Miller WC-2 2016WC 00 00 01A U WC-D-314-A (07-94)
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COMMERCIAL INSURANCE
WORKERS COMPENSATION AND EMPLOYERS LIABILITY
INSURANCE POLICY ---- INFORMATION PAGE
Servicing Office:
Insurance for this coverage part provided by:
1. Policy Number Renewal of Number
Named Insured and Mailing Address Producer and Mailing Address
Producer Code
Other workplaces not shown above:
FEIN:
NCCI Company No. New Renewal Rewrite of Prior Policy No.
This information page, with policy provisions and endorsements, if any, completes this policy.
Insured is:
2. Policy Period: From: to at 12:01 A. M. Standard Time at insured’s mailing address.
Insured’s Identification number(s):
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers’ Compensation Law of the
states listed here:
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.
The Limits of Liability under Part Two are: Bodily Injury by Accident: each accident
Bodily Injury by Disease: policy limit
Bodily Injury by Disease: each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
See Endorsement
D. This Policy includes these endorsements and schedules:
See Schedule of Forms and Endorsements.
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All
information required on the following Classification Schedule is subject to verification and change by audit.
See Classification Schedule
TOTAL ESTIMATED STANDARD PREMIUM $
PREMIUM DISCOUNT $
EXPENSE CONSTANT $
If indicated below, adjustments
of premium shall be made:
PREMIUM FOR ENDORSEMENT $
TAXES AND SURCHARGES $
TOTAL ESTIMATED ANNUAL PREMIUM $
MINIMUM PREMIUM $
DEPOSIT PREMIUM $
Annually
Semi-Annually
Quarterly
Monthly
This is a Three
Year Fixed Rate
Policy
Agent or Producer Countersigned by Resident Licensed Agent Date
10863 X
913646614\913646614\913646614\689359\913646614\2792299
X
CT,MA,MD,NJ,NY,PA
1,000,000
1,000,000
1,000,000
965,199.00
-172,750.00
338.00
25,189.00
817,976.00
SCHAUMBURG
1400 AMERICAN LANE
SCHAUMBURG,IL 60196
WC 0381721-01 WC 0381721-00
07-01-2016 07-01-2017
ZURICH AMERICAN INSURANCE COMPANY
CORPORATION
11882-000
23-2548775
WAMPOLE-MILLER, INC. DBA MILLER
(SEE NAMED INSURED ENDORSEMENT)
301 ALAN WOOD RD
CONSHOHOCKEN PA 19428
THE SAFEGARD GROUP INC
100 GRANITE DR STE 205
MEDIA PA 19063-5134
ABCOMMERCIAL INSURANCE
SCHEDULE OF FORMS AND ENDORSEMENTS
Policy Number:
Form Number & Edition Date Form Name
U-WC-320-A (07-94)
WC 0381721-01
COMMON POLICY FORMS AND ENDORSEMENTS
U-GU-406-A 07-94 INSTALLMENT PREMIUM SCHEDULE
FORMS AND ENDORSEMENTS
U-WC-D-314-A 07-94 WORKERS COMPENSATION INFORMATION PAGE
WC 99 03 02 05-04 FOREIGN VOLUNTARY COMPENSATION U-GU-1208-A CW 11-15 HEADQUARTERS ADDRESS CHANGE U-WC-315-A 07-94 CLASSIFICATION SCHEDULE
U-WC-D-322-A 07-94 SUPPLEMENTAL INFORMATION PAGE WC 00 00 00 C 01-15 INSURANCE POLICY WC 00 01 06 A 04-92 LONGSHORE/HARBOR WORKERS’ COMP COVG ENDT
WC 00 03 01 A 02-89 ALTERNATE EMPLOYER ENDORSEMENT WC 00 03 03 C 10-04 EMPLOYERS LIABILITY COV ENDT
WC 00 03 13 04-84 WAIVER OF RIGHTS TO RECOVER FROM OTHERS WC 00 04 04 04-84 PENDING RATE CHANGE ENDORSEMENT WC 00 04 14 07-90 NOTIFICATION OF CHANGE IN OWNERSHIP ENDT
WC 00 04 21 D 01-15 CATASTROPHE (OTHER THAN CERT ACTS) ENDT WC 00 04 22 B 01-15 TERRORISM RISK PGM REAUTH ACT DISCL ENDT WC 99 00 02 10-99 SCHEDULE OF INSUREDS AND LOCATIONS
WC 99 06 43 01-13 BLANKET NOTIFICATION TO OTH CANC/NONREN U-WC-332-A 07-94 CANCELLATION MANUSCRIPT U-WC-320-A 07-94 SCHEDULE OF FORMS AND ENDORSEMENTS
U-WC-321-A 07-94 NAMED INSURED SCHEDULE WC 00 03 11 A 08-91 VOLUNTARY COMPENSATION AND EMPLOYERS COV WC 00 03 02 04-84 DESIGNATED WORKPLACES EXCLUSION ENDT
WC 00 03 03 A 01-86 EMPLOYERS LIABILITY COVERAGE ENDORSEMENT WC 00 04 03 04-84 EXPERIENCE RATING MOD FACTOR ENDORSEMENT
WC 00 04 06 08-84 PREMIUM DISCOUNT ENDORSEMENT WC 00 04 06 A 07-95 PREMIUM DISCOUNT ENDT WC 06 03 01 04-84 CT APPLICATION OF WORKERS’ COMP INS
WC 06 03 03 C 07-11 CT WC FUNDS COVERAGE ENDT WC 06 06 01 01-03 CT NONRENEWAL ENDT WC 19 06 02 01-14 MD NOTIF 45-DAY UNDERWRITING PERIOD ENDT
WC 20 03 01 04-84 MA LIMITS OF LIABILITY ENDT WC 20 03 02 A 09-08 MA ASSESSMENT CHARGE WC 20 03 03 D 08-10 MA NOTICE TO POLICYHOLDER ENDT
WC200405 06-01 MA PREMIUM DUE DATE ENDT WC 20 06 01 A 07-08 MA CANCELLATION ENDT
WC 29 03 06 B 07-07 NJ PART TWO EMPLOYERS LIABILITY ENDT WC 31 03 08 04-84 NY LIMIT OF LIABILITY WC 31 03 19 G 10-13 NY CONST CLASS PREM ADJ ENDT
WC 31 06 17 A 10-08 NY FOREIGN VOLUNTARY COMP & EMP LIAB COV WC 31 06 18 03-15 NY POLICY NOTICE OF RIGHT TO APPEAL WC 37 06 01 04-84 SPECIAL PENN ENDT-INSPECTION OF MANUALS
WC 37 06 02 04-84 PA NOTICE WC 37 06 03A 08-95 PA ACT 86-1986 ENDT WC 37 06 04 10-99 PA EMPLOYER ASSESSMENT ENDORSEMENT
WC990001A 04-10 WC AND EMPLOYERS LIABILITY IN WITNESS WC 29 04 11 C 01-16 NJ PREMIUM DISCOUNT ENDORSEMENT WC 19 06 01 F 01-16 MD CANCELLATION AND NONRENEWAL ENDT
WC 20 04 01 11-90 MA PENDING PREMIUM CHANGE ENDT U-WC-402-A 05-03 MODIFICATION OF TIME FOR NOTICE OF CANCL
WC 00 04 19 01-01 PREMIUM DUE DATE ENDORSEMENT WC 99 03 15 09-04 FOREIGN VOLUNTARY COMPENSATION
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ABCOMMERCIAL INSURANCE
NAMED INSURED SCHEDULE
Policy Number:
U-WC-321-A (07-94)
WC 0381721-01
NAMED INSURED
WAMPOLE-MILLER, INC. DBA MILLER BROS; MILLER BROS ELECTRICAL CONTRACTORS; MILLER BROS SOLAR, LLC; MILLER BROS REALTY, LLC; 301 ALANWOOD ASSOCIATES, LP
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