Loading...
2021 WC policyWORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Extension Schedule Massachusetts Bay Self-Insurance Group, Inc. WC 00 00 01 A Policy Number Insurer:Massachusetts Bay Self-Insurance Group, Inc. Location Number 1 Insured: State:MA From:To: Policy Period 01/01/21 01/01/22 12:01 A.M.Standard Time Policy Rating Period 01/01/21 01/01/22 Code Premium Basis Classifications No.Total Actual Rate Per Actual Annual $100 of Annual Remuneration Remuneration Premium Paving & Repairing 5221 23,504$ 6.12$ 1,438$ Carpentry 5403 127,972$ 7.77$ 9,943$ Floor Covering Installs 5478 7,011$ 3.63$ 254$ Drivers 7380 187,654$ 5.32$ 9,983$ Clerical Office Employees NOC 8810 636,241$ 0.06$ 382$ Hotel: All Other Employees 9052 1,116,957$ 1.33$ 14,856$ Hotel: Restaurant Employees 9058 393,347$ 1.26$ 4,956$ Lawn Maintenance 9102 8,467$ 2.02$ 171$ -$ Total Payroll 2,501,153$ 41,984$ 41,984$ 420$ 42,404$ Exp. Mod. 1.01 42,828$ 1.00$ A.R.A.P. Surcharge -$ Comp 21 Discount 0%42,828$ 1,674$ Terrorism Risk 750$ 338$ Comp 21 Discount -$ 42,242$ 617$ 42,859$ Expense Constant Total Premium and Surcharge(s) Mass. DIA Assessment (.0144%) Total Estimated Premium Excess Employers Liability 1% Subject Premium Experience Modifier Premium Standard Premium WC202108373 A.R.A.P. Premium Discount The Lathrop Community Inc. 100 Bassett Brook Drive Easthampton, MA 01027 Manual Premium at The Insured Mailing Address Issue Date: November, 2020 Form 101 MASSACHUSETTS BAY SELF-INSURANCE GROUP, INC. Workers' Compensation And Employers Liability Insurance Certificate Massachusetts Bay Self-Insurance Group, Inc. 15 Cabot Road Woburn, MA 01801 To Report a Claim, Please Call (800) 222-5963 www.mbsig.org LATHROP COMMUNITY, INC. Issue Date: 11/23/2020 WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE CERTIFICATE Information Page WC 00 00 01 A (Ed. 01/02) Massachusetts Bay Self-Insurance Group, Inc. Certificate Number: WC202180373 Prior Certificate Number: WC202080373 1. INSURED: Lathrop Community, Inc. Producer: 100 Bassett Brook Drive Cabot Risk Strategies LLC Easthampton, MA 01027 Federal ID Number 15 Cabot Road 04 2996627 Woburn, MA 01801 Risk ID Number Business Type Corporation Other Named Insured: 2. CERTIFICATE PERIOD: The Certificate Period Is From: 01/01/2021 To 01/01/2022 12:01 A.M. Standard Time at The Insured Mailing Address 3. COVERAGES: A. Workers Compensation Insurance: Part One of the certificate applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the certificate applies to work in each state listed in item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $500,000 each accident Bodily Injury by Disease $500,000 certificate limit Bodily Injury by Disease $500,000 each employee C. Other States Insured: Part Three of the certificate applies to the states, if any, listed here: All States Except ND, OH, WA, WY, and states designated in Item 3A. D. This certificate includes these endorsements and schedules: WC 00 00 01 A, Form 102, WC 00 00 00 A, WC 00 04 06, WC 20 01 01, WC 20 03 01, WC 20 03 02, WC 20 03 03 A, WC 20 03 06 B, WC 20 06 01 4. COVERAGES: The premium for this certificate will be determined by our Manual of Rules, Classifications, Rates & Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Total Rate Per Estimated Classifications Code Estimated Annual $100 of Annual No. Remuneration Remuneration Premium See Information Page Extension. Minimum Premium Deposit Premium $ $ Interim Adjustment Annual Servicing Office: Cabot Risk Strategies LLC Total Estimated Premium $ 42,242 15 Cabot Road MA DIA Assessment $ 617 Woburn, MA 01801 Total Premium and Surcharge(s) $ 42,859 Issue Date: 11/23/2020 Countersigned by: Date: 11/23/2020 WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE CERTIFICATE Extension Schedule WC 00 00 01 A (Ed. 01/02) Massachusetts Bay Self-Insurance Group, Inc. Certificate Number: WC202180373 Insurer: Massachusetts Bay Self-Insurance Group, Inc. Location Number: 1 Insured: The Lathrop Community Inc. State: MA The Certificate Period Is From: 01/01/2021 To 01/01/2022 12:01 A.M. Standard Time at The Insured Mailing Address Certificate Rating Period: 01/01/2021 To 01/01/2022 Code Premium Basis Total Rate Per Estimated Classifications No. Estimated Annual $100 of Annual Remuneration Remuneration Premium Paving & Repairing 5221 $ 23,504 $ 6.12 $ 1,438 Carpentry 5403 $ 127,972 $ 7.77 $ 9,943 Floor Covering & Installs 5478 $ 7,011 $ 3.63 $ 254 Drivers 7380 $ 187,654 $ 5.32 $ 9,983 Clerical Office Employees NOC 8810 $ 636,241 $ 0.06 $ 382 Hotel: All Other Employees 9052 $ 1,116,957 $ 1.33 $ 14,856 Hotel: Restaurant Employees 9058 $ 393,347 $ 1.26 $ 4,956 Lawn Maintenance 9102 $ 8,467 $ 2.02 $ 171 Manual Premium $ 41,984 Excess Employers Liability 1% $ 420 Subject Premium $ 42,404 Exp. Modifier 1.01, Modified Premium $ 42,828 ARAP 1.00, Surcharge $ 0 Standard Premium $ 42,828 Premium Discount $ 1,674 Terrorism Risk $ 750 Expense Constant $ 338 Comp 21 Discount $ 0 Total Estimated Premium $ 42,242 Mass. DIA Assessment (.0144%) $ 617 Total Premium and Surcharge(s) $ 42,859 WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE CERTIFICATE Massachusetts Bay Self-Insurance Group, Inc. Installment Schedule Insured: Lathrop Community, Inc. Certificate Number: WC202180373 Certificate Installments: Installment Amount Due Date Deposit $ 10,715 01/01/2021 (1) $ 4,592 02/01/2021 (2) $ 4,592 03/01/2021 (3) $ 4,592 04/01/2021 (4) $ 4,592 05/01/2021 (5) $ 4,592 06/01/2021 (6) $ 4,592 07/01/2021 (7) $ 4,592 08/01/2021 Form: 102 (Ed. 01/02) Massachusetts Bay Self-Insurance Group, Inc. Page 1 of 6 WC 00 00 00 A (Ed. 01/02) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE CERTIFICATE In return for the payment of the premium and subject to all terms of this certificate, we agree with you as follows. GENERAL SECTION A. The Certificate This certificate includes at its effective date the Infor- mation 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 insur- ance are stated in this certificate. The terms of this certificate may not be changed or waived except by endorsement issued by us to be part of this certificate. 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 in- sured, 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 certificate pe- riod. It does not include any federal workers or workmen’s compensation law, any federal occupa- tional disease law or the provisions of any law that provide non-occupational disability benefits. D. State State means any state of the United States of Ameri- ca, and the District of Columbia. E. Locations This certificate covers all your workplaces listed in items or of the Information Page: and its covers all other workplaces in item 3.A. states unless you have other insurance or are self-insured for such workplac- es. PART ONE - WORKERS COMPENSATION INSURANCE A. How This Insurance Applies This workers compensation insurance applies to bodi- ly injury by accident or bodily injury by disease. Bodi- ly injury includes resulting death. 1. Bodily injury by accident must occur during the certificate period. 2. Bodily Injury by disease must be caused or ag- gravated by the conditions of your employment. The employee’s last day of last exposure to the conditions causing or aggravating such bodily in- jury by disease must occur during the certificate 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 in- vestigate 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 to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. Massachusetts Bay Self-Insurance Group, Inc. Page 2 of 6 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 un- til 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 com- pensation 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 other-wise 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. G. Recovery From Others We have your rights, and the rights of persons entitled 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. 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 or the workers compensation law. We are bound by decisions against you under the law, subject to the provisions of this certificate 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 oth- er 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. Nothing in these paragraphs relieves you of your du- ties under this certificate. 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. 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 certificate period. 4. Bodily injury by disease must be caused or ag- gravated by the conditions of your employment. The employee’s last day of last exposure to the conditions causing or aggravating such bodily in- jury by disease must occur during the certificate 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 Unit- ed States of America, its territories or possessions, or Canada. B. We Will Pay We will pay all sums you legally must pay as damag- es because of bodily injury to your employees, pro- vided the bodily injury is covered by this Employers Liability Insurance. Massachusetts Bay Self-Insurance Group, Inc. Page 3 of 6 The damages we will pay, where recovery is permit- ted 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 con- sequence 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 offic- ers; 4. any obligation imposed by a worker compensa- tion, occupational disease, unemployment com- pensation, or disability benefits law, or any similar 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 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 defama- tion, 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 non- appropriated Fund Instrumentalities Act (5 USC Sections 8171-8173), the Outer Continental Shelf Lands Act (43 USC Sections 1331-1356), the De- fense Base Act (42 USC Sections 1651-1654), the Federal Coal Mine Health and Safety Act of 1969 (30 USC Sec-tions 901-942), 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 em- ployment, 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 Sea- sonal Agricultural Worker Protection Act (29 USC Sections 1801-1872) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments 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 in- vestigate 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 du- ty to defend or continue defending after we have paid our applicable limit of liability under this insurance. 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, or suit we defend: 1. reasonable expenses incurred at our request, but not loss of earnings; Massachusetts Bay Self-Insurance Group, Inc. Page 4 of 6 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 judgment 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.B. 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 re- sults directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for “bodily injury by disease - certificate limit” is the most we will pay for all damages covered by this insurance and arising out of bodily injury by dis- ease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for “bodily injury by disease - each em- ployee” is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include disease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance. H. Recovery From Others We have your rights to recover our payment from an- yone 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 certif- icate: and 2. the amount you owe has been determined with our consent or by actual trial and final judgment. 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 1. This Other States Insurance applies only if one or more states are shown in item 3.C. of the Infor- mation Page. 2. If you begin work in any one of those states after the effective date of this certificate and are not insured or are not self-insured for such work, all provisions of the certificate will apply as though that state were listed in Item 3.A. of the Infor- mation Page. 3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have work on the effective date of this cer- tificate in any state not listed in item 3.A. of the Informa-tion 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. PART FOUR - YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this certificate. Your other duties are listed here. 1. Provide for immediate medical and other services required by the workers compensation law. Massachusetts Bay Self-Insurance Group, Inc. Page 5 of 6 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need. 3. Promptly give us all notices, demands and legal papers related to the injury, claim, proceeding or suit. 4. Cooperate with us and assist us, as we may re- quest, in the investigation, settlement or defense of any claim, proceeding or suit. 5. Do nothing after an injury occurs that would inter- fere with our right to recover from others. 6. Do not voluntarily make payments, assume obli- gations or incur expenses, except at your own cost. PART FIVE - PREMIUM A. Our Manuals All premium for this certificate will be determined by our manuals of rules, rates, plans and classifications. We may change our manuals and apply the changes to this certificate if authorized by law or a governmen- tal agency regulating this insurance. B. Classifications Item 4 of the Information Page shows the rate and premium basis for certain business or work classifica- tions. These classifications were assigned based on an estimate of the exposures you would have during the certificate period. If your actual exposures are not properly described by those classifications, we will assign proper classifications, rates and premium ba- sis by endorsement to this certificate. C. Remuneration Premium for each work classification is determined by multiplying a rate times a premium basis. Remunera- tion is the most common premium basis. This premi- um basis includes payroll and all other remuneration paid or payable during the certificate period for the services of: 1. all your officers and employees engaged in work covered by this certificate; and 2. all other persons engaged in work that could make us liable under Part One (Workers Com- pensation Insurance of this certificate. If you do not have payroll records for these persons, the contract price for their services and materials may be used as the premium basis. This para- graph 2 will not apply if you give us proof that the employers of these persons lawfully secured their workers compensation obligations. D. Premium Payments You will pay premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. E. Final Premium The premium shown on the Information Page, sched- ules, and endorsements is an estimate. The final premium will be determined after this certificate 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 certifi- cate. 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 the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this certifi- cate. If this certificate is canceled, final premium will be de- termined in the following way unless our manuals provide otherwise. 1. If we cancel, final premium will be calculated pro rata based on, the time this certificate was in force. Final premium will not be less than the pro rata share of the minimum premium. 2. If you cancel, final premium will be more than pro rate; it will be based on the time this certificate was in force, and increased by our short rate cancellation able and procedure. Final premium will not be less than the minimum premium. F. Records You will keep records of information needed to com- pute premium. You will provide us with copies of those records when we ask for them. G. Audit You will let us examine and audit all your records that relate to this certificate. These records include ledg- ers, journals, registers, vouchers, contracts, tax re- ports, payroll and disbursement records, and programs for storing and retrieving data. We may conduct the audits during regular business hours dur- ing the certificate period and within three years after the certificate period ends. Information developed by audit will be used to determine final premium. Insur- ance rate service organizations have the same rights we have under this provision. Massachusetts Bay Self-Insurance Group, Inc. Page 6 of 6 PART SIX - CONDITIONS A. Inspection We have the right, but are not obligated to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the 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 employees 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 Certificate If the certificate period is longer than one year and sixteen days, all provisions of this certificate will apply as though a new certificate were issued on each an- nual anniversary that this certificate is in force. C. Transfer Of Your Rights And Duties Your rights or duties under this certificate 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 representative as insured. D. Cancellation 1. You may cancel this certificate. You must mail or deliver advance notice to us stating when the cancellation is to take effect. 2. We may cancel this certificate. We must mail or deliver to you not less than ten days advance written notice stating when the cancellation is to take effect. Mailing that notice to you at your mailing address shown in item 1 of the Infor- mation Page will be sufficient to prove notice. 3. The certificate period will end on the day and hour stated in the cancellation notice. 4. Any of these provisions that conflicts with a law that controls the cancellation of the insurance in this certificate is changed by this statement to comply with that 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 certificate, receive return premium, and give or re- ceive notice of cancellation. In Witness Whereof, we have caused this certificate to be executed and attested, and, if required by state law, this certificate shall not be valid unless countersigned by our authorized representative. Signature Cecile Durham Title President WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE CERTIFICATE PREMIUM DISCOUNT ENDORSEMENT WC 00 04 06 (Ed. 01/10) Massachusetts Bay Self-Insurance Group, Inc. The premium for this certificate and the certificates, if any, listed in Item 3 of Schedule may be eligible for a discount. This endorsement shows your estimated discount in Items 1 or 2 of the Schedule. The final calculation of premium discount will be determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective rating is not subject to premium discount. Schedule 1. State Estimated Eligible Premium MA First Next Next Over $10,000 $190,000 $1,550,000 $1,750,000 0% 5.1 % 6.5% 7.5% 2. Average percentage discount: 3. Other certificates: 4. If there are no entries in Items 1, 2 and 3 of the Schedule, see premium discount endorsement attached to your Certificate number. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 20 01 01 Massachusetts Bay Self-Insurance Group, Inc. MASSACHUSETTS TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT ENDORSEMENT This Endorsement addresses requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2007. 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 there to 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 population 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 (including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance 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 applicable 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 Page 1 of 2 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 20 01 01 Massachusetts Bay Self-Insurance Group, Inc. $100,000,000,000. 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. Policyholder Disclosure Notice 1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses exceeds $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 exceeds $100,000,000,000. 3. The premium charged for the coverage for Insured Losses under this policy is shown in Item 4 of the Information Page. Page 2 of 2 WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE CERTIFICATE WC 20 03 01 (Ed. 01/02) Massachusetts Bay Self-Insurance Group, Inc. MASSACHUSETTS LIMITS OF LIABILITY ENDORSEMENT This endorsement applies only to the insurance provided by Part Two (Employers Liability Insurance) because Massachusetts is listed in Item 3.A. of the Information Page. Our liability to you under Section 25 of Chapter 152 of the General Laws of Massachusetts is not subject to the limit of liability that applies to Part Two (Employers Liability Insurance). WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE CERTIFICATE WC 20 03 02 (Ed. 01/02) Massachusetts Bay Self-Insurance Group, Inc. MASSACHUSETTS-ASSESSMENT CHARGE Massachusetts General Laws, Chapter 152, Section 65, as amended by Chapter 572 of the Acts of 1985, establishes a workers compensation special fund and a workers compensation trust fund. On behalf of the Department of Industrial Accidents (DIA), the insurance company providing workers compensation coverage is required to bill and collect an assessment charge covering the special and trust funds from insured employers and remit the amounts collected to the State Treasury. The assessment charge, which is determined by applying a rate (subject to annual change) to the standard premium developed under your certificate, is shown as a separate item on the information page of the certificate. The rate may be different for private employers and for the Commonwealth and its political subdivisions. The income derived from the assessment charge will be used to fund the operating expenses of the DIA and to fund certain employee benefits as described in Chapter 152. WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE CERTIFICATE WC 20 03 03 A (Ed. 01/02) Massachusetts Bay Self-Insurance Group, Inc. MASSACHUSETTS NOTICE TO POLICYHOLDER ENDORSEMENT This endorsement applies only to the insurance provided by the certificate because Massachusetts is shown in Item 3.A. of the Information Page. 1. Rates and Premium The policy contains rates and classifications that apply to your type of business. If you have any questions regarding the rates or classifications, please contact your agent or us. You may obtain pertinent rating information by submitting a written request to us at our address shown on this endorsement. We may require you to pay a reasonable charge for furnishing the information. You may also submit a written request for a review of the method by which your classifications, rates or premiums were determined. If you are not satisfied with the results of the review, you may appeal to the Commissioner of Insurance at the address shown in the endorsement. 2. Reserves and Settlements You may request a loss run which contains reserve and settlement information for claims that relate to the premium for this certificate. Such a request must be in writing and should be sent to our address shown on this endorsement. We will provide you with that information within thirty (30) days of receipt of our request, and at reasonable intervals thereafter. If you have any questions or believe that we set unreasonable reserves or made unreasonable settlements that affected your premiums or losses, you may make a written request through your agent or directly to us for a meeting with our company representative. If you are not satisfied with the results of the meeting, you may make a written appeal to the Insurance Commissioner at the address shown on this endorsement. Addresses Commissioner of Insurance Massachusetts Bay Self-Insurance Group, Inc. Division of Insurance 15 Cabot Road Commonwealth of Massachusetts Woburn, MA 01801-1728 One South Station Boston, MA 02110 WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE CERTIFICATE WC 20 03 06 B (Ed. 06/13) Massachusetts Bay Self-Insurance Group, Inc. MASSACHUSETTS LIMITED OTHER STATES BENEFIT ENDORSEMENT THIS ENDORSEMENT REPLACES PART THREE OF THE POLICY: OTHER STATES INSURANCE. A. How This Endorsement Applies 1. We do not provide other states insurance coverage as described in Part Three of the Policy. Furthermore, the Massachusetts Limited Other States Benefit Endorsement does not satisfy the requirements of another state’s workers’ compensation law. However, pursuant to this endorsement, we will pay promptly, when required by the workers’ compensation law of a state other than Massachusetts, the benefits due to employees pursuant to such other state’s law, but only if the claim for such benefits involves work performed by a Massachusetts employee. For purposes of this Endorsement, a Massachusetts employee is someone whose contract of hire was made in Massachusetts or whose work for you, as of the date of injury, has primarily been conducted in Massachusetts. Other state’s benefits will not be paid if: a. The employee is claiming benefits in a state where, at the time of injury, you have other workers’ compensation insurance coverage that would cover the injured employee, or b. You were, by virtue of the nature of your work or operations in that state, required by that state’s law to have obtained separate workers’ compensation insurance coverage in that state that would cover the injured employee. 2. If we are not permitted to pay the benefits directly to persons entitled to them under circumstances described in Item 1 above, we will reimburse you for the benefits required to be paid. 3. If you hire any employees to work outside Massachusetts or begin work or operations in any state other than Massachusetts, you must obtain any insurance coverage required by that state’s laws, as this Limited Other States Benefit Endorsement does not satisfy the requirements of that state’s workers’ compensation insurance law. 4. This endorsement does not affect the payment of Massachusetts benefits under this Policy. Notes: 1. Servicing carriers and voluntary direct assignment carriers must attach this endorsement to all policies issued through the Massachusetts Workers’ Compensation Assigned Risk Pool. Voluntary carriers may, as an option, elect to attach this endorsement to any policy showing Massachusetts in Item 3.A. of the Information Page. 2. Enter “COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06 B” in item 3.C. of the Information Page. WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE CERTIFICATE WC 20 06 01 (Ed. 01/02) Massachusetts Bay Self-Insurance Group, Inc. MASSACHUSETTS CANCELLATION ENDORSEMENT This endorsement applies only to the insurance provided by the certificate because Massachusetts is shown in Item 3.A. of the Information Page. The Cancellation Condition of the certificate is replaced by the following: Cancellation 1. You may cancel the certificate by mailing or delivering to us advance written notice requesting cancellation. Such cancellation shall not be effective until ten days after written notice is given by us to The Workers' Compensation Rating and Inspection Bureau of Massachusetts (Bureau), or until notice has been received by the Bureau that you have secured insurance from another insurance company, whichever occurs first. 2. We may cancel this certificate only if based on one or more of the following: (i) nonpayment of premium; (ii) fraud or material misrepresentation affecting your certificate; or (iii) a substantial increase in the hazard insured against. Such cancellation shall not be effective until ten days after written notice is given by us to you and The Workers' Compensation Rating and Inspection Bureau of Massachusetts (Bureau), or until notice has been received by the Bureau that you have secured insurance from another insurance company, whichever occurs first. 3. Any of the provisions that conflict with the law that controls the cancellation of this insurance certificate is changed by this statement to comply with the law.