provided through your Producer. This premium is subject to adjustment at the end of the policy period. At that time, you may receive a request for information in the mail or a premium auditor may contact you to review the necessary records. The information developed is needed to determine the final earned premium for this policy. Record Maintenance In order to facilitate audit service, it is necessary to maintain proper records and have them available at the proper time. Based on the nature of your business, some of the following data will be necessary to complete the audit: 1. General Ledger, Financial Statements 2. Payroll Records, Time Books, State Unemployment Returns, FICA Returns, Individual Earnings Records - Monthly totals separated by type of work and overtime. 3. Cash Receipts, Sales Journal 4. Cash Disbursements Journal - Including subcontractors. casual labor and material costs. 5. Certificates of Insurance IMPORTANT COVERAGE NOTE: If you utilize subcontractors whose legal status is that of sole proprietor /partner, we may charge premium for these persons as provided under Part 5 of the policy contract even though certificates of insurance may exist. Please contact your producer if you have any questions regarding your Workers' Compensation coverage needs. Work in Other States Please advise your Producer if employees are hired for work in states other than those listed in Item 3. of your policy. This will enable your producer to consider your need for coverage in accordance with state laws. We appreciate the opportunity to serve you. If you have any questions about the enclosed policy or any insurance matters please contact your producer or your Company representative. WUNN7F00 PN 04 99 02 B (Ed. 5 -02) POLICYHOLDER NOTICE CALIFORNIA WORKERS' COMPENSATION INSURANCE RATING LAWS Pursuant to Section 11752.8 of the California Insurance Code, we are providing you with an explanation of the California workers' compensation rating laws. 1. We establish our own rates for workers' compensation. Our rates, rating plans, and related information are filed with the insurance commissioner and are open for public inspection. 2. The insurance commissioner can disapprove our rates, rating plans, or classifications only if he or she has determined after public hearing that our rates might jeopardize our ability to pay claims or might create a mo- nopoly in the market. A monopoly is defined by law as a market where one insurer writes 20% or more of that part of the California workers' compensation insurance that is not written by the State Compensation Insur- ance Fund. If the insurance commissioner disapproves our rates, rating plans, or classifications, he or she may order an increase in the rates applicable to outstanding policies. 3. Rating organizations may develop pure premium rates that are subject to the insurance commissioner's ap- proval. A pure premium rate reflects the anticipated cost and expenses of claims per $100 of payroll for a given classification. Pure premium rates are advisory only, as we are not required to use the pure premium rates developed by any rating organization in establishing our own rates. 4. We must adhere to a single, uniform experience rating plan. If you are eligible for experience rating under the plan, we will be required to adjust your premium to reflect your claim history. A better claim history generally results in a lower experience rating modification; more claims, or more expensive claims, generally result in a higher experience rating modification. The uniform experience rating plan, which is developed by the insur- ance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. 5. A standard classification system, developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. The standard classification system is a method of recognizing and separating policyholders into industry or occupational groups according to their similarities and /or differences. We can adopt and apply the standard classification system or develop and ap- ply our own classification system, provided we can report the payroll, expenses, and other costs of claims in a way that is consistent with the uniform statistical plan or the standard classification system. 6. Our rates and classifications may not violate the Unruh Civil Rights Act or be unfairly discriminatory. 7. We will provide an appeal process for you to appeal the way we rate your insurance policy. The process re- quires us to respond to your written appeal within 30 days. If you are not satisfied with the result of your ap- peal, you may appeal our decision to the insurance commissioner. CALIFORNIA WORKERS' COMPENSATION INSURANCE NOTICE OF NONRENEWAL Section 11664 of the California Insurance Code requires us, in most instances, to provide you with a notice of nonrenewal. Except as specified in paragraphs 1 through 6 below, if we elect to nonrenew your policy, we are required to deliver or mail to you a written notice stating the reason or reasons for the nonrenewal of the policy. The notice is required to be sent to you no earlier than 120 days before the end of the policy period and no later than 30 days before the end of the policy period. If we fail to provide you the required notice, we are required to continue the coverage under the policy with no change in the premium rate until 60 days after we provide you with the required notice. We are not required to provide you with a notice of nonrenewal in any of the following situations: 1. Your policy was transferred or renewed without a change in its terms or conditions or the rate on which the premium is based to another insurer or other insurers who are members of the same insurance group as us. 2. The policy was extended for 90 days or less and the required notice was given prior to the extension. © 2002 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. W04NBA02 Page 1 of 2 PN 04 99 02 B (Ed. 5 -02) 3. You obtained replacement coverage or agreed, in writing, within 60 days of the termination of the policy, to obtain that coverage. 4. The policy is for a period of no more than 60 days and you were notified at the time of issuance that it may not be renewed. 5. You requested a change in the terms or conditions or risks covered by the policy within 60 days prior to the end of the policy period. 6. We made a written offer to you to renew the policy at a premium rate increase of less than 25 percent. (A) If the premium rate in your governing classification is to be increased 25 percent or greater and we intend to renew the policy, we shall provide a written notice of a renewal offer not less than 30 days prior to the policy renewal date. The governing classification shall be determined by the rules and regulations estab- lished in accordance with California Insurance Code Section 11750.3(c). (B) For purposes of this Notice, "premium rate" means the cost of insurance per unit of exposure prior to the application of individual risk variations based on loss or expense considerations such as scheduled rating and experience rating. This notice does not change the policy to which it is attached. © 2002 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. W04NBA02 Page 2 of 2 PN 04 99 01 D POLICYHOLDER NOTICE YOUR RIGHT TO RATING AND DIVIDEND INFORMATION I. INFORMATION AVAILABLE TO YOU A. Information Available from Us The Travelers Companies (1) General questions regarding your policy should be directed to: TRAVELERS P.O. Box 6512 21688 Gateway Center Drive Diamond Bar, CA 91765 Phone: 1- 909 - 612 -3609 Fax: 1- 909 - 612 -3629 (2) DIVIDEND CALCULATION. If this is a participating policy (a policy on which a dividend may be paid), upon payment or non - payment of a dividend, we shall provide a written explanation to you that sets forth the basis of the dividend calculation. The explanation will be in clear, understandable lan- guage and will express the dividend as a dollar amount and as a percentage of the earned premium for the policy year on which the dividend is calculated. (3) CLAIMS INFORMATION. Pursuant to Sections 3761 and 3762 of the California Labor Code, you are entitled to receive information in our claim files that affects your premium. Copies of documents will be supplied at your expense during reasonable business hours. For claims covered under this policy, we will estimate the ultimate cost of unsettled claims for statis- tical purposes eighteen months after the policy becomes effective and will report those estimates to the Workers' Compensation Insurance Rating Bureau of California (WCIRB) no later than twenty months after the policy becomes effective. The cost of any settled claims will also be reported at that time. At twelve -month intervals thereafter, we will update and report to the WCIRB the estimated cost of any unsettled claims and the actual final cost of any claims settled in the interim. The amounts we report will be used by the WCIRB to compute your experience modification if you are eligible for experience rating. B. Information Available from the Workers' Compensation Insurance Rating Bureau of California (1) The WCIRB is a licensed rating organization and the California Insurance Commissioner's desig- nated statistical agent. As such, the WCIRB is responsible for administering the California Workers' Compensation Uniform Statistical Reporting Plan -1995 (USRP) and the California Workers' Com- pensation Experience Rating Plan -1995 (ERP). Contact information for the WCIRB is: WCIRB, 525 Market Street, Suite 800, San Francisco, California 94105 -2767, Attention: Customer Service. You may also contact WCIRB Customer Service at 1- 888 - 229 -2472, by fax at 415 - 778 -7272, or via the Internet at the WCIRB's website: http: / /www.wcirbonline.org. The regulations contained in the USRP and the ERP are available for public viewing through the WCIRB's website. (2) POLICYHOLDER INFORMATION. Pursuant to California Insurance Code (CIC) Section 11752.6, upon written request, you are entitled to information relating to loss experience, claims, classification assignments, and policy contracts as well as rating plans, rating systems, manual rules, or other in- formation impacting your premium that is maintained in the records of the WCIRB. Complaints and Requests for Action requesting policyholder information should be forwarded to: WCIRB, 525 Market Street, Suite 800, San Francisco, California 94105 -2767, Attention: Custodian of Records. The Cus- todian of Records can be reached by telephone at 415 - 777 -0777 and by fax at 415 - 778 -7272. (3) EXPERIENCE RATING FORM. Each experience rated risk may receive a single copy of its current Experience Rating Form free of charge by completing a Policyholder Rate Sheet Request Form on W04NBGl l Page 1 of 3 PN 04 99 01 D the WCIRB's website at https : / /wcirbonline.org /ratesheet. The Experience Rating Form will include a Loss -Free Rating, which is the experience modification that would have been calculated if $0 (zero) actual losses were incurred during the experience period. This hypothetical rating calculation is pro- vided for informational purposes only. II. DISPUTE PROCESS You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1. A. Our Dispute Resolution Process. If you are aggrieved by our decision adopting a change in a classification assignment that results in in- creased premium, or by the application of our rating system to your workers' compensation insurance, you may dispute these matters with us. If you are dissatisfied with the outcome of the initial dispute with us, you may send us a written Complaint and Request for Action as outlined below. You may send us a written Complaint and Request for Action requesting that we reconsider a change in a classification assignment that results in an increased premium and /or requesting that we review the manner in which our rating system has been applied in connection with the insurance afforded or offered you. Written Complaints and Requests for Action should be forwarded to: TRAVELERS 11090 White Rock Road Rancho Cordova, CA 95670 -6001 Phone: 1- 800 - 328 -2189 Website: www.Travelers.com TRAVELERS P.O. Box 6512 21688 Gateway Center Drive Diamond Bar, CA 91765 Phone: 1- 909 - 612 -3609 Fax: 1- 909 - 612 -3629 Website: www.Travelers.com After you send your Complaint and Request for Action, we have 30 days to send you a written notice in- dicating whether or not your written request will be reviewed. If we agree to review your request, we must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If we decline to review your request, if you are dissatisfied with the decision upon review, or if we fail to grant or reject your request or issue a decision upon review, you may appeal to the insurance commissioner as described in paragraph II.C., below. B. Disputing the Actions of the WCIRB. If you have been aggrieved by any decision, action, or omission to act of the WCIRB, you may request, in writing, that the WCIRB reconsider its decision, action, or omission to act. You may also request, in writing, that the WCIRB review the manner in which its rating system has been applied in connection with the insurance afforded or offered you. For requests related to classification disputes, the reporting of experience, or coverage issues, your initial request for review must be received by the WCIRB within 12 months after the expiration date of the policy to which the re- quest for review pertains, except if the request involves the application of the Revision of Losses rule. For requests related to your experience modification, your initial request for review must be received by the WCIRB within 6 months after the issuance, or 12 months after the expiration date, of the experience modification to which the request for review pertains, whichever is later, except if the request for review involves the application of the Revision of Losses rule. If the request involves the Revision of Losses rule, the time to state your appeal may be longer. (See Section VI, Rule 14 of the ERP). You may commence the review process by sending the WCIRB a written Inquiry. Written Inquiries should be sent to: WCIRB, 525 Market Street, Suite 800, San Francisco, California 94105 -2767, Atten- tion: Customer Service. Customer Service can be reached by telephone at 1- 888 - 229 -2472, and by fax at 415 - 778 -7272. If you are dissatisfied with the WCIRB's decision upon an Inquiry, or if the WCIRB fails to respond within 90 days after receipt of the Inquiry, you may pursue the subject of the Inquiry by sending the WCIRB a written Complaint and Request for Action. After you send your Complaint and Request for Action, the WCIRB has 30 days to send you written notice indicating whether or not your written request will be re- viewed. If the WCIRB agrees to review your request, it must conduct the review and issue a decision W04NBGl l Page 2 of 3 PN049901 D granting or rejecting your request within 60 days after sending you the written notice granting review. If the WCIRB declines to review your request, if you are dissatisfied with the decision upon review, or if the WCIRB fails to grant or reject your request or issue a decision upon review, you may appeal to the insur- ance commissioner as described in paragraph II.C., below. Written Complaints and Requests for Action should be forwarded to: WCIRB, 525 Market Street, Suite 800, San Francisco, California 94105 -2767, Attention: Complaints and Reconsiderations. The WCIRB's telephone number is 1- 888 - 229 -2472, and the fax number is 415 - 371 -5204. C. California Department of Insurance — Appeals to the Insurance Commissioner. If, after you follow the appropriate dispute resolution process described above, we or the WCIRB decline to review your re- quest, if you are dissatisfied with the decision upon review, or if we or the WCIRB fail to grant or reject your request or issue a decision upon review, you may appeal to the insurance commissioner pursuant to CIC Sections 11737, 11752.6, 11753.1 and Title 10, California Code of Regulations, Section 2509.40 et seq. You must file your appeal within 30 days after we or the WCIRB send you the notice rejecting re- view of your Complaint and Request for Action or the decision upon your Complaint and Request for Ac- tion. If no written decision regarding your Complaint and Request for Action is sent, your appeal must be filed within 120 days after you sent your Complaint and Request for Action to us or to the WCIRB. The filing address for all appeals to the insurance commissioner is: Administrative Hearing Bureau California Department of Insurance 45 Fremont Street, 22nd Floor San Francisco, California 94105 You have the right to a hearing before the insurance commissioner, and our action, or the action of the WCIRB, may be affirmed, modified, or reversed. III. RESOURCES AVAILABLE TO YOU IN OBTAINING INFORMATION AND PURSUING DISPUTES A. Policyholder Ombudsman. Pursuant to California Insurance Code Section 11752.6, a policyholder om- budsman is available at the WCIRB to assist you in obtaining and evaluating the rating, policy, and claims information referenced in I.A. and I.B., above. The ombudsman may advise you on any dispute with us, the WCIRB, or on an appeal to the insurance commissioner pursuant to Section 11737 of the In- surance Code. The address of the policyholder ombudsman is WCIRB, 525 Market Street, Suite 800, San Francisco, California 94105 -2767, Attention: Policyholder Ombudsman. The policyholder ombuds- man can be reached by telephone at 415 - 778 -7159 and by fax at 415 - 371 -5288. B. California Department of Insurance — Information and Assistance. Information and assistance on policy questions can be obtained from the Department of Insurance Consumer HOTLINE, 1- 800 - 927 -HELP (4357) or http: / /www.insurance.ca.gov. For questions and correspondence regarding appeals to the Administrative Hearing Bureau, see the contact information in paragraph II.C. This notice does not change the policy to which it is attached. W04NBGl l Page 3 of 3 POLICYHOLDER NOTICE CALIFORNIA INSURANCE GUARANTEE ASSOCIATION (CIGA) SURCHARGE Companies writing property and casualty insurance business in California are required to participate in the California Insurance Guarantee Association. If a company becomes insolvent, the California Insurance Guarantee Association settles unpaid claims and assesses each insurance company for its fair share. California law requires all companies to surcharge policies to recover these assessments. If your policy is surcharged, "CA Surcharge" or "CA Surcharge (CIGA) Surcharge)" with an amount will be displayed on your premium notice. This notice does not change the policy to which it is attached. PN 04 99 04 (00) W04NDCO2 TRAVELERSJ� Your Workers' Compensation Benefits -California This form should be given to all newly hired employees in the State of California. Its content applies to industrial injuries on or after January 1, 2013. Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony. You may be entitled to workers' compensation benefits if you are injured or become ill because of your job, or are a victim of a workplace crime. Workers' compensation covers most work - related physical or mental injuries and illnesses. An injury or illness can be caused by one event (such as hurting your back in a fall) or by repeated exposures to a harmful condition (such as hurting your wrist from doing the same motion over and over). Workers' compensation benefits include: Medical Care: Doctor visits, hospital services, physical therapy, lab tests, x -rays, and medicines that are reasonably necessary to treat your injury. You should never see a bill. Physical therapy, occupational therapy and chiropractic visits may be limited to 24 each. Temporary Disability Benefits: Payments if you lose wages while recovering. For most injuries after April 18, 2004, temporary disability benefits are limited to 104 weeks within 5 years from your date of injury. Filing a timely Employment Development Department claim may result in additional state disability benefits when TTD benefits are terminated, delayed or denied. Permanent Disability Benefits: Payments if your injury causes a permanent disability. Once your injury stabi- lizes, your treating physician may find permanent disability, depending upon your level of recovery. The amount of permanent disability found by your doctor will be rated by your claims administrator according to your age and occupation in order to determine the percentage and corresponding dollar amount of permanent disability due. These amounts are set by state law. You have the right to obtain a state disability rating or appeal a rating. Return to Work Program: If you experience a permanent earnings loss as a result of your injury and your permanent disability benefits are determined to be disproportionately low, you may qualify for additional monies from the Department of Industrial Relation's Return to Work Fund. Contact the Department of Industrial Relations at: www.dir.ca.aov/ to learn more about this additional benefit. Supplemental Job Displacement Vouchers: If your injury causes you to miss time from work and results in permanent disability, you may receive a supplemental job displacement voucher if your employer has not offered modified, alternative or regular employment within 60 days of receipt of the doctor's medical report indicating you have made a maximum medical recovery. The voucher is for reimbursement of education - related costs and is capped at $6,000.00, If you receive a voucher as a result of your injury, you have two years from the date you are furnished the voucher or five years from your date of injury (whichever occurs later), to request reimburse- ment for qualifying expenditures. Death Benefits: Paid to dependents of a worker who dies from a work - related injury or illness. Burial expenses are also provided, with the maximum amount allowed dependent upon the date of injury. Temporary disability, permanent disability, and death benefits are all payable at a rate based on 2/3 of your average weekly wage, and subject to state minimum and maximum amounts in effect on your date of injury. These benefits are paid every two weeks while you are eligible. Voluntary, off duty, recreational, social or athletic activities may not be covered under workers' compen- sation. W04NEH13 Page 1 of 6 © 2013 The Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are registered trademarks of The Travelers Indemnity Company in the U.S. and other countries. CE -10277 New 1 -2013 This form complies with Labor Code requirements §3551, §3553, and Administrative Rule §9880, and has been approved by the Administrative Director of the Division of Workers' Compensation. This form cannot be altered. If you get hurt: Get Medical Care. If you need first aid, contact your employer. If you need emergency care, call for help immediately. Report Your Injury. Report the injury immediately to your supervisor. Don't delay. There are time limits. If you wait too long, you may lose your right to benefits. Your employer is required to provide you a claim form within one working day after learning about your injury, and must also authorize treatment within one working day after you have returned a signed and completed copy of the form. The statute of limitations for filing a workers' compensation claim is one year from the date of injury or, if resulting from repeated exposures, one year from when you realized or should have realized that your job caused the injury. See Your Treating Physician. Your primary treating physician is the doctor with overall responsibility for treating your injury or illness. He or she is charged with maintaining the continuity of your care, as well as initiating referrals to specialists. If your employer has an approved Medical Provider Network (MPN), they may be able to limit your choices of treating physicians retain medical control, and require you to treat with an MPN physician from the onset. (An MPN is a selected network of healthcare providers who provide treatment to workers injured on the job. See your employer for more information on your MPN.) Otherwise, your employer has the right to select the physician who will treat you for the first 30 days. If your employer does not have an approved MPN and you wish to change doctors in the first 30 days after reporting your claim, your claims administrator must select a new physician within five days of your request. If you have provided your employer with the name of your personal physician before your injury and have group health insurance at the time of injury, you may see your personal physician for treatment even if your employer has an approved MPN. Your personal physician must be a general practitioner or a board - certified or board - eligible internist, pediatrician, obstetrician - gynecologist, family practitioner, or multi - specialty medical group of doctors of medicine or osteopathy, and must have treated you and maintained your medical history and records before your work injury and must also agree to treat you for a work - related injury or illness. If your employer does not have an approved MPN and you gave your employer the name of your personal chiropractor or acupuncturist in writing before you were injured, you may switch to the chiropractor or acupuncturist upon request. If you still need medical care after 30 days, you may be able to switch to a doctor of your own choice. For your convenience, optional forms to predesignate your personal physician or multi - specialty medical group of doctors of medicine or osteopathy are attached to this document. Also attached, are forms to predesignate your personal acupuncturist or chiropractor if your employer does not have a medical provider network in place. By law, chiropractors are not allowed to be the treating physician after 24 visits. Discrimination: It is illegal for your employer to punish or fire you for having a work injury or illness, for filing a claim, or testifying in another person's workers' compensation case. If your employer has been found to discrimi- nate, you may be entitled to job reinstatement with back pay, increased compensation, and costs and expenses. You may also have additional rights under the Americans with Disabilities Act (ADA) or the Fair Employment and Housing Act (FEHA). For additional information, contact FEHA at (800) 884 -1684 or the Equal Employment Opportunity Commission (EEOC) at (800) 669 -3362. You can get free information from a state Division of Workers' Compensation Information & Assistance Officer. Hear recorded information and a list of local offices by calling toll -free (800) 736 -7401 or learn more online at: http: / /www.dir.ca.gov. If medical care is not being provided by your employer you have several options. First, contact your claims administrator to find out the status of your claim. If you have given your employer a completed and signed claim form but your claim has been delayed for investigation, your employer is still required to authorize treatment, up to $10,000.00, during the delay. If the claim has not been accepted yet and your medical costs have exceeded the statutory $10,000.00 cap, you can go to your group health plan for care, find a doctor, clinic or hospital that will bill the claims administrator directly, or use public health services. You have the right to disagree with decisions affecting your claim. If you have a disagreement, contact your claims administrator first to see if you can resolve it. W04NEH13 Page 2 of 6 © 2013 The Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are registered trademarks of The Travelers Indemnity Company in the U.S. and other countries. CE -10277 New 1 -2013 This form complies with Labor Code requirements §3551, §3553, and Administrative Rule §9880, and has been approved by the Administrative Director of the Division of Workers' Compensation. This form cannot be altered. Your Workers' Compensation Insurance Company is The Travelers Indemnity Company. You can also look up your insurance carrier at the WCIRB online lookup: httr, s: / /www.caworkcompcoveraae.com/ You can obtain free information from an Information and Assistance Officer of the state Division of Workers' Compensation, or you can hear recorded information and a list of local offices by calling (800) 736 -7401. A list of Information and Assistance offices can be found at the end of this pamphlet to help you locate the I &A office nearest you. You may also go to the DWC web site at: http: / /www.dir.ca.ciov, for further information. You can consult with an attorney. Most attorneys offer one free consultation. If you decide to hire an attorney, his or her fee may be taken out of some of your benefits. For names of workers' compensation attorneys, call the State Bar of California at (415) 538 -2120 or go to their web site at: http: / /www.californiaspecialist.orci. You may get a list of attorneys from your local information and assistance officer or look in your yellow pages. W04NEH13 Page 3 of 6 © 2013 The Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are registered trademarks of The Travelers Indemnity Company in the U.S. and other countries. CE -10277 New 1 -2013 This form complies with Labor Code requirements §3551, §3553, and Administrative Rule §9880, and has been approved by the Administrative Director of the Division of Workers' Compensation. This form cannot be altered. Predesignation of personal physician In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness by your personal medical doctor (M.D.) or doctor of osteopathic medicine (D.O.) or medical group if: • you have group health coverage at the time of injury; • the doctor is your regular physician, who shall be either a physician who has limited his or her practice of medicine to general practice or who is a board - certified or board - eligible internist, pediatrician, obstetri- cian- gynecologist, family practitioner, and has previously directed your medical treatment, and retains your medical records; • your "personal physician" may be a medical group if it is a single corporation or partnership composed of licensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical group providing comprehensive medical services predominantly for nonoccupational illnesses and injuries; • prior to the injury your doctor agrees to treat you for work injuries or illnesses; • prior to the injury you provided your employer the following in writing: (1) notice that you want your per- sonal doctor to treat you for a work - related injury or illness, and (2) your personal doctor's name and business address. You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work- related injury or illness and the above requirements are met. Notice of predesignation of personal physician Employee: Complete this section. Td: (name of employer) If I have a work - related injury or illness, I choose to be treated by: (Name of Doctor, M.D., D.O., or medical group) (Street address, city, state, zip code) (Telephone number) Employee Name (please print): Employee's Address: Employee's Signature Physician: I agree to this Predesignation: Date: Signature: Date: (Physician or designated employee of the physician or medical group) The physician is not required to sign this form, however, if the physician or designated employee of the physician or medical group does not sign, other documentation of the physician's agreement to be predesignated will be required pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3). W04NEH13 Page 4 of 6 © 2013 The Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are registered trademarks of The Travelers Indemnity Company in the U.S. and other countries. CE -10277 New 1 -2013 This form complies with Labor Code requirements §3551, §3553, and Administrative Rule §9880, and has been approved by the Administrative Director of the Division of Workers' Compensation. This form cannot be altered. Notice of personal chiropractor or personal acupuncturist If your employer or your employer's insurer does not have a Medical Provider Network, you may be able to change your treating physician to your personal chiropractor or acupuncturist following a work - related injury or illness. In order to be eligible to make this change, you must give your employer the name and business address of a personal chiropractor or acupuncturist in writing prior to the injury or illness. Your claims administrator generally has the right to select your treating physician within the first 30 days after your employer knows of your injury or illness. After your claims administrator has initiated your treatment with another doctor during this period, you may then, upon request, have your treatment transferred to your personal chiropractor or acupunctur- ist. You may use this form to notify your employer of your personal chiropractor or acupuncturist. By law, chiroprac- tors are not allowed to be the treating physician after 24 visits. Your Chiropractor or Acupuncturist's Information: (Name of chiropractor or acupuncturist) (Street address, city, state, zip code) (Telephone Number) Employee Name (please print): Employee Address Employee's Signature Date: W04NEH13 Page 5 of 6 © 2013 The Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are registered trademarks of The Travelers Indemnity Company in the U.S. and other countries. CE -10277 New 1 -2013 This form complies with Labor Code requirements §3551, §3553, and Administrative Rule §9880, and has been approved by the Administrative Director of the Division of Workers' Compensation. This form cannot be altered. Contact the information & assistance unit: • By phone at 1- 800 - 736 -7401 — For recorded information that helps injured workers, employers and others understand California's workers compensation system, and their rights and responsibilities under the law. By attending a workshop for injured workers By calling or going in person to a local Information & Assistance Unit office: Anaheim Oakland San Diego 1065 N. PacifiCenter Drive 1515 Clay Street, 7575 Metropolitan Drive, Anaheim 92806 6th floor Suite 202 (714) 414 -1801 Oakland, CA 94612 San Diego, CA 92102 -4424 (510) 622 -2861 (619) 767 -2082 wawa Bakersfield Oxnard San Francisco 1800 30th Street, 1901 N. Rice Ave.,Ste. 200 455 Golden Gate Avenue, Suite 100 Oxnard, CA 93030 2nd floor Bakersfield, CA 93301 -1929 (805) 485 -3528 San Francisco, CA 94102 -7014 (661) 395 -2514 (415) 703 -5020 Eureka Pomona San Jose 100 "H" Street, 732 Corporate Center Drive 100 Paseo de San Antonio, Room 202 Pomona, CA 91768 -2653 Room 241 Eureka, CA 95501 -0481 (909) 623 -8568 San Jose, CA 95113 -1402 (707) 441 -5723 (408) 277 -1292 Fresno Redding San Luis Obispo 2550 Mariposa Mall, 2115 Civic Center Drive 4740 Allene Way, Room 2035 Room 15 Suite 100 Fresno, CA 93721 -2219 Redding, CA 96001 -2796 San Luis Obispo, CA 93401 (559) 445 -5355 (530) 225 -2047 (805) 596 -4159 Goleta Riverside Santa Ana 6755 Hollister Avenue, 3737 Main Street, 605 W Santa Ana Blvd, Bldg Room 100 Room 300 28 Room 451 Goleta CA 93117 -5551 Riverside, CA 92501 -3337 Santa Ana, CA 92701 (805) 968 -4158 (951) 782 -4347 (714) 558 -4597 Long Beach Sacramento Santa Rosa 300 Oceangate Street, 160 Promenade Circle, 50 "D" Street, Suite 200 Suite 300 Room 420 Long Beach, CA 90802 -4304 Sacramento, CA 95834 Santa Rosa, CA 95404 -4771 (562) 590 -5240 (916) 928 -3158 (707) 576 -2452 Los Angeles Salinas Stockton 320 W. 4th Street, 1880 North Main Street, 31 East Channel Street, 9th floor Suite 100 Room 344 Los Angeles, CA 90013 -2329 Salinas, CA 93906 -2037 Stockton, CA 95202 -2314 (213) 576 -7389 (831) 443 -3058 (209) 948 -7980 Marina del Rey San Bernardino Van Nuys 4720 Lincoln Blvd 464 W. Fourth Street, 6150 Van Nuys Blvd., 2nd floor Suite 239 Room 105 Marina del Rey, CA 90292 -6902 San Bernardino, CA 92401 -1411 Van Nuys, CA 91401 -3370 (310) 482 -3820 (909) 383 -4522 (818) 901 -5367 Administrative Director of the Division of Workers' Compensation. This form cannot be altered,. W04NEH13 Page 6 of 6 © 2013 The Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are registered trademarks of The Travelers Indemnity Company in the U.S. and other countries. CE -10277 New 1 -2013 This form complies with Labor Code requirements §3551, §3553, and Administrative Rule §9880, and has been approved by the Administrative Director of the Division of Workers' Compensation. This form cannot be altered. TRAVELERSJ� Sus Beneficios de compensacion laboral - California Este formulario debe entregarse a todos los empleados recien contratados en el estado de California. Su contenido se aplica a los accidentes de trabajo ocurridos a partir del 1 de enero de 2013. Cualquier persona que haga o propicie que se haga cualquier declaracion sustancial a sabiendas falsa o fraudulenta con el proposito de obtener o denegar beneficios o pagos de compensacion laboral es culpable de un delito. Usted puede tener derecho a beneficios de compensacion laboral si resulta lesionado o se enferma a causa de su trabajo, o si es victima de un delito en el lugar de trabajo. La compensacion laboral cubre la mayoria de las lesiones y enfermedades fisicas o mentales relacionadas con el trabajo. Una lesion o enfermedad puede ser causada por un acontecimiento (como lastimarse la espalda en una caida) o por exposiciones repetidas a una circunstancia perjudicial (como lastimarse la muneca por hacer el mismo movimiento una y otra vez). Los beneficios de compensacion laboral incluyen: Atenci6n medica: consultas medicas, servicios hospitalarios, fisioterapia, analisis de laboratorio, radiografias y medicamentos que sean razonablemente necesarios para tratar su lesion. No debe recibir nunca una factura. Es posible que las visitas para fisioterapia, terapia ocupacional y al quiropractico tengan un limite de 24 visitas para cada tipo. Beneficios por incapacidad temporal: Pagos si usted deja de recibir su salario mientras se recupera. Para la mayoria de las lesiones ocurridas despues del 18 de abril de 2004, los beneficios por incapacidad temporal se limitan a 104 semanas dentro del lapso de 5 anos a partir de la fecha de la lesion. Presentar de forma oportuna una reclamacion en el Departamento de Desarrollo Laboral (Employment Development Department) puede conducir a la obtencion de beneficios estatales adicionales por incapacidad cuando se terminan los beneficios por incapacidad total temporal (TTD, por sus siglas en ingles), o cuando estos se demoran o los deniegan. Beneficios por incapacidad permanente: Pagos si su lesion causa una incapacidad permanente. Una vez que su lesion se estabilice, es posible que el medico que to trata determine que usted tiene una incapacidad perma- nente, dependiendo de su grado de recuperacion. La cantidad de incapacidad permanente que su medico determine sera clasificada por su administrador de reclamaciones segun su edad y ocupacion con el fin de determinar el porcentaje y la cantidad correspondiente en dolares que se le debe a usted a causa de la incapaci- dad permanente. La ley estatal establece dichas cantidades. Usted tiene derecho a obtener una clasificacion estatal de incapacidad o a apelar la clasificacion. Programa para reintegrarse al trabajo: Si usted sufre la perdida permanente de sus ingresos como resultado de su lesion y se determina que sus beneficios por incapacidad permanente son desproporcionadamente bajos, es posible que usted califique para recibir dinero adicional del Fondo para la reintearacion al trabajo del Depar- tamento de Relaciones Laborales (Department of Industrial Relations , Comuniquese con el Departamento de Relaciones Laborales en: www.dir.ca.gov/ para conocer mas acerca de este beneficio adicional. Vales suplementarios por destitucion laboral: Si su lesion conlleva a que usted falte a su trabajo y le causa una incapacidad permanente, usted puede recibir un vale suplementario por destitucion laboral si su empleador no le ofrece un empleo modificado, alternativo o regular dentro de 60 dias de haber recibido el informe medico que indique que usted logro una recuperacion medica maxima. El vale es para reembolsar los costos educativos y tiene un limite de $6,000.00. Si usted recibe un vale como consecuencia de su lesion, tiene dos anos desde la fecha en que le proporcionen el vale o cinco anos desde la fecha de su lesion (lo que ocurra ultimo), para solicitar el reembolso de los gastos que califiquen. Beneficios por muerte: Se pagan a los dependientes de un trabajador que muere a causa de una lesion o enfermedad laboral. Tambien se cubren los gastos del entierro; la cantidad maxima permitida depende de la fecha de la lesion. W04NFH13 Page 1 of 7 © 2013 The Travelers Indemnity Company. Todos los derechos reservados. Travelers y el logotipo con la sombrilla de Travelers son marcas registradas de The Travelers Indemnity Company en los EE. UU. y otros paises. CE -10277 New 1 -2013 Este formulario cumple con los requisitos §3551, §3553, y el Reglamento Administrativo §9880 del C6digo Laboral, y fue aprobado por el Director Administrativo de la Divisi6n de Compensaci6n Laboral. Este formulario no puede modificarse. Los beneficios por incapacidad temporal, incapacidad permanente y muerte se pagan a una tasa basada en 2/3 de su salario semanal promedio, y estan sujetos a las cantidades minimas y maximas vigentes en el estado en la fecha de su lesion. Estos beneficios se pagan cada dos semanas mientras usted sea elegible. Es posible que las actividades como voluntario, en sus horas libres, recreacionales, sociales o atleticas no esten cubiertas bajo la compensaci6n laboral. Si se lastima: Obtenga atenci6n medica. Si necesita primeros auxilios, comuniquese con su empleador. Si necesita atencion urgente, pida ayuda de inmediato. Informe sobre su lesion. Informe de inmediato a su supervisor sobre su lesion. No demore en haberlo; existen limites de tiempo. Si espera demasiado, puede perder los derechos que tiene a recibir beneficios. Su empleador tiene que proporcionarle un formulario de reclamaci6n a mas tardar un dia laborable despues de que este enterado de su lesion, y tambien debe autorizar el tratamiento a mas tardar un dia laborable despues de que usted le entregue una copia del formulario Ileno y firmado. El plazo de prescripci6n para presentar una reclama- ci6n de compensaci6n laboral es de un ano a partir de la fecha de la lesion o, si esta se debe a exposiciones repetidas, un ano a partir del momento en que usted se dio cuenta o debi6 darse cuenta de que su trabajo caus6 la lesion. Vea a su medico tratante. Su medico tratante primario es el medico con la responsabilidad global de tratar su lesion o enfermedad. El o ella estan a cargo de mantener la continuidad de su atencion, asi como de remitirlo a los especialistas. Si su empleador tiene una Red de Proveedores Medicos (MPN, por sus siglas en ingles) aprobada, es posible que ellos puedan limitar sus opciones de medicos tratantes, que retengan el control medico, y que le exijan que se atienda con un medico de la MPN desde el principio. (Una MPN es una red escogida de proveedores de atencion medica que proveen tratamiento a los empleados que se lesionan en el trabajo. Consulte con su empleador para obtener mas informacion sobre su MPN). De to contrario, su empleador tiene el derecho de escoger el medico que to tratara a usted por los primeros 30 dias. Si su empleador no tiene una MPN aprobada y usted desea cambiar de medico en los primeros 30 dias despues de presentar su reclama- ci6n, su administrador de reclamaciones debe escoger un medico nuevo en un lapso de cinco dias despues de que usted to solicite. Si usted le proporcion6 a su empleador el nombre de su medico personal antes de sufrir la lesion y tiene seguro medico de grupo al momento de la lesion, usted puede tratarse con su medico personal incluso si su empleador tiene una MPN aprobada. Su medico personal debe ser un medico general o un medico internista, pediatra, ginecobstetra o medico de familia con certificado de especialidad o que hays completado su especialidad, o un grupo medico con multiples especialidades con doctores o licenciados en medicina, y debe haberlo tratado y tener sus antecedentes medicos y su historia clinica antes de su lesion laboral y tambien debe estar de acuerdo en tratarlo por una lesion o enfermedad laboral. Si su empleador no tiene una MPN aprobada y usted le dio a su empleador por escrito el nombre de su quiropractico o acupunturista personal antes de sufrir la lesion, usted puede cambiarse al quiropractico o acupunturista cuando to solicite. Si todavia necesita recibir atencion medica luego de 30 dias, quizas pueda cambiarse a un medico de su propia elecci6n. Para mayor comodidad, se adjuntan a este documento formularios opcionales para predesignar a su medico personal o a un grupo medico con multiples especialidades con doctores o licenciados en medicina. Tambien se adjuntan formularios para predesignar a su acupunturista o quiropractico personal si su empleador no cuenta con una red de proveedores medicos. Por ley, no se permite que los quiropracticos sean el medico tratante luego de 24 visitas. Discrimination: Es ilegal que su empleador to castigue o to despida por sufrir una lesi6n o enfermedad laboral, por presentar una reclamaci6n, o por testificar en el caso de compensaci6n laboral de otra persona. Si se determina que su empleador ha cometido discriminaci6n, usted puede tener derecho a que se le reincorpore a su puesto de trabajo con pagos retroactivos, una mayor compensaci6n, y costos y gastos. Es posible que usted tenga otros derechos bajo la Ley de Protecci6n para Personas Discapacitadas (ADA, por sus siglas en ingles) o la Ley de Igualdad en el Empleo y la Vivienda (FEHA, por sus siglas en ingles). Para obtener mas informaci6n, comuniquese con FEHA al (800) 884 -1684 o con la Comisi6n de Igualdad de Oportunidades Laborales (EEOC, W04NFH13 Page 2 of 7 © 2013 The Travelers Indemnity Company, Todos los derechos reservados. Travelers y el logotipo con la sombrilla de Travelers son marcas registradas de The Travelers Indemnity Company en los EE. UU. y otros paises. CE -10277 New 1 -2013 Este formulario cumple con los requisites §3551, §3553, y el Reglamento Administrativo §9880 del C6digo Laboral, y fue aprobado por el Director Administrativo de la Divisi6n de Compensaci6n Laboral. Este formulario no puede modificarse. por sus siglas en ingles) al (800) 669 -3362. Puede obtener informaci6n gratuita de un funcionario de informaci6n y ayuda de la Division de Compensaci6n Laboral de su estado. Puede escuchar informaci6n grabada y una lista de las oficinas locales Ilamando sin costo al (800) 736 -7401 o averiguar mas en linea en: http: / /www.dir.ca.gov. Si su empleador no le proporciona atenci6n medica, usted tiene varias opciones. Primero, comuniquese con su administrador de reclamaciones para averiguar el estado de su reclamaci6n. Si le entreg6 a su empleador un formulario de reclamaci6n Ileno y firmado pero su reclamaci6n esta retrasada por la investigaci6n, su empleador tiene que autorizar el tratamiento, hasta un maximo de $10,000.00, durante el retraso. Si todavia no se ha aceptado la reclamaci6n y sus costos medicos sobrepasan el limite reglamentario de $10,000.00, usted puede acudir a su plan medico de grupo para recibir atenci6n, buscar un medico, una clinica o un hospital que le facture directamente al administrador de reclamaciones, o utilizar los servicios pOblicos de atenci6n medica. Usted tiene derecho a estar en desacuerdo con [as decisiones que afectan su reclamaci6n. Si esta en de- sacuerdo, comuniquese primero con su administrador de reclamaciones para ver si to pueden resolver. Su compahla de seguros de compensaci6n laboral es The Travelers Indemnity Company. Tambien puede buscar su compania de seguros en el directorio en linea de WCIRB: https : / /www.caworkcomi)coverage.com/ Puede obtener informaci6n gratuita de un funcionario de Informaci6n y Ayuda de la Division de Compensaci6n Laboral de su estado, o puede escuchar informaci6n grabada y una lista de las oficinas locales Ilamando al (800) 736 -7401. Al final de este folleto, encontrara una lists de las oficinas de Informaci6n y Ayuda. Esto to ayudara a localizar la oficina mas cerca de usted. Para mas informaci6n, tambien puede visitar el sitio web del DWC en: http://www.dir.ca.gov. Puede consultar con un abogado. La mayoria de los abogados ofrecen una consulta gratuita. Si decide contratar un abogado, es posible que los honorarios se saquen de algunos de sus beneficios. Para obtener los nombres de los abogados especializados en compensaci6n laboral, Ilame al Colegio de Abogados del estado de California al (415) 538 -2120 o visite su sitio web en: http: / /www.californiaspecialist.org. El funcionario local de informaci6n y ayuda puede proporcionarle una lista de los abogados o usted puede buscarlos en las paginas amarillas. W04NFH13 Page 3 of 7 © 2013 The Travelers Indemnity Company. Todos los derechos reservados. Travelers y el logotipo con la sombrilla de Travelers son marcas registradas de The Travelers Indemnity Company en los EE. UU. y otros paises. CE -10277 New 1 -2013 Este formulario cumple con los requisitos §3551, §3553, y el Reglamento Administrativo §9880 del C6digo Laboral, y fue aprobado por el Director Administrativo de la Division de Compensaci6n Laboral. Este formulario no puede modificarse. Predesignaci6n del medico personal En caso de que sufra una lesion o enfermedad relacionada con su empleo, su medico (doctor (M.D.) o licenciado (D.O.) en medicina) personal o grupo medico pueden atenderlo si: • usted tiene cobertura medica de grupo al momento de la lesion; • el medico es su medico habitual, y debe ser un medico cuyo ejercicio de la medicina se limita a medicina general o que es un medico internista, pediatra, ginecobstetra o medico de familia con certificado de espe- cialidad o que haya completado su especialidad, y que anteriormente haya estado a cargo de su tratamiento medico y tenga en su poder su historia clinica; • su "medico personal" puede ser un grupo medico si se trata de una corporaci6n con un solo miembro o una sociedad constituida por doctores o licenciados en medicina, que opere un grupo medico integrado con multiples especialidades que brinde servicios medicos integrales predominantemente para enfermedades y lesiones que no sean de tipo laboral; • antes de la lesi6n, su medico acepta tratarlo por lesiones o enfermedades laborales; • antes de la lesi6n, usted le proporcion6 a su empleador to siguiente por escrito: (1) notificaci6n de que usted desea que su medico personal to trate por lesiones o enfermedades laborales, y (2) el nombre y la direcci6n del consultorio de su medico personal. Puede usar este formulario para notificar a su empleador si desea que su medico o licenciado en medicina personal to trate por una lesi6n o enfermedad laboral, siempre que se cumplan los requisitos anteriores. Notificaci6n de predesignaci6n del medico personal Empleado: Llene esta secci6n. Para: ( nombre del empleador) Si sufro una lesi6n o enfermedad laboral, escojo ser atendido por: ( Nombre del medico, doctor en medicina, licenciado en medicina o grupo medico) (Direcci6n, ciudad, estado, c6digo postal) (NOmero de telefono) Nombre del empleado (en letra de imprenta): Direcci6n del empleado: Firma del empleado Fecha :, W04NFH13 Page 4 of 7 © 2013 The Travelers Indemnity Company. Todos los derechos reservados. Travelers y el logotipo con la sombrilla de Travelers son marcas registradas de The Travelers Indemnity Company en los EE. UU. y otros paises. CE -10277 New 1 -2013 Este formulario cumple con los requisitos §3551, §3553, y el Reglamento Administrativo §9880 del C6digo Laboral, y fue aprobado por el Director Administrativo de la Divisi6n de Compensaci6n Laboral. Este formulario no puede modificarse. Medico: Estoy de acuerdo con esta predesignaci6n. Firma: Fecha: (Medico o empleado designado del medico o del grupo medico) No se requiere que el medico firme este formulario, sin embargo, si el medico o el empleado designado del medico o del grupo medico no firma, se necesitara otra documentaci6n de la aceptaci6n del medico a ser predesignado, conforme al Capitulo 8, C6digo de Disposiciones Reglamentarias de California, apartado 9780.1(a)(3). W04NFH13 Page 5 of 7 © 2013 The Travelers Indemnity Company. Todos los derechos reservados. Travelers y el logotipo con la sombrilla de Travelers son marcas registradas de The Travelers Indemnity Company en los EE. UU. y otros paises. CE -10277 New 1 -2013 Este formulario cumple con los requisitos §3551, §3553, y el Reglamento Administrativo §9880 del C6digo Laboral, y fue aprobado por el Director Administrativo de la Division de Compensaci6n Laboral. Este formulario no puede modificarse. Notificaci6n de quiropractico personal o acupunturista personal Si su empleador o la compania de seguros de su empleador no tienen una Red de Proveedores Medicos, usted quizas pueda cambiar su medico tratante a su quiropractico o acupunturista personal despues de una lesion o enfermedad laboral. Para cumplir los requisitos para hacer este cambio, debe proporcionarle a su empleador, por escrito, el nombre y la direcci6n del consultorio de un quiropractico o acupunturista personal antes de que ocurra la lesion o enfermedad. Por to general, su administrador de reclamaciones tiene el derecho de escoger su medico tratante dentro de los primeros 30 dias despues de que su empleador este enterado de su lesion o enfermedad. Luego de que su administrador de reclamaciones inicie su tratamiento con otro medico durante este periodo, usted podra, previa solicitud, hacer que transfieran su tratamiento a su quiropractico o acupuntur- ista personal. Usted puede utilizar este formulario para notificar a su empleador acerca de su quiropractico o acupunturista personal. Por ley, no se permite que los quiropracticos sean el medico tratante luego de 24 visitas. Informaci6n de su quiropractico o acupunturista: ( Nombre del quiropractico o acupunturista) (Direcci6n, ciudad, estado, c6digo postal) (NOmero de telefono) Nombre del empleado (en letra de imprenta): Direcci6n del empleado: Firma del empleado Fecha: W04NFH13 Page 6 of 7 © 2013 The Travelers Indemnity Company. Todos los derechos reservados. Travelers y el logotipo con la sombrilla de Travelers son marcas registradas de The Travelers Indemnity Company en los EE. UU. y otros paises. CE -10277 New 1 -2013 Este formulario cumple con los requisitos §3551, §3553, y el Reglamento Administrativo §9880 del C6digo Laboral, y fue aprobado por el Director Administrativo de la Divisi6n de Compensaci6n Laboral. Este formulario no puede modificarse. Comuniquese con la unidad de informacion y ayuda • Por telefono al 1- 800 - 736 -7401: Para obtener informacion grabada que ayuda a los trabajadores lesionados, los empleadores y otras personas a entender el sistema de compensacion laboral de California, y sus dere- chos y responsabilidades conforme a la ley. • Asistiendo a un taller para trabajadores lesionados • Llamando o yendo en persona a una oficina local de la Unidad de informacion y ayuda: Anaheim Oakland San Diego 1065 N. PacifiCenter Drive 1515 Clay Street, 6th floor 7575 Metropolitan Drive, Anaheim 92806 Oakland, CA 94612 Suite 202 (714) 414 -1801 (510) 622 -2861 San Diego, CA 92102 -4424 (619) 767 -2082 Bakersfield Oxnard San Francisco 1800 30th Street, 1901 N. Rice Ave., 455 Golden Gate Avenue, Suite 100 Ste. 200 2nd floor Bakersfield, CA 93301 -1929 Oxnard, CA 93030 San Francisco, CA 94102 -7014 (661) 395 -2514 (805) 485 -3528 1 (415) 703 -5020 Eureka Pomona San Jose 100 "H" Street, 732 Corporate Center Drive 100 Paseo de San Antonio, Room 202 Eureka, CA 95501 -0481 Pomona, CA 91768 -2653 Room 241 (707) 441 -5723 (909) 623 -8568 San Jose, CA 95113 -1402 (408) 277 -1292 Fresno Redding San Luis Obispo 2550 Mariposa Mall, 2115 Civic Center Drive 4740 Allene Way, Room 2035 Room 15 Suite 100 Fresno, CA 93721 -2219 Redding, CA 96001 -2796 San Luis Obispo, CA 93401 (559) 445 -5355 (530) 225 -2047 (805) 596 -4159 Goleta Riverside Santa Ana 6755 Hollister Avenue, 3737 Main Street, 605 W Santa Ana Blvd, Bldg Room 100 Room 300 28 Room 451 Goleta, CA 93117 -5551 Riverside, CA 92501 -3337 Santa Ana, CA 92701 (805) 968 -4158 (951) 782 -4347 (714) 558 -4597 Long Beach Sacramento Santa Rosa 300 Oceangate Street, 160 Promenade Circle, 50 "D" Street, Suite 200 Suite 300 Room 420 Long Beach, CA 90802 -4304 Sacramento, CA 95834 Santa Rosa, CA 95404 -4771 (562) 590 -5240 (916) 928 -3158 (707) 576 -2452 Los Angeles Salinas Stockton 320 W. 4th Street, 1880 North Main Street, 31 East Channel Street, 9th floor Suite 100 Room 344 Los Angeles, CA 90013 -2329 Salinas, CA 93906 -2037 Stockton, CA 95202 -2314 (213) 576 -7389 (831) 443 -3058 (209) 948 -7980 Marina del Rey San Bernardino Van Nuys 4720 Lincoln Blvd 464 W. Fourth Street, 6150 Van Nuys Blvd., 2nd floor Suite 239 Room 105 Marina del Rey, CA 90292 -6902 San Bernardino, CA 92401 -1411 Van Nuys, CA 91401 -3370 (310) 482 -3820 (909) 383 -4522 (818) 901 -5367 W04NFH13 Page 7 of 7 © 2013 The Travelers Indemnity Company. Todos los derechos reservados. Travelers y el logotipo con la sombrilla de Travelers son marcas registradas de The Travelers Indemnity Company en los EE. UU. y otros paises. CE -10277 New 1 -2013 Este formulario cumple con los requisitos §3551, §3553, y el Reglamento Administrativo §9880 del C6digo Laboral, y fue aprobado por el Director Administrativo de la Divisi6n de Compensaci6n Laboral. Este formulario no puede modificarse. POLICYHOLDER NOTICE JANUARY 1, 2014 AUDIT REQUIREMENTS FOR POLICIES WITH FINAL PREMIUM OF LESS THAN $10,000 THAT DEVELOP PAYROLL IN HIGH WAGE DUAL WAGE CONSTRUCTION OR ERECTION CLASSIFICATIONS Dual wage classifications are pairs of classifications that describe the same construction or erection operation yet are assigned based upon whether the employee's hourly wage is above or below a specified threshold. Each pair of dual wage classifications contains one "high wage" classification that is assignable to payrolls earned by employees whose regular hourly wage equals or exceeds a specified wage threshold and one "low wage" classification that is assignable to payrolls earned by employees whose regular hourly wage is less than the specified threshold. If your policy effective on or after January 1, 2014 produces a final premium of less than $10,000 and develops payroll in a high wage classification, a physical audit of the policy is required unless the policy is a renewal and a physical audit was completed for one of the two immediately preceding policy periods. If your policy produces a final premium of $10,000 or more, a physical audit is required at least once a year. A "physical audit" is defined as an audit of payroll, whether conducted at the policyholder's location or at a remote site, that is based upon an auditor's examination of the policyholder's books of accounts and original payroll records (in either electronic or hard copy form) as necessary to determine and verify the exposure amounts by classification. W04N1B13 Page 1 of 1 PN 04 99 07 STATE OF CALIFORNIA IMPORTANT LOSS CONTROL INFORMATION The Loss Control Services outlined in the enclosed Safety Services notice are available at no additional cost to you. Workers' Compensation insurance policyholders may register comments about the insurer's loss control consultation services by writing to: State of California, Department of Industrial Relations, Division of Occupational Safety and Health, P.O. Box 420603, San Francisco, CA 94142. W04N1C01 POLICYHOLDER NOTICE PAYROLL RECORD REQUIREMENTS FOR DUAL WAGE CONSTRUCTION OR ERECTION CLASSIFICATIONS Dual wage classifications are pairs of classifications that describe the same construction or erection operation yet are assigned based upon whether the employee's hourly wage is above or below a specified threshold. Each pair of dual wage classifications contains one "high wage" classification that is assignable to payrolls earned by employees whose regular hourly wage equals or exceeds a specified wage threshold and one "low wage" classification that is assignable to payrolls earned by employees whose regular hourly wage is less than the specified threshold. Your policy includes one or more dual wage construction or erection classifications. The assignment of a high wage classification to any non - salaried employee is contingent on verifying that employee's hourly wage by reconciling the total number of hours the employee actually worked during the policy period against the em- ployee's time cards or time sheets that document the operations performed, the daily start and stop times and the total hours worked each day for that employee. The non - salaried employee's regular hourly wage shall be determined by dividing that employee's total remu- neration by the hours worked, irrespective of whether the employee is paid on an hourly, piecework, production or commission basis. The payroll earned by any non - salaried employees for whom we are unable to verify the total number of hours worked will be assigned to the low wage classification that describes the operations performed. The regular hourly wage of salaried employees is determined by dividing the total annual remuneration by 2000 hours. If an employee is salaried for less than 12 months, the regular hourly wage for the salaried period is calculated on a prorated basis. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Premium $ Insurance Company Countersigned by 01111H BHO173 PN 04 99 06 Page 1 of 1 ATTENTION The following Posting Notices must be displayed in a prominent location in the workplace. Please distribute these notices to the appropriate workplace locations. In the event that additional copies are desired, please contact your agent and request the number of copies of the particular notices that you may need. Posting notices for the states of MO, MN, NM and TX (Spanish Version) are provided in two separate forms which need to be connected to create one large notice to be posted. Please contact us at wcppn@travelers.com for assistance in completing the healthcare provider information on posting notices in PA, GA, TN, and VA. WUNNNB13 PN T5 53 07 13 Page 1 of 1 ISSUED TO: BUCKNAM INFRASTRUCTURE GROUP, ,w INC. STATE OF CALIFORNIA — DEPARTMENT OF INDUSTRIAL RELATIONS Division of Workers' Compensation Notice to Employees — Injuries Caused By Work You may be entitled to workers' compensation benefits if you are injured or become ill because of your job. Workers' compensation covers most work - related physical or mental injuries and illnesses. An injury or illness can be caused by one event (such as hurting your back in a fall) or by repeated exposures (such as hurting your wrist from doing the same motion over and over). Benefits. Workers' compensation benefits include: • Medical Care: Doctor visits, hospital services, physical therapy, lab tests, x -rays, and medicines that are reasonably necessary to treat your injury. You should never see a bill. There is a limit on some medical services. • Temporary Disability (TD) Benefits: Payments if you lose wages while recovering. For most injuries, TD benefits may not be paid for more than 104 weeks within five years from the date of injury. • Permanent Disability (PD) Benefits: Payments if your injury causes a permanent disability. • Supplemental Job Displacement Benefit: A nontransferable voucher payable to a state approved school if your injury arises on or after 1/1/04 and results in a permanent disability that prevents you from returning to work within 60 days after TD ends, and your employer does not offer you modified or alternative work. • Death Benefits: Paid to dependents of a worker who dies from a work - related injury or illness. Naming Your Own Physician Before Injury or Illness (Predesignation). You may be able to choose the doctor who will treat you for a job injury or illness. If eligible, you must tell your employer, in writing, the name and address of your personal physician or medical group before you are injured and your physician must agree to treat you for your work injury. For instructions, see the written information about workers' compensation that your employer is required to give to new employees. If You Get Hurt: 1. Get Medical Care. If you need emergency care, call 911 for help immediately from the hospital, ambulance, fire department or police department. If you need first aid, contact your employer. 2. Report Your Injury. Report the injury immediately to your supervisor or to an employer representative. Don't delay. There are time limits. If you wait too long, you may lose your right to benefits. Your employer is required to provide you a claim form within one working day after learning about your injury. Within one working day after you file a claim form, your employer shall authorize the provision of all treatment, consistent with the applicable treating guidelines, for your alleged injury and shall be liable for up to ten thousand dollars ($10,000) in treatment until the claim is accepted or rejected. 3. See Your Primary Treating Physician (PTP). This is the doctor with overall responsibility for treating your injury or illness. If you predesig- nated by naming your personal physician or medical group before injury (see above), you may see him or her for treatment in certain circum- stances. Otherwise, your employer has the right to select the physician who will treat you for the first 30 days. You may be able to switch to a doctor of your choice after 30 days. Different rules apply if your employer offers a Health Care Organization (HCO) or has a Medical Provider Network (MPN). You should receive information from your employer if you are covered by an HCO or a MPN. Contact your employer for more information. 4. Medical Provider Networks. Your employer may be using a MPN, which is a selected network of health care providers to provide treatment to workers injured on the job. If your employer is using a MPN, a MPN notice should be posted next to this poster to explain how to use the MPN. You can request a copy of this notice by calling the MPN number below. If you have predesignated a personal physician prior to your work injury, then you may receive treatment from your predesignated doctor. If you have not predesignated and your employer is using a MPN, you are free to choose an appropriate provider from the MPN list after the first medical visit directed by your employer. If you are treat- ing with a non -MPN doctor for an existing injury, you may be required to change to a doctor within the MPN. For more information, see the MPN contact information below: Current MPN's toll free number: (800) 287 -9682 MPNwebsite: WWW. MYWCINFO. COM MPN Effective Date Current MPN's address:, P.O. BOX 6510 DIAMOND BAR CA 91765 Discrimination. It is illegal for your employer to punish or fire you for having a work injury or illness, for filing a claim, or testifying in another person's workers' compensation case. If proven, you may receive lost wages, job reinstatement, increased benefits, and costs and expenses up to limits set by the state. Questions? Learn more about workers' compensation by reading the information that your employer is required to give you at time of hire. If you have questions, see your employer or the claims administrator (who handles workers' compensation claims for your employer): TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA Claims Administrator Phone 1 -800- 238 -6225 Workers' compensation Insurer, (Enter "self- insured" if appropriate) Policy Expiration Date 09-16-14 If the workers' compensation policy has expired, contact a Labor Commissioner at the Division of Labor Standards Enforcement (DLSE). You can also get free information from a State Division of Workers' Compensation Information & Assistance Officer. The nearest Information & Assistance Officer can be found at location: or by calling toll -free (800) 736 -7401. Learn more information about DWC and DLSE online: www.dwc.ca.gov or www.dir.ca.gov /dlse. False claims and false denials. Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony and may be fined and Your recreational',. social, or ath DWC 7 (6/10) W04P2H10 ISSUED TO: BUCKNAM INFRASTRUCTURE GROUP, INC. ESTADO DE CALIFORNIA - DEPARTAMENTO DE RELACIONES INDUSTRIALES Division de Compensacion de Trabajadores Aviso a los Empleados - Lesiones Causadas por el Trabajo Es posible que usted tenga derecho a beneficios de compensacion de trabajadores si usted se lesiona o se enferma a causa de su trabajo. La compensacion de trabajadores cubre la mayoria de las lesiones y enfermedades fisicas o mentales relacionadas con el trabajo. Una lesion o enfermedad puede ser causada por un evento (como por ejemplo el lastimarse la espalda on una caida) o por acciones repetidas (como por ejemplo lastimarse la muneca por hater el mismo movimiento una y otra vez). Beneficiios. Los beneficios de compensacion de trabajadores incluyem • Atenci6n Medica: Consultas medicas, servicios de hospital, terapia fisica, analisis de laboratorio, radiograf as y medicinas que son razonablemente necesarias para tratar su les6n. Usted nunca debera ver un cobro. Hay un limite para ciertos servicios medicos. • Beneficios por Incapacidad Temporal (TD): Pagos si usted pierde sueldo mientras se recupera. Para la mayoria de las lesiones, beneficios de TD no se pagaran por mas de 104 semanas dentro de cinco anos despues de la fecha de la lesion. • Beneficios por Incapacidad Permanente (PD): Pagos si su lesion le causa una incapacidad permanente. • Beneficio Suplementario por Desplazamiento de Trabajo: Un vale no- transferible pagadero a una escuela aprobada por el estado si su lesion surge en o despues del 1/1/04, y le ocasiona una incapacidad permanente que le impida regresar al trabajo dentro de 60 dias despues de que los pagos por TD terminen y su empleador no le ofrece a usted un trabajo modificado o alternativo. • Beneficios por Muerte: Pagados a los dependientes de un(a) trabajador(a) que muere a causa de una lesion o enfermedad relacionada con el trabajo. Designaci6n de su Propio Medico Antes de una Lesion o Enfermedad (Designaci6n previa). Es posible que usted pueda elegir al medico que le atendera en una lesion o enfermedad relacionada con el trabajo. Si elegible, usted debe informarle al empleador, por escrito, el nombre y la direcci6n de su medico personal o grupo medico, antes de que usted se lesione y su medico debe estar de acuerdo de atenderle la lesion causada por el trabajo. Para instrucciones, vea la informacion escrita sobre la compensacion de trabajadores que se le exige a su empleador darle a los empleados nuevos. Si Usted se Lastima: 1. Obtenga Atencion Medica. Si usted necesita atenci6n de emergencia, Ilame al 911 para ayuda inmediata de un hospital, una ambulancia, el departamento de bomberos o departamento de policia. Si usted necesita primeros auxilios, comuniquese con su empleador. 2. Reporte su Lesion. Reporte la lesion inmediatamente a su supervisor(a) o a un representante del empleador. No se demore. Hay limites de tiempo. Si usted espera demasiado, es posible que usted pierda su derecho a beneficios. Su empleador esta obligado a proporcionarle un formulario de reclamo dentro de un dia laboral despues de saber de su lesion. Dentro de un dia despues de que usted presente un formulario de reclamo, el empleador autorizara todo tratamiento medico de acuerdo con las pautas de tratamiento aplicables a su presunta lesion y sera responsable por diez mil dolares ($10,000) en tratamiento hasta que el reclamo sea aceptado o rechazado. 3. Consulte al Medico que le esta Atendiendo (PTP). Este es el medico con la responsabilidad total de tratar su lesion o enfermedad. Si usted design6 previamente a su medico personal o grupo medico antes lesionarse (vea uno de los parrafos anteriores), en ciertas circunstancias, usted puede consultarlo para el tratamiento. De otra forma, su empleador tiene el derecho de seleccionar al medico que le atendera durante los primeros 30 dias. Es posible que usted pueda cambiar a un medico de su preferencia despues de 30 dias. Hay reglas diferentes que se aplican cuando su empleador ofrece una Organization de Cuidado Medico (HCO) o si tiene una Red de Proveedores Medicos (MPN). Usted debe recibir informacion de su empleador si esta cubierto por una HCO o una MPN. Hable con su empleador para mas informacion. 4. Red de Proveedores Medicos (MPN): Es posible que su empleador use una MPN, to cual es una red de proveedores de asistencia medica seleccionados para dar tratamiento a los trabajadores lesionados en el trabajo. Si su empleador usa una MPN, una notification de la MPN debe estar al lado de este cartel para explicar como usar la MPN. Usted puede pedir una copia de esta notification hablando al numero de la MPN debajo descrito. Si usted ha hecho una designaci6n previa de un medico personal antes de lesionarse en el trabajo, entonces usted puederecibir tratamiento de su medico previamente designado. Si usted no ha hecho una designation previa y su empleador esta usando una MPN, usted puede escoger un proveedor apropiado de la lista de la MPN despues de la primera visita medica dirigida por su empleador. Si usted esta recibiendo tratamiento de parte de un medico que no pertenece a la MPN para una lesion existente, puede requerirse que usted se cambie a un medico dentro de la MPN. Para mas informacion, vea la siguente informacion del contacto de la MPN : Numero gratuito de la MPN vigente: (800) 287 -9682 Pagina web de la MPN:. WWW. MYWCINFO. COM Fecha de vigencia de la MPN Direcci6n de la MPN vigente P.O. BOX 6510 DIAMOND BAR, CA 91765 Discrimination. Es ilegal que su empleador le castigue o despida por sufrir una lesion o enfermedad en el trabajo, por presenter un reclamo o por testificar en el caso de compensacion de trabajadores de otra persona. De ser probado, usted puede recibir pagos por perdida de sueldos, reposici6n del trabajo, aumento de beneficios y gastos hasta los limites establecidos por el estado. LPreguntas? Aprenda mas sobre la compensacion de trabajadores leyendo la informacion que se requiere que su empleador le de cuando es contratado. Si usted tiene preguntas, vea a su empleador o al administrador de reclamos (que se encarga de los reclamos de compensacion de trabajadores de su empleador): Administrador TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA de Reclamos Telefono 1- 800 - 238 -6225 Asegurador del Seguro de Compensacion de trabajador ( Anote "autoasegurado" si es apropiado) Fecha de Vencimiento de la P61iza 09-16-14 Si la p6liza de compensacion de trabajadores se ha vencido, comuniquese con el Comisionado Laboral, en la Division para el Cumplimiento de las Normas Labora /es (Division of Labor Standards Enforcement- DLSE). Usted tambien puede obtener informacion gratuita de un Oficial de Informaci6n y Asistencia de la Division Estatal de Compensacion de Trabajadores. El Oficial de Informacion y Asistencia mas cercano se localiza en o Ilamando al numero gratuito (800) 736 -7401. Usted puede obtener mas informacion sobre de la DWC y DLSE en el Internet en: www.dwc.ca.gov o www.dir.ca.gov /dise. Los reclamos falsos y rechazos falsos del reclamo. Cualquier persona que haga o que ocasione que se haga una declaraci6n o una representation material intencionalmente falsa o fraudulenta, con el fin de obtener o negar beneficios o pagos de compensacion de Irabaiadores. es culpable de un delito orave v ouede ser multado v encarcOado, en cuaiquaer activ+aaa Mora aet xraoafo, recreaarva, social o avoisca que no sea parse ce sus NAME INSURED: BUCKNAM INFRASTRUCTURE GROUP, INC. POLICY NUMBER: (XJUB- 3790T99 -A -13) EFFECTIVE DATE: 09 -16 -13 GUNTHER OPERATOR: MANUALLY INSERT 1 COPIES OF W04P1 CALIFORNIA OVERSIZED POSTING NOTICE W04X1 U10 See instructions on other side.