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Home My WebLink About96-05507 " ~ LAW OFFICES OF SIMASEK, TUTOKI & RUZZI BY: Joel S, Jenkins. Esquire 1818 Market Street, Suite 3400 Philadelphia, PA 19103-3634 215-448-3309 1.0, #41206 Attorney for Plaintiff Transportation Insurance Company TRANSPORTATION INSURANCE COMPANY 401 Penn Street, Reading, PA 19610 CUMBERLAND COUNTY COURT OF COMMON PLEAS (L'(}~L VS, NO: y~'- 5Jr) 7 SUZANNE M, DELERME d/b/a SERVPRO WESTSHORE. INC, AND SERVPRO WESTSHORE, INC, 167A South Enola Orive Enola. PA 17025 CIVIL ACTION COMPLAINT NOTICE A VISO You have been sued in court. If you wish to defend against the claims set forth in the following pages. you must take action within twenty (20) days after this complaint and notice are served. by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections 10 the claims set forth against you. You are warned that if you fail 10 do so the case may proceed without you and ajudgmcnt may be entered against you by the court without further notice fOT any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you, Le han demandndo a usted en In corte. Si wiled quiere defencerse de estas demandas expuestas en las paginas siguientes, usted tiene veinte (20) dins de plazo a1 partir de la feena de la demanda y 1a notificaeion. Haec faita aseentar una compareneia eserita 0 en persona 0 con un abogado y cnlregar a la corte en fonna escritn sus defensas 0 sus objeciones n las demandas en conua de su persona. Sea nvisaco que si usted no se defiende,ln corte tomara medidas y puede continuar In rJemanda en contra sllya sin previa aviso 0 noticacion. Ademas, In corte puede decidir n favor del demandante y requiere que usted cumpla con todas 1as provisioncs de esta dcmanda. Usted puede perder dinero 0 sus propiedades U otros derecnos importantes para usted. YOU SHOULD TAKE THIS PAPER TO YOUR LA WYER AT ONCE, IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP, LLEVE EST A DEMANDA A UN ABOGADO IMMEDlATEMENTE. SI NO TIENE ABOGADO 0 SI NO TIENE EL D1NERO SUFICIENTE DE PAGAR TAL SERVICIO, VAYA EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUV A D1RECCION SE ENCUENTRA ESCRITA ABAJO PARA A VERIGUAR DONDE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. COURT ADMINISTRATOR'S OFFICE ONE COURTHOUSE SQUARE CARLISLE, PENNSYLVANIA 17013 (717) 240-6200 COURT ADMINISTRATOR'S OFFICE ONE COURTHOUSE SQUARE CARLISLE, PENNSYLVANIA 17013 (717) 240.6200 LAW OFFICES OF SIMASEK. TUTOKI & RUZZI BY: Joel S, Jenkins. Esquire 1818 Market Street. Suite 3400 Philadelphia, PA 19103-3634 215-448-3309 1.0, #41206 Attorney for Plaintiff Transportation Insurance Company vs, CUMBERLAND COUNTY COURT OF COMMON PLEAS NO: 'It, ,5 :fO 7 6.~;,; ;;;~ TRANSPORTATION INSURANCE COMPANY SUZANNE M, DELERME d/b/a SERVPRO WESTSHORE. INC. AND SERVPRO WESTSHORE,INC, CIVIL ACTION COMPLAINT I, Plaintiff, Transportation Insurance Company, is a corporation licensed to do business in Pennsylvania and is engaged in the business of providing insurance coverage pursuant to the laws regulating the insurance industry within the Commonwealth of Pennsylvania, 2, Defendant. Suzanne M, Delerme doing business as Servpro Westshore, Inc, is an individual engaged in a business at 167A South Enola Drive, Enola, PA 17025, 3, Defendant, Servpro Westshore, Inc, is a corporation with its primary business location at l67A South Enola Drive, Enola. PA 17025, 4, Plaintiff. Transportation Insurance Company. at the request of the defendants. provided defendants with a workers compensation insurance policy #WC-07906282 that covered the policy period of September 6. 1993 to September 6. 1994, Said policy of insurance was, in fact. provided to the defendants, Although the plaintiff, however. fulfilled all of its obligations to the defendants under the aforementioned policy of insurance, the defendants failed to pay the premium earned on the said policy, OIA' .....AIIOIteo.-,,-,,1.I ......U- ., 4" . .. ,.;~~ CNA Insu "-"", Companies CNA Plalta . .f' , Chicago, Illinois 60685 AUOI T AUD IT FINAL P~PT: AuDIT ") P AG E STATEMENT - WORKERS' COMPE~SATION PERIOD - 09/06/93 TO 09/06/94 AUD IT 6037 AUOITO~: REG BASED ON AUDITOR'S REPORT 1 POLiCY NUMBER : !l 07906282 FROM POLiCY PERIOD TO COVERAGE is PROVIDED BY AGENCY 09/06/93 09/06/94 TRANSPORTATIOh INSURANCE CO. AGENT 038759090 NAMED INSURED AND ADDRESS SUZANNE M OELERME DBA SERVPRO WEST S~ORE INC '167 A SOUTH ENOLA CRIVE ENOLA, PA 17025 STANLEY MCDONALD AGENCY OF ILLINOI 2018 STATE ROAO PO BOX 1446 LACROSSE WI 54601 WORKERS' COMPENSATION AUDIT SUMMARY, TOTAL EARNEO PREMIUM (SEE ATTACHED SCHEDULE) '16,058 *TOTAL PREVIOUSLY CHARGEO $9,139 AMOUNT CUE COMPANY $6,919 \ ': I , ! 'i \ 11)'.: \ , \ ,~ ) ) ," , I .. I -' .--'" -...I- 1'1': III .. THIS PRE"IlU/"I AlJOIT EILL I~"'V"LlO ONLY IF A"'OUNT INCICAHD AS P?tVIOUSLV CHARGED HAS, I~ FACT, jeEN RECEIVED ~y CNA. . 'TE OF IS:;I)E: Ll/09/94 ~LtCY iSSUl';r, ')FFlCE: MIL.A,:t<,U ";;,AI.C.,; \' RVPllO 5150 ,9Q9.B 3, BRANCH CWA P'wAIIU.c-.ll-..uYouMaU" CNA inaura )companles CNA Plaza Chlcago,lIl1nol.6068S AUDIT -STA,TEMENT - WORKERS' COMPENSATION AUDIT PERIOD - Oq/O~/9J TO 09/06/94 CORREC TED AUO IT PRPT: 6037 AUDITOR: REG AUDIT BASED ON AUDITOR'S REPORT . ~ . .' .-.; ," - POLICY NUMBER FROM POLICY PERIOD TO COVERAGE IS PROVIDED BY AGENCY ': 0 0790~262 09/06/93 09/0b/94 TRANSPORTATION INSURANCE CO. 03a75909'~ NAMED INSURED AND ADDRESS AGENT SUZANNE M OELERME OBA SERYPRO WEST SHORE INC 167 A SOUTH ENOLA CRIYE ENOLA, PA 17025 STANLEY MCOONALO AGENCY OF ILLINOI 2018 STATE ROAD PO BOX 1446 LACROSSE ~I 54601 REASON FOR CORRECTION YOIOS AUOIT BILLED 10/18/94 FOR $5,232. REYISEO TO AMEND EXPOSURES PER RECeIPT OF NEW INFORMATION. "LEASE ADVI SE YOUR CNA ACCOl1NTIN~ /lEp OF ANY DISPUTES OR PAYMENT DELAY~ aN THIS AUDIT BY DEe 2 Q IQQ, ' THANK YOU WE APOLOGIZE FeR ANY INCONvENIENCE. ~UALITY ~cRVIC~ AND CUSTOMER SATISFACTIO~ REMAINS OUR TOP PRIORITY. , OF I SSIJ": 11/09/94 I j'CY ISSlIIW. l'p~i.' ~ l ("d.' 13 I OFFICE: ~ILkAUK[[ hRA~CH . CNA In.urance Companiee PREMIUM AUDIT REPORT . .adit Id: 10777589 naured: SBRVPRO WEST SHORB , ranch: 470 olicy Period: 09/06/93 to 09/06/94 , ,gency: . Date: 10/17/94 MOde: P Page 1. Policy pre/./MOd: WC 0 07906282 Auditor: 1013 - STBVE DEMPS BY Type of Audit: ANNUAL 05 AUDIT INFORMATION REPORT ~LING INSTRUCTIONS: [] RUSH [] RBAODIT (] CANCELLATION [] UNO. ALERT [] MIDTERM RBVIBW [] COMMENTS i .BCORDS USED: SOURCE DOCUMENTS [X] PAYROLL REGISTER C] GBNERAL LBDGBR [] GENERAL JOURNAL [l CASH DISBtlRSBMBN'I'S [] CBRTIPICATBS OP INS. VERIFICATION DOCUMBNTS [] PEDERAL 941'S [l STATB UC'l" S [] INCOME TAX RBPORTS [] W-2, W-3, OR 940 [] OTHER: '.BCORDS CONDITION: LX] ADBQUATE [] OTHER: .OCATION OF RECORDS/CONTACT/TELEPMONB NUMBER: SUZANNB DBLERME 732-6000 167A SOUTH EOOLA DRIVB BNOLA, PA 17025 :NTITY OR OWNERSHIP STATUS, [X] CORPOPATION [ ] PARTNERSHIP [ ] PROPRIBTOR [] OTHER: PFICBR/PARTNER/OWNER INFORMATION: NAME: A. B. DBLERME TITLE: PRESIDENT DUTIBS:OUTSIDE SALBS WeIGL CODE [951 1 [ t ADM [ SALARY ] [ 31600] [ SALSS [ 1 SUPV WeIGL CHARGEABLE 31600] [ [ ] LAB [ 0] ] NAME : S.DBLBRMB [951 ] [ 1 [ 18560] [ 18560] [ 0] TITLE: VP t ADM [ ] SALBS [ ] SUPV [ ] LAB [ ] DUTIES:OUTSIDE SALES NAME: [ ] [ ] [ 0] [ 0] [ 0] TITLE: t ADM [ ] SALES SUPV [ ] LAB [ ] DUTIES: NAME: [ ] [ ] [ , 0] [ 0] [ 0] TITLE: t ADM ( ] SALES ] SUW [ ] LAB [ ] p~IBS : NAME: [ ] [ ] [ 0] [ OJ [ OJ ':'ITLE: " ADM [ SALES SUPV [ ] LAB [ ] DUTIES: ESCRIPTION OF OPERATIONS:INSURBD DOBS RESIDENTIAL CARPET CLRANING. THEY .LSO ACT AS A JANITORIAL SERVICE CONTRACTOR CLEANING OFPICE BUILDINGS. HE INSURED ALSO DOES CLRANING FOR FIRE AND WATER DAMAGE. Audl' I~: 107775S9 0"'"1 10/11/96 Modol P PlIO: 1 I......ad. ..~ Wl!n .~ Plllly Prl/'/MCld. IlC o 019C6W 05 'rmclll 4111 AUdItor. 1013 . IT~ OE~IE1 Pollly Porloch 09/06/93 '" 09/06/94 Typo If AlIdlu ANNUAL All.....v: 2 3 4 5 6 7 I PA OIPT 100 DEl'T 200 UPT 300 DIPT 4DO Din 5DO DIP! 6(10 DEPT 1\lO TOT4L I:MP~T O,P1e! om CIU IWIAGllGNT 11M CLIAN 'UI/WATU IAIoIiI PA TROLL CLWINO unClATlOW CLAn COlli 141 953 ", 911 91' 971 951 'ReM PATROLL RlOIITIR ep 93 1,"9 4,'60 ',~O 2,102 1,795 ... 12,111 OCT 3,'" Z42 6,240 2,475 2,041 ' 1,1142 113 17,'" NQY 2,376 1,114 4,160 1,~0 ',11I2 2, Z2!l 1,321 14,104 DIC 2,5n 96 1,210 1,~O 2,394 1,739 2,m 12,1116 JAIl 96 2,321 391 4,320 1,~D 2,205 2,038 1,112 14,AlI1 PlI' 2,009 1,056 ',6ao 1,650 2,000 1,151 2,1114 14,530 MAl 2,209 3,105 4,4aO ',650 3,:00 702 ',6'" 19,702 API 3,159 6,103 5,210 2,'15 5,lI64 1,112 1,919 27,m MAT 2,453 4,416 4,450 1,650 3,nl 2,271 2,030 21,141 J JUN 2,745 4,434 3,760 1,~O 3,003 1,63. 3,019 20,319 . JUL 2,4ZI ',4n 3,040 2,2n 3,326 4,677 2,412 24,6S0 5 AIlQ a,7Al1 7,907 4,480 1,700 1,017 2,492 Z,911 29,326 I 1 *TOTAL" 37,066 36,756 50,1Al1 22,125 33,589 23,752 25,635 229,013 \ \ Audit I~. 107T7Slt InIUJ'odl UlYPIC welT IIIClI! I~w/l: 47'0 'olley ,..lld' 09/06I'/J to 09/06/94 AlII1lCY. , . 9 10 'A 141 lAUlIOlY , I CWI ClXlI ileAl> Z 3 37iC66* , 1IP9J , ac1 6 '/IN 7 OIC S .lAlI94 9 ,It 0 HAll I m 2 MAY , ~UN 4 JIlL , AUG 6 7 "TOTAL" \ \ II 'A 971 IlJILIIIMlII 79,466. Ootll 10117/94 Mado, P ''''' Z 'olley ,ro/'/MOd. we 0 IlT906ZI2 05 Auditor: 1013 . allYl! OllnlY Type of ALd!c, AIlI1UAL 12 PA 953 CLlftlCAL 16. 'IJ6. I' PA 951 W.!sMlN 75,795. , 'r.' '., ~AlM- . '. =~~~~"'~Yoa~ ) " STANllAR. ~OR"ER~ CO"'fN~AT10" AND EMPLOYERS LIABILITY PO~ICY .'" , -- --- IN,OAi'lATION PAG! . ReNEWAL OF WC 0 079D6lS2 . . f . , . LICY NUMBER ~e/'li ,0.t906282 . ~;'.: ,'" FROM POLICY PERIOO TO COVERAGE IS PROVIDEO BY . TRANSPO~TATldN I~SURAHCE CO. AGENCY 031175909C 09/06/93 09/06/9. NAMEO I"SUR~O,A P ADDRESS GE ~~ '. . ~ 1~',' DlIi, SERVPRO ,~@J~.7, ..~ 'O,Ul'H. : :':'" I!JlOLA. Pit . ' ,:',~ "~'. lI!sTSHO~E IHC eNOLA; DA1:YE ' ZOIe STATr; 'ROAD 'PO BOX I'H6 L.ACAOSse; WI 5.601 .'f 17001 . all. 1._ IB!... (AliIT! iT INTRASTATE 10 NO: 372711290 ~THER WOR" PLACES NOT SHOWN ASOVE: NO ADDITIONAL LOCATIONS YOU ARE A '- CORPORATION/S l. POl.ICY PERIOD'- 09/06/93 TO 09/06/94 12: 01 AM STANDARD TlI~E AT THE INSUREDS "AILING ADDRESS. 3A. PART ONE OF THIS POl.ICY APPLIES TO THE WOR"ERS COMPENSATION l.AW AND ANY OCCUPATIONAL DISEASE LAW OF EACH OF THE STATES LISTED HERE: PA. la. PART T~O OF THIS POl.ICY APPLIES TO EMPLOYERS LIABILITY INSURANCE FOR WORK IN EACH STATE LISTED IN ITEM 3A: THE Lli'lITS OF LIABILITY ARE: BOOILY INJURY BY ACCIDENT 1100,000 EACH ACCIOENT BOOILY INJURY BY DISEASE 1500,000 POLICY l.IMIT BODILY INJURY BY DISEASE $100,000 EACH E"PLOYEE 3C. PART THREE OF THIS POl.ICY APPLIES TO OHlER STATES, IF ANY, LISTED HERE: ALL STATES EXCEPT AK, ME, NV, NO, OH, WA, WV AND STATES DESIGNATED IN ITEM 3A OF THE INFOR"ATION PAGE. 30. THIS POl.ICY INCl.UOES THESE ENDORSEPlEN,TS AND SCHEDULES: SEE ATTACHED SCHEDULE. --------------------------~----------------------------------------------------- " THE PREMIUM FOR THIS P,Dl.ICY wILl. DE DETERPlINED ~Y OUR MANUAL OF RULES, Cl.ASSIFICATIONS, RATES, AND RATING PLANS. Al.L t~FORMATtON REqUIRED BELOw IS SUBJECT TO VERIFICATION AND CHANGE BY AUOIT. ADJUSTMENT OF PREHIU" SHALL BE "ADE: AT POl.ICY EXPIR~TIDN CLASSIFICATION OF OPERATIONS EST ANNUAL PRE"'IUI'I SEE ATTACHED 'b,IG7 PREMIU" OISCOUNT 3'0 ExPENSE CONSTANr 14~ MINI"'UM PREMIUM It,~2S TOTAL ESTIMATE.D ANNU.l. PREMIUM '7,'h~ DEPOSIT PREI'IIUM ~7,969 ,ATE. OF tSS",,: O'J/OZ/9J -'OLlC.Y It.~ulN:' QFf ,,(.to.: ~.lL...;'U"'f:.:. _OUhTEN~IG~:.:. __________________ (jAil ~y---------------------------- .~ IJ f t1:J'< 1 ~...::. tIo (of;."'" T I\~J* Corpo'alt SeClltlry \Iv (. ;;0 I) C ) I '''-3JJ;'~-:: (i../. r,/".7. I. . ~ "',) ....- --- ~ ,~ . ,,' ... \ STAIIDAR. ORICERS COIl~1'lS'A'10N AIIO' EIlPLOYER5 LIA~lLITY'POeICV , .. . ,.>> RIIIENAL Of wt 0 07906ae2 (:. ., .... ... w...- . ~..~ \.': , ' 111,a~"ATIOII ,AG! - ..... ~ .... , . COVERAGE IS PROVIDED BY TRAIISPORTATIOII INIURA~Ce CO. ,., AGENCY 038759090 "~,j~j;''I90,un 0,/06/93 0'/06/'" DAD RESB ,.' ',ll~'~ ",""'"0 III1T .HOII. JIIC .!~~..,a: ',/\ .9UTtf aHolo" 0111\11', '.j~. &:AI 'A ~ I,..~, :I'~ .". . FROM LI Y TO GE N U/l It: R P31203U WCOOOOOOA WC00040 J "'C000406 wt37060 I WC370602 ...C370603 201!SSTATE IlOAD pp ,BOll 1446 ~ACRQSSE . WI 54.01 170a ..:-.;;. . .. END 0 R 5 E MEN T 5 C H E D U L E .. SCHEOULl PAGE 1 DESCRIPTION EDlTIO,", DATE PARTICIPATING PROVISION COVERAGE PART EXPERIENtE RATING MODIFICATION FACTOR ENDORSEMENT PREIlIUM DISCOUNT ENDORSEMENT PENNSYLVANIA SPECIAL ENDT. INSPECTION OF MANUAL PENNSYLVANIA NOTICE PENNSYLVANIA ACT 86-1986 ENDORSEHENT 01/88 04/92. 04/84 08/04 04/84 04/84 12./87 ATE. OF l~~Ut.: :;1.//O~/'i3 JL.1CV l~!>>~ll"c. (,fflC.i.: MIL~4llt<tt.. i\~t~ Cofpottll &lcl.1I1Y ... C 0 J 0 0 \J 1 P - J J ':14 t\ - t (f,:'1 . tll :, 7 1 ~~ " ,~ ''la .....' .lc Yoi:'_ , . . lit: Ii" -- --- I .; : " . ~ , STANOAR~ DRKERS CD~eENSA~IDN AIlD EI1PLOYERIS LI/BIL Ii'y' potICY .t ..... .,..~. . .. .\ .. ,di.o--'- '..~;" . "',,' ",'.' . -. .# _... L U B R FROM POLICY PERIOD TO COVERAGE IS PROVIDED BY TRANSPORTATION INSURANCE CO. GE AGENCY 038759090 . ,Ie, O,,019061ea iit/06/93 09/06/94 N MED I S R A ADDRESS . jj'~S.Ry,.~O..Ut,'SHORe. lNC .. .;,.U:t...A J',~~JI(,E~.I;J~A DI'IVE" , ; , ::: :~~D~A.~/~>: "::' .... .J...."...\ .. " " r,;-;'.. ; '. ~ ,.;)'1'01 2018 &TATE ROAD . PO BOX lH6 . LACROSS!!: WI 54601 '. APPLICABLE PARTICIPATIN' PLANS PLAIl NUI1BER/ DIVIDEND SCH!DULE APPLICABLE STATES COPlI1IS S I ON SCALE 44-00 PA 5\ SAFETY GROUP: BSCIP - BLOC SERVICE CONTRACTORS INSURANCE PROGRA~ JATE OF tSSl,;S: O<'/i:2/~J ~OLICV ISSUING OfFltt: MrL~~UKfE ~~t~ COrporat. Secr.llry p-Jl:j:S--, (LO. lis..:l; 'WORKERS COMPENSATION .~tO EMPLOYERS LIABILITY INSURANC" POLICY we 00 (l.4 06 (Ed,8.~: PREMIUM OISCOUNT ENDORSEMENT The premium lor this policy and the policies. If any, listed in Item 3 olthe Schedule may tle eligible for a dis. count. This endorsement shows your estimated discount in item 1 or 2 of the Schedule. The final calculation 01 premium discount will De determIned by our manuals and your premium basis as determined tly audit. Premium sutlject to retrospective rating is not subject to premium discount. Schedule . Estimated Eligible Pttmlum First Next Next 1. State $5,000 $95,000 $400,000 Balance - 1'BIIIISlLVARIA NIL 3.5J. 5.0%. 7.0J. . 2. Average percentage di$COunt~ % 3. Other policIes: .. <I. II there are no entries in items 1. 2and 3, of the Schedule slle the Premium Discount Enckl~rnent attachel:l to your policy number: ' This cndomm.nl clW1gcs tile poU<:y III wl\idl it is ~ atIIl is ttltdlYe on tlIC dill iuucd uollss 0lMtWlse SWOd. (TIM ~ Mlow II ~ oaIy .110. l!lIs __ is ic&vl1l ..,*"".0111 JI1panlloa tllllc ,..,.) El'lClCmtntl\t E/16CIlV< Policy Ita, ~ Mo. tnsutld PtCllium $ InSurane.o ~ Co<JntmiQncd By , --., we 00 (l.4 OG' (Ed, 8.84) ~ 1'SC. 1UA JrrU\IotI.&l cMlftdl... c..a-o-...U04'l LIt&~.nca. WORK~RS COMPENSATION ANO EI 'PYERS LIABILITY INSURANCE POLlCV WC 189 :.: ~.a_ WC 37 0601 SPECIAL PENNSYLVANIA ENDORSEMENT-INSPECTION OF MANUALS ThiS endorsement changes tne POliCY to #~:cn It 's at~acnea effect;'J= on tre incept .:r: dat.; :7 ::1e ~C;i'Cl 'J~;=:;5 J different date IS indicated belc', ITne IOilCw,r';g "at:a<:nlng '::;a...se" neee::e :::I"P":,.ew: -;,..1, .'I~l!" ::"'1$ ~~::o~S'l:";":er.:s .sswe: s~:sea:..;~~~::: :re:J'):':~ ~~ :~e =c.:. . This endorsement, effective on :::.~~ at 12:01 A,M, standaro time, torms a ~ar: v: Policy No, of the ...:.'''t:~ "S.../l,l...C! ':J't"':'''V' issued to Autho"z~d .;eorese!"l!at"Je I I ,I , I I I , i The manuals of rules, rating plans, and classifications are approved pursuant to the provisions of Section 654 of the Insurance Company Law of May 17, 1921, p.L. 682, as amended, and are on file with the Insurance Commissioner of the Commonwealth of Pennsylvania, ..-....... O:UTHEN;I~O ~...7":':,:...' . ":::~/"gtl! : =18J P~rll1:",lv,ll~,.l CJmppn~~II(Hl RJ~Ir';~ BUfP.JlI ......~. ""'" \ot4 (Ed: 4-84) PENNSYLVANIA NOTICE , Ar1lnsurance Company, il:l ag.lnCl, empl~, or ~r;ica COnlt3C'.ors aCling cn its ber.alt, mZI p1'QO,/ic:e ~Jiccs:o rec~ce the likelihood of injury, death or 10= These sar;ices may include any of the folloNing or related sarvicas incident to !he , application for. is,suance, renewal or continuation of. a policy of insurance: 1. surveys; 2. consultation or advice; or 3. inspections. : The "Insurance Consultation Sarvices Exemptionkl" of Pennsylvania pmrides thai the Insurance Company, its agents, : employees or sarvicecontractors acting on its behlat, is not liable lor damageS from injul)'. death Of loss occuring as a , result of ant act or pmission by ant person in the furnishing 01 or the failure to furnish lhasa services. , The Act does not apply: ,. if the Injury, death or loss occucred during the actUal performance of the satVices and was ea. ISed by tile negligence of the Insurance ComPant, its agents, employees or service contraclors; , " 2. to consultation sel'llices required to be performed under a written service conlt8Cl not relaled ~ a policy of insurance; or 3. if any acts or omissions of the Insurance Company. ils'agents, employees or servica contractors are judicially deter- mined to constitute a crime. actual malice, or gross negligence. :'This endcrscment c.han.ges tne poHel to whic., a is ~rrac!'lU oUld is cflective an ir.a d3.!d issued unless oUlerNise soted. fTbelnfunnlll.. below is raquired only when Ihl..nd....",.nt is i=led Illboaquenllc ,re"""U.. ollila P.Ucy.) Endorsement EHec:ive Policy No, E:.Jcrseme.1l No. i Insured Premium $ : Insu~nce Camc3ny C~ur.t!rsigned by ,WC37 06 02 (Ed. 4-84) : CoP'I'Tlgnt 1~ JJ.nn..,I\OInl. C4mponuUOA fUUn-g au.....u. WORKERS COMPENSATION AND lPLOYERS LIABILITY INSURANCE POLle WC 346 lEd, 12-87) WC 37 06 03 PENNSYLVANIA ACT 86-1986 ENDORSEMENT NONRENEWAL, NOTICE OF INCREASE OF PREMIUM, and RETURN OF UNEARNED PREMIUM This endorsement changes the policy to which it IS attached effective on the inception date of the policy unless a different date is indicated below, (The lollCM'in8 "at1aChing ctause- need be ClJmplelCd onl)' wnen :hlS endorsement is Issued subseQuent to prepar.l:ion oIlhe polit:y.) This endorsement, effective on at 12:01 A,M, stondard time, forms a part of IDAT!) Policy No. Endorsement No, of the (NAME OF' INSUR",,~CE COMPANY) issued to Authorized Representative This endorsement applies only to the insurance provided by the policy because Pennsylvania is shown in Item 3,A. of the Information Page, The policy conditions are amended by adding the follow- ing regarding nonrenewal, notice of increase in premium, and return of unearned premium, Nonrenewal 1. We may elect not to renew the policy, We will mail each named insured, by first class mail, not iess than 60 days advance notice stating when the nonrenewal will take effect. Mailing that notice to you at your mailing address last known to us wili be sufficient to prove notice, 2, Our notice of nonrenewal will state our specific rea- sons for not renewing, 3, If we have indicated our willingness to renew, we will not send you a notice of nonrenewal. However, the poli- cy will still terminate on its expiration date if: a, you notify us or the agent or broker who procured this policy that you do not want the policy renewed: or b, you fail to pay all premiums when due: or c, you obtain other insurance as a replacement of the policy, Notice of Increase in Premium 1. We will provide you with not less than 60 days notice of intent to increase the premium on the renewal of this policy, if it is our intent to offer such renewal. 2, We will provide you with not less than 30 days notice of an estimate of the renewal premium, if it is our in- tent to offer such renewal. 3, The above notification requirements will be satisfied if we have issued a renewal policy before the time peri- ods indicated in Items 1. and 2, above, 4, If a policy has been written or is to be written on a retrospective rating plan basis, the notice of increase in premium provisions of this endorsement do not apply, Return of Unearned Premium 1. If this policy is canceled and there is unearned premi- um due you: a, If the Company cancels, the unearned premium will be returned to you within 10 business days af- ter the effective date of cancelation. b, If you cancel, the unearned premium wil! be returned within 30 days after the effective date of cancelation, 2, Because this policy was written on the basis of an es- timated premium and is subject to a premium audit, the unearned premium specified in la, and Ib, above. if any, shall be returned on an estimated basis, Upon our completion of computati0n of the ..xact premium, an additional return premium or charge will be made to you within 15 days of the final computation, 3, These return or unearned premium provisions shall not apply if this policy is written on a retrospective rating plan basis, ,..--........ OAUTHENTICO --...;..:::~. CopyrIght 1987 Pcnnsvlv~niil COrT1rl:ll~ilIIOn Riltlllr Bure~\1 ,TE COUNTERSIGNING AGENT: ) .. {~POliCI Jd Gny .ndorsemlfnu:thlfll01 . . . . has been r,quested to COUNTERSIGN THE ATTACHED Endorsem,nthl I'. . K8IP.countenigni'!Q I",nl copy fOr your fill and: Countersign.turI Endors'~.nt (.~d ::opi.. .nlched th.rlfOI 1. ~ Return all other cop,ia, to CNA Producing Br.nch In e"closed return Gflv,lop.. 2. 0 Return Producing Branchtopv \" CNA Producing Branch; lIInd all other materials Cane,lIetion to Producing Agent showf1.betow. B Cancellation} cal. ..<:i.1 D'- Final Audit No Countersignature Required ;tru' ,n. 1, Os Counttnignlng fee is dua CIS agenlshown at left. Producing AQlnI prease remit thi, amount direct to CIS agent within 45 davs, Count'''!II"l"; Agent Nam. & Addrns: [Ii'......' IlOGU "ADSL. !WiLl'DU.l'.1 ."-W IClIoBCIU. UIIII I/IICII1'I& oa GAtLllI4l'BII. ~ -....a L .. ..J 2. D $ Countersignature fee will be billed to the producer through the MAC system; 3. [3 No colfntersigning fee for this item. . .~ :~',~~,~ ~ ;;'.{: ~1i.,~':~ ';: .:'r,. - ~ .. '.',: -~ i~~~:'" ',' ~,:;';'..' .' . C/SAQer;Jt ~omp.ny Code No. ....." . ~.'.(p.:,r.: :-:.,'. _:: _.:, .t>',:~ ','.{S':.:.t\,.:J':. ,~;~.~,::,t:.:.: ;.. ''l,:t'' ..'.... ~..._~, '''w...~-,:,-",...,w~ '. '. ..,,~<i.. .'. .~., .~. .....le. 4. 0 No c~unteri'i~~~t~r" fee.~~!~~t~e~i t~~~-':"~de at ihis time. .'~i~,;::.''-....... . ..... '1 '.,~" .d~?: {'S.CO~,NTERSiGNAT\,J!lE E~O:o.~~FY..~~T*~:~;, ;~"n~~~\:~~';'~' ~'.:~~: ..::~.~.. .' >'~~ ....A:; " ,;~:l~t.:.~~~~".,~.., :~; ::'~;~!cflt~~.'~~. ....:.,= .':.'._::'; FOrAlI"~~~YoU:~;-..i.; ,:~,~:.rt;. lj..:':,~ . . ",~;~:~~.,~~::.~::;:;".._~~, ,'. ;:.d;,....:: -;' '\: ~l ".~.~,:,..iIt,'.~~~~:.:: . ..:. ce' ~1J~ '~-'~"'-"~~'''''' ;..J'. \. "';~l1." . " . :, .(..... .~;)t . .~. ".... .', ;..... r' . - 11' . "_' 'Tvpe.o' NF ~ ';-~t"":"~""~.~ :,>1 "'. ...,', ';""'''v'':'r''.,~;":!,, I. 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P;_odu~ing' A;nt Company COdl N'O. 0;0 (sIgnature) " . . ,,' "5 - PRODUCING BRANCH D/R COPY , .... -,',.' . :A,,':.. ........... .' ,'.)'1'>". ~ " , 'N.mlo' ~. Insured ,~ ::.';' 1 ; '., . :...... '''' " J . .. ',' .- ~ ;'.0' ~'. .. '.:.... " ........;.. " - ;::::. .-,' .~>; ;: .;:cou~t.rsignaturll';or:ih."It~'of, ,;:< l'IlllWlIft.YAJILt,', " ;",' .. ;..;, .....,.,. ..... -. .' 'ATIACHED'TD AND HEREBY MADEA PART OF THE ABOVE , POLICY OR BONO COUNTERS'IGNED AT . . I . ...~,: .... " , DAY OF " ON THIS 19 -'-- . , "~; .... Licensed Rnldent AOInt ..". Q-35442-F " OUNTERSIGNATURE WORKSHEET TRANSACTION: D N~; ([] Renewal; o Cancellation: o Endorsement; 0 Flnel Audit PR Code 60 3t.te Premium This State Commission Thil State Baslso' Amount CIS F.. Tran.mltted by Producing Agent CIS F~~ of ". has non. resident ~ Audll,D.po.1t on IV '!6 Amount CIS F.. Pro- CNA (Show tun.. code) Dcen.. ' , dUClr To: Installment - DlltI!I Next CIS St.te Premium Due y" No Not re. Agent Pool qulred '01,,11 (2.1 12bl 12,1 lcol.3) 14.1 14bl (col. 5) (col. 61 17.1 17bl (7,1 PA X I. $7,989. 050 399. NIL NIL we 102 (4-92) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY PLEASE READ THE POLICY CAREFULLY. QUICK REFERENCE BEGINNING ON PAGE INFORMATION PAGE GENERAL SECTION......,....,....,..........,....,..,..,....",., 1 A, The Policy......,........,......:,:....,.......... 1 ...8, ,Wh,o Is Insured....,....................,...... 1 , C, .workers Compensation Law......,...... 1 D, State......,..,:,........,..,........................, 1 E, Locations......,....,........................,:.... 1 PART ONE-WORKERS COMPENSATION INSURANCE 1 A, How This Insurance Applies,....,...... 1 8, We Will Pay,..:,..\I'.;....:..,:..:......~.L';,;-l 1", C, We Will Defend..................,..,.......... 1 D, We Will Also' Pay..,....,.........,........,_,.. 1 {E, Other Insurance................,..".......,.. 1 ,F, 'Payments You Must Make.............., 2 G, Recovery From Others..,".....,.......... 2 H. Statutory Provisions,......,.."........",.. 2 .l~ PART TWO-EMPLOYERS LIABILITY INSURANCE......, 2 A, How This Insurance Applies....,......, 2 8. We Will Pay................:,.................... 2 C, Exclusions..,..,....,....,........................, 3 D, We Will Defend,..,..,....,..................., 3 E. We Will Also Pay.......,..,............,...... 3 F, Other Insurance........,..............,....,.. 3 G, Limits Of Liability......,......,..........;..., 3 '; BEGINNING ON PAGE PART TWO-EMPLOYERS LIABILITY INSURANCE......,..4 (Cont'd.l H, Recovery From Others,......,..,..,....,.. 4 I. Actions Against Us:..,......................, 4 PART THREE-OTHER STATES INSURANCE,..,.......... 4 A, How This Insurance" Applies............ 4 '8, Notice..,..........:....,..............,............, 4 PART FOUR-YOUR DUTIES IF INJURY OCCURS,......, 4 -~ -' .:.:~ '.,' ) . ,: , ' PART FIVE-PREMiUM........................................... 4 A, Our Manuals"......,..................,..,...... 4 " ".' 8, Classificati6'~s..........,....,......,............ 4 C. . Remuneration:,...."..........,......:......,.. 4 D, PremiumP~yments.........,..,....,........ 5 E, Final Premium,..,............,....,..,..,...., 5 F, Records..,..,........,....,..,;............,......, 5 G, Audit..,...,..,..,:,......,................,;,....,.. 5, PART SiX-CONDITIONS........,..,...................,........, 5 A, ,Inspection........,..........,..........,......... 5 B, long Term Policy............................, 5 C, Transfer Of Your Rights And Duties 5 0, Cancelation.......,..,..,..,......,.............. 5 E, Sole Representative........,..........,...., 5 IMPORTANT: This Quick Reference is not part of the Workers Compensation and Employers Liability Insurance Policy and does not provide coverage, Refer to the Workers Compensation and Employers Liability Insur- ance Policy itself for actual contractual provisions, "..,....'..-." OAUTHENTlCO ~-::':";:.,.olo'. Copyright 1991 National Council on Compensation Insurance. we 00 00 00 A (Ed. 4.92) WORKERS COMPENSATI, ; 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 , GENERAL SECTION A, The Policy This policy Includes at its effective date the Informa- tion Page and ail endorsements and schedules list. ed 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 partnersh,ip's ,employees, C. Workers Compensation Law Workers Compensalion Law means the workers or - ., workmen's compensation law and occup,. ease law of each state or territory named Ir of the Information Page, It includes any am. to that law which are in effect during the ~' od, it does not include any federal worker' men's compensation law, any federal occ disease law or the provisions of any law the nonoccupational disability benefits, D. State Stote means any slate of the United States c ca, and the District of COiumbia, E, Locations This policy covers all of your workplaces Items 1 or 4 of the Information Page: and I all other workplaces in Item 3,A, states un have other insurance or are self.insured f workplaces, 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 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 poiicy 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 lhe 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 t amounts payable under this insurance, as par' claim, proceeding or suit we defend: 1, reasonable expenses incurred at our requ€ not loss of earnings; . . . . . .' 2, premiums for bonds to release attachmer for appeal bonds in bond amounts up amount payable under this insurance: 3, litigation costs taxed against you; 4, interest on a judgment as required by la', we offer the amount due under this insu' and 5, expenses we incur. E, Other Insurance We will not pay more than our share of benefit costs covered by this insurance and other inse or self.insurance, Subject to any limits of liabil" may apply, all shares will be equal until the paid, If any insurance or self.insurance is ex~ ed, the shares of all remaining insurance will be unlil the loss is paid, Page 1 s- , F. Payments You Must Ma~ 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 fall to comply with a health or safety law or regulation: or 4, you discharge, coerce or othelWise 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, Q, Recovery From Others We have your rights, and the rights of persons enti- tled to the benefits of this insurance, to recover our payments from anyone liable for the Injury, You will do everything necessary to protect those rights for us and to help us enforce them, H, Statutory Provisions , ' These statements apply where they are required by law, 1. As between an injured worker and us, we have 'e r:ctll:i( nt~ Injury when you have notice. 2, Your delault 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 dllectly and primarily liable to any per- son entitled to the benefits payable by this insur. ance 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 iaw, We are bound by decisions against you under that iaw, 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.' .~. ," ... Nothing in these paragraphs relieves you of your duties under this policy, ' 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 inciden- tal 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 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 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 Unit- ed States of America, its territories or posses- sions, or Canada, B, We Will Pay" We will pay all sums you legally must pay as damages because of bodily injury to your employees, provid- ed the bodily injury is covered by this Employers lia- bility Insurance, The damages we viill pay, where recovery is permit- ted by law, include qamages: 1. for which you are liable to a third party by rea- son of a claim or suit against you by that third party to recover the damages claimed against such th.ird party as a result of injury to your em- ployee: 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, Page 2 J -..., '- C. Exclusions 1 12, damages payi. hmderthe Migrant and Season. This insurance does not cover 1 al Agricultural Worker Protection Act (29 USC Sections 1801-1872) and under any other fed. 1. liability assumed under a contract. This exclu. erallaw awarding damages for violation of those sion does not apply to a warranty that your work laws or regulations issued thereunder, and any will be done in a workmanlike manner: amendments to those laws, 2. punitive or exemplary damages because of bodily D, We Will Defend injury to an employee employed in violation of We have the right and duty to defend, at our expense, law; any claim, proceeding or suit against you for damages 3, bodily injury to an employee while employed in payable by this insurance, We have the right to in. vestigate and settle these claims, proceedings and violation of law with your actual knowledge or the suits, actual knowledge of any of your executive officers: We have no duty to defend a claim, proceeding or 4, any obligation imposed by a workers compensa. suit that is not covered by this insurance, We have no duty to defend Cr continue defending after we H, tion, occupational disease, unemployment com- have paid our applicable limit of liability under tllis pensation, or disability benefits law, or any insurance, similar law; E, We Will.Also Pay A, 5, bodily injury intentionally caused or aggravated by you; We will also pay these costs, in addition to other 6. bodily injury occurring outside the United States amounts payable urder this insurance, as pa'rt of any claim, proceeding, or suit we defend: of America, its territories or possessions, and " Canada, This'exclusion does not apply to bodily 1. reasonable expenses incurred at our request, but injury to a citizen or resident of the United States not loss of earnings; of America or Can,ada who is temporarily outside 2, premiums for bonds to release attachments and these countries; for appeal bonds in bond amounts up to the Iim. 7, damages arising out of coercion, criticism, de- it of our liability under this insurance: motion, evaluation, reassignment, discipline, 3. litiga.\i9n "osts taxed against you; defamation, harassment, humiliation, dlscrimi., ' .'.... nation against or termination of any employee, 4, Interest on a judgment as required by law until or any personnel practices, policies, acts or we offer the amount due under this insurance: T, omissions; and te 8. bodily injury to any person in work subject to the 5, expenses we incur, 1. Longshore and Harbor Workers' Compensation Act (33 USC Sections 901.950), the Nonap- F, Other Insurance propriated Fund Instrumentalities Act (5 USC 2, Sections 8171.8173), the Outer Continental Shelf We will not pay more than our share of damages and Lands Act (43 USC Sections 1331-1356), the De- costs covered by this insurance and other insurance fense Base Act (42 USC Sections 1651.1654), or self-insurance, Subject to any limits of liability that 3, the Federal Coal Mine Health and Safety Act of apply, all shares will be equal until the loss is paid, 1969 (30 USC Sections 901-942), any other fed. If any insurance or self.insurance is exhausted, the eral workers or workmen's compensation law or shares of all remaining insurance and self.lnsurance other federal occupational disease law, or any will be equal until the loss is paid, amendments to these laws: G, Limits of Liability A 9. bodily injury to any person in work subject to the Our liability to pay for damages is limited, Our limits Federal Employers' Liability Act (45 USC Sections of liability are shown in Item 3,B, of the Information 51.60), any other federal laws obligating an em- Page, They apply as explained below, ployer to pay damages to an employee due to 1. Bodily Injury by Accident. The limit shown for bodily injury arising out of or in the course of em. ployment, or any amendments to those laws: "bodily injury by accident-each accident" is the B most we will pay for all damages covered by this 10, bodily injury to a master or member of the crew insurance because of bodily injury to one or more of any vessel: employees In anyone accident. 11. fines or penalties imposed for violation of feder, A disease is not bodily injury by accident unless al or state law: and it results directly from bodily injury by aCCident. Page 3 odily Injury by 0' )">e. The limit shown for ~odily injury by a,.",ase-policy limit" is the 10stwe will pay for all damages covered by this 1surance and arising out of bodily injury by dis. ase, regardless of the nember of employees ,hO sustain bodily injury by disease, The limit ,own for "bodily injury by disease-each em. loyee" is the most we will pay for all damages ecause of bodily inj~ry by disease to anyone mployee, ;odily injury by disease does not include disease ,at results directly from a bodily injury by ac' I ident. . . I 'Ie will not pay ary claims for damages after we !,ave paid the.applicable limit of our liability un. I Jer this insurance, l very From Others i ave your rights to recover our payment from any. I ",", .~ . .- one liabl I an injury covered by this insurance, You will do e,., ything 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 poli. cy; and 2, The amount you owe has been determined with our consent or by actual trial and final judgmeni, 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 obliga' tions under this Part, PART THREE-OTHER STATES INSURANCE , ' , This Insurance Applle~ ". ",: . by the workers compensation law of that state This other states insurance applies only if one if we are not permitted to pay the benefits directly )r more states are shown 'in Item,3,C, of the In. to persons entitled to \hem," ' . 'ormation Page, 4, If you have work on the effective date of this poli- f you begin work in anyone of those states after cy in any state not listed in Item 3,A, of the In. :he' effective date of this policy and are not in. formation Page, coverage will not be afforded for ;ured or are not self-insured for such work, all that state unless we 'are notified within thirty ~rovisions of the policy will apply as though that days, ' :" ' ' ;tate were listed in Item 3,A, of the Information B, Notice ~age, ' ' , "Tell us at once if you begin work in any state listed 'lie will reimburse you for the benefits required ,','n.. 'in Item 3.C, of the Information Page, , '.r.' PART 'FOUR-YOUR DUTIES IF INJURY OCCURS ;,' ," .:' ,t once if injury occurs that may,be covered by :y, Your other duties are listed' nere, ,.' . l . - . id~'ior immediate 'medical and other services re- ,d by 'the workers compensation law, ' , us or our agent the names and addresses of the 'ed persons and of witnesses, and other inform a- we'mayneed, ' nptly give us all notices, demands and legal pa- pers related to the injury, claim, proce.ediiig or suit. 4. Cooperate with us and assist us, as we may request, in the investigation, settlement or defense of any claim, proceeding or suit. ' , . 5: Db nothing after an injury occurs that would inter. fere with our right to recover (r?m others, 6, Do not voluntarily make payments, assume obliga- tions or incur expenses, except at your own cost. PART FIVE-PREMIUM Manuals >remium for this policy will be determined by our 1uals of rules, rates, rating plans and classifica- s, We may change our manuals and apply the ,ges to this pOlicy if authorized by law or a gov- nental agency regulating this insurance, isifications 1 4 of the Information Page shows the rate and "ium basis for certain business or work classifi- )ns, These classifications were assigned based .n estimate of the exposures you would have dur- ing the policy 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 policy, C, Remuneration Premium for each work classification is determined by mulliplying a rate times a premium basis, Remuneration is the most common premium basis, This premium basis includes payroll and all other remuneration paid or payable during the poliCY peri- od lor the services of: Page 4 1; all yo'ur officers and employees' yged in work covered by this policy; and 2. all other persons engaged in work that could make us liable under Part One (Workers Com. pensation Insurance) of this policy, If you do not have payroll records for these persons, the con. tract price for their services and materials may be used as the premium basis, This paragraph 2. will not apply if you give us proof that the em. ployers of these persons lawfully secured their workers compensation obligations, Premium Payments You will pay all premium when due, You will pay the prem;um even if part or all of a workers compensa- tion 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 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 poli- cy. If th~, 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 policy, If this policy IS cane ~. final premium will be de. termined in the fOllow"'6 way unless our manuals pre- vide otherwise: 1, 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, 2, If you cancel, final premium will be more than pro rata: it will be based on the time this policy was in force, and increased by our short rate cancelation table 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 policy, These records include ledgers, journals, registers, vouchers, contracts, tax reports, payroll and disbursement records, and programs for storing and retrieving data. We may conduct the au. dits during regular business hours during the policy period and within three years after the policy period ends, Information developed by audit will be used to determine final premium, Insurance rate service organizations have the same rights we have under this provision. PART SIX-CONDITIONS A, Inspection '" 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 loss'es, 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 Policy If the policy period is longer than one year and six- teen days, all provisions of this policy will apply as though a new policy were issued on each annual an- niversary 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 consen!. If you die and we receive notice within thirty days after your death, we will cover your legal representative as insured: D, Cancelation" 1, You may cancel this policy, You mu~t mail or de. liver advance written notice to us stating when the cancelation is to take effect. 2, We may cancel this policy, We must mail or de- liver to you not less than ten days advance writ- ten 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, 3, The policy period will end on the day and hour stated in the cancelation notice. 4, Any of these provisions that conflict with a law that controls the cancelation of the insurance in this policy is changed by this statement to com- ply with the iaw, 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 cancelation. Page 5 ',-,,' COVERAGES , " -..... ' . Limits Ar ual of Deductible Pre lium Liability I .---- --- " PROPERTY II Building-All Risk $ 250 - Not Bound Replacement Cost ,l, J Contents-All Risk $ 9,000 $ 250 TO' Follow* Actual Cash Value Janitorial Equipment $ 30,740 $ 250 'IO, Follow* All Risk Actual Cash Value Bailees $ 30,000 $ 250 Tc Follow* (Incl. Theft in Transit) Actual Cash Value CRIME Third Party Theft Legal Defense $ 25,000 $ 10,000 $ 500 $ 500 r I 'l\' Follow* Each Occurrence Limit Bodily Injury & Property Damage Personal (Exclusions "A" and "C" Deleted) and Advertising Injury Medical Expense (Any One Person) Fire Damage (Any One Fire) Products/Completed Operations Aggregate General Aggregate (Other than Products & Completed Operations) Independent Contractors Blanket Contractual Care.Custody.Control Lost Key Coverage Extended Property Damage Employee Benefits Liability $1,000,000 Property Damage Deductible Only $ 250 I GENERAL LIABILITY $1,000,000 $ 250 Janit(.rial rate is 5.5 of p?,i'rolls I . I CarpE t Clng. of ~,rrolls $ 5,000 No Deductible $100,000 $ 250 $1,000,000 $ 250 $1,000,000 $ 250 , -, , ! 'lbI Follow (P~: 'urn based on 11s of Ja~i orial $21,800 Ca~t Clng. $42,100) :V , 1; It, ,~ l' " " Included Included $100,000 $ 25,000 $150,000 $ 250 $ 250 $ 250 $ 250 $ 250 , , l't1 , " $500,000 $1,000 '" : I UMBRELLA AUTOMOBILE 3 Trucks $ 500,000 C $ 500,000 PI 'r" N'<n: 30und I fl00 Deducti 1~ c.c~~prehenSiVe(car) 250 Deducti le <}l.'.lision(car) 250 Oed. Co p. (;t:::ucks) ,. , ' ;; L , l)IU 9/6/90 u U' , . Stanley McDonald Agency of Illinois, Inc. INSURANCE 9/6/91 APPLICATION BUILDING AND CARPET CLEANING INDUSTRY WORKER'S COMPENSATION & EMPLOYER'S LIABILITY INSURANCE (All of the following Items must be completed.) - 1. Mr, 0 Mrs. ~ Ms. 0 Owner(s) Name(s): Suzanne M. Delerme Name of Business: Servpro West Shore, Inc. Franchlse/Customer No.: 5250 , I , , I I I I 2. Taxpayer 1.0, Number (mandatory for filing purposes): I I 3. Mailing Address: I 23 2597197 185 Cragmoor Rd, York Co., York Haven, PA 17370 (Street) (County) (City) (State) (Zip) 4. Other Locations: 5. Type of Ownership: [ xl Corporation [ I Partnership [ I Individual [ I Other 6. As "Individual" or "Partnership," or "Officer," do you wish to be covered If applicable In your state? [xlYes [I No (Include all corporate officers or partners, active or not. For Individual, Include all data.) Include or Salary Active or Exclude In Name Title Age Duties /Draw Inactive Coverage A. Edsel Delerme Pres 31 production 17,000. active include Suzanne M. Delerme Vice Pres 24 clerical 6,400. active include Is Salary/Draw Included In Question No.7 Annual Payroll? [ xl Yes [ ] No. If yes, amount 17.000 6,400. Code 14J 953 Employee Data: Dept. or Job Description Number of Employees Full Time Part Time Annual Payroll Code U!t(Carpet) Code ii1tk(CommerClal) 1. I,.., ... - .....~... 4',10Q___ _. - . ", 2 5 21,800. to ~~~ ;"'-l.\- or All Il>o Commit-.. Yoo Malle" ) " . ..... ~ ".., , STAt..j)~. WO~"i:jlt5 C:J"~t.""SATJor. "'NO EMPI.ClYE.RS I.IA81tIT~'''POI.ICY CMA ..... c...... IIllfNlM 101I' AM~~C~O IN~ORM~TtU~ PAGE EFF~CTIVE. O~/Oo/~J DUE. TO CHANOEO EXPE.RIENCE ~OOIFtCATIO~ FA M POLICY PERIOD T COVERAGE IS PROVIDED BY AGENCY I. 07906262 09/00/9J 09/06/94 NAMED INSUREO AND ADDRESS SUZANNE " DEI.E.AME. DBA SERVPRO ~EST SHORE INC 167 A SOUTH ENOI.A DRIVE ENOLA, PA TRANSPORTATION INSU"ANC~ CO. OJ675~0' AGENT :HANI.EY MCOONAL.O AO<.~CY OF II.I.IN'_1 2016 STATE ROAD PO BOX 1446 I.ACROSSE wI 54601 1702 FEIN NUM6ER: 232597197 INTil~5TATE 10 NO: J72711290 ~CC1 CA~~ll~ c~ut h~: lZ~UO OTHER wOR" PI...CES NOT Sria"" A~av,,: "a AOl.ITIG'j"l. l.l.lCATICNS YOU ARE. A - cailPORATION/S POI.ICY PERIOO- 09/0~/9j TO 09/00/94 12:01 ;,,., STAN:;<.f,a TtME. AT THE. tN$URE05 MAILING AODQESS. Ja. PA~T O~E CF THIS peLley ~?PL1~S TO TtiE wORK~RS CO~P~~5ATIOI4 LAA ~hC ~~y OCCUPATIONAL DIS;AS~ L~~ OF p.~,~ o~ THE ~T~TE~ L!5T~u H~~c: PA. jil. ?ART TwO OF THiS POL.ICY AP;:IoLlcS T..:I EMPLJVE.qS LIAc!LITY I~iSL.P<;.4~'C[ Fuo1 1?0o':;;": IN ~ACH STATE. I.tSTED l~ ITE~ 3~: THE l.lMlTS OF l.l~8tl.IT' A~E: BODILY INJURY &Y ACCI~ENT flOO,OOO EACH ~CCIGE~T 9uOll.Y INJUilY bY DISEASE iSOO,OOO POLICY I.IMIT BOOII.Y lNJU~Y BY otSEASE $100,000 E~CH EMPl.CYEE PART THR~~ OF THIS POLICY ~P~LILS TO OTne~ ST~T~SJ It M~YJ LlSTlD H~~~: ALL STATE.S eXCE:.PT ;"1<., ME, NV, Nu, OH, ,....., ;,.,;V io4~U ~'ri..\T~~ !.:'E.Slt.N&.T('C I~. lrE."': JA OF THE rNFOQMATtO~ PAGE. TtiIS POLICV INCLUDi:.S ThESE f.N:iUR3E:.ME.NTS AND SCHf:.QuLES: ::i::i. ~TTAC!1E(; :::'C~::,~~;.l:"':-. ------------------------------------------------------------------------------- THE PkEMIUM FO~ THIS POLICY ~rLL ~E DET~~~l~E~ UY ~UI~ ~A~.UAL OF kUL~S, CL4S$[FICATIONS, kATes, Al\ii.) RhTING PLAN:i. ALL I~FOR"',Arlu!4 Ftc.:>.oIUIQEtJ [;!:..L'J... i~ SUBJECT TO VERIF lCATIOt< AND CHA.,GE bY AJUll. CLASSIFICATtU'~ OF ~PE;?~TION5 !.: ~ T :. ~.J. .-,'._ ;:o~:::"'.r ~:t" 1",'-<. 5E.E:. ATTtoCHt.D PK;~ ~IUI1 oJ! ~C.Jl:,'..T - , -.:...:,..f.r.~~_ i:":';"Sl;..~'li 1- f J;( ~ :.:.~ ~ "v v Jd J'=>.:!~ f .; r 1 j ~ ;., :,"" !- t.., ;~ ,....:... :.. T ..; '.~ :...J L 1 ~ ;.~. T:T:,L f srI ~...... T L u r..... :'. U :41.. .' .:.' f. :.. I U"" L ".' I ~ ~ M I:-~ I t"'U ~ ;jEPO::;IT T:1::: ~~i:.!"qlJM pf( (; ~IU'" ;...... t..:.1_:': ..;".':':'" ::. ;,::'1'" Il.:'" i.: ~ llll' ~T:: uF l:':'':'~L: )./v.'.j',,, ..:it.rcy 1~.~...1'..,. ..J.":....:.: ..:~...~.~...:-.. ~. .... T~' .' :.:.... ------------------ -------------.--------------- " I , .' I .. ,. ~ : : :. ; ,1 kl "1 1 ' . N LAl(D;{J/;"I':")'.rI" nalrman 01 the Board c , \,j .. . -:-,'.-,,,.., .... .,J '.1. 51'C!l'!Olrv tNJt~ -::- :...,..:;~ .... AJJ Cho ~ltmO:'llt.f9a /olab" .' J c....... ~-- " . ....~ ,,- STA~J. ~ORKE~S C~PENSATION ANO E"'PLOYERS LIADILITi''''POLICY AAE~OEO INFOR"ATION PAGE EFFECTIVE 09/06/93 OUE TO CHANG~O EXPERIENCE MOOlrICATIO~ POLICY ~UMSER , F POLICY PERIOD T COVERAGE IS PROVIDED Y AGENCY '~ ~C O'~790~282 09/0~/9J 09/06/94 NAMEO INSURED AND ADDRESS SUZANNE M OELERME DBA Sf.RVPRO WEST SHORE INe ~67A SOUTH ENDLA ORIVE ,ENOL'A. ,6>A i.'," ,;... TRANS~ORTATION INSVRANCE CO. OJ87590~' AGENT STANLEY MCOONALD AGENCY OF ILLINCI 201 B STA TE ROAD PO BOX 1446 LACROSSE 101 5460J '. 7G2 *. S C rl ~ J U L f G FOP ~ k ~ r I 0 I~ S ** STAT~: PE~NSYLVA~tA SCt1::~l.J:-::. PAGE . . ~OC CLASS :,0. COOE CLASSIFICATION OF UP E.RA r I o~.s loT TDTAL "ATE PE>l A~N RE"UN ~100 RE~UN t; S T ~N{...l,,;';' P!<~"'lI :';," JOl 014t 0971 0953 095t LAUNORY ~.OC 8UILDINGS CLER 1 CAL OFF ICE SALE SME:.k 4~ J' 100 21,500 t~.ooc J ,t 00 t='a~ ...CCAT!Oti 1 J. fJo It .77 .52: 1.01 001 5 J r1.;: ti'tPLCV.EeS 2 . ~ ~ ':' c; ..:l suo TOTAL $ d I 4,.. TOTAL PREMIUM SUbJECT TO EXPERIE~CE KUOIFICArIQ~ 989b EXPER:LNCE MOO, EFF 09/06/93, USING FACTO; INTRASTATE ID. NO: 37271tZ90 t .1 170 8. It 'J.. ';1), OOuJ 0900 TOTAL E~rl~AT;O $TH~uARO P~[Mlu~ PREMtUM C15CUUNT - ~Tac~ EXPENSE CONSTANT,NCCI REVISED PROGRAM TorAL EsrlMATED PREKIUM 1'" :.; 19,1..} .. I., J '- t:', '" ~. -Tt 1..>- :.j~.J:: ~..i:-../... .]l..1'" t!.l:;~ ;i,. .rF l<.-: ..:L...........'.l,t f:I C/,~^'"~:4.' 'ha,lfman ollhe BOard ('\ " L, ~ ..\.~::_... S(~ClI'I,lr't' , . ,'- J.' .' .,. -:. I:..;. ! I ~. '... . .... . .. ...'.. ,~.., C'NA'.-;- ~"" 'orAD tho Com..t-.,.. Yoa_ ') . " -II STAI'jO: )WO>lKE~~ cd':1pr,NSAT10N . . ~ .. ANO EMPLOYERS LIAGILITY peLtCY CNA ..... CNuto. 111I........ AMENOEO II'jFO~MATION PAGE ~FFECTIV~ 09/0o/~3 DUE TO CHANGEO E~PERIENce MOOIFICATION POLICY I'jUMBER POLICY PERIOO F T COVERAGE IS PROVIDED BY AGENCY 07906282 09/06/93 09/06/94 NAMED INSURED AND ADDRESS SUZANN~ " OELEkME DBA SERVPRO WEST SHJRE INC l67 A SOUTH ENOLA ORIVE ,','ENOLA, PA ...... TRANSPORTATION INSURANCE CU. 03a75~O~ AGENT STANLEY MCOOI'j^LO AG~~CY 0 ILLINOI 20tO STATE ROAD PO BOX 1446 LACROSSE wI 54601 1702 ,"":':. .. ENe 0 R S EMf. N T .. ~CHr;":dl.. SCHE;;ULE. PAGE NUMBER ::'E.$C~IPTION i..:;:iIT1:J:. :>;'Ti::. P31203D WCOOOOOOA WC000406 oIC370bOl WC3'/Ob02 WC 37060 3 PARTICIPATI~G PROUISION COVE RAe.=. PART PREMIUM DISC~UNT ENDCRSE~E~T P(N!'4SYLVANIA 5Pf.CIAL E~ur. IN5PECTI:JN OF MANUAL PE~NJVLVA~IA NOTICE PENNSYLVA~t~ ACT 66-19J~ ENDOR~EMENT clio:: o'-/~~ ~~/o. 04/04 04/ d'" t2/,,7 .~Tt:. l.oF t:,:"J:: ~.../~":"I"'" 'JLIGV I'.I~vJ'\:, ..r-'~l':..: ...;._....., . 1:/ CI,"',"'"':);...., halrman Ollhe BOard (", \1{ . - ,"-' (.... .. I .' ~ 'oJ LJ. I ( , ...:-.....-.......", SPCr{'l.lrV . C'NA~-~ ,-...\, ,. A111ba ~Dl_U You_ " -, , .....,... ) . '. ....' STA"O"~ 'y WORI(E'IlS Ccl'MP;:"SAT10" ANJ EMPLOYERS LIA~ILIT~~POLICY c....... ~ IMIftM IOIU POLICY NUMBER AGENCY POLICY PERIOD T COVERAGE IS PAOVIDED Y FR M 07906Z82 09/06/93 09/06/94 NAMED INSURED AND ADDAESS SUZANNE M OELERME ,OBA SERVPRO WEST SHORt INC 167 A SOUTH ENOLA OR1VE E/lOLA, FA TRANSPORTATION INSURA"CE CO. 03675909 AGENT STANLEY MCOONALD AGENCY OF ILLINOI 201~ STATE ROAO PO BOX 1446 LACROSSE ~l 54601 1702 PARTIC.IPATI"G PRCVISIDN 'i'I'.~ '<~:~~ ...~OU.SHALL PARTICIPATE IN T~E EA~NINCS OF T~E C~~PA~Y TO THE EXr~~T AND UPD~ THE CO"DITIO"S OETE~MINEO UY THE BOARD OF DIRECTOQ5 OF IHE CO~PAHY IN ACCORDANCE WITH LAW ~Nj ~~D~ APPLICA~LE TG TrlI~ Pv~lCf. PKOvlv~O THAT ~C ~IVI0ENO SH4LL Dc PAYAULE HER~UNtCR UNL[~S you nAVE COMPLIED ~!Trl THE T~R~$ OF THE POLICY IN RESPECT TO THE P~YME~T OF PRE"lu~S. U"DER CALIFORNIA LAW IT IS UNLAwFUL FOR A" INSuAE~ TO PROMISE THE FUTUNE PAYMENT OF UtVIUENOS ~NOER AN UNEXPIRED ~OAI(ERS COMPENSATIUN POLICY OR T~ MISREPRESENT THE CONOITIONS FUR OIUIDEND PAYMeNT, JIVloe"cs ARE PAYABLE LNLY PURS~ANT TO THE CONDITIONS DETERMINED ~y T~E 3UARC OF OIRECTuR~ OR OTHER GOU~~NING OOARD OF THE CO~PA~Y FaLLO~ING POLICY eX?Ik.TION. IT IS A MISDEMEANOR FOR ~NY :N~U~ER UR UFFICE~ J~ A~~~T THEREOF, OR AhV INS~HANCE bROKER OR SOLICITOR, TO P~JMIS~ THE P~YMtr,T OF F~TURE ~O~KE~~ CQMP~NSATto" DIVIDENDS. THIS ENDORSEMENT FORMS A PA~T OF I~CEPTICN UATE, UNLESS UTHE~~1~~ CO~CU~R[~TLY ~ITrl THE PuLICY. THE POLICY ANU IS SUeJ~tT TO T~I~ SA~E ~TATEO. TH[S t~OO~3EML~.T ~~PII(ES .. r :. : f I ~ '> u t: '.I: I . ': ,'", :. _ _ 1:1 j ~~l.: . .' -' "" I :;: '. : ... .....' I . # CIz"(./.a'~"41'" :.h.urman 01 the Boald Il~\ \~ ~ - ,I .: , .' I I -V,''',,'''. SI'C1l'I.lrv 1""'.:; ~ ,- , :J',' ,. " lji " .j,:" f, 'II; -,:: -.'-,. -:,', : " ~ J I L: .. ~, t\ , 'f , , " c, , ... ../ " ! 'J': -::I,ld c,l' '. l ',:-,: ,)'- h~ ~,' ;" ':!I'-.. , .: i - .:: _ i: 'Co- ~ '-' .-:,,'.' ., :-. f _.':] I "I:: ') : .-~-;;. :::,'.{I,': C: " " ] ,oIl ,,- c, C0.:.t.I-C-<,~ {if" ;.", '--f'1''''''--c (" ! )ILLU'~ ,ILV 7 .~.~. l' ,.j/' // /;:;;;:"->-".~-<':1~ ~ ("'J '- c f,: \:) 9 :j4 ~t ~. :.) ..'_. :<.)~.~ -~~ ..-:;: ~')~ ~o ., Cl ::'-0 u: )/ ,......". tEl>' <.... :;',(';) J, l.. :.}b.. ....' l- ,. L~. ..n ":'"::; 0 0' 0 J ~ '~'" ..,. " 'j ~ ~ ~ ~ -l: cr1 l ~ .. . . ~ J ~ ~ ~ ~ .,. ,! ~ ~ ~ J ~ ~ \tr -:=; 1 . ~ ! ~ 'it ~ :s ~ ~ ~ ~ ~ \'l ~ N W N i-l N ow'" a::l..... ..-1 l'l .....w<ll ....>P< m<ll ~ ' ..c::..c:: .... .... C' i-l i-l W ::l ::l ao.Q i-lr.. Ul w .... ............. WO'.-I !:IMP< % ~ j , , . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION TRANSPORTATION INSURANCE COMPANY : 401 Penn Street, Reading, PA Plaintiff, : No:96-5507 CIVIL v. SUZANNE M. DELERME d/b/a SERVPRO WESTSHORE IRe. AND SERVPRO WESTSHORE, INC. Defendants. PRELIMINARY OBJECTIONS ON THE GROUNDS OF LEGAL INSUFFICIENCY OF THE PLEADING (DEMURRER) AND NOW, comes the Defendants, Suzanne M. Delerme and Servpro Westshore, Inc., by their attorneys Delerme & Gallimore, and file this Preliminary Objection on the Ground of Legal Insufficiency of the Pleading (Demurrer), respectfully representing and setting forth as follows: 1. The Plaintiffs' Complaint fails to state facts constituting a cause of action against Defendant Suzanne M. Delerme in that the facts so alleged do not show any causal connection of any acts or omissions of this Defendant and the injury and damages allegedly sustained by the plaintiff. WHEREFORE, it is respectfully requested that the Demurrer to the Complaint be sustained and that Defendant Suzanne M. Delerme \ LAW OFFICES OF SIMASEK, TUTOKI & RUZZI BY: Joel S. Jenkins, Esquire 1818 Market Street, Suite 3400 Philadelphia, PA 19103-3634 2 I 5-448-3309 !.D. #41206 Attorney for Plaintiff Transportation Insurance Company TRANSPORTATION INSURANCE COMPANY CUMBERLAND COUNTY COURT OF COMMON PLEAS vs. NO: 96-5507 SUZANNE M. DELERME d/b/a SERVPRO WESTSHORE, INC. AND SERVPRO WESTSHORE, INC. CIVIL ACTION AMENDED COMPLAINT 1. Plaintiff, Transportation Insurance Company, is a corporation licensed to do business in Pennsylvania and is engaged in the business of providing insurance coverage pursuant to the laws regulating the insurance industry within the Commonwealth of Pennsylvania. 2. Defendant, Suzanne M. Delerme doing business as Servpro Westshore, Inc. is an individual engaged in a business at 167 A South Enola Drive, Enola, P A 17025. 3. Defendant, Servpro Westshore, Inc. is a corporation with its primary business location at 167 A South Enola Drive, Enola, P A 17025. 4. Plaintiff, Transportation Insurance Company, at the request of both of the defendants referred to above herein in paragraphs 2 and 3, provided defendants, Suzanne M. Delerme doing business as Servpro Westshore, Inc. and Servpro Westshore, Inc., with a workers compensation insurance policy #WC-07906282 that covered the policy period of September 6, 1993 to September 6, 1994. Said policy of insurance was, in fact, provided to the above referred to defendants. Although the plaintiff, however, fulfilled all of its obligations to the defendants .... ~'~... under the aforementioned policy of insurance, the defendants failed to pay the premium earned on the said policy. 5. Pursuant to the attached copy of the Workers Compensation and Employers Liability Insurance Policy under General Section B. - Who is Insured - It is stated, "you are insured if you are an employer named in Item 1 of the Information Page." 6. The Information Page regarding the insurance policy, WC 007906282, for the Policy Period of 9/6/93-9/6/94, a copy being attached hereto as an exhibit, indicates in Item #1 that the named insured is Suzanne M. De1erme d/b/a Servpro Westshore, Inc. at 167 A South Eno1a Drive, Enola, P A. 7. Pursuant to the insurance policy, Suzanne M. Delerme d/b/a as Servpro Westshore, Inc. is the named insured and a party to the insurance policy. 8. According to the attached copy of Part One - Workers Compensation Insurance, under B. We wi\1 Pay, _ the plaintiff, Transportation Insurance Company, agreed to "pay promptly (to both defendants indicated in this action in paragraphs 2 and 3 above, herein,) when due the benefits required of you by the workers compensation law. 9. By the provision of the above said insurance policy, the plaintiff, Transportation Insurance Company was, therefore, among other duties as listed, under a contractual obligation to both of the defendants named in paragraphs 2 and 3 above, herein this action, to provide workers compensation benefits as called for under the workers compensation act for the period 9/6/93 - 9/6/94. 10. Pursuant to the attached copy of Part Five - Premium, of the Workers Compensation and Ernployers Liability Insurance, "You (referring to the insured) will pay all premiums when due. You will pay the premium even if part or all of a workers compensation law is not valid." 11. The defendant's indicated herein, Suzanne M. De1mere d/b/aJ Servpro Westshore, Inc. and Servpro Westshore, Inc. had a contractual obligation to make premium payments. 12. Pursuant to the attached copy of Part Five. Premium Item E, of the above referred to Insurance Policy, the Final premium is set forth as: The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will bc detcrmincd aftcr this policy ends by using the actual, not the estimated, premium basis and thc 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 the balance to you. The final premium will not be less than the highcst minimum premium for the classifications covered by this policy. If this policy is cancelled, final premium will be determined in the following way unless our manuals provide otherwise: 1. Ifwe cancel, final premium will be calculated pro rata bascd on the time this policy 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 rata; it will be based on the time this policy was in force, and incrcased by our short rate cancallation table and procedure. Final premium will not be less than the minimum premium. 13. Consideration existed under this writtcn contract or insurance policy as both the plaintiff and both defendants as named herein in paragraphs 2 and 3 of this action had contractual duties or obligations to perform or to be prepared to perform. 14. The plaintiff, Transportation Insurance Company, had fulfilled all of its obligations under this contract and had been prepared to make payments for benefits called for under the policy. 15. The defendants, Suzanne M. Delerme d/b/a Servpro Westshore, Inc. and Servpro Westshore, Inc., failed and neglected to perform the conditions or contractual duties of said contract by failing to pay to the plaintiff the insurance premiums due and owing on the policy of insurance referred to above in thc preceding paragraphs in thc total sum of$6,919.00. Payment has been due and had been demanded by the plaintiff previously. Copies of the policy and of the audit papers are attached hereto. g~~~..:........ , .' ,..,,, ",..,t. CNA Inau ..-..,,; lpanies CNA PI... . J Chicago, illinois eoea5 AUOI T AUDIT FrNAL P"PT: AUDIT "J PAGE , STATEMENT - WORKeRS' COMPE~SATION PERIOO - 09/06/93 TO 09/06/9~ AUDIT 6037 AUDITOR: REG BAseD ON AUDITOR'S REPORT POLICY NUMBER o 07906282 FROM POLICY PERIOD TO COVERAGE IS PROVIDED BY 09/06/93 09/06/94 TRANSPORTATION INSURANCE CO. AGENT 0387590QC AGENCY NAMED INSURED AND ADDRESS , SUZANNE M DELERME ! JBA SERVPRO WEST S"ORE rNC /!67 A SOUTH ENOLA DRIVE ,=NOLA, PA I I i I 17025 STANLEY MCDONALD 2018 STATE ROAO PO BOX 1446 LACROSSE AGENCY OF ILLINOI wr 5~601 WORKERS' COMPENSATION AUDIT SUMMARY. TOTAL EARNED PREMIUM (SEE ATTACHED SCHEDULE) *TOTAL PREVIOUSLY CHARGEe AMOUNT DUE COMPANY $16,058 $9,139 $6,919 \ \ \.- I '-.L i , ( )i.: /'/1 J II) , -. ! -.,. .., )) " _Jl , 11 .. .- I, ..~ , I . .. -' , THI S PRE'lZUM AIJDlT SILL IS'.VALID ONLY IF A"'CUNT INDICATED AS PREYl!)USLV CHARGEe I-lAS, I~ FAC T, ;SEEN R;;CErVEO BY CIIA. OF IS:il)E: lL/OQ/94 CY rsstJP;G aFFICE: "IL~A<.;K[( ,1;;Ar,CH 5150 3. BRANCH .. \. 1 .C'J'IA . . ""~~:::'ItMftlLl""Mab. -.... CNA Ins ural CNA Plaza _ Chicago, illinois 60685 "panles PAGE : . . . .~- ,<so'" AUDIT STATEMENT - WORKERS' COMPENSATION AUDIT PERIOO - 09/06/93 TO 09/06/q~ FI'lAL AUDIT PRPT: 6037 AUDITOR: REG AUDIT BASED ON AUDITOR'S REPORT POLICY NUMBER , FROM .POLICY PERIOD TO COVERAGE IS PROVIDED BY AGENCY o 07906282 09/06/93 09/06/94 TRANSPORTATION INSURANCE CO. AGENT 03875909J NAMED INSURED AND ADDRESS SUZANNE M OELERME 08A SERVPRO WEST SkORE INC 167 A SOUTH ENOLA DRIVE =NOLA, PA 17025 STANLEY ~COONALD AGENCY OF ILLINOI 2018 STATE ROAD. PO 80X l't~6 LACROSSE WI 54601 .. AUeIT ANOCOHHISSION STATEMENT .. DUE TO AN AUDIT, IT IS AGREED THAT THE ADJUSTEO PREMIUM OF THIS POLICY IS PAYABLE AS FOLLOWS: 8ILL DATE 11/09/94 11/09/94 AMOU~T DUE COMPANY PREMIUI'! $847- 57,766 COMM ISSION 2: 0.0 5.0 56,919 OCT 12 '95 01: 17PM ~ COM"ERCIR.. SLf'PORT READING P,3 I ' I :Sit Id: 10777589 ;ured: SBRVPRO WEST SHORB !U1ch: 470 licy Period: 09/06/93 to 09/06/94 .ncy: A Inlurance companies PlU!MIUM AUDIT REPORT , Date: 10/17/94 Mode: P Page 1. iolicy pre/#/Mod: WC 0 07906282 Auditor: 1013 . STBVE DEMPS~ Type of Audit: ANNUAL 05 AUDIT INFO~TION REPORT .:mLING INSTRUCTIONS: (] RUSH (] RBAUDIT (] CANCBLLATION (] UND. ALERT [] MIDTBRM REVIEW (] COMMENTS CORDS USED: SOURCE DOCUMENTS VERIFICATION DOCUMBNTS (X] PAYROLL REGISTBR ( ] FEDERAL 941' S ( ] GENERAL LEDGER ( ] STATB UCT'S ( ] GBNERAL JOURNAL ( ] INCONS TAX REPORTS ( J CASH DISBURSEMENTS ( J W-2, W-3, OR 940 ( ] CERTIFICATES OP INS. ( ] OTHER: :ORDS CONDITION: (X] ADBQUATE [ ] OTHER: ~TION OF RECORDS/CONTA~r/TBLEPHONB NUMBER: SUZANNE DBLERME 732.6000 167A SOUTH EOOLA DRIVB BNOIA, PA 17025 ~ITY OR OWNERSHIP STATUS: [X] CORPORATION ( ] PARTNERSHIP ( ] PROPRIBTOR [ ] OTHER: FICER/PARTNBR/OWNBR INFORMATION: WC/GL SALARY WC/GL CODE CHARGEABLE NAME: A.E.DEI..ERME (951 J ( ] [ 31600] [ 31600] ( 0] TITLE: PRESIDENT t ADM ( SALES [ J SUPV [ J LAB [ ] DUTIES:OUTSIDE SALES NAME: S.DEI..BRMB [951 ] [ ] [ 18560] [ 18560] [ OJ TITLE: VP t ADM [ J SALES [ ] SUPV [ ] LAB [ ] DUTIES:OUTSIDE SALES NAMB: [ ] [ ] ( 0] [ 0] [ 0] TITLE: t ADM [ ] SALES SUPV [ ] LAB [ ] DUTIES: NAME: [ ] ( ] [ , 0] ( 0] [ 0] TITLE: " ADM [ SALES ] SUPV J LAB [ ] p~I'!'IES : NAME: [ ] [ ] [ 0] [ 0] [ 0] TITLE: t ADM [ SALES SUPV ] LAB [ ] DUTIES: SCRIPTION OF OPERATIONS: INSURED DOES RES IDENTIAL CARPET CLEANING, THEY SO ACT AS A JANITORIAL SERVICE CONTRACTOR CLEANING OFFICE BUILDINGS. E INSURED ALSO DOBS CLEANING FOR FIRE AND WATER DAMAGE. OCT 12 '95 01: 18PM Of'l COIH:RCIfL SLf'PORT RES'lDING P.? Audit Id: Ig777H9 D.U' 10/17/96 Mado. , ,.... , I.......... uam.o IoInT IHOllE Pilley ,...t'/MGd. IlC o o79Q6ZU as Irandl' 470 ~Itor. 101' . ITrvE ol",ll1 'oLley ,.,1011. 09/06/93 to 09/06/94 Typo .f Al.dU I A1l1IUAL Aa"""Y: 2 3 4 5 6 7 8 PA DIPT lOa oUT 200 DIPT 30G DIPT 4llCl DIPT 500 DIPT 600 Dl'T 700 TOTAl. CAVlT o"le! omelll IWIAIIIIlIKT 11M CLW 'IRI/101ATU IAl.U PAIROLL eLlIAlIlKO RlI1ORATIOlI eLAn CODI 141 953 '" 911 971 971 ", 'laK PATRoLL IIGIITII u, n 1,959 4,160 1,650 2,602 I,m "' 12,8\4 OCT 3,415 Z42 6,240 2,475 2,047 . 1,842 au 11.'44 NDV 2,376 1,184 4,160 1,650 1,IlIl2 2,lZ5 1,327 14,104 ole 2,"2 96 1,210 1,650 2,394 1,739 1,995 12,706 JAIl 94 l,321 391 4,320 1,650 2,205 2,03& 1,712 14,631 '11' 2,009 1,056 4,4Ill 1,650 2,000 1,151 2,114 14,531) lIAR 2,2D9 3,805 4,410 1,650 3,%01 702 3,'" 19,702 API 3,159 6,703 ',ZlIg 2,475 5,864 1,182 1,919 27,%82 MAT 2,453 4,416 4,480 ',650 3,nl 2,271 2,~g 21,141 JUII 2,745 4,434 3,760 1,650 3,OOJ 1,63' 3,019 21),319 JUL 2,4ZB 6,452 3,01.ll 2,275 3,326 4,671 2,412 24,680 ~O 8,740 7,907 4,480 1,700 1,017 2,491 2,918 29,3Z4 "TOTAI.* 37,066 36,756 '0,160 22,125 33,589 23,752 25,635 229,0&3 \ \ WA--.: AD *r~..w-c. YoG wu.- ) c..._ --- STANUA~. R~E~S COM'EN~ATIDh AND EMPLOYERS LIABILITY PO~ICY . ... . IN,OAMATION PAGe - ReweWAL 0' WC 0 07906~82 ~ ,,. i I I I I L,~;V NUMBER ! ;., 0,01906202 09/06/93 09/06/,. i :. i NAMED I S!,JR 0 A P ADDRESS Ii ,;. D~~.seRVPRO weST ~HO~E INC '.:' ~fp7." SOU.1'". eNOl.A; OAt.IIE . \' . '.;' )"c:iL~ ~ PA . . '~ I I I I ! FROM POLICY PERIOD TO COVERAGE IS PROVIDED BY TRANSPORTATION INSURANCE co. AGENCY 0307590'il~ GE 2011/ STATE ROAD po lIOX 1446 LACRosse WI 54601 1702 INT~A5TATE 10 NO: 372711290 ~THER WORK PLACES NOT SHOWN ABOVE: NO ADDITIONAL LOCATIONS YOU ARE A.- CORPORATION/S POLICY PERIOD~ 09/06/93 TO 09/06/94 12:01 AM $TANDARD TIME AT THE INSUREDS MAILING ADDRESS. PART ONE OF THIS POLICY APPLIeS TO THE WORKERS COMPENSATION LAW AND A~Y OCCUPATIONAL DISEASE LAW OF EACH OF THE STATES LISTED HERE: PA. PART T~O OF THIS POLICY APPLIES TO EMPLOYERS LIABILITY INSURANCE FOR WORK IN EACH STATE LISTED IN ITEM 3A: THE LIMITS OF LIABILITY ARE: BODILY INJURY OY ACCIDENT '100,000 EACH ACCIDENT BODILY INJURY BY DISEASE '500,000 POLICY LIMIT BODILY INJURY ay DISEASE '100,000 EACH EMPLOYEE PART THREE OF THIS POLICY APPLIES TO OTHER STATES, IF ANY, LISTED HERE: ALL STATES EXCEPT AK, ME, NV, NO, OH, WA, WU AND STATES DESIGNATED IN ITEM 3A OF THE INFORMATION PAGE. THIS POLICY INCLUDES THESE ENOORSEMENJS AND SCHEOULES: SEE ATTACHED SCHECULl -------------------------~----------------------------------------------------- THE PREMIUM FOR THIS POLICY WILL DE DETERMINED ~Y OUR MANUAL OF RULES, CLASSIFICATION,S, RATES, AND RATING PLANS. ALL INFORI1ATIDN REqUIREO BELOW IS SUaJECT TO VERIFICATION AND CHANGE BY AUDIT. ADJU5TMENT OF PREMIUl't SHALL B~ .MAOE: AT POLICY EXPLR~TIDN CLASSIFICATION OF OPERATIONS ll, ~2 5 ~7,9aY f'REMIUl't DISCOUNT EXPEl'S!: CONSTAN r ESTIMATEG ANNUuL PREMIUM EST ANNUtoL PilE"IUM ~b, I ~ 7 J'" 1...: , 7 , 9~.\ '1 SEE ATrACriED MINlPO:U" PREMIuM CEPDSIT PREI1IUM TOTAL 'TL OF lS~~": O./v2/~J ~l..l'Y l::'~uL~'J ;JFfl(..L: :-'.lL.....:.UI\E.:. JU~TEk~IG~:.: __________________ t:. to II ~y---------------------------- ,~u f 1101( I l::';; &4("f::" T ~~ Ch.llmln ollh. BOlrd ...( \JO~:':> I ~-3JJ;~-c (~~. b/~7) WORKERS COMPENSATION ANO EI f' 'qS LIABILITY INSURANCE POLICY WC lB9 .::.: .;.~- WC 37 06 01 SPECIAL PENNSYLVANIA ENDORSEMENT-INSPECTION OF MANUALS This endorsement changes tne poliCY to ,^,~lch It !s attacnea eH~ct:.~~ on tne incept .:r. cate :~ ::1e ~v:,Cj J;,,::a:..: ~ different date is Indicated belc",. (Tne 'OllcwJr.g "at:acmng -::a..;$e . neee :Ie :::~;::'el~C ~"'i:t,l/:;e~ :r'I!. '!:"'COfs'!":"er.: 'S .SS:Je'J sl.,;:se:::...e~: :-:: ~re:J'J~.C. :0' :"! :.; .:, . This endorsement, effective on at 12:01 A.M. standard time. !erms a ~ar: 0: o;:,:":'!; Policy No. of the ".lo'~E :~"5:.;;:U"C!; ':,J'10,l.~1' issued to Authorized Re:)rese!"tat:'J! The manuals of rules, rating plans, and classifications are approved pursuant to the provisions of Section 654 of the Insurance Company Law of May 17, 1921, p.L. 682, as amended, and are on file with the Insurance Commissioner of the Commonwealth of Pennsylvania. ....-.......... ~~ ............. .:;;::~/'jghl : 38-1 P~n'l:.~lv,lr~I.Il..~,Jmpt'n;~IIl'f1 RJ!Il'!~ Burp.all WORKER.S COMPENSATION AND )YERS LIABILITY INSURANCE POLlC WC 346 (Ed. 12.a7l WC 37 06 03 PENNSYLVANIA Ar:r 86-1986 ENDORSEMENT NON RENEWAL, NOTICE OF INCREASE OF PREMIUM, and RETURN OF UNEARNED PREMIUM This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. This endorsement, effective on (The IOllON1nS -attaching clause' need be c"mcleled only when this endorsement is issued subseQuent to prepafol:ion d the pelicy,) at 12:01 A.M, st~ndard time, forms a part of (DAm Policy No. of the Endorsement No. issued to (NAME OF' INSUR,ArlCE COMPANY') This endorsement applies only to the insurance provided by the policy because Pennsylvania is shown in Item 3,A. of the Information Page. The policy conditions are amended by adding the follow- ing regarding nonrenewal, notice of increase in premium, and return of unearned premium. Nonrenewal 1. We may elect not to renew the policy, We will mail each named insured, by first class mail, not less than 60 days advance notice stating when the nonrenewal will take effect. Mailing that notice to you at your mailing address last known to us will be sufficient to prove notice. 2, Our notice of non renewal will state our specific rea- sons for not renewing. 3, If we have indicated our willingness to renew, we will not send you a notice of non renewal. How"ever, the poli- cy will still terminate on its expiration date if: a, you notify us or the agent or broker who procured this policy that you do not want the policy renewed; or b. you fail to pay all premiums when due; or c. you obtain other insurance as a replacement of the policy. Notice of Increase in Premium 1. We will provide you with not less than 60 days notice of intent to increase the premium on the renewal of this policy, if it is our intent to offer such renewal. ,.......""".'" ~,~ -_1-- . Authorized Representative 2, We will provide you with not less than 30 days notice of an estimate of the renewal premium, if it is our in- tent to offer such renewal. 3. The above notification requirements will be satisfied if we have issued a renewal policy before the time peri- ods indicated in Items 1. and 2, above. 4. If a policy has been written or is to be written on a retrospective rating plan basis, the notice of increase in premium provisions of this endorsement do not apply. Return of Unearned Premium 1. If this policy is canceled and there is unearned premi. um due you: a. If the Company cancels, the unearned premium will be returned to you within 10 business days af. ter the effective date of cancelation. b. If you cancel, the unearned premium will be returned within 30 days after the effective date of cancelation, 2. Because this policy was written on the basis of an es- timated premium and is subject to a premium audit, the unearned premium specified in la. and lb. above, if any, shall be returned on an estimated basis. Upon our completion of computation of the exact premium, an additional return premium or charge will be made to you within 15 days of the final computation. 3. These return or unearned premium provisions shall not apply if this policy is written on a retrospective rating plan basis. Copyflght 1987 PcnnsvlvMi;, COrT'l('lCILsat.on R:lllne Bt.lreau E '-7-93 '1IIa COUNTERSIGNATURE REQUEST COlJhTf"'RSI5N!NG AGENT: . '. {~POlit,. .ny endors.m.n1s~h.rerof . . his bI.n r,quested to COUNTERSIGN THE ATTACHED Endo,s.ementhl \" . Keep count..~.lgni'1g Ig.nt copy for your fill end: Countersignature endoml~.nt (.~d :opi.. .nached tl'l."to) 1. ~ Return all other copl.. to CNA Producing E1rench In e"closed return envelope. 2. D Return Producing Br.nc/'l~oPY f(J CNA Producing Branch; send all other materials Cancellation to Producing Agent shO...V'lI'.bI!low. 0 Cancellation} Dale o Final Audit No Countersignature Required 1, Os .1 ,. . Countersigning f.. i. due CIS agent shown at roft. Producing Agent please remit this amount direct to CIS agent within 45 days. Countersigning Agent Nem. & Address: . lii:avuI,' IlQGIJt '.&JlilSL, IWIU' aLL!'.1 ,,,.~ 1IOl.II:"'~. DIU ~ oa. GAtiJI Melli' DADlJ8 Wltc:II L -.'''.' 2, Os Countersignature fee will be billed to the prOducer through the MAC svs1em; '. -.J . ....,~..:: . ." .;::..:....~:~,... ....~.. .~'. ;.<.,:.'; ,... '-,' '.- 7':::~"'~-'~;;~':.':~:"~"::"': ~',,""" ,'.') .f.."" "'.C/SAlJfntComp.ny.C~No.,.:." _......4. '"', ~: <:.";;;:,\"'I.",:~.~: .:: ':.,tt;.~~"~ ;.;J); ':,:~f,"~~ ~'.f.~r:.t!~:i:,.''': .'.:';'~,:i:'( ': :.:~~:: . ,~'., f..~'''~,-;~'t.,j'):';';-:~r.:,..'' J,', ..,.::t--',~:" .....:.....:'i:.,:......'~~:.~..:.,~.;~....~,':'.::;,.J!!~.....\ ~.. '';'''. 3, ~ No col.fntersigning felt for this item. o ~O..c~u~~8rsi~~~tur' fe~ a~;J_;t'~e~i t~ ; ~.~ at ihil time. .:~7~:;;..~\~~..:~:.. .:'..... :':...... ,~~,':;"\...~;:..::":.- '.; .j;;E:ff.~:;:COiJNTERSrGNATjJFiEENl56RsEMENT;P;';..: <~::"';::;~~t:',/:'''_''=_,~::'';--:!,,~.. .~ . "..,-'C"N" - '-'..' 'j"' /'~[:!~::;~~J ..t"~~,. -1S;,.r &;~".' '.-" -'., " " -. .. "_.~.:~.,. .....' ,-. " ~~~;J;'"r~i:.?~?:.:~..i..;.if~':.~~:~ .';"' F~~Ait~COP'niltmce'riii:OIi:~~"x,.l:i.~. .~ .:.'? .~..,:;..~J;"~' ,,'t. ..........' " .:;,' <,.', ,."-'.' ~ '-.t .; ~~ "':'''''~'.'' .... . """.,............, , ".' .". .,.. ,...~""...",."...., -., ==. ~4~~ [~:~:;~r~i~~:"" . '.:..:. . . '. :.;; ~, ': ::"1". .:~~:.;:.,i.:~,:~.#.t~.:. :.,.:. ,~:' 'TVP~.O~ . = ~~. }S:.i,~,:~~r.. ';," '".;;'~J. ",.,,, ,'~ ~.....~.....,:,_T:~.:.;l,'. l. . _Policyor ~ '~~Y~!a~ -:',:.r~.: '~'''!-: ,". . ,.;:-~':!,'.~. ~COY". ;_; Effectlve-. '. :..';I...~;.: ."':.-.~.1:.~.::1. COu'~18nigM1u;.'-iO-;'ij,;;'Ita1.'of:'. . .' .... -. . .--..-.... .' ,,' .... ..,.,. <~ ;~~....\.. ..........._~.... . ..:;..... . , . ,'. '~.... ...". .,. , " .~.,:~..' r ...- _ " .. '1;'.. '.' .....,.~. '. ~ .E~::ta..~..~;~~l~, 71,;4\:c'Y: .'....' .~~~t~~~gNADNg)~~~~~~.~~~~ ~~ARTOf T,HE ABOVE ;:.~f~J;.:}.:.~r~f..,~;;._i.:.:,~j.::..~:~:~.,."./;i~:;.;.;~,:../i,:<:.t:/~,i~;;~:;~.:~:-\i: .;~..:..i '_~':{"< .~':...:~. '. . ''',' . -',~';' ON THIS ..~"~. ,,",,""" "'$ 'r.-;; .,... . ,"e~. , .. ,. . ,'~""'., '. " DAY OF . . ~ 19 "-- .:.~~':,',,,j~.t~~i~\~t:\:\7;:;.'~':;::<'I:E'::~~1/)~~~i(;-:...':;,~;.>~, ,~7'.~ _ ... . .... . ;.i<: . .... . ,.. 03fI~' .. ...... . ~.~ :~ ...., : 'p;odu~in~; A~Y;1C:ompan~ Code 'N:~.' 0;0 (slgn~u~). . '.. LIcensed Rnlden1 Agent , '". 5. PRODUCING BRANCH OIR COPY . '~, ":.'.:.' 'lo :1. _....r..:...;:.... ..:~sli.l,,: . ..~ . DlV....,. ,. '...: .. Nemeof ~. I Muted , \ ;~ ::';::: ~ .-:. -' ". -. .. ... J "'. . '.' .- .;', ,~ ,<-..' .'-' " ;.,,,.,' . ~~. .'..'. ......'.: ~. .. ~ '. : ,'. -~:'~. . .. '. ....,. , JNTERSIGNATURE WORKSHEET TRANSACTION: D N.~: ~ Renewal; D Cancellation: o Endorsement; 0 Final Audit PR Cod. 60 10 Premium This Statl Commission This State easls of Amount CIS F.. TransmlUed by " Producing Aoont CIS Fl!!t of ha. non-resident ~ Audlt.D.pod' only % Amount CIS F.. Pro' CNA (Show trans. codel neense ' , due., To: Installment - Dat. Next CIS State Premium Due Ves No Notr. Aglnt Pool qUlred 1) 12,1 1201 (2c) Icol.31 (4,1 (40) (col. 5) Icol.61 17.1 1701 17.) X $7.989. 050 399. NIL NIL we 102 (4.92) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY PLEASE READ THE POLICY CAREFULLY. QUICK REFERENCE BEGINNING ON PAGE INFORMATION PAGE GENERAL SECTION."."""...,...",.....,......",..""..,',.. 1 A, The Policy.....................;:.:........,..:.., 1 ."B, .w.h.o Is Insured................................ 1 ,.C, Workers Compensation Law............. 1 D. State.........,::.....................;,.............. 1 E. Locations......................:................... 1 .~ . . , PART ONE-WORKERS COMPENSATION INSURANCE 1 A, How This Insurance Applies............ 1 B. We Will Pay..::..,\.',;,:..;..,:..:,:....:,\.::,:.V C. We Will Defend................................ 1 D. We Will Also" Pay,......,..................,.... 1 l E. ?ther: Ins~rance.............:.....'........... 1 . F" Payments You Must Make...........,... 2 G. Recovery From Others...",............... 2 H, . Statutory Provisions........,.::........".., 2 " . PART TWO-EMPLOYERS LIABILITY INSURANCE....... 2 A, How This Insurance Applies............ 2 B. We Will Pay....',....,.....:,.........,.......... 2 C. Exclusions,.........................,...........,.. 3 D. We Will Defend.............,.................. 3 E, We Will Also Pay.............................. 3 F. Other Insurance.............................., 3 G. Limits Of Liability........................:.... 3 'j" BEGINNING ON PAGE PART TWO-EMPLOYERS LIABILITY INSURANCE.........4 ICont'd,) H. I. Recovery From Others..................... 4 Actio~S Against Us:....:....,:.........:...., 4 PART THREE-OTHER STATES INSURANCE.............. 4 A, How This Insurance Applies............ 4 . B. Notice............"............:.................... 4 PART FOUR-YOUR DUTIES IF INJURY OCCURS........ 4 _~.: :.:~::;:~ .', _ ",) ,',.", J PART FIVE-PREMiUM........................................... 4 A, Our Manua.ls......,...............,........,..,... 4 J" ,'.. B. 9Iassificati6:~s................,.................. 4 C, . Remuneration:.:....,.................:......... 4 D. Premium..Pilyments........................., 5 E, Final Premium..........,...................... 5 F, Records.......................,.................... 5 G. Audil...,........,:......,........,........,:........ 5. PART SiX-CONDITIONS......:,..........,...................... 5 A. Inspection,:...............,....................., 5 B. long Term Policy............................. 5 C. Transfer Of Your Rights And Duties 5 D. Cancelation...................................... 5 E, Sole Representative........................, 5 IMPORTANT: This Quick Reference is not parlof the Workers Compensation and Employers Liability Insurance Policy and does not provide coverage. Refer to the Workers Compensation and Employers Liability Insur- ance Policy itself for actual contractual provisions. ~............~ {JAUTHE NTICO .....~.:~...... COPYright 1991 National Council on Compensation Insurance. wc 00 00 00 A lEd. 4-921 we 102 (4.92) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY PLEASE READ THE POLICY CAREFULLY. QUICK REFERENCE BEGINNING ON PAGE INFORMATION PAGE GENERAL SECTION................................................ 1 A. The Policy......................:.:............... 1 ".B, ,Wh.o Is Insured................................ 1 ,C, .workers Compensation Law............. 1 D. State...........:..................................... 1 E. Locations......................:.................... 1 PART ONE-WORKERS COMPENSATION INSURANCE 1 A. How This Insurance Applies............ 1 B. We Will Pay...:..,\..,~:..;...;..:,:....~.\.:;,;-l;. C. We Will Defend................................ 1 D, We Will Also' Pay.......,..................,.... 1 ,E. Other. Insurance....................,.......... 1 , . 'F, 'payments You Must Make............... 2 G. Recovery From Others...",............... 2 H, Statutory Provisions..........::........~... 2 ..'~ . PART TWO-EMPLOYERS LIABILITY INSURANCE....,.. 2 A, How This Insurance Appiies............ 2 B, We Will Pay.................:.................... 2 C. Exclusions...:.................................... 3 D, We Will Defend................................ 3 E, We Will Also Pay.............................. 3 F, Other Insurance............................... 3 G, Limits Of Liability.......................,;.... 3 'j' BEGINNING ON PAGE PART TWO-EMPLOYERS LIABILITY INSURANCE.........4 (Cont'd,) H. Recovery From Others..................... 4 I. Actions Against Us:....:..................... 4 , PART THREE-OTHER STATES INSURANCE.............. 4 A, How This Insurance" Applies............ 4 . '. . B. Notice.............,................................. 4 PART FOUR-YOUR DUTIES IF INJURY OCCURS........ 4 . .~ _' ':::4 .:.;;.... ,', _ ",) ,',~', ' . PART FIVE-PREMiUM........................................... 4 A. Our Manuals...................................... 4 B. i;:lassificati6:ns.::.::....:....................... 4 C, . Remuneration:.:....,.................:......... 4 D. Premium' Payments.......................... 5 E, Final Premium,................................ 5 F, Records.......................;.................... 5 G, Audit.............:........................,:........ 5. PART SiX-CONDITIONS.....:.............:..................... 5 A. Inspection,:...................................... 5 B. Long Term Policy............................. 5 C. Transfer Of Your Rights And Duties 5 D. Cancelation...................................... 5 E. Sole Representative,........................ 5 IMPORTANT, This Quic'< Reference is not part of the Workers Compensation and Empioyers Liability Insurance Policy and does not provide coverage. Refer to the Workers Compensation and Employers Liability Insur. ance Policy itself for actual contractuai provisions. ".......~,,, IIAUTHENTICO ""::":~""'. COP/right 1991 National Council on Compensation Insurance. we 00 00 00 A lEd. 4-921 WORKERS r.OMPENSATI, ; AND EMPLOYEk~ LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as , GENERAL SECTION A, The Policy ThiS policy includes at its effective date the Informa- tion Page and all endorsements and schedules list- ed there. It is a contract of Insurance between you (the employer named in Item 1 of the Information Pagel 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 oniy in your capacity as an employer of the partnershjp's ,employees. C. Workers Compensation Law Workers Compensation Law means .the workers or J " ,.. .'. 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 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 policy period. 8, 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. workmen's compensation law and OCCUC2 ease law of each state or territory named ,r of the Information Page. It includes any am, to that law which are in effect during the ~ od. It does not include any federal worke" men's compensation law, any federal oce disease law or the provisions of any law the nonoccupational disability benefits. 0, State State means any state of the United States c ca, and the District of Columbia. E. Locations This pOlicy covers.all of your workplaces Items 1 or 4 of the Information Page; and, all other workplaces in Item 3.A. states un have other insurance or are self:insured f workplaces. 0, We Will Also Pay We will also pay these costs, in ,addition :: amounts payable under this insurance, as pa,' claim, proceeding or suit we defend: 1, reasonable expenses incurred at our requ€ not loss of earnings; . .. ,.',. 2, premiums for bonds to. release altachmer for appeal bonds in bond amounts up amount payable under this insurance; 3. litigation costs taxed against you; 4, interest on a judgment as required by la., we offer the amount due under this insc' and 5, expenses we incur, E, Other Insurance We will not pay more than our share of beneii: costs covered by this insurance and other inse or self-insurance. Subject to any limits of liabil:- may apply, all shares will be equal until the paid, If any insurance or self-insurance is ex' ed, the shares of all remaining insurance will be until the loss is paid. Page 1 F. Payments You Must Me 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 sertOUS and willful miscondlJct; 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 otherNise discriminate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits reguiariy provided by the workers compensation iaw on your behalf, you will reimburse us promptly. G, Recovery From Others We have your rights, and the rights of persons enti- tled to the benefits of this insurance, to recover our payments from anyone Iiabie 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 betw,een an inju.red worker and u's, we have rct~.. ne Injury when 'IOU 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, W€ are directly and primarily liable to any per, son entitled to the benefits payable by this insur- ance, 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, payme~ts into security or other special funds, and assessments payable by us under that law, 6, Terms of this insurance that conflict with the workers compens"ation law are changed by this statement to coni~rn:' to ',that law'- Nothing in these paragraphs relieves you of your duties under this policy, . PART TWO-EMPLOYERS LIABILITY INSURANCE .;::,:.1 ;1.: 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 inciden- tal 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 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 policy period. S. 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 0: America, its territories or posses, sions, or Canada, B, We Will Pay' We will pay all sums you legally must pay as damages because of bodily injury to your employees, provid, ed the bodily injury is covered by this Employers Lia, bility Insurance,. ' The damages we will pay,where recovery is permit- ted by law, include i!amages: . . 1. for which you are lia,ble to a third party by rea- son of a claim or suit against you by that third party to recover the damages claimed against such thjrd party as a result of injury to your em- ployee; 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 12, damages pay, 'under the Migrant and Season- This insurance does not cover: al Agricultural Worker Protection Act (29 USC Sections 1801,1872) and under any other fed. 1, liability assumed under a contract. This exclu, erallaw awarding damages for violation of those laws or regulations issued thereunder, and any sion does not apply to a warranty that your work amendments to those laws. will be done in a workmanlike manner; 2, punitive or exemplary damages because of bodily D, We Will Delend injury to an employee employed in violation of We have the right and duty to delend, at our expense, law; any claim, proceeding or suit against you for damages 3, bodily injury to an employee while employed in payable by this insurance. We have the right to in, vestigate arid settle these claims, proceedings and violation of law with your actual knowledge or the suits. actual knowledge of any of your executive officers; We have no duty to defend a claim, proceeding or 4. any obligation imposed by a workers compensa- suit that is not covered by this insurance, We have no duty to defend Or continue defending after we H, tion, occupational disease, unemployment com, have paid our applicable limit of liability und~, this pensation, or disability benefits law, or any insurance. . . similar law; E. We WiII.Also Pay A. 5. bodily injury intentionaily caused or aggravated by you; We will also pay these costs, in addition to other 6, bodily injury occurring outside the United States amounts payable upder this insurance, as pa'rt of any claim, proceeding, or suit we defend: of America, its territories or possessions, and ': ,.... Canada, This'exclusion does not apply to bodily 1. reasonable ~xpenses incurred at our. request, but injury to a citizen or resident of the United States not loss of earnings; , " ' of America or Canada who is temporarily outside 2. premiums for bonds to release attachments and these countries; for appeal bonds in bond amounts up to the Iim. 7. damages arising out of coercion, criticism, de. it 01 our liability under this insurance; motion, evaluation, reassignment, discipline, 3. Iitigali9n c.osts taxed against you; defamation, harassment, humiliation, discrimi-.,' i" ',' ...., nation against or termination of any employee, 4, interest on a judgment as required by law until or any personnel practices, policies, acts or we offer the amount due under this insurance; T, omissions; and Ii' 8, bodily injury to any person in work subject to the 5, expenses we incur, 1. Longshore and Harbor Workers' Compensation Other Insurance Act (33 use Sections 901-950), the Nonap- F. propriated Fund Instrumentalities Act (5 USC 2, We wili not pay more than our share of damages and Sections 8171,8173), the Outer Continental Shelf costs covered by this insurance and other insurance Lands Act (43 USC Sections 1331-1356), the De. or self.insurance, Subject to any limits of liability that fense Base Act (42 use Sections 1651-1654), 3. the Federal Coal Mine Health and Safety Act of apply, all shares will be equal until the loss is paid, If any insurance or self.insurance is exhausted, the 1969 (30 USC Sections 901.942), any other fed- shares of all remaining insurance and self,insurance eral workers or workmen's compensation law or will be equal until the loss is paid, other federal occupational disease law, or any amendments to these iaws; G, Limits 01 Liability A 9. bodily injury to any person in work subject to the Our liability to pay for damages is limited, Our limits Federal Employers' Liability Act (45 use Sections of liability are shown in Item 3.B. of the Information 51-60), any other federal laws obligating an em- Page. They apply as explained below, player to pay damages to an employee due to 1. Bodily Injury by Accident. The limit shown for bodily injury arising out of or in the course of em. ployment, or any amendments to those laws: "bodily injury by accident-each accident" is the E most we will pay for all damages covered by this 10, bodily injury to a master or member of the crew insurance because of bodily injury to one or more of any vessel; employees in anyone accident. 11, fines or penalties imposed for violation of feder- A disease is not bodily injury by accident unless al or state la,w; and it resulls directly from bodily injury by accident. jily Injury by r} "e. The limit shown Jdily injury by o,"~ase-policy limit" is the ,st we will pay for all damages covered by this ',urance and arising out of bodily injury by dis, 5e, regardless of the number of employees o sustain bodily injury by disease. The limit Jwn for "bodily injury by disease-each em- 'yee" is the most we will pay for all damages :ause of bodily injury by disease to anyone 'ployee. dily injury by disease does not include disease lt results directly from a bodily injury by ac- lent. ~ will not pay ary claims for damages after we ve paid the applicable limit of our liability un- r this insurance. ery From Others Ie your rights to recover our payment from any- o . ,'. ;~ . ~ ., PART THREE-'-OTHER STATES INSURANCE one liabl ! an injury covered by insurance: You will do e,., ything necessary to prUlect 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 poli- cy: and 2, The amount you owe has been determined with our consent or by actual trial and final judgmenf. 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 obliga, tions under this Part. .. " ,. . ' . 'his Insurance Applies .: ,.,,:. . by the workers compensation law of that state is' other states insur,a~ce~appiies only if one if we ai~ not permitted to pay the benefits directly more states are shown in Item 3,C. of the In- to persons entitled to them. " ' .. . -mation Page.. 4, If you have work on the effective date of this poli, IOU begin work in anyone of those states after cy in any'state not listed in Item 3.A, of the In, ~'effective date of this policy and are not in- formation Page, coverage will not be afforded for red or are not self,insured for such work, all that state unless vie 'are notified within thirty Jvisions of the policy will appiy as though that days. ,.,.,. . lte were listed in Item 3,A. of the Information B, Notice ;ge. ," .. .' .Tell us at once if you begin work in any state listed ~ will reimburse you for the benefits required v,.- 'in Item 3.C. of the Information Page. 'CC" PART 'FOUR-YOUR DUTIES IF INJURY OCCURS r,' .5' .-, lnce if injury occurs that may.be covered by . Your other duties are listed' nere. . .. . I . . e'forimmediate 'medical and other services reo . by 'the workers compensation law., . . 5 or our agent the names and addresses of the j persons and of witnesses, and other informa- a "may, need,. . ltly give us all notices, demands and legal pa' , pers related to the injury, ciaim, p~o~e~din~or suit. 4, Cooperate with us and assist us, as we may request, in the investigation, settlement or defense of any claim, proceeding or suit. . ' 5: Db nothing after an 'injury occurs that would inter, fere with our right"to recover lrom others, . '. . , 6. Do not voluntarily make payments, assume obliga, tions or incur expenses, except at your own cost. PART FIVE-PREMIUM lanuals lmium for this policy will be determined by our 31s of rules, rates, rating plans and classifica, We may change our manuals and apply the 'as to this policy if authOrized by law or a gov- 'ntal agency regulating this insurance. ficalions _ of the Information Page shows the rate and Jm basis for certain business or work classifi. s. These classifications were assigned based estimate of the exposures you would have dur- ing the policy 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 policy. C, Remuneration Premium for each work classification is determined by multiplying a rate times a premium basis. Remuneration is the most common premium basis. This premium basis includes payroll and all other remuneration paid or payable during the policy peri- od for the services of: Page 4 1. ~II vour officers and employees' 1'6, ,n work covered by this pOlicy: and 2. all other persons engaged in work that could make us liable under Part One (Workers Com, pensation Insurance) of this policy. If you do nol have payroll records for these persons, the con, tract price for their services and materials may be used as the premium basis. This paragraph 2. will not apply if you give us proof that the em, players of these persons lawfully secured their workers compensation obligations. ). Premium Payments You will pay all premium when due. You will pay the premium even if part or all of a workers compensa' tion law is not valid, Final Premium The premium shown on the Information Page, SChed, ules, and endorsements is an estimate, The final premium 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 poli, cy, If th~. 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 policy. If this policy is cane V, final premium will be de, lermined in lhe follow" '6 way unless our manuals pro- vide otherwise: 1. If we cancel, final premium will be calculated pro rata based on the time this pOliCY was in force. Final premium will riot be less than lhe pro rala share of the minimum premium. 2, If you cancel, final premium will be more than pro rata: it will be based on the time this policy was in force, and increased by our short rate cancelation lable 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 policy, These records include ledgers, journals, registers, vouchers, contracts, tax reports, payroll and disbursement records, and programs for storing and retrieving data. We may conduct the au- dits during regular business hours during the polley period and within three years after the policy period ends. Information developed by audit Will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provision, PART SIX-CONDITIONS A, Inspection '" We h.ave 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 re~ommend 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 ar.. 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 six- teen days, all provisions of this policy will apply as though a new policy were issued on each annual an, niversary that thi, 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 representative as insured: 0, Cancelation' 1. You may cancel this policy. You mu~t mail or de- liver advance written notice to us stating when the cancelation is to take effect. 2, We may cancel this policy, We must mail or de- liver to you not less than ten days advance writ- ten 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, 3, The policy period will end on the day and hour stated in the cancelation notice. 4, Any of these provisions that conflict with a law that controls the cancelation of the insurance in this policy is changed by this statement to com- ply with the law. E, Sole Representative The insured first named in Ite Page will act on behalf of all I ur policy, receive return premiu ,a notice of cancelation, f the Information s to change this d give or receive COVERAGES , ,{ .; " '.....,;' '. . i I Limits Ar . ual of Deductible Prfil lium Liability I -- ., -"10PERTY II uilding-AII Risk $ 250 . Bound No =leplacement Cost ,I, ontents-AII Risk $ 9,000 $ 250 TO~ Follow* Actual Cash Value 3nitorial Equipment $ 30,740 $ 250 To. Follow* All Risk Actual Cash Value I $ , ailees 30,000 $ 250 Tc Follow* :Incl. Theft in Transit) Actual Cash Value .RIME I hird Party Theft $ 25,000 $ 500 ! egal Defense $ 10,000 $ 500 Te' Follow* , - ---- ,ENERAL LIABILITY Property Damage . ~ Deductible Only Each Occurrence Limit $1,000,000 $ 250 Janit (.ria1 rate is 5.: Bodily Injury & of Pf.~'rolls Property Damage I I Personal (Exclusions $1,000,000 $ 250 CarpE I C1ng. rate is : "A" and "C" Deleted) of ~.~ 'rolls and Advertising Injury Medical Expense $ 5,000 No Deductible . - ------, ~... ' .. ", ;'...-1.t ) . -~ , 004 C:NA~ l , c:~l*"",-IOMI All tbo Comm(tme... Y"" Make" ,. . -'''''7''' .. ~., STAf<DA, ""WOR"CIlS C:l'JII'E.I>oSATIO'. ." ~. "'NO EMPLOYE-RS LIA81LI TY "'POL ICY AMEND~O IN~ORM"'TION PAGE EFFoCTlvE- O~/Oo/q3 DU~ ro CHANGE~ EXPE.RIENCE MODIFICATIOf< lLlCY NUMBER FA M POLICY PERIOD T COVERAGE IS PROVIDED BY AGENCY 07906Z0Z Oq/D6/93 OQ/06/94 NAMED INSURED AND ADDRESS SUZANNf " OELE.RME DBA SERVPRO .EST SHORE INC 167 A SOUTH ENOLA DRIVE ENOLA, PA TRANSPORTATION INSVRAf<CE CO. 03675i01 AGENT STANLEY MCDONALD A.CE.~CY OF ILl. 1'.'. I 2016 STATE ROAD PO BOX 1446 l.ACROSSE wI 54601 1702 FEIN NVMSER: 232597197 INTRASTATE. 10 NO: 372711290 ~CCl CAR~lEH cou~ ~~: 12'08 OTHER WURK PLACES f<OT 5rlO~~ ABOUf: NO ADLITIONAL LOCATIONS YOU ARE A - CORPORATIOl>o/S POLICY PERIO~- 09/00/93 ro 09/0b/94 12:01 A~ 5TANC"'R~ TIMc AT THc INSUREDS MAILING AOQRESS. PA~T ONE OF THIS pelley A?PLltS TO THE wORKERS co~p~t.GATlO'~ LAA ~~c ~~y CCCUPATtONAL OISEAS~ LA~ OF ~~tH O~ THE gT~TE~ LlST~D H~qE: PA. PART T~O OF THIS POLICY AP~LI~S T~ EMPL~V~R5 Ll~UlLITY 1~4S~k~~C~ FQ~ k~~~ IN cACH STATE LISTED IN ITE~ JA: THE LIMITS Or LIA81LITY A~E: BODILY INJURY QY Accr~ENT 1100,000 EACH ACCIGE~T buDILY INJURY bY DISEASE $500,000 POLICY LIMIT BODILY INJU4Y BY i:lISEASE $100,000 el-\CH tl1~L!JYi:E PART THRg~ OF Trl15 POLICY ~PPlI[S TO UTneK ST~Tt5J IF ~~Yt LlSTLD H~~~: ALL STATES €XC~PT ":"1<, M~, NV I NO, GH, r.it:.., ViV Ai\O ~r~T;: ~ ~t:.Sl(,,~ATf.C I~. ! T~.-: 3A OF THE INFO"MATIO~ PAGE. Ttit~ POlICV INCLUDf:.S TMEgE ENJOR.if.ME.HTS AND SCM!:.OuLES: ~::C ~TTAC!1E:t: ~Crof:.~~;.):..::. .----------------------------------------------------------------------------- THE PREMIUM F~~ THIS POLICY wILL Uf OET~R~l~E~ HY au'~ ~A~.U~L OF ~UL~St CLASSIFICATIONS, J.(~Tc:5, AN;) RhTlr,G PLAN;j. ALL l""Fn~I~Arlur~ Ftc::""UIQEtJ Ut.L:J~ i: SUbJECT TO VE..IFIC"'TIO~ ANO C"AHOE bY AUDIl. CLASSIFICATIUN OF aPERATIONS ~ ~ T t.:.I. 'J .._ ;)I-\=:."\I..:r' '",10(. 5f.E. ATT.GoCHt.C PK'_ :'"!!'.J11 J~ ~C,:.j\.:I'.T , . ~,lO"'f.t.S.':.. C..::.'.ST.:."-:i 1..... T M ':: f J :( ':.. (.:": : 'v ~ ;":,,", f '" ;~ ,".:.. ~~ T ~:..: ~.J L i ~ ~ r'. H1'1 /..:J... r 1 : ".oJ", ~:... :;. ~ !:. IV' Il.:Y. :.:: ~ 1,} ,~.;, ~ 1 -i 11 J'j T:T~L fSTl~~rlL ~~~~~L ~'kE~IG~ L ~. I ~ _ MIf-~I,..tJ~ :;I~d.~IvM ;jEPa~IT PFCE:"jIUf'I 11,1' T f- II F ~::':.. ..; C': ,j i'. / v ~,I ., .. ,I. r {y l~, ':..' 1 .~ " .' J. e :':":.: ...:........, ..'''' .... r",":.:.,'.:.. ,. ---------,------------------- ------------------ _ I " .. i ,... ,_' ~ : :.. i .. .'. ". T c ~ 'Vl ,. ~,,,"-....,,~, ..,'.. J l. . ,. . M" '..,"", ....-.." . , )I rAll....COmml-....Yoa Make" <. -, , '-'l... ) . . " 4...... f1/ ---", STAND" " WOR>(E'IlS Cc!MPCNSATlON AN:! EMPl.OYEkS l.lAbr"l.IT"'.POI.ICY c........ auc.,.. ,...... toUI OLICY NUMBER POLICY PERIOD F T COVERAGE IS PROVIDED V AGENCY C 0 079062B2 09/06/93 09/06/94 NAMED INSUREO AND ADDRESS SUZANNE 11 DEI.ER"E .68A SEAUPRD WEST SHORE INC 167 A .SOUTH ENDl.A DRIVE ENOLA I ,PA TRANSPORTATIOk INSURANCE CO, 03675~C~ AGENT STANl.EY MCDONAl.:! AG~NCY OF ILl.INOt 20111 5TATE ROAD PO BOX 1446 l.ACIlOSSE ..1 S4601 1702 P A II TIC I PAT I " G PRc:,VJ~IrJN ~~~;. '~OU'5HALL PARTICIPATE IN THE EARNINC:; OF THE C~"P"~Y TO THE Exr~NT "h~ UPO~ rHE CONDITIOhS DETERMINEO ~y THE BOARO OF DIRECTOqs OF IHt COMPANY IN ACCORDANCE WITH l.AW AN:! MADE APPLICABLE TO THIS p~LIC'. PROvIC~D THAr Ne ~IV1CENO SH4~L De PAYAOLE HEREUNtEK UNLt~s You hAVE COM~LtEO wITrl THE reR~~ OF THE POLICY IN Kt5PECT T~ rHE PAYMENr OF PRE~lU~S. UNDER CAl.IFORNIA LAW IT 15 UNLAWFUL FOR AN INSUR~W TO P"OMISE THE FUTURE PAYMENT OF UIUIU~NOS UNOtR AN UNEXPIRED ~DIlKERS COMPENSATION POLICY OR TO MISREPRESENT THE CONDITIONS FOR DIVlnEN:! PAYMENT. OIvIOe"as ARE PAYABLE ~~L' PURSUANT TO THE CONUITIONS DETERMrNEO bY THE SCAlia OF DIRECTURS OR OTHER GOVERNING OOARO OF THE CGMPA~Y FOLLO~INC POLICY EXPlkATION. IT IS A MISDEMEANOR FOR ~NY :NSU~~R UR OFFICER ~~ A~~~T rHe~ECF, OR AhY I"SUNANCE bROKER DR SDLICITa~, TO PROM1St rH€ PAYM~hT OF FLTUR~ ~ORKE~~ COMPENSATION OIVIDENOS. THIS ENDORS~M~NT FJRMS A PART OF rHE POl.lCY A/iU IS SUB.)"CT H; Tht:: SA"~ I~CEPTICN DATEt UNLES5 urhER~tSe ~TATED. THI$ ~~OD~3EM~'IT f~prJ(ES CO~CUHRC~T~Y ~ITrl THE puLley. r:. : r .1: I I ~ '.. i"j ~ : II.~ / ... '.',' " ~ .,'( I oJ _1 '. . . .' :.~'" : : '. : ..... , , ., IL \ \..,~ i" ..~..,......... , , ~ - . 1 .: . hI -: I.. . . "1Oot-,i ,"-.,. WA'.'~ .W u.o Commltmea..Y4a_ ) CN,A""", ~11lN'e"'" LICY NUMBER FR POLICY PERIOD ; 0 079D62B2 09/06/93 09/06/94 NAMED INSURED AND ADDRESS SUZANNE H DELERHE OBA SERVPRO WEST SHORE INC 167 A SOUTH ENOLA DRIUe ENOl.A,' P,A . . '. .' <;TAN!J"h~r "OR" E'R 5 Cdl1PENSATlON AND el1PLoJYERS 1,IAaI"LIT"y.PULICY T COVERAGE IS PROVloeo BY AGENCY TRANSPORTATION INSURANCl: ~O. OJB7S~O~' AGENT STANLEY I1CDDNALD AGENCY OF ILLINOI 2018 STATE ROAD PO BOX 1446 LACROSSE WI 54601 1702 APPLICAbLE PARTICIPATING PLANS PLAN IIUI10i::R/ DIVIDEND SCHEDULE 44-00 APPLICABLE STATES CO,",HISSIO" SC':'LE PA ~~ SAFETY GROUP: DSCIP - bLOC; SERVICE CONTRACTORS I...SURANCt PROG~AM T ~ :.1 ~ I:. ~ ~I t.: ;.. / ~, :. /..:, .. _ I C. y : 5~,~: :,.. .. r f : \. ~: ,.. 1 ~ ^ . ...". L. j a.J.a~':"'., 'man ollhe BOard (\ 4{ (- -:.n-!~'\, Sf'CIC!,"y ;..... . I ..;... . - . . . .... , --~. . ~'....,. .. - , . . .. ~ . AD tIotC;.",_tl-'a You Make' ". _...... ') c........ c-.--' STA~D:f')WDRI(E~':; COIl'I'E"SATID" MHl E~PLOYE~S LIABH.*ITY 'OLICY ... PA~"ENT PLAN SCHEDULE ... .'-, . . ..... J~ICY NUMBER FR M POLICY PERIOD COVERAGE IS PROVIDED BY AGENCY T 007906282 09/06/9J 09/06/9~ NAMED INSURED AND ADDRESS ... '.SUZANNE. " DI'LERME ~DBA SERVPRO WEST SHORE INC ,.'67 A SOUTH fNDLA DRIVE ..ENOLA. PA ., TRANSPDRTATIDrl INSURANC!: -CD. OJ1l75900 AGENT STANLEY "CDDNALC A~E"CY OF ILLINOI 2018 STA TE ROAD PO HOX 1~~6 LACROSSE wI 54601 1702 .. ReVISeO PAYMENT PL~N ~'H~OUL~ ** ~UE TO A POLICY CHANCE, IT IS AGREED THAT TH~ REVISeO ESTIMATEC PREMIUM OF THIS POLICY IS PAYABLE AS FOLLOwS: EFFECTIVE OArE PREMIUM CO"lMI5S10>; ... C.ASH oue AMOU,",T , 14 I .00- $I ,:!'H .00 0.0 5.0 R~MAININC PREMIUM DUE $1,150.00 'rE r':'F I~!..U;.,: ~!.i/:'h/ ,.. _ I " Y 1 ~::.; 'N' 1', (, :. r r 1 : l.: :"; J ~ . ,. ...' :. : j CI..,,/,.t);..... 'man ollhe Board ." (, ' \.1 \('! "v\ ,,~, ~ ~ I 'I. . . - oJ,' (" ~<')-~......~ V) "i>- " >- C", '0 If: " ~- ~, .... 1-' C- C. \;.:1 LU;: )..:.. C,..)C' "'- U:-,~ '- ..]2 ~i.: (~ r:r') <I) ,- N i>< w;... ,:z -'.. t-: .J'..'.J u::.... 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