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HomeMy WebLinkAbout14-4696 Supreme Cott ennsylvania Cou GCOM ve MO leas For Prothonotary Use Only: C iIo t Docket No: , ti Cu hand` County f , - X9(0 +vi 1 /term /I. The information collected on this form is used solely for court administration purposes. This form does not supplement or replace the filing and service of pleadings or other papers as required by 1014,or rules of court. ffs ent of Action: Snt Writ of Summons 0 Petition from Another Jurisdiction Declaration of Taking E Cs Name: Lead Defendant's Name: Tand Industry Insurance Company Newburg Transport LLC I damages requested? iX Yes 0 No Dollar Amount Requested: Owithin arbitration limits (check one) Ooutside arbitration limits N Is this a Class Action Suit? 0 Yes No Is this an MDJAppeal? 0 Yes l9 No A Name of Plaintiff'/Appellant's Attorney: Barbara S.Zicherman Check here if you have no attorney(area Self-Represented I Pro Sed Litigant) Nature of the Case: Place an"X"to the left of the ONE case category that most accurately describes your PRIMARY CASE. If you are making more than one type of claim, check the one that you consider most important. TORT(do not include Mass Tort) CONTRACT(do not include Judgments) CIVIL APPEALS 0 Intentional 0 Buyer Plaintiff y Administrative Agencies 0 Malicious Prosecution El Debt Collection:Credit Card ] Board of Assessment Motor Vehicle n Debt Collection:Other Board of Elections 0 Nuisance Insurance policy Dept.of Transportation S 0 Premises Liability Statutory Appeal:Other 3 Product Liability (does not include E' mass tort) Employment Dispute: 0 Slander/Libel/Defamation Discrimination C Other: 0 Employment Dispute:Other Zoning Board T 0 Other: I Other: O MASS TORT 0 Asbestos N 0 Tobacco 0 Toxic Tort-DES [] Toxic Tort-Implant REAL PROPERTY Toxic Waste MISCELLANEOUS 0Other: 0 Ejectment 0 Common Law/Statutory Arbitration B 0 Eminent Domain/Condemnation 0 Declaratory Judgment 0 Ground Rent J Mandamus 0 Landlord/Tenant Dispute Non-Domestic Relations 0 Mortgage Foreclosure: Residential Restraining Order PROFESSIONAL LIABLITV 0 Mortgage Foreclosure:Commercial 0 Quo Warranto 0 Dental Partition -' Replevin 0 Legal 0 Quiet Title 0 0 Medical 117 Other: Other: Other Professional: Updated 1/1/2011 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION - LAW COMMERCE AND INDUSTRY No. Iq-4691v alvitTerol INSURANCE COMPANY, Plaintiff, ,; V. z: cG-) - rµ NEWBURG TRANSPORT LLC ` ' `{c; Defendant. NOTICE CJ6 f �� taut 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 to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claims or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOCIATION 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 1-800-990-9108 717-249-3166 FITZPATRICK LENTZ & BUBBA, P.C. BY: G Barbara S. Zicherman ID #207348 4001 Schoolhouse Lane, P.O. Box 219 Center Valley, PA 18034-0219 (610) 797-9000 Attorneys for Plaintiff +11E-75 e'71R48177637 a#3096 / IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION- LAW COMMERCE AND INDUSTRY No. INSURANCE COMPANY, : Plaintiff, V. NEWBURG TRANSPORT LLC Defendant. COMPLAINT Plaintiff, Commerce and Industry Insurance Company, by its attorneys, Fitzpatrick Lentz & Bubba, P.C., files the instant Complaint against the Defendant, Newburg Transport LLC, and, in support thereof, avers as follows: 1. Plaintiff, Commerce and Industry Insurance Company, is a New York corporation with an office address of 175 Water Street, 18`h Floor, New York, New York, 10038, and is engaged in the underwriting and sale of workers compensation and employer liability insurance policies in the commonwealth of Pennsylvania. 2. Defendant, Newburg Transport LLC is, upon information and belief, a Pennsylvania corporation, with a business address of 25 Turnpike Road, Newburg, Pennsylvania, 17240. COUNT 3. Plaintiff incorporates by reference the averments contained in Paragraphs 1 and 2 above as if fully set forth herein. 4. During the period March 29, 2011 through March 29, 2012, Commerce and Industry Insurance Company provided workers compensation and employer liability insurance to Newburg Transport LLC pursuant to a policy of insurance (Policy No. WC 051-75-0614) (the "Policy"). A true and correct copy of the Policy and endorsements thereto is attached hereto as Exhibit"A," and is incorporated herein by reference. 5. At all times relevant hereto, and in accordance with the terms of the Policy, Newburg Transport LLC agreed to be responsible for the premium due under the policy and to pay timely the amount due. 6. The Policy provides that the final premium will be determined after the policy ends by using the actual, not estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by the policy. 7. According to the terms of the Policy, if the final premium is more than the premium that Newburg Transport LLC paid to Commerce and Industry Insurance Company, Newburg Transport LLC is required to pay Commerce and Industry Insurance Company the difference. 8. In order to determine the final premium, Newburg Transport LLC contractually bound itself to allow Commerce and Industry Insurance Company to examine and audit its records that relate to the Policy and to cooperate with Commerce and Industry Insurance Company's efforts to conduct the audit. 9. In accordance with the Policy, Commerce and Industry Insurance Company conducted an audit of Newburg Transport LLC's records relating to the Policy to determine the final premium. A true and correct copy of the Audit Worksheets is attached hereto as Exhibit "B," and is incorporated herein by reference. 10. Based on the audit, Commerce and Industry Insurance Company calculated the final premium to be $43,216. A true and correct copy of the Audit Advice and Audit Advice Summary is attached hereto as Exhibit"C" and is incorporated herein by reference. 11. At the time the final premium was calculated, Newburg Transport LLC had paid a total of$9,651 towards the Policy. 12. Thus the final premium of$43,216 was greater than the amount paid by Newburg Transport LLC. 13. Pursuant to the terms of the Policy, as described in Paragraph 7 herein, Newburg Transport LLC is obligated to pay to Commerce and Industry Insurance Company the difference between the final premium and the amount paid by Newburg Transport LLC 14. Accordingly, on or about May 3, 2013, Commerce and Industry Insurance Company issued an invoice in the amount of$29,077 (the difference between the final premium and the premium paid by the Defendant, plus $130 in processing fees, minus $90 in fees that were written off, minus $4,528 in premium that was written off) to Newburg Transport LLC stating that the outstanding balance was due on or before June 2, 2013. A true and correct copy of the invoice is attached hereto as Exhibit "D," and incorporated herein by reference. 15. Despite demand for payment, Newburg Transport LLC has failed and refused, and continues to fail and refuse, to pay the outstanding balance due under the Policy in the amount of$29,077. 16. At all times, Commerce and Industry Insurance Company fully performed all of its obligations under the Policy. WHEREFORE, Plaintiff, Commerce and Industry Insurance Company, demands judgment in its favor and against Newburg Transport LLC in the amount of $29,077, together with prejudgment interest from June 2, 2013 and its costs of suit. FITZPATRICK LENTZ & BUBBA, P.C. Date: July 29, 2014 BY: ,6vtm Barbara S. Zicherman ID #207348 4001 Schoolhouse Lane P.O. Box 219 Center Valley, PA 18034-0219 (610) 797-9000 Attorneys for Plaintiff VERIFICATION I, Tammy Tedesco, do hereby verify that I am an employee of the AIG Property Casualty U.S., Inc. law department as a Custodian of Records. I am authorized to make this Verification on behalf of Commerce and Industry Insurance Company, which is a wholly owned subsidiary of AIG Property Casualty U.S., Inc., a division of AIG Property Casualty Inc., and that as such, make this verification and aver that the facts set forth in the within Complaint are true and correct to the best of my knowledge, information and belief and that I am making these statements subject to the penalties of 18 PA C.S.A. 4904 relating to unsworn falsifications to authorities. Dated: AAy d, o p ammy e esco Effective 12:01 AM 03/29/2011 Policy No. WC 051-75-0614 Issued to NEWBURG TRANSPORT LLC By COMMERCE AND INDUSTRY INSURANCE COMPANY Partners In Productivity RiskTool System https://www.chart!sinsurance.com/SWC Specialty Workers' Compensation A division of Chartis NOTICE TO POLICYHOLDER This notice is to alert you to Specialty Workers' Compensation's online, loss prevention and risk management platform, called RiskTool System. RiskTool System can assist you in managing the risks your company and employees face everyday. As a valued customer, you can employ this tool to assess your specific needs, take steps to prevent injuries from occurring, and build and monitor your own loss prevention and risk management program. The RiskTool System can be accessed at our Partners in Productivity website at: https://www.chartisinsurance.com/SWC The site can also provide you with: • information about us, frequently asked questions, and Contact Us access • information on workers' compensation insurance • the ability to locate medical providers for an injured worker • the ability to report voluntary premium audits, and • news and links to related workers compensation websites When accessing the Partners in Productivity website have your policy close by so that you can enter the following information: • Policy Number • Agent or Broker Number • Issuing Company This valuable service is only available to current policyholders and their brokers. If you have questions, please call us toll free at 1-800-645-2259. Member Companies of Chartis American Home Assurance Company, Chartis Casualty Company, AIU Insurance Company, Commerce and Industry Insurance Company, Granite State Insurance Company, Illinois National Insurance Company, New Hampshire Insurance Company, National Union Fire Insurance Company of Pittsburgh, Pa, The Insurance Company of the State of Pennsylvania SWCPN (Ed. 12/09) Archive Copy EXHIBIT A POLICYHOLDER NOTICE Thank you for purchasing insurance from a Chartis company. Chartis companies generally pay compensation to brokers and independent agents, and may have paid compensation in connection with your policy. You can review and obtain information about the nature and range of compensation paid by Chartis companies to brokers and independent agents in the United States by visiting our website at www.chartisinsurance.com/producercompensation or by calling Chartis at 1-800-706-3102. 91222 (1 2i0od Vd))Y EXHIBIT A ISSUED BY THE STOCK INSURANCE COMPANY HEREIN CALLED THE COMPANY '• COMMERCE AND INDUSTRY INSURANCE COMPANY 0075190-00 WC 051-75-0614 15172 --------------------------------------------- 013-82-0311-00 . - RK NEWBURG TRANSPORT LLC C H A R T 15 2 TURNPIKE ROAD N WBURG, PA 17240-0000 A Chartis company EXECUTIVE OFFICES: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 175 Water Street New York, NY 10038 I.D# PAUI#: ••••ly@A ETIMMMIFT.791ri••• WORKERS COMPENSATION AND EMPLOYERS PMC INSURANCE AGENCY INC.50 50 CABOT STREET LIABILITY POLICY INFORMATION PAGE PO BOX 920179 NEEDHAM MA 02492-0002 INSURED IS PREVIOUS POLICY NUMBER LIMITED LIABILITY COMPANY I NEW OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 ITEM 2 POLICY PERIOD 12:01 A.M.standard time at the Insured's mailing address FROM 03/29/11 TO 03/29/12 ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: PA B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100.000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY OK OR RI SC SO TN TX UT VA VT WI WV D. This policy includes these endorsements and schedules: SEE EXTENSION OF ITEM 3.13. OF THE INFORMATION PAGE - WC990612 ITEM The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rate Per Estimated classifications Code Number Total Remuneration $100 OF Re. Premium ❑X Annual ❑3 Year muneration Annual ❑3 Year SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $195 EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) MINIMUM PREMIUM $1 ,5550 PA TOTAL ESTIMATED ANNUAL PREMIUM $9,416 If indicated below,interim adjustments of premium shall be made: ❑ Semi-Annually ❑ Quarterly ❑ Monthly DEPOSIT PREMIUM 03/31/11 PARS I PPANY 82 Issue Date Issuing Office Authorized Representative WC 00 00 01A 39%7(Revd 04/08) Archive Copy EXHIBIT A EXTENSION OF ITEM 3.D. OF THE INFORMATION PAGE Policy Number: WC 051-75-0614 Effective Date: 03/29/2011 TRSMNOTA FOREIGN TERRORISM POLHOLDR NOT-PREM DTMN WC000406 PREMIUM DISCOUNT ENDORSEMENT WC000421C CATASTROPHE PREMIUM ENDORSEMENT WC000422A TRIPRA DISCLOSURE ENDORSEMENT WCOFAC NOTICE REG OFFICE OF FOREIGN ASSET CTRL 107437 PRIVACY POLICY WC000419 PREMIUM DUE DATE ENDORSEMENT WC370601 PA INSPECTION OF MANUALS WC370602 PA NOTICE WC370603A PA ACT 86-1986 ENDORSEMENT WC993703A PA NOTIFICATION OF AVAILABILITY WC990610 NAMED INSUREDS/ADDRESSES WC 99 06 12 (Ed. 1/97) (Rev'd 04108,4rchive Copy EXHIBIT A WORKERS COMPENSATION AND EMPLOYERS LIABILITY II INSURANCE POLICY I National Union Fire Insurance Company of Pittsburgh, Pa. C H A FtT 15 irso- I® American Home Assurance Company �I I® The Insurance Company of The State of Pennsylvania EXECUTIVE OFFICES �I Chartis Property Casualty Company 175 WATER STREET Commerce and Industry Insurance Company NEW YORK, NY 10038 Granite State Insurance Company Illinois National Insurance Company New Hampshire Insurance Company I I® I® Coverage is provided by the Company designated on the Information Page �I IN A Stock Insurance Company WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY QUICK REFERENCE BEGINNING ON PAGE GENERALSECTION................................................................................................................................................................................................1 A. The Policy ...........................................................................................................................................................................................................................1 B. Who 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 .......................................................................................................................................................................................................................1 C. We Will Defend.................................................................................................................................................................................................................1 D. We Will Also Pay ............................................................................................................................................................................................................1 E. Other Insurance .............................................................................................................................................................................................................. 2 F. Payments You Must Make...........................................................................................................................................................................................2 G. Recovery From Others .................................................................................................................................................................................................2 H. Statutory Provisions ......................................................................................................................................................................................................2 THE ABOVE REFERENCED POLICY PROVISIONS WITH THE INFORMATION PAGE AND ENDORSEMENTS, IF ANY,ISSUED TO FORM A PART THEREOF,COMPLETE THIS POLICY. WC 00 00 00 A (STANDARD) (Ed. 04/92) (Rev'd 08/10) Archive Copy EXHIBIT A QUICK REFERENCE - CONTINUED BEGINNING ON PAGE PART TWO-EMPLOYERS LIABILITY INSURANCE..................................................................................................................................................2 A. How This Insurance Applies........................................................................................................................................................................2 B. We Will Pay..........................................................................................................................................................................................................3 C. Exclusions ............................................................................................................................................................................................................3 D. We Will Defend..................................................................................................................................................................................................3 E. We Will Also Pay................................................................................................................................................................................................4 F. Other Insurance..................................................................................................................................................................................................4 G. Limits of Liability...............................................................................................................................................................................................4 H. Recovery From Others....................................................................................................................................................................................4 I. Action Against Us..............................................................................................................................................................................................4 PARTTHREE-OTHER STATES INSURANCE................................................................................................................................................................4 A. How This Insurance Applies....................................................................................................................................................................... 4 B. Notice......................................................................................................................................................................................................................5 PART FOUR-YOUR DUTIES IF INJURY OCCURS.....................................................................................................................................................5 PARTFIVE-PREMIUM..........................................................................................................................................................................................................5 A. Our Manuals.........................................................................................................................................................................................................5 B. Classifications......................................................................................................................................................................................................5 C. Remuneration.......................................................................................................................................................................................................5 D. Premium Payments............................................................................................................................................................................................5 E. Final Premium......................................................................................................................................................................................................5 F. Records....................................................................................................................................................................................................................6 G. Audit..........................................................................................................................................................................................................................6 PARTSIX-CONDITIONS........................................................................................................................................................................................................6 A. Inspection...............................................................................................................................................................................................................6 B. Long Term Policy...............................................................................................................................................................................................6 C. Transfer of Your Rights and Duties..........................................................................................................................................................6 D. Cancellation..........................................................................................................................................................................................................6 E. Sole Representative..........................................................................................................................................................................................6 PLEASE READ THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CAREFULLY Archive Copy EXHIBIT A ATTACH FORM AND ENDORSEMENTS (IF ANY) HERE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows. GENERAL SECTION A. The Policy C. Workers Compensation Law This policy includes at its effective date the Infor- Workers Compensation Law means the workers or mation Page and all endorsements and schedules workmen's compensation law and occupational listed there. It is a contract of insurance between disease law of each state or territory named in Item you (the employer named in Item 1 of the Informa- 3.A. of the Information Page. It includes any amendments to that law which are in effect during tion Page) and us (the insurer named on the Infor- the policy period. It does not include any federal mation Page). The only agreements relating to this workers or workmen's compensation law, any fed- insurance are stated in this policy. The terms of eral occupational disease law or the provisions of this policy may not be changed or waived except any law that provide nonoccupational disability by endorsement issued by us to be part of this benefits. policy. D. State State means any state of the United States of America, and the District of Columbia. B. Who Is Insured E. Locations You are insured if you are an employer named in This policy covers all of your workplaces listed in Item 1 of the Information Page. If that employer is Items 1 or 4 of the Information Page; and it covers a partnership, and if you are one of its partners, you all other workplaces in Item 3.A states unless you are insured, but only in your capacity as an em- have other insurance or are self-insured for such ployer of the partnership's employees. workplaces. PART ONE - WORKERS COMPENSATION INSURANCE A. How This Insurance Applies C. We Will Defend This workers compensation insurance applies to We have the right and duty to defend at our ex- bodily injury by accident or bodily injury by disease. pense any claim, proceeding or suit against you for Bodily injury includes resulting death. benefits payable by this insurance. We have the right to investigate and settle these claims, pro- 1. Bodily injury by accident must occur during the ceedings or suits. policy period. We have no duty to defend a claim, proceeding or 2. Bodily injury by disease must be caused or suit that is not covered by this insurance. aggravated by the conditions of your employ- D. We Will Also Pay ment. The employee's last day of last expo- sure to the conditions causing or aggravating We will also pay these costs, in addition to other such bodily injury by disease must occur dur- amounts payable under this insurance, as part of ing the policy period. any claim, proceeding or suit we defend: 1. reasonable expenses incurred at our request, B. We Will Pay but not loss of earnings; We will pay promptly when due the benefits re- 2. premiums for bonds to release attachments quired of you by the workers compensation law. and for appeal bonds in bond amounts up to the amount payable under this insurance; WC 00 00 00 A Archive Copy 1 of 7 EXHIBIT A 3. litigation costs taxed against you; our payments from anyone liable for the injury. You will do everything necessary to protect those rights 4. interest on a judgment as required by law until for us and to help us enforce them. we offer the amount due under this insurance; and H. Statutory Provisions 5. expenses we incur. These statements apply where they are required by law. E. Other Insurance 1. As between an injured worker and us, we have We will not pay more than our share of benefits and notice of the injury when you have notice. costs covered by this insurance and other insur- ance or self-insurance. Subject to any limits of li- 2. Your default or the bankruptcy or insolvency ability that may apply, all shares will be equal until of you or your estate will not relieve us of our the loss is paid. If any insurance or self-insurance duties under this insurance after an injury oc- is exhausted, the shares of all remaining insurance curs. will be equal until the loss is paid. 3. We are directly and primarily liable to any F. Payments You Must Make person entitled to the benefits payable by this insurance. Those persons may enforce our You are responsible for any payments in excess of duties; so may an agency authorized by law. the benefits regularly provided by the workers Enforcement may be against us or against you compensation law including those required be- and us. cause: 4. Jurisdiction over you is jurisdiction over us for 1. of your serious and willful misconduct; purposes of the workers compensation law. We are bound by decisions against you under 2. you knowingly employ an employee in violation that law, subject to the provisions of this policy of law; that are not in conflict with that law. 3. you fail to comply with a health or safety law 5. This insurance conforms to the parts of the or regulation; or workers compensation law that apply to: 4. you discharge, coerce or otherwise discrimi- a. benefits payable by this insurance or; nate against any employee in violation of the workers compensation law. b. special taxes, payments into security or other special funds, and assessments If we make any payments in excess of the benefits payable by us under that law. regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. 6. Terms of this insurance that conflict with the workers compensation law are changed by this G. Recovery From Others statement to conform to that law. We have your rights, and the rights of persons en- Nothing in these paragraphs relieves you of your titled to the benefits of this insurance, to recover duties under this policy. PART TWO - EMPLOYERS LIABILITY INSURANCE A. How This Insurance Applies 3. Bodily injury by accident must occur during the This employers liability insurance applies to bodily policy period. injury by accident or bodily injury by disease. 4. Bodily injury by disease must be caused or Bodily injury includes resulting death. aggravated by the conditions of your employ- ment. The employee's last day of last expo- 1. The bodily injury must arise out of and in the sure to the conditions causing or aggravating course of the injured employee's employment such bodily injury by disease must occur dur- ing the policy period. 2. The employment must be necessary or inci- dental to your work in a state or territory listed 5. If you are sued, the original suit and any re- in Item 3.A. of the Information Page. lated legal actions for damages for bodily injury WC 00 00 00 A Archive Copy 2 of 7 EXHIBIT A by accident or by disease must be brought in 6. bodily injury occurring outside the United the United States of America, its territories or States of America, its territories or pos- possessions, or Canada. sessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resi- B. We Will Pay dent of the United States of America or We will pay all sums you legally must pay as dam- Canada who is temporarily outside thesecountries; ages because of bodily injury to your employees, provided the bodily injury is covered by this Em- 7. damages arising out of coercion, criticism, ployers Liability Insurance. demotion, evaluation, reassignment, discipline, The damages we will pay, where recovery defamation, harassment, humiliation, discrimi- g p y ry is per- nation against or termination of any employee, miffed by law, include damages: or any personnel practices, policies, acts or 1. for which you are liable to a third party by omissions. reason of a claim or suit against you by that g bodily injury to any person in work subject to third party to recover the damages claimed the Longshore and Harbor Workers' Compen- against such third party as a result of injury to your employee; sation Act (33 USC Sections 901-950), the Nonappropriated Fund Instrumentalities Act (5 2. for care and loss of services; and USC Sections 8171-8173), the Outer Conti- nental Shelf Lands Act (43 USC Sections 3. for consequential bodily injury to a spouse, 1331-1356), the Defense Base Act (42 USC child, parent, brother or sister of the injured Sections 1651-1654), the Federal Coal Mine employee; Health and Safety Act of 1969 (30 USC provided that these damages are the direct copse- Sections 901-942), any other federal workersor workmen's compensation law or other fed- quence of bodily injury that arises out of and in the course of the injured employee's employment by eral occupational disease law, or any amend- you; and ments to these laws. 4. because of bodily injury to your employee that 9• bodily injury to any person in work subject to arises out of and in the course of employment, the Federal Employers' Liability Act (45 USC claimed against you in a capacity other than Sections 51-60), any other federal laws obli- as employer. gating an employer to pay damages to an employee due to bodily injury arising out of or C. Exclusions in the course of employment, or any amend- ments to those laws. This insurance does not cover: 10. bodily injury to a master or member of the 1. liability assumed under a contract. This ex- crew of any vessel. clusion does not apply to a warranty that your work will be done in a workmanlike manner; 11. fines or penalties imposed for violation of fed- eral or state law. 2. punitive or exemplary damages because of bodily injury to an employee employed in vio- 12. damages payable under the Migrant and Sea- lation of law; sonal Agricultural Worker Protection Act (29 USC Sections 1801-1872) and under any 3. bodily injury to an employee while employed other federal law awarding damages for vio- in violation of law with your actual knowledge lation of those laws or regulations issued or the actual knowledge of any of your execu- thereunder, and any amendments to those tive officers; laws. 4. any obligation imposed by a workers compen- D. We Will Defend sation, occupational disease, unemployment compensation, or disability benefits law, or any We have the right and duty to defend, at our ex- similar law; pense, any claim, proceeding or suit against you for damages payable by this insurance. We have the 5. bodily injury intentionally caused or aggravated right to investigate and settle these claims, pro- by you; ceedings and suits. WC 00 00 00 A Archive Copy 3 of 7 EXHIBIT A We have no duty to defend a claim, proceeding or A disease is not bodily injury by accident un- less results directly from bodily injury by ac- it suit that is not covered by this insurance. We have less it no duty to defend or continue defending after we . have paid our applicable limit of liability under this 2 Bodily Injury by Disease. The limit shown for insurance. "bodily injury by disease-policy IimiV is the E. We Will Also Pay most we will pay for all damages covered by this insurance and arising out of bodily injury We will also pay these costs, in addition to other by disease, regardless of the number of em- amounts payable under this insurance, as part of ployees who sustain bodily injury by disease. any claim proceeding, or suit we defend; The limit shown for "bodily injury by disease- each employee" is the most we will pay for all 1. reasonable expenses incurred at our request; damages because of bodily injury by disease but not loss of earnings; to any one employee. 2. premiums for bonds to release attachments Bodily injury by disease does not include dis- and for appeal bonds in bond amounts up to ease that results directly from a bodily injury the limit of our liability under this insurance; by accident. 3. litigation costs taxed against you; 3. We will not pay any claims for damages after 4. interest on a judgment as required by law until we have paid the applicable limit of our liability we offer the amount due under this insurance; under this insurance. and H. Recovery From Others 5. expenses we incur. We have your rights to recover our payment from F. Other Insurance anyone liable for an injury covered by this insur- We will not pay more than our share of damages ance. You will do everything necessary to protect and costs covered by this insurance and other in- those rights for us and to help us enforce them. surance or self-insurance. Subject to any limits of I Actions Against Us liability that apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is There will be no right of action against us under this exhausted, the shares of all remaining insurance insurance unless: and self-insurance will be equal until the loss is paid. 1. You have complied with all the terms of this policy; and G. Limits of Liability Our liability to pay for damages is limited. Our limits 2. The amount you owe has been determined with our consent or by actual trial and final of liability are shown in Item 3.6. of the Information judgment. Page. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for This insurance does not give anyone the right to "bodily injury by accident-each accident is add us as a defendant in an action against you to the most we will pay for all damages covered determine your liability. The bankruptcy or by this insurance because of bodily injury to insolvency of you or your estate will not relieve us one or more employees in any one accident. of our obligations under this Part. PART THREE - OTHER STATES INSURANCE A. How This Insurance Applies though that state were listed in Item 3.A. of the Information Page. 1. This other states insurance applies only if one or more states are shown in Item 3.C. of the 3. We will reimburse you for the benefits required Information Page. by the workers compensation law of that state if we are not permitted to pay the benefits di- 2. If you begin work in any one of those states rectly to persons entitled to them. after the effective date of this policy and are not insured or are not self-insured for such 4. If you have work on the effective date of this policy in any state not listed in Item 3.A. of the work, all provisions of the policy will apply as WC 00 00 00 A ,archive Copy 4 of 7 rmil 11P 1T A Information Page, coverage will not be af- B. Notice forded for that state unless we are notified Tell us at once if you begin work in any state listed within thirty days. in Item 3.C. of the Information Page. PART FOUR - YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by 4. Cooperate with us and assist us, as we may this policy. Your other duties are listed here. request, in the investigation, settlement or de- l. Provide for immediate medical and other ser- fense of any claim, proceeding or suit. vices required by the workers compensation 5 Do nothing after an injury occurs that would law. interfere with our right to recover from others. 2. Give us or our agent the names and ad- dresses of the injured persons and of wit- g. Do not voluntarily make payments, assume nesses, and other information we may need. obligations or incur expenses, except at your 3. Promptly give us all notices, demands and le- own cost. gal papers related to the injury, claim, pro- ceeding or suit. PART FIVE - PREMIUM A. Our Manuals that the employers of these persons lawfully secured their workers compensation obli- All premium for this policy will be determined by our gations. manuals of rules, rates, rating plans and classifica- tions. We may change our manuals and apply the D. Premium Payments changes to this policy if authorized by law or a You will pay all premium when due. You will pay governmental agency regulating this insurance. the premium even if part or all of a workers com- B. Classifications pensation law is not valid. Item 4 of the Information Page shows the rate and E Final Premium premium basis for certain business or work classi- fications. These classifications were assigned The premium shown on the Information Page, based on an estimate of the exposures you would schedules, and endorsements is an estimate. The have during the policy period. If your actual expo- final premium will be determined after this policy sures are not properly described by those classi- ends by using the actual, not the estimated, pre- fications, we will assign proper classifications, rates mium basis and the proper classifications and rates and premium basis by endorsement to this policy. that lawfully apply to the business and work cov- ered by this policy. If the final premium is more C. Remuneration than the premium you paid to us, you must pay us Premium for each work classification is determined the balance. If it is less, we will refund the balance by multiplying a rate times a premium basis. to you. The final premium will not be less than the Remuneration is the most common premium basis. highest minimum premium for the classifications This premium basis includes payroll and all other covered by this policy. remuneration paid or payable during the policy pe- If this policy is canceled, final premium will be de- riod for the services of: termined in the following way unless our manuals 1. All your officers and employees engaged in provide otherwise. work covered by this policy; and 1. If we cancel, final premium will be calculated 2. All other persons engaged in work that could pro rata based on the time this policy was in make us liable under Part One (Workers force. Final premium will not be less than the Compensation Insurance) of this policy. If you pro rata share of the minimum premium. do not have payroll records for these persons, the contract price for their services and mate- 2. If you cancel, final premium will be more than rials may be used as the premium basis. This pro rata; it will be based on the time this policy paragraph 2 will not apply if you give us proof was in force, and increased by our short rate WC 00 00 00 A ,archive Copy 5 of 7 rvul0IT A cancellation table and procedure. Final pre- G. Audit mium will not be less than the minimum pre- You will let us examine and audit all your records mium. that relate to this policy. These records include ledgers, journals, registers, vouchers, contracts, tax F. Records reports, payroll and disbursement records, and programs for storing and retrieving data. We may You will keep records of information needed to conduct nng thehpo policy audits per uring regul within business hours three years after compute premium. You will provide us with copies the policy period ends. Information developed by of those records when we ask for them. audit will be used to determine final premium. In- surance rate service organizations have the same rights we have under this provision. PART SIX- CONDITIONS A. Inspection If you die and we receive notice within thirty days after your death, we will cover your legal represen- We have the right, but are not obliged to inspect tative as insured. your workplaces at any time. Our inspections are p Cancellation not safety inspections. They relate only to the insurability of the workplaces and the premiums to 1. You may cancel this policy. You must mail or deliver advance written notice to us stating be charged. We may give you reports on the con- when the cancellation is to take effect. ditions we find. We may also recommend changes. While they may help reduce losses, we do not 2. We may cancel this policy. We must mail or undertake to perform the duty of any person to deliver to you not less than ten days advance provide for the health or safety of your employees written notice stating when the cancellation is to take effect. Mailing that notice to you at or the public. We do not warrant that your your mailing address shown in Item 1 of the workplaces are safe or healthful or that they comply Information Page will be sufficient to prove with laws, regulations, codes or standards. Insur- notice. ance rate service organizations have the same rights we have under this provision. 3. The policy period will end on the day and hour stated in the cancellation notice. B. Long Term Policy 4. Any of these provisions that conflicts with a law that controls the cancellation of the insur- If the policy period is longer than one year and six- ance in this policy is changed by this state- teen days, all provisions of this policy will apply as ment to comply with that law. though a new policy were issued on each annual anniversary that this policy is in force. E. Sole Representative C. Transfer of Your Rights and Duties The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this Your rights or duties under this policy may not be policy, receive return premium, and give or receive transferred without our written consent. notice of cancellation. WC oo 00 00 A Archive Copy 6 of 7 wwRIT 4 In Witness Whereof, the company has caused this policy to be executed and attested, but this policy shall not be valid unless countersigned by a duly authorized representative of the company. ��144 4��' 6"- 4 President President American Home National Union Fire Assurance Company Insurance Company of Pittsburgh, PA x 6�1 vC President President Chartis Property Casualty Company The Insurance Company of The State of Pennsylvania vC. President President Granite State Insurance Company Commerce and Industry Insurance Company vC. President President New Hampshire Insurance Company Illinois National Insurance Company 7D�-� Secretary National Union Fire Insurance Company of Pittsburgh, PA American Home Assurance Company The Insurance Company of The State of Pennsylvania Chartis Property Casualty Company Commerce and Industry Insurance Company Granite State Insurance Company Illinois National Insurance Company New Hampshire Insurance Company WC000000A 7of7 Archive Copy GYUIRIT A Page 1 Of 1 EXTENSION OF ITEM 4. OF THE INFORMATION PAGE WC 051-75-0614 PENNSYLVANIA INTRA/Independent State Risk ID Policy Prefix 8,No. Schedule ------------------------- 013-82-0311-00 NEWBURG TRANSPORT LLC Item 4.Classification of Operations Premium Basis Rates Code Estimated Total Per$100 of Estimated No. Annual Remuneratio Remuneration Annual Premiums RATING GROUP: 0001-01 WASTE REMOVAL-INDUSTRIAL AND/OR DOMESTIC 995 62,00 15.51 9,616 STATE OF PENNSYLVANIA TOTALS 9,616 TOTAL CLASSIFICATION PREMIUM 9,616 TOTAL UNMODIFIED PREMIUM 0 9884 0 MERIT RATING PLAN 9,616 MODIFIED STANDARD PREMIUM 9,616 UNDISCOUNTED PREMIUM -5,20 0063 -500 PREMIUM DISCOUNT 9, 116 DISCOUNTED PREMIUM 3.00 9740 288 TERRORISM 0.0 9741 12 CATASTROPHE (SEE WC 00 04 21C) 9,416 TOTAL ESTIMATED PREMIUM 2.07 0938 195 EMPLOYER ASSESSMENT (NON-COAL) 9,611 TOTAL DUE TOTAL PREMIUM FOR TERRORISM COVERAGE INCLUDED $28 IN TOTAL ESTIMATED PREMIUM WC 7754 (Ed.4-81)(Rev'd 04/08) Archive Copy CYUIRIT A TERRORISM (TRIPRA) POLICYHOLDER NOTICE - PREMIUM DETERMINATION As indicated in the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement(s) included in this Policy, the premium you have been charged for coverage under the Terrorism Risk Insurance Program Reauthorization Act of 2007 ( TRIPRA') is shown in Item 4 of the Information Page, and State Schedule Page form WC 7754. The Schedule below shows how the premiums for TRIPRA were determined. Schedule State/Jurisdiction Premium Determination Method Arizona, Colorado, Connecticut, Florida, Idaho, New Rate per $100 of Remuneration. Jersey, New Mexico, North Carolina, West Virginia and Wisconsin................................................................................. Rate per New York.............................................................................••••• 100 of Premium.oration and rate applied to Total Class Kansas, Maine, New Hampshire and Virginia............................ Included in rates applied to Premium Basis (Remuneration) for calculation of annual premium for each applicable classification of operations. Alabama, Alaska, Arkansas, Iowa, Montana, Nevada, Rate per $100 of Remuneration to addition ditio um c arg as Remu eration) e Tennessee and Texas...........................................................• in cluded in rates appliedfor calculation of annual premium for each applicable classification of operations. All Other States/Jurisdictions.................................................... Rate applied to Total Classification Premium. TRSMNOTA (Ed. 12/10) Archive Copy GYWIRIT A PREMIUM DISCOUNT ENDORSEMENT 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 following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 03/29/2011 forms a part of Policy No. WC 051-75-0614 Issued to NEWBURG TRANSPORT LLC By COMMERCE AND INDUSTRY INSURANCE COMPANY The premium for this policy and the policies, if any, listed in Item 3 of the Schedule may be eligible for a discount. This endorsement shows your estimated discount in Items 1 or 2 of the Schedule. The final calculation of premium discount will be determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective rating is not subject to premium discount. Schedule Estimated Eliaible Premium 1. State First Next Next $5,000 $95,000 $420 6000 Balance Pennsylvania 10.90 2. Average percentage discount: 5.20 % 3. Other policies: 4. If there are no entries in Items 1, 2 and 3 of the Schedule, see Premium Discount Endorsement attached to your policy number: Countersigned b — — — WC000406 9 Y - - - - - - - - - - - - - - - - - - - - - - - - - - - (Ed. 4-84) ,archive Copy Authorized Representative EXHIBIT A • CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT 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 following"attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 03/29/2011 forms a part of Policy No. WC 051-75-0614 Issued to NEWBURG TRANSPORT LLC By COMMERCE AND INDUSTRY INSURANCE COMPANY This endorsement is notification that your insurance carrier is charging premium to cover the losses that may occur in the event of a Catastrophe (other than Certified Acts of Terrorism) as that term is defined below. Your policy provides coverage for workers compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism). This premium charge does Reauthorizationefunding for Certified Acts of Terrorism Act Disclosure Endorsement (WC 00 04 22 A)contemplated attached to this Terrorism Risk policy. Insurance Program For purposes of this endorsement, the following definitions apply: • Catastrophe (other than Certified Acts of Terrorism): Any single event, resulting from an Earthquake, Noncertified Act of Terrorism, or Catastrophic Industrial Accident, which results in aggregate workers compensation losses in excess of$50 million. • Earthquake: The shaking and vibration at the surface of the earth resulting from underground movement along a fault plane or from volcanic activity. • Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary of Treasury pursuant to the Terrorism Risk Insurance Act of 2002 (as amended) but that meets all of the following criteria: a, It is an act that is violent or dangerous to human life, property, or infrastructure; b. The act results in damage within the United States, or outside of the United States in the case of the premises of United States missions or air carriers or vessels as those terms are defined in the Terrorism Risk Insurance Act of 2002 (as amended); and c. It is an act that has been committed by an individual or individuals as part of an effort to influence the policy or affect the conduct of the United States Government by coercion. • Catastrophic Industrial Accident: A chemical release, large explosion, or small blast that is localized in nature and affects workers in a small perimeter the size of a building. The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism) is shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate Premium WC 00 04 21C Countersigned by (Ed. 09108) 0 Copyright 2008 National Counha>tPTce Inc. All rights reserved. Authorized Representative S=YPIRIT A TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT 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 following"attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 03/29/2011 forms a part of Policy No. WC 051-75-0614 Issued to NEWBURG TRANSPORT LLC By COMMERCE AND INDUSTRY INSURANCE COMPANY This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2007. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2007. "Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property or infrastructure. c. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss" means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2008, and ending on December 31, 2014, an amount equal to 20% of our direct earned premiums, over the calendar year immediately preceding the applicable Program Year. "Program Year" refers to each calendar year between January 1, 2008 and December 31, 2014, as applicable. Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a Program Year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of to Insured have Losses that exceeds h ns $100,000,000,000; 0,00, 00 e0 as' and as for determinedhe Secretary of the Treasury. WC we will pay only WC 00 04 22A (Ed. 09/08) ® Copyright 2008 National CounyypL~aLy yi3nCe,Inc.All Rights Page 1 of 2 ry a.� ``�"`''MMJJ�� EXHIBIT A Policyholder Disclosure Notice 1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses exceeds $100,000,000 in a Program Year, the United States Government would pay 85% of our Insured Losses that exceed our Insurer Deductible. 2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceeds $100,000,000,000. 3. The premium charge for the coverage your policy provides for Insured Losses is included in the amounts shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate Premium WC 00 04 22A Countersigned by (Ed. 09/08) ® Copyright 2008 National Coun iMa`'�Yi�le ynce,Inc.All Rights Reserved. Authorized Representative "'IM' Page 2 of 2 EXHIBIT A IMPORTANT NOTICE TO OUR CUSTOMERS REGARDING THE OFFICE OF FOREIGN ASSETS CONTROL Your rights as a policyholder and payments to you, any insured, additional insured, loss payee, mortgagee, or claimant, for loss under this policy may be affected by the administration and enforcement of U.S. economic embargoes and trade sanctions by the OFFICE OF FOREIGN ASSETS CONTROL ("OFAC"). WHAT IS OFAC? OFAC is an office of the Department of the Treasury and acts under presidential wartime and national emergency powers, as well as authority granted by specific legislation, to impose controls on transactions and freeze foreign assets under U.S. jurisdiction. OFAC administers and enforces economic embargoes and trade sanctions primarily against: • Targeted foreign countries and their agents • Terrorism sponsoring agencies and organizations • International narcotics traffickers PROHIBITED ACTIVITY • OFAC enforces certain embargoes and sanctions against certain designated countries. No U:S. business or person may enter into certain transactions in or connected to such designated "sanctioned" countries. • OFAC maintains a directory known as the "Specially Designated Nationals and Blocked Persons" ("SDNBP") list. No U.S. business or person may transact business with any person or entity named on the SDNBP list. Additional and more in-depth information on OFAC is available at the following website: http://www.ustreas.gov/offices/eotffc/ofac. OBLIGATIONS PLACED ON US BY OFAC If we determine that you or any insured, additional insured, loss payee, mortgagee, or claimant are on the SDNBP list or are connected to a sanctioned country as described in the regulations enforced by OFAC, we must block or "freeze" property and payment of any funds transfers or transactions and report all blocks to OFAC within ten (10) days. POTENTIAL ACTIONS BY US 1. We may immediately cancel your coverage effective on the day that we determine that we have transacted business with an individual or entity associated with your policy on the SDNBP list or connected to a sanctioned country as described in the regulations enforced by OFAC. 2. If we cancel your coverage, you will not receive a return premium unless approved by OFAC. All funds will be placed in an interest bearing blocked account established on the books of a U.S. financial institution. 3. We will not pay a claim, accept premium or exchange monies or assets of any kind to or with individuals, entities or companies (including a bank) on the SDNBP list or connected to a sanctioned country as described in the regulations enforced by OFAC. And, we will not defend or provide any other benefits under your policy to individuals, entities or companies on the SDNBP list or connected to a sanctioned country as described in the regulations enforced by OFAC. YOUR RIGHTS AS A POLICYHOLDER If funds are blocked or frozen by us in conjunction with the OFFICE OF FOREIGN ASSETS CONTROL, you may complete an "APPLICATION FOR THE RELEASE OF BLOCKED FUNDS" and apply for a specific license to request their release. Forms are available for download at the OFAC website. See http://www.ustreas.gov/offices/eotffc/ofac/legal/forms/license.pdf WCOFAC Archive (Ed. 07/05) Copy EXHIBIT A Chartis U.S. Workers' Compensation and Group Benefits Privacy and Data Security Notice About This Notice This Privacy and Data Security Notice applies only to Personal Information about an individual (see definitions below) obtained by one of the Chartis U.S. Companies or their affiliates listed at the end of this notice, in connection with a Workers' Compensation or Group Benefits policy to which this notice is attached. Chartis U.S. has established practices, procedures and system protections that are designed to help protect the privacy and security of this Personal Information. This notice outlines how we collect, handle, and disclose such Personal Information. The term "Individual," as used in this Privacy and Data Security Notice, means a natural person who is a beneficiary of or claimant under a Workers' Compensation or Group Benefit policy. The term "Individual" also means a natural person who purchases Workers' Compensation insurance for personal, family or household purposes in the United States. The term "Individual" does not include a natural person or organization that is a commercial purchaser of a Workers' Compensation or a Group Benefits policy even if they are the recipient of this notice. The term "Personal Information," as used in this Privacy and Data Security Notice, means information that identifies an Individual. Examples of Personal Information include a first and last name, a home or other physical address, an email address, a financial account or credit card number, a driver's license number, or information on a physical condition or health status. I. Information Privacy We may collect Personal Information through applications, enrollment forms, in claims processing, or in your other interactions with us and with our Affiliates. We will collect Personal Information only in accordance with applicable laws or regulations, whether we collect it in response to a request for a product or service.from us or otherwise. Information Sharing We may share Personal Information with Affiliates and Non-Affiliates as described below. With our Affiliates: Our Affiliates may include other insurance companies, insurance holding companies, insurance agents and agencies, claims administrators, marketing companies, e-commerce service providers, and companies providing administrative services. We may share Personal Information, including Personal Information of a health nature, with our Affiliates that assist us in servicing insurance policies. Examples are administration (billing and collections), risk management, underwriting, and claims handling. We may also share Personal Information with Affiliates for the purpose of detecting and preventing fraud, or as otherwise permitted or required by law. With Non-Affiliates: We may share Personal Information, including Personal Information of a health nature, with Non-Affiliates that assist us in servicing insurance policies. Examples are administration (billing and collections), risk management, underwriting, and claims handling. We may also share Personal Information with Non-Affiliates for the purpose of detecting and preventing fraud, as authorized by that Individual, or as otherwise permitted or required by law. We may also enter into joint marketing agreements with Non-Affiliates to share non-health Personal Information as permitted by law. These Non-Affiliates may include providers of financial products or services such as insurance companies, financial institutions, and securities firms. 107437 (Ed. 01/11) Page 1 of 2 Archive Copy EXHIBIT A Because we do not share Personal Information with either Affiliates or Non-Affiliates in any other way, there is no need for an opt-out process in our privacy procedures. For California and Vermont Residents: If it becomes necessary to share an Individual's Personal Information with Non-Affiliates other than as specifically allowed by law, we will not do so without first obtaining permission from the Individual. II. Data Security To help prevent unwarranted disclosure of Personal Information and secure it from theft, we utilize secure computer networks. Access is restricted to those persons who have a business need to use Personal Information in connection with servicing Workers' Compensation or Group Benefits Policies. We also maintain physical, electronic, and procedural safeguards designed to protect your Personal Information in compliance with federal and state privacy and information security laws. Non-Affiliates that assist us in servicing insurance policies or who enter into joint marketing agreements with us are required to take measures to maintain the security of Personal Information in compliance with federal and state privacy and information security laws. III. Maintaining Personal Information We also maintain procedures to ensure that the Personal Information we collect is accurate, up-to-date, and as complete as possible. An Individual who believes the information we have in our records or files is incomplete or inaccurate, may request that we make additions or corrections, or if it is feasible, that we delete the Individual's information from our files. An Individual may make this request in writing to (include your name, address, policy number or claim number): Chief Privacy Officer Chartis U.S. 175 Water Street, 17th Floor New York, NY 10038 Fax: 212 458-7081 E-Mail: ClPrivacy@chartisinsurance.com Special Notice: Individuals can obtain access to any non-public Personal Information we have about them if they properly identify themselves and submit a written request to the address above describing the information they want to review. We will also tell them the identity, if recorded, of persons to whom we have disclosed their non-public Personal Information within the preceding two years. Individuals subject to this notice may request that we correct, amend or delete information about them. If we do so, we will notify organizations that provided us with that information and, upon such Individual's request, persons who received that information from us within the preceding two years. If we cannot grant a request to correct, amend or delete the information, the Individual may give us a written statement of the reasons why they disagree, which we will place in their file and give to the same parties who would have been notified of the requested change. Important Information Conceming the Applicability and Future Changes to this Privacy and Data Security Notice We may change this Privacy and Data Security Notice from time to time, and if particular changes are required by law to be communicated to you we will do so. Our family of companies includes: American Home Assurance Company; Chartis Casualty Company; Chartis Property Casualty Company; Chartis Select Insurance Company; Chartis Specialty Insurance Company; Commerce and Industry Insurance Company; Granite State Insurance Company; Illinois National Insurance Co.; Landmark Insurance Company; Lexington Insurance Company; National Union Fire Insurance Company of Pittsburgh, Pa.; National Union Fire Insurance Company of Vermont; New Hampshire Insurance Company; The Insurance Company of the State of Pennsylvania; other Chartis U.S. companies, and American International Life Assurance Company of New York and American General Life Ihsurance Company of Delaware. 107437 (Ed. 01/11) Page 2 of 2 Archive Copy EXHIBIT A PREMIUM DUE DATE ENDORSEMENT 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 following"attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 03/29/2011 forms a part of Policy No. WC 051-75-0614 Issued to NEWBURG TRANSPORT LLC By COMMERCE AND INDUSTRY INSURANCE COMPANY PART FIVE PREMIUM D. Premium is amended to read: You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. The due date for audit and retrospective premiums is the date of the billing. WC 00 04 19 Countersigned by (Ed. 01/01) Archive Copy Authorized Representative EXHIBIT A SPECIAL PENNSYLVANIA ENDORSEMENT-INSPECTION OF MANUALS 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 following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 03/29/2011 forms a part of Policy No. WC 051-75-0614 Issued to NEWBURG TRANSPORT LLC By COMMERCE AND INDUSTRY INSURANCE COMPANY The manuals of rules, rating plans, and classifications are approved pursuant to the provisions of Section 654 of the In- surance Company Law of May 17, 1921, P.L. 682, as amended, and are on file with the Insurance Commissioner of the Commonwealth of Pennsylvania. WC 37 06 01 Countersigned by — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — (Ed. 484) Archive Copy Authorized Representative FXHIRIT A PENNSYLVANIA NOTICE 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 following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 03/29/2011 forms a part of Policy No. WC 051-75-0614 Issued to NEWBURG TRANSPORT LLC By COMMERCE AND INDUSTRY INSURANCE COMPANY An Insurance Company, its agents, employees, or service contractors acting on its behalf, may provide services to reduce the likelihood of injury, death or loss. These services may include any of the following or related services incident to the application for, issuance, renewal or continuation of, a policy of insurance: 1. surveys; 2. consultation or advice; or 3. inspections. The "Insurance Consultation Services Exemption Act' of Pennsylvania provides that the Insurance Company, its agents, employees or service contractors acting on its behalf, is not liable for damages from injury, death or loss occurring as a result of any act or omission by any person in the furnishing of or the failure to furnish these services. The Act does not apply: 1. if the injury, death or loss occurred during the actual performance of the services and was caused by the negligence of the Insurance Company, its agents, employees or service contractors; 2. to consultation services required to be performed under a written service contract not related to a policy of insur- ance; or; 3. if any acts or omissions of the Insurance Company, its agents, employees or service contractors are judicially de- termined to constitute a crime, actual malice, or gross negligence. WC 37 06 02 Countersigned by_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (Ed. 484) Archive Copy Authorized Representative EXHIBIT A PENNSYLVANIA ACT 86-1986 ENDORSEMENT 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 following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 03/29/2011 forms a part of Policy No. WC 051-75-0614 Issued to NEWBURG TRANSPORT LLC By COMMERCE AND INDUSTRY INSURANCE COMPANY NONRENEWAL, NOTICE OF INCREASE OF PREMIUM, and RETURN OF UNEARNED PREMIUM 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 following 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 to 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 nonrenewal will state our specific reasons for not renewing. 3. If we have indicated our willingness to renew, we will not send you a notice of nonrenewal. However, the policy 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 30 days advance notice of an increase in renewal premium of this policy, if it is our intent to offer such renewal. 2. The above notification requirement will be satisfied if we have issued a renewal policy more than 30 days prior to its effective date. 3. If a policy has been written or is to be written on a retrospective rating plan basis, the notice of increase in premium provision of this endorsement does not apply. Return of Unearned Premium 1. If this policy is canceled and there is unearned premium due you: a. If the Company cancels, the unearned premium will be returned to you within 10 business days after the effective date of cancellation. WC370603A (Ed. 08-95) Page 1 of 2 Archive Copy EXHIBIT A b. If you cancel, the unearned premium will be returned within 30 days after the effective date of cancellation. 2. Because this policy was written on the basis of an estimated premium and is subject to a premium audit, the unearned premium specified in 1a. and 1b. 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 of unearned premium provisions shall not apply if this policy is written on a retrospective rating plan basis. WC370603A Countersigned by _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (Ed. 08-95) Archive Copy Page 2 of 2 Authorized Representative EXHIBIT A NOTIFICATION OF AVAILABILITY OF ACCIDENT AND ILLNESS PREVENTION SERVICES IN THE STATE OF PENNSYLVANIA AIG Consultants, Inc., a member company of American International Group, Inc. (AIG), maintains and provides accident and illness prevention services as required by the nature of the policyholder's business or its operation, in accordance with the Pennsylvania Workers' Compensation Act. A 5% premium discount is available to employers who form a certified workplace safety committee. Services include: Surveys Recommendations Training Programs Consultations Analysis of Accident Causes Industrial Hygiene Services Industrial Health Services For more information about these services, contact AIG Consultants at 212-770-5038, e-mail us at aig-consultants@aig.com or write to: AIG Consultants, Inc. 1700 Market Street-Suite 1800 Philadelphia, Pa. 19103 Fax# 215-255-6561 WC 99 37 03A (Ed. 08/02) ,archive Copy EXHIBIT A PAGE 1 EXTENSION OF ITEM 1. OF THE INFORMATION PAGE This endorsement, effective 12:01 AM 03/29/2011 Forms a part of policy no.: WC 051-75-0614 Issued to: NEWBURG TRANSPORT LLC By: COMMERCE AND INDUSTRY INSURANCE COMPANY LOC NO. NAME AND ADDRESS SCHEDULE FEIN UI # 0001 NEWBURG TRANSPORT LLC 274846397 2 TURNPIKE ROAD USABURG, PA 17240-0000 BUSINESS TYPE: LIMITED LIABILITY COMPANY NAIC: 562111 Issue Date: 03/31/11 Authorized Representative WC990610(Ed. 1-Araq,060O49oPY EXHIBIT A THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Endorsement No. 001 This endorsement, effective 12:01 AM 03/29/2011 Forms a part of Policy No. WC 051-75-0614 --------------------------- 013-82-0311-00 Issued to NEWBURG TRANSPORT LLC By COMMERCE AND INDUSTRY INSURANCE COMPANY NOTICE TO POLICYHOLDER This endorsement modifies insurance provided under this Workers Compensation and Employers Liability Insurance Policy Premium for this endorsement: 0 THE FOLLOWING LOCATION IS DELETED FROM THIS POLICY: LOC NO 1 NAME: NEWBURG TRANSPORT LLC ADDRESS: 25 TURNPIKE ROAD,NEWBURG, PA 172400000 FEIN: 274846397 U/ I : THE FOLLOWING LOCATION IS ADDED TO THIS POLICY: LOC NO 2 NAME: NEWBURG TRANSPORT LLC ADDRESS: 565 TRESTLE PLACE,DOWNINGTOWN, PA 193350000 FEIN: 274846397 U/I : Issue Date: 05/13/11 WC 99 06 11 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - (Ed. 01/97) Archive Copy Authorized Representative EXHIBIT A PAGE 1 EXTENSION OF ITEM 1. OF THE INFORMATION PAGE This endorsement, effective 12:01 AM 03/29/2011 Forms a part of policy no.: WC 051-75-0614 Issued to: NEWBURG TRANSPORT LLC By: COMMERCE AND INDUSTRY INSURANCE COMPANY LOC NO. NAME AND ADDRESS SCHEDULE FEIN UI # 0002 NEWBURG TRANSPORT LLC 274846397 g65 TRESTLE PLACE 33 BUSH NESSOTTYOE: LIPA VIRDOL ABILITY COMPANY NAIC: 562111 Issue Date: 05/13/11 Authorized Representative WC990610(Ed. 1-0"( b OOPOPY EXHIBIT A THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Endorsement No. 002 This endorsement, effective 12:01 AM 03/29/2011 Forms a part of Policy No. WC 051-75-0614 --------------------------- 013-82-0311-00 Issued to NEWBURG TRANSPORT LLC By COMMERCE AND INDUSTRY INSURANCE COMPANY NOTICE TO POLICYHOLDER This endorsement modifies insurance provided under this Workers Compensation and Employers Liability Insurance Policy Premium for this endorsement: 0 THE FOLLOWING RATING PLAN HAS BEEN DELETED FROM THIS POLICY: MERIT RATING PLAN STATE: PA AMOUNT: 1 Issue Date: 06/14/11 WC 99 06 11 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - (Ed. 01/97) Archive Copy Authorized Representative EXHIBIT A Page 1 of 1 EXTENSION OF ITEM 4. OF THE INFORMATION PAGE WC 051-75-0614 PENNSYLVANIA Policy Prefix&No. Schedule INTRA/Independent State Risk ID ------------------------- 013-82-0311-00 NEWBURG TRANSPORT LLC Item 4.Classification of Operations Premium Basis Rates Code Estimated Total Per$100 of Estimated No. Annual Remuneratioi i Remuneration Annual Premiums RATING GROUP: 0001-01 WASTE REMOVAL-INDUSTRIAL AND/OR DOMESTIC 995 62,00 15.51 9,616 STATE OF PENNSYLVANIA TOTALS TOTAL CLASSIFICATION PREMIUM 9,616 TOTAL UNMODIFIED PREMIUM 9,616 MODIFIED STANDARD PREMIUM 9,616 UNDISCOUNTED PREMIUM 9,616 PREMIUM DISCOUNT -5.20A 0063 -500 DISCOUNTED PREMIUM 9, 116 TERRORISM 3.00 9740 288 CATASTROPHE (SEE WC 00 04 21C) 0.02 9741 12 TOTAL ESTIMATED PREMIUM 9,416 EMPLOYER ASSESSMENT (NON-COAL) 2.07 0938 195 ANNUALIZED TOTAL 9,611 TOTAL PREMIUM FOR TERRORISM COVERAGE INCLUDED IN TOTAL ESTIMATED PREMIUM $28 WC 7754 (Ed.4-81)(Rev'd 04/08) Archive Copy EXHIBIT A THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Endorsement No. 003 This endorsement, effective 12:01 AM 03/29/2011 Forms a part of Policy No. WC 051-75-0614 --------------------------- 013-82-0311-00 Issued to NEWBURG TRANSPORT LLC By COMMERCE AND INDUSTRY INSURANCE COMPANY NOTICE TO POLICYHOLDER This endorsement modifies insurance provided under this Workers Compensation and Employers Liability Insurance Policy Premium for this endorsement: SUBJECT TO AUDIT THE FOLLOWING EXPERIENCE MODIFICATION FACTOR IS ADDED TO THIS POLICY: STATE: PENNSYLVANIA RISK ID : 3303496 MOD TYPE: ACTUAL FACTOR: 0.00 THE FOLLOWING CLASS CODE IS ADDED TO THIS POLICY: STATE: PENNSYLVANIA RATING GROUP: 0001-01 CLASS CODE: 953(CLERICAL OFFICE EMPLOYEES) ANNUAL PREMIUM BASIS: $0.00 PRO RATA FACTOR: 1 FINAL RATE: .49 ANNUAL CLASSIFICATION PREMIUM: $0.00 Issue Date: 05/02/13 WC 99 06 11 - - - - - - - - - - - - - - - - - - — — — — — — — — — — — — (Ed. 01/97) Archive Copy Authorized Representative EXHIBIT A Page 1 of 1 EXTENSION OF ITEM 4. OF THE INFORMATION PAGE WC 051-75-0614 PENNSYLVANIA 3303496 Policy Prefix&No. Schedule INTRA/Independent State Risk ID ------------------------- 013-82-0311-00 NEWBURG TRANSPORT LLC Item 4.Classification of Operations Premium Basis Rates Code Estimated Total Per$100 of Estimated No. Annual Remuneratioi i Remuneration Annual Premiums RATING GROUP: 0001-01 CLERICAL OFFICE EMPLOYEES 953 IF ANN 0.49 WASTE REMOVAL-INDUSTRIAL AND/OR DOMESTIC 995 62,00 15.51 9,616 STATE OF PENNSYLVANIA TOTALS TOTAL CLASSIFICATION PREMIUM 9,616 TOTAL UNMODIFIED PREMIUM 9,616 MODIFIED STANDARD PREMIUM 9,616 UNDISCOUNTED PREMIUM 9,616 PREMIUM DISCOUNT -5.20 0063 -500 DISCOUNTED PREMIUM 9, 116 TERRORISM 3-00A 9740 288 CATASTROPHE (SEE WC 00 04 21C) 0.02 9741 12 TOTAL ESTIMATED PREMIUM 9,416 EMPLOYER ASSESSMENT (NON-COAL) 2.07A 0938 195 ANNUALIZED TOTAL 9,611 TOTAL PREMIUM FOR TERRORISM COVERAGE INCLUDED IN TOTAL ESTIMATED PREMIUM $28 WC 7754 (Ed.4-81) (Rev'd 04/08) Archive Copy EXHIBIT A THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Endorsement No. 000 This endorsement, effective 12:01 AM 03/29/2012 Forms a part of Policy No. WC 051-75-0614 --------------------------- 013-82-0311-00 Issued to NEWBURG TRANSPORT LLC By COMMERCE AND INDUSTRY INSURANCE COMPANY NOTICE TO POLICYHOLDER This endorsement modifies insurance provided under this Workers Compensation and Employers Liability Insurance Policy Premium for this endorsement: 0 THIS POLICY HAS BEEN NON RENEWED EFFECTIVE 3/29/2012. Issue Date: 01/10/12 WC 99 06 11 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - (Ed. 01/97) Archive Copy Authorized Representative EXHIBIT A Audit Billing Ticket Case Name: 051750614-000-R4 003 Company Code: Commerce&Industry Ins Co Policy Status: Completed-reaudit Division: 013 Auditor's Name: Jonna Lyn Isip Auditor Number: BCIJISI Vendor Co.Name: Audit Method: Physical Audit Date Range: 4/25/2013-4/25/2013 Risk ID: SPARC Completion Date: 04/25/2013 Audit Type: Reaudit Insured Name: NEWBURG TRANSPORT LLC Due Date: Audit Period: 03/29/2011-03/29/2012 Technician Rejecting Audit: Policy Period: 03/29/2011-03/29/2012 Prior Policy Number: new Policy Prefix: we Policy#: 051750614 LOB: WC-AIWCS Policy ID: na Name of Program/Wrap-Up: na Contract/Acct#: na All Audits Completed: Yes Shelled: No Auditor#1 Auditor#2 Auditor#3 Travel Time: 0.00 0.00 0.00 Audit Time: 2.50 0.00 0.00 Write-Up Time: 1.00 0.00 0.00 Other(Explain): 0.00 0.00 0.00 Billing Hours: 3.50 0.00 0.00 Total Hours: 3.50 Audit States: PA COMPANION POLICIES Policy Number Status BILLING TICKET NOTES rpa Date Start Finish MinutesAction Total Minutes: PROCESSING INFORMATION Date Received: 05/13/2014 Due Date: 05/23/2014 PAPC#: Technician Minutes: Technician#: Deposit Premium: 14,139 Date Completed: Additional/Return Premium: Tracking Completion Done By: EXHIBIT B CHARTIS Workers' Compensation Audit Prepared for: Commerce&Industry Ins Co Report prepared by: AIG-Premium Audit Division Policy Number: 051750614 Policy Term: 03/29/2011-03/29/2012 Audit Period: 03/29/2011-03/29/2012 Audit Date: 04/25/2013 EZ-Audit software by InsuraTek Corp. Date Printed:5/13/2014 1:50:01AM www.insuratek.com FXHIRIT R Workers Compensation Audit Date: 04/25/2013 Legal Entity: Limited Liability Co Auditor ID: CAPXKLA Agent ID: 0075190-00 Auditor Name: Account Number: 051750614-000-114 3/21/2013 003 Audit Period: 03/29/2011 03/29/2012 Policy Number: 051750614 Policy Period: 03/29/2011 03/29/2012 Insured Name: NEWBURG TRANSPORT LLC Audit Method: Phvsical Exposure Summary State Class Code Description Exposure From aQ Entity: 0001 NEWBURG TRANSPORT LLC Location: 0002 PA PA BLNC BALANCE CLASS 0 03/29/11 03/29/12 PA 953 Clerical Office Employees 49,925 03/29/11 03/29/12 PA 995 WASTE REMOVAL-INDUSTRIAL AND/OR D 290,539 03/29/11 03/29/12 INSURED INFORMATION Contact: Donnal Burkholder Phone: (717)477-0275 Title: Office Phone 2: Company Name: NEWBURG TRANSPORT LLC Mobile: Address: 25 TURNPIKE ROAD Fax: NEWBURG,PA 17240 E-Mail: dburkholder.newburgtransport@yahoo.com Entities Number Entity Name Federal ID State ID Date Added Date Deleted 0001 NEWBURG TRANSPORT LLC 274846397 Locations Location: 0002 PA Added: Deleted: Location of Records Entity: 0001 Location: 0002 Sequence: 1 Territory: Description: Description of Operations Newburg Transport Inc.is a transportation company engaged in curbside pickup of recyclable materials. Trucks are unloaded at the policyholder address and materials are sorted for further disposal by other entities. Sorting is not a principal portion of the insured's business. Refuse collection The company began operating at the policy inception. There are twelve trucks and approximately 17 drivers. Code 995 applies to the payroll of drivers and yard employees. Code 953 is added at audit and applies to the payroll of employees whose duties are performed exclusively within a separate office and consist of recordkeeping and correspondence. General Notes ******************************Reaudit by Kristine Lampkin Audit was opened again after the audit contact submitted actual payroll records. Some of the information was not legible and I contacted Donna Burkholder again. She was to submit W-2s for 2011 but has not. Audit is being transmitted using the records as interpreted by auditor. Year to date 12-31-11 records have been confirmed to include payroll from April 2011 through December 2011 only,and first quarter 2012 PA UC2 was used for the remaining period. Overtime credit does not apply in PA. Pennsylvania bureau file#3303496 shows the risk is not qualified for experience rating. Codes on the policy are deemed authorized. Checked claims on line-2 filed,both coded correctly for active employees. Tax return verification was not available for all quarters. Audit is being completed with available information. No tour taken. Audited exposure is nearly five times higher than estimated. The company began operating in 2011 and has grown. Federal ID is correct. Name on policy is incorrect. Should be Newburg Transport Inc,not LLC. Date Printed:5/13/2014 1:50:01 AM American International Group Page 3 of 10 EXHIBIT B Account Number: 051750614-000-R4 3/21/2013 003 Audit Period: 03/29/2011 03/29/2012 Policy Number: 051750614 Policy Period: 03/29/2011 03/29/2012 Insured Name: NEWBURG TRANSPORT LLC Audit Method: Phvsical Key employee-Erick Booz,owner. Miscellaneous employees-none. Exit interview by e-mail with Donna Burkholder. Discussed overall operations and specific employee duties. No issues outstanding. No signatures obtained-info submitted electronically. from prior versions: ******************************Reaudit by Kristine Lampkin Audit was originally processed as nonproductive/estimated. Received information from agent Mike Scher at RR Beach including contact name and phone number(Donna Burkholder). Contacted Donna by phone on 1-28-13 and discussed what records would be necessary. She stated she would forward the information by 2-6-13. Followed up with an e-mail summarizing our conversation that same day. Nothing was received. Followed up with e-mail on 2-15-13. No response. Sent e-mail to Donna with copies to RR Beach(Mike Scher and Jim Zimmie)stating that audit was being returned with no changes. Also notified Jade Diana in legal collections. Please call our Customer Service Number-888-646-0551 -This is an estimated audit. As your workers&rsquo;compensation insurance carrier,we will be forced to do a final accounting on the basis of our estimate of your payrolls. Then there will be a bill based on the estimate. Our attempts to schedule and complete an audit with you were unsuccessful: Date Contact Name Phone Number Action 4/30/2012 Mailed out letter for appt.on 5/10/2012 5/9/2012 Rafael Nadal 363-414-7894 Called to confirm appt at the#on the policy.This number is the wrong number. 5/10/2012 I attempted to find another number for the insured,to no avail. Date Producer(Broker) Phone Number Action 5/10/2012 PMC Insurance Agency 717-214-2800 Emailed info@pmcinsurance.com regarding non-pro status. No return email recieved. Date Contact Name Phone Number Action 5/15/2012 Mailed&quot;Follow Up Request for Audit&quot;letter Date Underwriter Name Phone Number Action Not necessary as the policy is a DIV 13 policy Your current insurance,if it&rsquo;s with the same workers&rsquo;compensation insurance carrier,could be cancelled or non-renewed. Also,your workers&rsquo;compensation insurance carrier will be unable to report premium basis and loss data to the rating bureau(s). This may affect your future Experience Rating premium,as the experience modification may be published by the rating bureau(s)excluding the unaudited payrolls for this policy but including all applicable loss data and could result in a higher experience modification than might otherwise apply. If you have questions or concerns regarding this matter,please contact the number provided to request a re-audit. Claims Verification and Analysis: The claims report for this policy was reviewed. There were no claims reported. Audit Reconciliation State Class Code Description Exposure From 12 Entity: 0001 NEWBURG TRANSPORT LLC Location: 0002 PA PA Gross Payroll 340,464 03/29/11 03/29/12 PA <Alspaugh> -5,773 03/29/11 03/29/12 Date Printed:5/13/2014 1:50:O1AM American International Group Page 4 of 10 EXHIBIT B Account Number: 051750614-000-R4 3/21/2013 003 Audit Period: 03/29/2011 03/29/2012 Policy Number: 051750614 Policy Period: 03/29/2011 03/29/2012 Insured Name: NEWBURG TRANSPORT LLC Audit Method: Phvsical PA <Black> -16,308 03/29/11 03/29/12 PA <Booz K> -11,865 03/29/11 03/29/12 PA <Brink> -15,613 03/29/11 03/29/12 PA <Byers> -1,892 03/29/11 03/29/12 PA <Deimler B> -21,848 03/29/11 03/29/12 PA <Deimler C> -8,467 03/29/11 03/29/12 PA <Estep> -34,920 03/29/11 03/29/12 PA <Fogelsanger> -7,441 03/29/11 03/29/12 PA <Hernandez> -5,382 03/29/11 03/29/12 PA <Hoch> -25,065 03/29/11 03/29/12 PA <Jones> -4,785 03/29/11 03/29/12 PA <Mayberry> -12,782 03/29/11 03/29/12 PA <Meza> -1,554 03/29/11 03/29/12 PA <Miller> -29,186 03/29/11 03/29/12 PA <Morehouse> -17,516 03/29/11 03/29/12 PA <Rickard> -21,645 03/29/11 03/29/12 PA <Sanchez> -5,389 03/29/11 03/29/12 PA <Stahlman> -18,640 03/29/11 03/29/12 PA <to balance> 291 03/29/11 03/29/12 PA <Wells> -13,435 03/29/11 03/29/12 PA <Wenger> -12,182 03/29/11 03/29/12 PA <Wiser> -18,988 03/29/11 03/29/12 PA <Wynn> -8,327 03/29/11 03/29/12 PA <Booz,Erick A> -21,752 03/29/11 03/29/12 E PA BLNC Balance BALANCE CLASS 0 03/29/11 03/29/12 PA 953 Black 16,308 03/29/11 03/29/12 PA 953 Booz K 11,865 03/29/11 03/29/12 PA 953 Principals 21,752 03/29/11 03/29/12 PA 953 Total Clerical Office Employees 49,925 03/29/11 03/29/12 PA 995 Alspaugh 5,773 03/29/11 03/29/12 PA 995 Brink 15,613 03/29/11 03/29/12 PA 995 Byers 1,892 03/29/11 03/29/12 PA 995 Deimler B 21,848 03/29/11 03/29/12 PA 995 Deimler C 8,467 03/29/11 03/29/12 PA 995 Estep 34,920 03/29/11 03/29/12 PA 995 Fogelsanger 7,441 03/29/11 03/29/12 PA 995 Hernandez 5,382 03/29/11 03/29/12 PA 995 Hoch 25,065 03/29/11 03/29/12 PA 995 Jones 4,785 03/29/11 03/29/12 PA 995 Mayberry 12,782 03/29/11 03/29/12 PA 995 Meza 1,554 03/29/11 03/29/12 PA 995 Miller 29,186 03/29/11 03/29/12 PA 995 Morehouse 17,516 03/29/11 03/29/12 PA 995 Rickard 21,645 03/29/11 03/29/12 PA 995 Sanchez 5,389 03/29/11 03/29/12 PA 995 Stahlman 18,640 03/29/11 03/29/12 PA 995 to balance -291 03/29/11 03/29/12 PA 995 Wells 13,435 03/29/11 03/29/12 PA 995 Wenger 12,182 03/29/11 03/29/12 PA 995 Wiser 18,988 03/29/11 03/29/12 PA 995 Wynn 8,327 03/29/11 03/29/12 PA 995 Total WASTE REMOVAL-INDUSTRIAL AND/O 290,539 03/29/11 03/29/12 Date Printed:5/13/2014 1:50:OIAM American International Group Page 5 of 10 EXHIBIT B Account Number: 051750614-000-114 3/21/2013 003 Audit Period: 03/29/2011 03/29/2012 Policy Number: 051750614 Policy Period: 03/29/2011 03/29/2012 Insured Name: NEWBURG TRANSPORT LLC Audit Method: Phvsical Principals State Class Code Nam Tatl£ Dates Entity: 0001 Location: 0002 PA 953 Booz,Erick A President 03/29/11 03/29/12 1.000 Min: 20,800 Max: 109,200 Payroll: 21,752 Amount Incl: 21,752 Office duties principally Payroll Verification Entity: 0001 Location: 0002 Verification Type: State Unemployment Forms State: PA Orr Startine Amount Adjustment Otr Total Description Adjustment 0 0 0 1 st Qtr 2011 0 0 0 2nd Qtr 2011 57,975 0 57,975 3rd Qtr 2011 0 0 0 4th Qtr 2011 0 63,618 63,618 illegible 1 st Qtr 2012 218,871 0 218,871 Adjustment 0 0 0 Gross Total: $340,464 Verification Total: 340.464 Deviation: $0 Audit Worksheet State Class Code Name Order Dept Empl.Dates Total Entity: 0001 Location: 0002 Gross Payroll PA Gross Payroll 10 03/29/11 03/29/12 340,464 Notes: Year to date 12-31-11 shown in fourth quarter. Per audit contact,company began operation on 3-29-11 so no wages were paid in the first quarter of 2011. 04/01/2011: 0 07/01/2011: 0 10/01/2011: 121,593 01/01/2012: 218,871 Adjustment: 0 Total Gross Payroll 340,464 Classified PA 953 Black 80 03/29/11 03/29/12 16,308 Duties: Office 04/01/2011: 0 07/01/2011: 0 10/01/2011: 12,508 01/01/2012: 3,800 Adjustment: 0 PA 953 Booz K 70 03/29/11 03/29/12 11,865 Duties: Office 04/01/2011: 0 07/01/2011: 0 10/01/2011: 11,215 01/01/2012: 650 Adjustment: 0 PA 995 Alspaugh 210 03/29/11 03/29/12 5.773 Duties: sorting recyclables 04/01/2011: 0 07/01/2011: 0 10/01/2011: 250 01/01/2012: 5,523 Adjustment: 0 PA 995 Brink 250 03/29/11 03/29/12 15,613 04/01/2011: 0 07/01/2011: 0 10/01/2011: 1,000 01/01/2012: 14,613 Adjustment: 0 PA 995 Byers 120 03/29/11 03/29/12 1,892 04/01/2011: 0 07/01/2011: 0 10/01/2011: 1,892 01/01/2012: 0 Adjustment: 0 PA 995 Deimler B 130 03/29/11 03/29/12 21,848 04/01/2011: 0 07/01/2011: 0 10/01/2011: 4,403 01/01/2012: 17,445 Adjustment: 0 Date Printed:5/13/2014 1:50:01 AM American International Group Page 6 of 10 EXHIBIT B Account Number: 051750614-000-R-4 3/21/2013 003 Audit Period: 03/29/2011 03/29/2012 Policy Number: 051750614 Policy Period: 03/29/2011 03/29/2012 Insured Name: NEWBURG TRANSPORT LLC Audit Method: Physical PA 995 Deimler C 220 03/29/11 03/29/12 8,467 04/01/2011: 0 07/01/2011: 0 10/01/2011: 0 01/01/2012: 8,467 Adjustment: 0 PA 995 Estep 20 03/29/11 03/29/12 34,920 04/01/2011: 0 07/01/2011: 0 10/01/2011: 18,912 01/01/2012: 16,008 Adjustment: 0 PA 995 Fogelsanger 240 03/29/11 03/29/12 7,441 04/01/2011: 0 07/01/2011: 0 10/01/2011: 0 01/01/2012: 7,441 Adjustment: 0 PA 995 Hernandez 60 03/29/11 03/29/12 5,382 04/01/2011: 0 07/01/2011: 0 10/01/2011: 5,382 01/01/2012: 0 Adjustment: 0 PA 995 Hoch 40 03/29/11 03/29/12 25,065 04/01/2011: 0 07/01/2011: 0 10/01/2011: 12,526 01/01/2012: 12,539 Adjustment: 0 PA 995 Jones 170 03/29/11 03/29/12 4,785 04/01/2011: 0 07/01/2011: 0 10/01/2011: 0 01/01/2012: 4,785 Adjustment: 0 PA 995 Mayberry 200 03/29/11 03/29/12 12,782 04/01/2011: 0 07/01/2011: 0 10/01/2011: 0 01/01/2012: 12,782 Adjustment: 0 PA 995 Meza 50 03/29/11 03/29/12 1,554 Duties: sorting recyclables 04/01/2011: 0 07/01/2011: 0 10/01/2011: 1,554 01/01/2012: 0 Adjustment: 0 PA 995 Miller 100 03/29/11 03/29/12 29,186 04/01/2011: 0 07/01/2011: 0 10/01/2011: 16,332 01/01/2012: 12,854 Adjustment: 0 PA 995 Morehouse 140 03/29/11 03/29/12 17,516 04/01/2011: 0 07/01/2011: 0 10/01/2011: 1,655 01/01/2012: 15,861 Adjustment: 0 PA 995 Rickard 110 03/29/11 03/29/12 21,645 04/01/2011: 0 07/01/2011: 0 10/01/2011: 9,335 01/01/2012: 12,310 Adjustment: 0 PA 995 Sanchez 90 03/29/11 03/29/12 5,389 Duties: sorting recyclables 04/01/2011: 0 07/01/2011: 0 10/01/2011: 5,389 01/01/2012: 0 Adjustment: 0 PA 995 Stahlman 150 03/29/11 03/29/12 18,640 04/01/2011: 0 07/01/2011: 0 10/01/2011: 3,029 01/01/2012: 15,611 Adjustment: 0 PA 995 to balance 260 03/29/11 03/29/12 -291 04/01/2011: 0 07/01/2011: 0 10/01/2011: -291 01/01/2012: 0 Adjustment: 0 PA 995 Wells 190 03/29/11 03/29/12 13,435 04/01/2011: 0 07/01/2011: 0 10/01/2011: 0 01/01/2012: 13,435 Adjustment: 0 PA 995 Wenger 180 03/29/11 03/29/12 12,182 04/01/2011: 0 07/01/2011: 0 10/01/2011: 250 01/01/2012: 11,932 Adjustment: 0 PA 995 Wiser 160 03/29/11 03/29/12 18,988 Date Printed:5/13/2014 1:50:O1AM American International Group Page 7 of 10 EXHIBIT B Account Number: 051750614-000-R4 3/21/2013 003 Audit Period: 03/29/2011 03/29/2012 Policy Number: 051750614 Policy Period: 03/29/2011 03/29/2012 Insured Name: NEWBURG TRANSPORT LLC Audit Method: Physical 04/01/2011: 0 07/01/2011: 0 10/01/2011: 1,000 01/0112012: 17,988 Adjustment: 0 PA 995 Wynn 230 03/29/11 03/29/12 8,327 04/01/2011: 0 07/01/2011: 0 10/01/2011: 500 01/01/2012: 7,827 Adjustment: 0 Total Classified 318,712 Principals PA 953 Booz,Erick A 30 03/29/11 03/29/12 21,752 Duties: Office duties principally 04/01/2011: 0 07/01/2011: 0 10/01/2011: 14,752 01/01/2012: 7,000 Adjustment: 0 Total Principals 21,752 Class Codes State Class Code &U Balance Description Entity: 0001 Location: 0002 PA 953 10 Clerical Office Employees PA 995 0 WASTE REMOVAL-INDUSTRIAL AND/OR DOMESTIC PA BLNC 0 Balance BALANCE CLASS Records Requested/Audited Entity: 0001 Location: 0002 R A Description Entity: 0001 Location: 0002 R A Description R A ,Description ❑p Q Quarterly reports 11 11 Social Security (Fed 941's) 11 11 Sales Journal ❑ ❑ Sales Tax Reports ❑ ❑ Cash Disbursements ❑ 191 State Unemployment Reports ❑ ❑ Checkbook ❑ ❑ Individual Payroll Cards ❑ ❑ Job Costs Sheet ❑ ❑O Payroll Book(Listings) ❑ ❑ Receipts Journal ❑ ❑ General Ledger ❑ ❑ Summaries ❑ ❑ Certificates of Insurance ❑ ❑ Financial Statement Date Printed:5/13/2014 1:50:01AM American International Group Page 8 of 10 EXHIBIT B Account Number: 051750614-000-R4 3/21/2013 003 Audit Period: 03/29/2011 03/29/2012 Policy Number: 051750614 Policy Period: 03/29/2011 03/29/2012 Insured Name: NEWBURG TRANSPORT LLC Audit Method: Phvsical Status/Non-Productive Report Auditor Name: Jorma Lyn Isip Auditor Number: CAPXKLA Insured: NEWBURG TRANSPORT LLC Policy#• 051750614 Company: 0107 Audit Period: 03/29/2011-03/29/2012 Division/Region: 013 Policy Period: 03/29/2011-03/29/2012 Location of Audit: VisitDate: Estimate%: Contact Typt Contact Name Telephone# Ralk Contact Results Date Printed:5/13/2014 1:50:0IAM American International Group Page 9 of 10 EXHIBIT B Account Number: 051750614-000-R-4 3/21/2013 003 Audit Period: 03/29/2011 03/29/2012 Policy Number: 051750614 Policy Period: 03/29/2011 03/29/2012 Insured Name: NEWBURG TRANSPORT LLC Audit Method: Phvsical Date Printed:5/13/2014 1:50:O1AM American International Group Page 10 of 10 EXHIBIT B s Specialty Workers' Compensation 800 645 2259 Customer Service AIG Your Audit Advice To our Valued Policy Holder " Enclosed is the Audit Advice for your Workers' Compensation and Employer's Liability Insurance policy. The policy number and the Audit Period are shown in the upper right corner of the Audit Advice Summary. This Audit Advice results either from an audit that we recently performed on your payroll records, or if we were not able to perform such an Audit, from our estimate of your payrolls. The Audit Advice Summary Overview 1. This Summary shows how the Earned Premium amount is determined for the referenced policy based upon your payrolls ("Remuneration") and the Workers' Compensation rates and rating plans, by state and classification. 2. The "Audited Earned Premium Amount" is the total premium and surcharges that have been earned based on the audit performed. The "Prior Estimated Earned Amount" also shows the premium and surcharges that had been previously estimated. The difference between the two amounts is the "Total Audit Adjustment". The "Adjustment" may not be exactly the additional amount that you must pay us, or that we must return to you, unless you have actually paid us (net of any returns to you) exactly the"Prior Estimated Earned Amount". 3. This Audit Advice Summary is not an Invoice. We will send you a separate Invoice for any additional premium due to us, or return of premium due to you. 4. For WCPAYGO® customers, the invoiced amount will not be electronically withdrawn; you must remit a check for payment. For Assistance with Your Audit If you disagree with Audit Advice Summary or if you have any questions regarding the Summary, please contact the Premium Audit Department by one of the below methods: Telephone: 800-341-5541 Fax: 602-280-1918 Email: PAD-phoenixcs(aAIG.com Mail: AIG Insurance Premium Audit Division 2929 North Central Avenue, 9th Floor Phoenix,AZ 85012 To dispute an Audit you must provide a written description of the items with which you disagree and any supporting information available. AIG http://www.aig.com Page t of 2 swc01 o-v.12 Archive Copy EXHIBIT C EIG Your dispute will be reviewed promptly and we will either accept your dispute or we will present an explanation on why no revisions are necessary. If we accept your dispute we may have to audit your records again, and if changes are made, we will issue a revised Audit Advice and an Invoice. Estimated Audits - an estimated audit occurs when you have failed to allow an Audit of your payroll records. Please contact the Premium Audit Department (as shown above) immediately to schedule an audit. All audit disputes and requests for audits must be made prior to the due date of the Invoice to avoid any premium collection issues or possible cancellation of your current policy with us I All Invoice questions should be directed to SWC Customer Service at 800-645-2259. If you have any questions regarding why a premium audit is required for a workers' compensation policy or other question that our Premium Audit team was unable to answer, your broker is always your best source of advice. Sincerely, Your Specialty Workers'Compensation Underwriting Team I i I ! AIG http://www.aig.com I i j Page 2 of 2 SW C010-v.12 Archive Copy EXHIBIT C i i Page 1 of 2 I COMMERCE AND INDUSTRY INSURANCE COMPANY WORKERS' COMPENSATION INSURANCE AUDIT ADVICE 175 WATER STREET - EXECUTIVE OFFICES, NEW YORK, NY 10038 INSURED NEWBURG TRANSPORT LLC POLICY PERIOD 25 TURNPIKE ROAD FROM: 03/29/11 TO: 03/29/12 NEWBURG, PA 17240-0000 AUDIT PERIOD USA FROM: 03/29/11 TO: 03/29/12 PRODUCER PMC INSURANCE AGENCY, INC CANCELLED: PRO-RATAI I SHORT RATE 60 CABOT STREET PO BOX 920179 BUREAU ID: 3303496 NEEDHAM, MA 02492-0002 AUDIT TYPE: PHYSICAL FOR STATE OF: Pennsylvania ISSUE DATE: 05/02/13 DIVISION: BRANCH: POLICY NO: TYPE OF ADJUSTMENT: 013 PARSIPPANY WC 051-76-0814--------- FINAL REVISED 013-82-0311-00 DESCRIPTION CODE EXPOSURE RATE PREMIUM PERIOD: 03/29/11 - 03/29/12 1 RATING GROUP: 0001-01 LOC NO 0002 NEWBURG TRANSPORT LLC 565 TRESTLE PLACE DOWNINGTOWN, PA 19335-0000 I CLERICAL OFFICE EMPLOYEES 953 49,925 0.49 245 WASTE REMOVAL-INDUSTRIAL AND/OR 995 290,539 15.51 45,083 i DOMESTIC TOTAL CLASSIFICATION PREMIUM 45,308 TOTAL FOR SPLIT PERIOD: 03/29/11 - 03/29/12 j TOTAL CLASSIFICATION PREMIUM 45,308 I TOTAL UNMODIFIED PREMIUM 45,308 i MODIFIED STANDARD PREMIUM 45,308 I i i I I I I I THIS IS NOT A BILL ' WC990613 (Ed.4-97)(Rev'Arroive Copy EXHIBIT C Page 2 of 2 COMMERCE AND INDUSTRY INSURANCE COMPANY WORKERS' COMPENSATION INSURANCE AUDIT ADVICE 175 WATER STREET - EXECUTIVE OFFICES, NEW YORK, NY 10038 INSURED NEWBURG TRANSPORT LLC POLICY PERIOD 1 25 TURNPIKE ROAD FROM: 03/29/11 TO: 03/29/12 NEWBURG, PA 17240-0000 AUDIT PERIOD USA FROM: 03/29/11 TO: 03/29/12 PRODUCER PMC INSURANCE AGENCY, INC CANCELLED: PRO-RATA SHORT RATE 50 CABOT STREET PO BOX 920178 BUREAU ID: 3303488 NEEDHAM, MA 02492-0002 AUDIT TYPE: PHYSICAL FOR STATE OF: Pennsylvania ISSUE DATE: 05/02/13 DIVISION: BRANCH: POLICY NO: TYPE OF ADJUSTMENT: 013 PARSIPPANY WC 051-75-0614FINAL REVISED 013-82-0311-00 DESCRIPTION CODE EXPOSURE RATE PREMIUM TOTAL FOR STATE Pennsylvania MODIFIED STANDARD PREMIUM UNDISCOUNTED PREMIUM 45,308 PREMIUM DISCOUNT -9.70% 0063 45,308 DISCOUNTED PREMIUM -4,395 TERRORISM 3.00% 9740 40,913 CATASTROPHE (SEE WC 00 04 21C) 0.02 8741 1,359 TOTAL PREMIUM 88 EMPLOYER ASSESSMENT (NON-COAL) 2.07% 0938 42,340 STATE FINAL TOTAL 878 43,216 TOTAL PA REMUNERATION: 340,464 TOTAL PREMIUM FOR TERRORISM COVERAGE INCLUDED IN TOTAL ESTIMATED PREMIUM $1,359 i i i i I� . I I THIS IS NOT A BIL. I. i i j WC990613 (Ed.4-97)(Rev'drrolVe Copy EXHIBIT C Page 1 of 1 COMMERCE AND INDUSTRY INSURANCE COMPANY WORKERS' COMPENSATION INSURANCE 175 WATER STREET - EXECUTIVE OFFICES, NEW YORK, NY 10038 AUDIT ADVICE SUMMARY INSURED NEWBURG TRANSPORT LLC POLICY PERIOD 25 TURNPIKE ROAD NEWBURG, PA 17240-0000 FROM: 03/29/11 TO: 03/29/12 AUDIT PERIOD FROM: 03/29/11 TO: 03/29/12 PRODUCER PMC INSURANCE AGENCY, INC CANCELLED: [ j PRO-RATA 50 CABOT STREET [ SHORT RATE PO BOX 920179 NEEDHAM, MA 02492-0002 AUDIT TYPE: PHYSICAL ISSUE DATE: 05/02/13 DIVISION: BRANCH: POLICY NO: TYPE OF ADJUSTMENT: 013 PARSIPPANY WC 051-75-0814 FINAL REVISED 001 ------------------------- 013-82-0311-00 DESCRIPTION TAXsuRSSESSMs"TS/ PREMIUM THE PREVIOUS AUDIT DATED 06/22/12 HAS BEEN REVISED FOR THE FOLLOWING REASON(S) : THE EXPOSURES WERE UPDATED FROM ESTIMATED TO ACTUAL If you have questions about this Audit Advice Summary, please contact the Audit Department at (800) 341-5541. For billing inquiries, please contact Customer Service at (800) 645-2259. TOTAL POLICY REMUNERATION: 340,484 AUDIT EARNED PREMIUM AMOUNT 876 42,34 PRIOR ESTIMATED EARNED AMOUNT 287 13,852 TOTAL AP/RP AMOUNT 589 28,488 TOTAL AUDIT ADJUSTMENT 29,077 THIS IS NOT A BILL PRIOR ESTIMATED EARNED AMOUNT IS THE ORIGINAL POLICY PREMIUM AND ALL PREMIUM BEARING ENDORSEMENTS PLUS INTERIM AUDIT ADJUSTMENTS, IF APPLICABLE. THIS AUDIT ADJUSTMENT DOES NOT REFLECT THE ACTUAL PREMIUM DUE FROM OR TO THE INSURED UNLESS ALL AMOUNTS PREVIOUSLY BILLED HAVE BEEN PAID. WC990614 Archive Copy (Ed.4/97)(Rev'd 12/09) EXHIBIT C a s „ LALI GAIG .j Specialty Workers Compensation Group Invoice number: 400000146798 INVOICE For billing inquiries call:(800)645-2259 Email SWCLCD9aig.com Billing Date: 05/03/2013 POLICY: 51750614 Page 1 of 1 Billed to: 1026498671 Producer: P0075190 PMC INSURANCE AGENCY, INC NEWBURG TRANSPORT LLC PMC INSURANCE GROUP 25 TURNPIKE ROAD 50 CABOT STREET NEWBURG, PA 17240-0000 PO BOX 920179 NEEDHAM, MA 02492-0002 FINAL AUDIT PREM/UM BILLING. — 17- _ Pease contact your producer for any questions regarding your policy AMOUNT BILLED ON THIS INVOICE OUTSTANDING TOTAL PREVIOUSLY B9j,EDCURRENTLY 8lLt.ED PAYMENT FEE OUTS.TANDIMG + ITEMS POLICY RECEIVED CHARGE BALANCE* Due Date Amount Due'Date Amotxit AUDIT WC 51750614 0.00 0.00 29,077.00 0.00 + 06/02/2013 29,077.00 AMOUNT DUE** 0.00 29,077.00 Account summary through TOTAL POLICY PREMIUM 43,216.00 TOTAL PAYMENT RECEIVED TO DATE 9,651.00 TOTAL REFUNDS FEES BILLED TO DATE 130.00 TOTAL OUTSTANDING BALANCE* 29,077.00 FFadure edpytabove.he above rnghc resuk in cancellation of an workers' covering the insured y compensation policy chatrs currently in force Thank you for kisrring with A/G RETURN PAYMENT COUPON BELOW WITH YOUR PAYMENT **** DO NOT SEND A PHOTOCOPY 'INVOICE CUSTOMER ID AMOUNT DUE DETAIL ABOVE** AMOUNT ENCLOSED 400000146798 1026498671 29,077.00 POLICIES INVOICED - - - - - -- -- - - - -- — C 51750614 ❑ CHECK HERE IF YOUR ADDRESS HAS CHANGED AND COMPLETE FORM ON REVERSE SIDE ❑ CHECK HERE IF YOUR POLICY IS FINANCED Please make your check payable to AIG and include this Payment Coupon to ensure proper credit to your account. AIG BILLED TO: NEWBURG TRANSPORT LLC 22427 Network Place 25 TURNPIKE ROAD Chicago, IL 60673-1224 NEWBURG, PA 17240-0000 INSUREDS COPY 013 00000000400000146798 06022013 0 00000002907700 6 EXHIBIT D AIG AUDUBON INSURANCE COMPANY GRANITE STATE INSURANCE CO. CHARTIS SPECIALTY INS. CO. ILLINOIS NATIONAL INSURANCE CO. NEW HA N INDEMNITY COMPANY CHARTIS SELECT INSURANCE COMPANY INS CO OF THE STATE OF PENN NEW HAMPSHIRE INSURANCE CO. AMERICAN HOME INSURANCE CO. LEXINGTON INSURANCE COMPANY LANDMARK INSURANCE COMPANY CHARTIS PROPERTY CASUALTY CO. CHARTIS CASUALTY COMPANY NATIONAL UNION F.L. E LA CHARTIS COMMERCE& INDUSTRY INS CO. NATIONAL UNION FIRE INS. CO. AIG INSU EXCESS LIMITED URANCE COMPANY OF CANADA ADDITIONAL INFORMATION Please refer to the policy Extension form 7754 for each state for any state surcharges/assessments. EXPLANATION OF TERMS and CANCELLATION PROCEDURE If a Notice of Cancellation has been issued in connection with any policy identified in the Invoice, this Invoice does not rescind or supercede the Notice of Cancellation or reinstate the policy; nor is it an offer to do so. The "Currently Billed Due Date" is the date your payment is due in our office. Fees and charges, if applicable, will be assessed on the next bill date. See fees and charges section for detail. If you fail to pay the currently billed amount, or pay less than the currently billed amount, we may issue a legal cancellation notice due to nonpayment of premium. FULL PAYMENT PAYMENT OPTIONS Pay the premium in full, with no installment fee. SELECTED PAYMENT PLAN Pay the premium on the payment schedule shown below. WC Policy Period: 03/29/2011 to 03/29/2012 Full Pay Due Date: Due Amt: FEES DCHARGES, Fees and charges vary by state. Actual fees and charg s a especiifedon the reverse erse de of the invoice where applicable. Fees and charges applicable to your account may include the following: -An installment service fee of up to$10.00 may be charged for each installment billed. -A late fee of up to $25.00 may be charged if an invoiced amount is not received by the invoice due date. -An insufficient funds(NSF)fee of up to$30.00 may be charged for checks returned due to insufficient funds. -A reinstatement fee of up to$30.00 may be charged when we agree to reinstate the policy after it has been cancelled for non-payment of premium. GENERAL INFORMATION Please make your check payable to AIG. Include this Payment Coupon with your check to ensure proper credit to your account. Please notify us immediately of any changes of address. It will help us to serve you better, and may prevent a late payment fee or revocation of the installment payment privileges. For policy changes please contact your producer. Print change or address,fax,telephone and e-mail below. SEND PAYMENTS TO: AIG 22427 Network Place STREET ADDRESS Chicago, IL 60673-1224 CITY STATE ZIP SEND CORRESPONDENCE TO: BUSINESS PHONE NUMBER AIG Specialty Workers Compensation Group FAX NUMBER PO Box 409 Parsippany, NJ 07054-0409 E-MAIL ADDRESS EXHIBIT D Ronny R Anderson Sheriff Jody S Smith Chief Deputy Richard W Stewart Solicitor SHERIFF'S OFFICE OF CUMBERLAND COUNTY r -,LEO -Ir F ICE. THE P ROI HONE ?0R SEP -2 PM 3: 57 CUMBERLAND COUNTY PENNSYLVANIA Commerce and Industry Insurance Company vs. Newburg Transport LLC Case Number 2014-4696 SHERIFF'S RETURN OF SERVICE 08/12/2014 Sheriff Ronny R Anderson, being duly sworn according to law, states he made diligent search and inquiry for the within named Defendant to wit: Newburg Transport LLC, but was unable to locate the Defendant in his bailiwick. The Sheriff therefore returns the within requested Complaint & Notice as "Not Served" at 25 Turnpike Road, Hopewell Township, Newburg, PA 17240. Defendants are not located at this address they are now located at 10680 Cumberland Highway, Orrstown, which is in Franklin County. 08/12/2014 Sheriff Ronny R Anderson, being duly sworn according to law, states he made diligent search and inquiry for the within named Defendant to wit: Newburg Transport LLC, but was unable to locate the Defendant in the Sheriffs bailiwick. The Sheriff therefore deputizes the Sheriff of Franklin, Pennsylvania to serve the within Complaint & Notice according to law. 08/18/2014 01:08 PM - The requested Complaint & Notice served by the Sheriff of Franklin County upon Shannon Black, who accepted for Newburg Transport LLC, at 10680 Cumberland Highway, Orrstown, PA 17244. Dane Anthony, Sheriff, Return of Service attached to and made part of the within record. SHERIFF COST: $28.00 SO ANSWERS, August 25, 2014 RONfSS', R ANDERSON, SHERIFF tc) CountySuite Shanff, Teleoserf. Inc. 0 0 rn 0 a w 10680 CUMBERLAND HIGHWAY, ORRSTOWN, PA 17244 NEWBURG TRANSPORT LI Ronny R Anderson Sheriff Jody S Smith Chief Deputy SHERIFF'S OFFICE OF CUMBERLAND COUNTY ai�«Lp fI0 OF,F10E OF T:RE SRERIFF Richard W Stewart Solicitor Commerce and Industry Insurance Company vs. Newburg Transport LLC Case Number 2014-4696 SERVICE COVER SHEET Service Details. Category: Manner: Notes: Serve To: Name: Primary Address: Phone: Alternate Address: Phone: Civil Action - Complaint & Notice Deputize Expires: 09/05/2014 Zone: Warrant: Newburg Transport LLC 10680 Cumberland Highway Orrstown, PA 17244 DOB: F..inahService: Served: Adult In Charge: Relation: Date: Deputy: Personally • Adult In Charge • Posted Other M/N040 SLA -CX, piib� Time: Mileage: 130e Name: Barbara S. Zicherman [ Service Attem Date: Time: Mileage: Deputy: Phone: 610-797-9000 is `i d ` pr �"` µ 'c .. �w M1fi -'., .. eY. "'SZ�� A - l'S �� 'n:.'<�"yj�A � .��i�d..:, S 1 't?^`' w. 11) E E0WE' AUG 2014 .13 Notes / Special=lnstruction Now, August 12, 2014 I, Sheriff of Cumberland County, Pennsylvania do hereby deputize the Sheriff of Franklin County to execute service of the documents herewith and make return thereof according to law. Return To: Cumberland County Sheriffs Office One Courthouse Square Carlisle, PA 17013 c) Couni;Snne Shrift. Teleosoft. Inc. Ronny R Anderson, Sheriff SHERIFF'S RETURN - REGULAR CASE NO: 2014-00293 T COMMONWEALTH OF PENNSYLVANIA: COUNTY OF FRANKLIN COMMERCE AND INDUSTRY INSURANC VS NEWBURG TRANSPORT LLC BRIAN J CRAMER County, Pennsylvania, , Deputy Sheriff of FRANKLIN who being duly sworn according to law, says, the within COMPLAINT NEWBURG TRANSPORT LLC was served upon the DEFENDANT , at 1308:00 Hour, on the 18th day of August , 2014 at 10680 CUMBERLAND HIGHWAY ORRSTOWN, PA 17244 by handing to SHANNON BLACK PRESIDENT a true and attested copy of COMPLAINT together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge .00 .00 .00 .00 .00 .00 Sworn and Subscribed to before me this ///4 ---day of aoPA A.D. A -01-4A;'-- Notary 7 So Answers: BRIAN J CRAMER By e Deputy eriff 08/19/2014 BARBARA S ZICHERMAN ESQ COMMONWEALTH. OF PENNSYLVANIA RICHARDNOT' • AL SEAL O. *CARTY, Notary Public Chambersburg Boro. My Commission Franklin Spires Jan. 29,, 20 2015 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION - LAW COMMERCE AND INDUSTRY INSURANCE COMPANY, Plaintiff, V. NEWBURG TRANSPORT LLC Defendant. No. 14-4696 Civil Term C) - cp ' rn CD PRAECIPE FOR DEFAULT JUDGMENT PURSUANT TO Pa.R.C.P. 1037(B)-:1 TO THE PROTHONOTARY: • • Please enter Judgment by Default in favor of Plaintiff and against Defendant for failing to file an answer or otherwise plead to the Complaint. The amount of the judgment is as follows: $29,077.00 Amount requested in Complaint 28.00 Sheriff fees 16.50 Additional Court fees $29,121.50 Kindly enter judgment in the amount of $29,121.50. (X) () Pursuant to PaRCP 237.1, I hereby certify that notice to file this praecipe was mailed to the above-named Defendant on September 22, 2014 and copy of the 10 Day Notice, Certificate of Mailing and correspondence relating to same is attached hereto as Exhibit "A". Pursuant to PaRCP 237 (notice of praecipe for final judgment or decree), I hereby certify that a copy of this praecipe has been mailed to each other party who has appeared in the action or to his Attorney of Record. Center Valley, Pennsylvania: October 3, 2014 Signature of Filing Party Barbara S. Zicherman I. D. No. 207348 4001 Schoolhouse Lane, P. 0. Box 219 Center Valley, PA 18034-0219 (610) 797-9000 Attorney for Plaintiff r jvcv g.sopgm bot 77 -vi Pit 319a-Pf iNje Edward J. Lentz Joseph A Fitzpatrick. Jr. Joseph A Bubba Timothy D. Charlesworth Douglas J. Smillie' Emil W. Kantra II Joseph S. D'Amico, Jr.* Michael R Nesfeder Catherine E N. Durso Jane P Long Erich J. Schock James A. Bartholomew Jacob M. Sitman* Edward Hoffman, Jr.* Steven T. Boell Joshua A Gldea Marie K. McConnell* Barbara S. Zichermant Anthony S. Rachuba IV* Maraleen D. Shields* Thomas J. Schlegel* Colin J. Keefet Gretchen L Geisser• Mallory J. Sweeney' tAlso admitted in NewYarc *Also admitted in New Joie/ FITZPATRICK LENTZ &BUBBA ATTORNEYS AT LAW FITZPATRICK LENTZ & BUBBA, P.C. • 4001 SCHOOLHOUSE LANE • PO BOX 219 • CENTERVALLEY, PA 18034-0219 STABLER CORPORATE CENTER • PHONE: 610.797.9000 • FAX: 610.797.6663 • www.fkblaw.com bzicherman@flblaw.com September 22, 2014 Newburg Transport LLC 10680 Cumberland Highway O rstown, PA 17244 RE: Commerce & Industry Insurance Company v. Newburg Transport LLC Cumberland County C.C.P. Docket No. 14-4696 Civil Term Dear Sir or Madam: Enclosed is a Notice of Intent to Enter Default Judgment against you in the above - captioned matter, Please read the Notice and give it your immediate attention. BSZ/cjc Enclosure Very truly yours, cc,%t/ti./k\> Barbara S. Zicherman cl aUNITED STATES POSTAL SERVICE• Certificate Of Ma C") This Certificate 61 Maainy provides evidence that mail has been passer -dad St91d`s ThIs loan may be used for domestic end International mai. From: .ie . „ick ntz & Bu as P.C. d3S6 To: P. O. Box 219 Center Valley, PA 180 Newburg Trans • ort LLC 10680 Cumberland Highway 4311410 r) . 03 0) 3: a Orrstown, PA 17244 PS Form 3817, Apr112007 PSN 7530-02.000.9065 EXHIBIT A to 0 I0 t 9" 4 P4 James G Kellar 1927-2002 John R Mondschein Special Counsel Family and Matrimonial Law Douglas Panzer° OfCousel Mteiectiel Properly Law Albertina 13 Lombardi* Kathleen M. Mils Of Counsel IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION - LAW COMMERCE AND INDUSTRY INSURANCE COMPANY, Plaintiff, v. NEWBURG TRANSPORT LLC Defendant. To: Newburg Transport LLC 10680 Cumberland Highway Orrstown, PA 17244 Date: September 22, 2014 No. 14-4696 Civil Term IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOCIATION 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 1-800-990-9108 717-249-3166 FITZPATRICK LENTZ & BUBBA, P.C. By: a%(114, Barbara S. Ziherman I.D. No. 207348 4001 Schoolhouse Lane, P.O. Box 219 Center Valley, PA 18034-0219 (610) 797-9000 Attorney for Plaintiff EXHIBIT A IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION - LAW COMMERCE AND INDUSTRY INSURANCE COMPANY, Plaintiff, v. NEWBURG TRANSPORT LLC Defendant. TO: Newburg Transport LLC 10680 Cumberland Highway Orrstown, PA 17244 No. 14-4696 Civil Term (X) Notice is given that judgment in the above -captioned Tatter has been entered against you in the amount of $29,121.50 on lol $11 . Notice is given that a judgment by confession in the above -captioned matter has been entered against you in the amount of $ on () (X) A copy of all documents filed with the Prothonotary - Civil Division in support of the within judgment is/are enclosed. Prothonotary/Clerk BY: If you have any questions regarding this Notice, please contact the filing party: NAME: Barbara S. Zicherman ADDRESS: Fitzpatrick Lentz & Bubba, P.C. 4001 Schoolhouse Lane P.O. Box 219 Center Valley, PA 18034-0219 TELEPHONE NO. (610) 797-9000 (This Notice is given in accordance with Pa.R.C.P. 236.) IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION PRAECIPE FOR WRIT OF EXECUTION Commerce & Industry Insurance Comp Confessed Judgment Plaintiff Other VS. File No. 14-4696 Civil Term Newburg Transport LLC Amount Due $29,121.50 Defendant Interest Address: 10680 Cumberland Highway Orrstown, PA 17244 Atty's Comm Costs TO THE PROTHONOTARY OF THE SAID COURT: The undersigned hereby certifies that the below does not arise out of a retail installment sale, contract, or account based on a confession of judgment, but if it does, it is based on the appropriate original proceeding filed pursuant to act 7 of 1966 as amended; and for real property pursuant to Act 6 of 1974 as amended. Issue writ of execution in the above matter to the Sheriff of County, for debt, interest and costs, upon the following described property of the defendant (s) PRAECIPE FOR ATTACHMENT EXECUTION Issue writ of attachment to the Sheriff of Cumberland County, for debt, interest and costs, as above, directing attachment against the above-named garnishee(s) for the following property (if real estate, supply six copies of the description; supply four copies of lengthy personalty list) Any and all bank accounts at Members 1st Federal Credit Union including but not limited to acct. #7774104819 ICAin Simly pehl j ..4-5 Pn-t74S7 and all other property of the defendant(s) in the possession, custody or control of the said garnishee(s). 0 (Indicate) Index this writ against the garnishee (s) as a lis pendens against real estate of the defendant(s) described in the attached exhibit. Date 10/16/14 Signature: r,,,,,,L4e9ficbpti eAsF s.1(` " Lo so, 11 Print Name: Address: Attorney for: Telephone: Barbara S. Zicherman P. 0. Box 219 Center Valley, PA 18034 Plaintiff 610-797-9000 SupremeiZ ID No: 207348 Dj1---ORPc 2 a y(st (JU 1/eI 66 THE COURT OF COMMON PLEAS CUMBERLAND COUNTY PA DAVID D. BUELL, PROTHONOTARY One Courthouse Square • Suite100 • Carlisle, PA • 17013 (717) 240-6195 www.cepa.net COMMERCE & INDUSTRY INSURANCE COMPANY Vs. NO 14-4696 Civil Term CIVIL ACTION — LAW NEWBURG TRANSPORT, LLC WRIT OF EXECUTION (Pa R.C.P. 3252) TO THE SHERIFF OF CUMBERLAND COUNTY: To satisfy the judgment, interest and costs against NEWBURG TRANSPORT, LLC, 10680 CUMBERLAND HIGHWAY, ORRSTOWN, PA 17244 Defendant (s) (1) you are directed to levy upon the property of the defendant (s) and to sell the defendant (s) interest therein; (2) you are also directed to attach the property of the defendant (s) not levied upon in the possession of MEMBERS 1ST FEDERAL CREDIT UNIONGARNISHEE(S), as garnishee, 401 EAST KING STREET, SHIPPENSBURG, PA 17257 (Specifically describe property) and to notify the garnishee that ANY AND ALL BANK ACCOUNTS AT MEMBERS 1sT FCU INCLUDING BUT NOT LIMITED TO ACCT. #7774104819 AND ALL OTHER PROPERTY OF THE DEFENDANT(S) IN THE POSSESSION, CUSTODY OR CONTROL OF SAID GARNISHEE(S). (a) an attachment has been issued; (b) except as provided in paragraph (c), the garnishee is enjoined from paying any debt to or for the account of the defendant (s) and from delivering any property of the, defendant (s) or otherwise disposing thereof; (c) the attachment shall not include (i) the first $10,000 of each account of the defendant (s) with a bank or other financial institution containing any funds which are deposited electronically on a recurring basis and are identified as being funds that upon deposit are exempt from execution, levy or attachment under Pennsylvania or federal law. ) each account of the defendant (s) with a bank or other financial institution in which funds on deposit exceed $10,000.00 at any time if all funds are deposited electronically on a recurring basis and are identified as being funds that upon deposit are exempt from execution, levy or attachment under Pennsylvania or federal law. (iii) any funds in an account of the defendant (s) with a bank or other financial institution that total $300 or less. If multiple accounts are attached, a total of $300 in all accounts shall not be subject to levy and attachment as determined by the executing officer. The funds shall be set aside pursuant to the defendant (s) general exemption provided in 42 Pa.C.S. § 8123. (3) if property of the defendant (s) not levied upon and subject to attachment is found in the possession of anyone other than a named garnishee, you are directed to notify such other person that he or she has been added as a garnishee and is enjoined as above stated. Amount Due $29,121.50 Interest Attorney's Comm. % Attorney Paid $189.25 Date: 10/20/14 (Seal) Plaintiff Paid Law Library $.50 Due Prothonotary $2.25 Other Costs David D. Buell, Prothonotary REQUESTING PARTY: Name : BARBARA S. ZICHERMAN, ESQUIRE Address: FITZPATRICK, LENTZ & BUBBA, P.C. P.O. BOX 219 CENTER VALLEY, PA 18034 Attorney for: PLAINTIFF Telephone: 610-797-9000 Supreme Court ID No. 207348 MAJOR EXEMPTIONS UNDER PENNSYLVANIA AND FEDERAL LAW 1. $300 statutory exemption 2. Bibles, school books, sewing machines, uniforms and equipment 3. Most wages and unemployment compensation 4. Social Security benefits 5. Certain retirement funds and accounts 6. Certain veteran and armed forces benefits 7. Certain insurance proceeds 8. Such other exemptions as may be provided by law 2 Ronny R Anderson Sheriff Jody S Smith Chief Deputy Richard W Stewart Solicitor SHERIFF'S OFFICE OF CUMBERLAND COUNTY u -OFF T Ht_ PRO -ft -IONS -TAW( 2011 OCT 24 M 9: 52 nFFICL FTHE .ERIFF CuMBERLAND COUNTY, • PENNSYLVANIA Commerce and Industry Insurance Company vs. Case Number Newburg Transport LLC 2014-4696 SHERIFF'S RETURN OF SERVICE 10/22/2014 11:05 AM - William Cline, Deputy, who being duly sworn according to law, attached as herein commanded all goods, chattels, rights, debts, credits, and monies of the Defendant, in the hands, possession, or control of the within named garnishee, Members 1st Federal Credit Union, 1166 Walnut Bottom Road, South Middleton Township, Carlisle, PA 17015, Cumberland County, by handing to Paula Breitenbach, Member Service, personally three copies of interrogatories together with three true and attested copies of the Writ of Execution and made the contents there of known to her. The writ of execution and notice to defendant was mailed on October 23, 2014 to ewbu;: Transport, Inc. at 10680 Cumberland Highway, Orrstown, PA 17244. W"LIA CLINE, DEPUTY SO ANSWERS, October 23, 2014 RONNY R ANDERSON, SHERIFF (c) CountySu o Sheriff, Teleosoff. enc Ronny R Anderson Sheriff Jody S Smith Chief Deputy Richard W Stewart Solicitor 'c nGGir� n� r1 ilnnD�DI A Mfl ('ni IMTV C7 ris Commerce and Industry Insurance Company vs. Newburg Transport LLC Case Number 2014-4696 SHERIFF'S RETURN OF SERVICE 10/22/2014 11:05 AM - William Cline, Deputy, who being duly sworn according to law, attached as herein commanded all goods, chattels, rights, debts, credits, and monies of the Defendant, in the hands, possession, or control of the within named garnishee, Members 1st Federal Credit Union, 1166 Walnut Bottom Road, South Middleton Township, Carlisle, PA 17015, Cumberland County, by handing to Paula Breitenbach, Member Service, personally three copies of interrogatories together with three true and attested copies of the Writ of Execution and made the contents there of known to her. The writ of execution and notice to defendant was mailed on October 23, 2014 to Newburg Transport, Inc. at 10680 Cumberland Highway, Orrstown, PA 17244. 10/29/2014 Ronny R. Anderson, Sheriff, who being duly sworn according to law, states this writ is returned STAYED at request of plaintiffs attorney. SHERIFF COST: $89.76 SO ANSWERS, October 29, 2014 RONNY R ANDERSON, SHERIFF (c) CountySuito Sheriff, Teleosoft, Inc. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION - LAW COMMERCE AND INDUSTRY INSURANCE COMPANY, Plaintiff, v. NEWBURG TRANSPORT LLC, Defendant, v. MEMBERS 1ST FEDERAL CREDIT UNION, Garnishee. No. 14-4696 Civil Term PRAECIPE TO DISSOLVE WRIT OF EXECUTION AS TO GARNISHEE, MEMBERS 1ST FEDERAL CREDIT UNION TO THE PROTHONOTARY: Kindly dissolve Plaintiff's Writ of Execution Attachment as to Garnishee, Members 1st Federal Credit Union, in the above captioned matter. FITZPATRICK LENTZ & BUBBA, P.C. Dated: October 29, 2014 BY: ' CUA/t3 Barbara S. Zicherman" I.D. No. 207348 4001 Schoolhouse Lane P.O. Box 219 Center Valley, PA 18034-0219 Attorney for Plaintiff attOrq *a/Ad- et,v --72/ Tit ?i'/9ef