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Home My WebLink About06-2444 THIS IS AN ARBITRA rrON CASE MSEl'S'\ENT OF DAMAGES H~ I$NOTREQUIRED / JAMES W. ADELMAN, ESQUIRE Mail@morrisadelman.com IDENTIFICATION #02604 MORRIS & ADELMAN, P.C. PO BOX 30477 Philadelphia, Pennsylvania (215) 568-5621 ATTORNEY FOR PLAINTIFF Erie Insurance Company 19103-8477 Erie Insurance Company 100 Erie Insurance Place Erie PA 16530 COURT OF COMMON PLEAS CUMBERLAND COUNTY CIVIL DIVISION vs. Bo02 Milk Transport Inc. 199 Bo02 Road Shippensburg PA 17257-9726 . : NO. Ot.,. - ;;2'ft.;l/ COMPLAINT '/ CIVIL ACTION NOTICE TO DEFEND c;ulL~~Y>[ 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 claim 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. LAWYER REFERENCE SERVICE Cumberland County Bar Association 2 Liberty Av Carlisle PA 17013 717/249-3166 JWA0425.2 1. Plaintiff is Erie Insurance Company, an insurance company duly authorized to issue insurance policies in the Commonwealth of Pennsylvania. 2. Defendant is Booz Milk Transport Inc. COUNT I 3. At the request of Defendant or Defendant's authorized agent, Plaintiff issued a Worker's Compensation and Employer's Liability policy naming Defendant as the insured. A true and correct copy of the application for insurance is attached hereto as Exhibit "A," A true and correct copy of the policy is attached hereto as Exhibit "B." 4. The total annual estimated earned premium for the insurance year set out in the policy was $17,185.00. In accordance with the rules, rates and classifications of the Pennsylvania Worker's Compensation Bureau (PWCB) and the premium endorsement, the estimated premium is subject to increase or decrease in accordance with the actual payroll figures established by the insured but not available at time of policy issuance. 5. Plaintiff was permitted to audit the true and correct books and records of the Defendant. -1- JWA0425.2 6. As a result of Plaintiff's audit of Defendant's payroll, an adjusted premium of $11,527.00 became due and owing Plaintiff by Defendant for insurance year as set forth on the final earned premium adjustment endorsement, a true and correct copy of which is attached hereto, incorporated herein and marked Exhibit "CU. 7. All credits to which Defendant is entitled are set forth on the statement of account, a true and correct copy of which is attached hereto, incorporated herein and marked Exhibit "D". 8. By virtue of the foregoing, Defendant is indebted to Plaintiff in the amount of $11,527.00 for an additional premium. 9. Although Plaintiff has made demand upon Defendant for $11,527.00, Defendant has failed and refuses to pay the same or any part thereof. WHEREFORE, Plaintiff claims there is now justly due and owing by Defendant(s) the sum of $11,527.00 with interest at 6% from April 23, 2004 and costs on Count I. COUNT II 10. Paragraphs 1 through 9 are incorporated by reference. -2- JWA0425.2 11. On or before April 23, 2004, Plaintiff provided insurance services to Defendant at the times, of the kinds, in the quantities, and for the premiums set forth in Plaintiff's books of original entry, true and correct copies of which are shown as Exhibits "A", "B" and "C". 12. Defendant received and accepted the insurance services shown on Exhibits "A", "B" and "CO, and benefitted thereby. 13. Defendant received the benefit of the insurance services from Plaintiff and it is unconscionable for Defendant to receive those benefits without making restitution to Plaintiff. 14. It can be inferred from the acts in the light of the surrounding circumstances that Defendant implied it would pay Plaintiff for the insurance services. 15. Under the circumstances of the case, the ordinary course of dealing and the common understanding of mean, there is shown a mutual intention by Plaintiff and Defendant to sell and pay for these insurance services. -3- JWA0425.2 16. All conditions precedent to the present action have occurred or been performed. 17. Defendant is liable to the Plaintiff in the sum of $11,527.00 under the theory of quantum valebant, quantum meruit, quasi contract, implied contract, insurance had and received, and/or unjust enrichment. WHEREFORE, Plaintiff claims there is now justly due and owing by Defendant(s) the sum of $11,527.00 with interest at 6% from April 23, 2004 and costs on Count II. ES W. ADELMAN, ESQUIRE A torneys For Plaintiff Post Office Box 30477 Philadelphia, PA 19103-8477 (215) 568-5621 -4- JWA0425.2 NO'I-7-2005 02: l1P FRDM: v UCI-25-20US 17: 14 10:18148702250 po"" P.'04 i I ~ \ . Carol S. Weirich Vice President & Manager , states that he/she is of Erie Insurance Company I i and that the facts set forth in.~f~oing ~ . ~ are true and correct to the best of his! her personal knowledge or infonnatio and belief, and that this stateIV"'ot is made Agent & Policyholder Services ;~ Ii. '\~ ','~'" ....:~#i ,~~tJli ....... ...; subject to the penalties of 18 Pa. C SA 4904 relating to WlSWOm: fa!"ification to authoritiel>. Dated: UI"'/Y;Jdrz?! I OCT-25-2005 TUE 06:03PM ID: ;"-,' jJ;:J&~ ...~ PAGE: 4 SIGNATURE APPLICATION AS PER CINDY RESnOl/SKI ,...IbIs__brlll._UIlll1 0.... 0 N. n"v..,".llachcopyol_Shool. Q88 7300009 32 WORKERS COMP AND EMPlOYERS UABILITY APP o REWRITE-PRIOR POLICY NO, The Applicant appUes for Insurance and represents the following to be true. 1.AGElfrSNO. Produl::e E , ERIE INSURANCE GROUP 100 Erie Insurance Place Erie, PA 16530 PLEAse 00 NOT WRITE OR STAPLE IN THIS SPACE - FOR HOME OFFICE USE ONLY - ~ F APf'UCANT'SPtlONEHo. AA7401 CAlL L CRAIlER INSURANCE LLC 2. POUCY EFF!CTM 0.... 0'" FROM 10 ) 1lImERW, CODE APPl.ICNIT'S FED. 10 N\NIBER 25-1867316 soaAL SECURl1Y No.(5) STAlE COUI/TV ZI' 0,""'.0,"" 0",", OJoIntV, DLLCo. 'Tof8I_Ho:~::' ""_.0. ;"-" ~ S. IJESCRlBEAPPI.JCMrSIlPERA1lONS_______.w____....____________.__._______.......__.____.....___.._...__.._..._..._._........_......, toCIt .__....____..__M.____..._.___........__.____.._..__..._....__._____...._.._..__.".........__.._._...__.__.__.____ .. LOCAtIINS Iif OR FROMwtIat OPEMJIONS CIWERED BYTIIS POUCV' ARE CONDUCTED (GIVE SPfCIfIC DIREC11OHS--DO NlJTlJS( 1m OR PO BOX NlIMBfRS) ------.---.----...-------....---.--.--------..-...-.---.---...-...-----..--.-____.___.__.____'H._.MMH_.._M_M_. -_.__.__HM____.__.M.__..M___.__.___.__._.__M_._____M_H--..-.-_____.M_______M_.__M_____.._._.._.M.__.._._._..._.___ .M_H____.MH_...____.__HM________.___.....M__..M._____..__.._______M..__.MH..._._M_...___...__.__._.._._.__..____._.____ PARr DHE OFtlE P01JCY APPUES 10 1HE WDRIlERS CDMPENSRION LAW OF EACH OF THE RUOWING STATES: 0.. 0"" OVA 000 Oil 0111 ONe 0 PARrTWO OF THE POLICY APPUES lOWORIC IN EACH STA1i USTED IN 7A. lHEUMRSDFlIUIUTY {BOOO.YWJlIIYBYACaDENTS100.000EACHACCIBT} lJIIlESSornONAl. UNDER PNlTTWO ARE: BODU ILAIRY' BY DISEASE S5DO,IXlO POUCr LNT UMITS ARE SHOWN IIOOI.Y DUIJRY BY OISEASI: $too.a EM2I EIIPlDtEE EllP.1K.nllSQ OP1lONAl LIMnS '-__,___ ,QOD......ACCIIlENT $ 'M_'M_'" .000 PDUCr UM1T $ M'_.___. .000 EACH EMPl.O'1tE PMTlIRE OFTHEfIOUC'( APPlJES 10 &TATES.IFIINY.USTm KERE: AU. STATES EXCEPT IN, NO. OK, WA, ~ wr. STATES DESIGNMED UIIlER 7AABOYE ._H_.M__.___.M.._M__.____.._._M__.___M.._M_.__.__M__.__..____M ____.___MM__._ ...__.:...~. ---.-.--.__.._.__..__M......_.__..__.M_.__.._._____M__....__ _.__.___.M__.____.. M_._._.__...._.... _.'_M_. ...M___M_.______H .M-____.__.__._.______M__..M..___.....____.M__.___M.._M___ ...______._ __....__ M...____.__._._...._._ ..._._.__ _....._M_._..__M.... --.--.---.-___H..._.__..________.__..._..____M___...._. '__'__"H__" .'M_.__. __....___._.._..... '''M'~'-_' .H._.._........M._.._. H---...--.---._____..______._.____HM___.._.____M._... _____.. _..._._ ._____HM__._.M.__ ..____...__ _'M_._.._._..__. EllPEIIIENCE_1 .-----.-....---...-.-.--.-.-.--.____.__MH..______....M_..M_.._ _M____. ._._._ __._..___.______.. ...______ '_'__'M'''__.___ DEIllIClIIIE 0 YES 0 110 $ AMDIIfT llF DEDucnBlE PIlEIIIlIII DISCOIIfT ( ----.--.-..--...-.----....--___.___...._.__..M.______M__.___ ____..._ .._....M.__. _.___.....___......_. __.__. ...._...___.M...___.. CASH TIJW. EmMATED PREMIUM S '~_"__"_H_"_ PAYMENT I IIAWICE S __._.._____._ I. FORMS.._.______.__..___..M___._._ ,i~:'~;'~~W -- OEPOSIT PftEMRlM _Plan ABC D MllnthIy o DO 0 0 ACCr.BI1. ~i1~.e:l~~.~~~~ _._..___.____M_.__......_M...__.__.._.__.._ SUPPORllNGlIABlJI'Y _.._.__.._._.M__M_____._.._.____......__.._._ $ $ UF-1S1S 4199 ACCEI'IBl BIlE BY ...----.,_.._ __..RATED BY --.__,____.IlBl. _._._. CHECKED BY -___....._,____Ilato._..__ I PLAINTIFF'S EXHIBIT f, 10. HOW LONG HAS APPUCANT OPERATlDlHIS BUSINESS? ._...___._...._._~~..._.___._.lF lESSTHAN ONE YEAR DESCRIBE ANi PREVIOUS EXPERIENCE ..-....-.-.--....--.......:. ____._.~__.____..__..M.___.M._...._..._____._..____..._.__M'M' -_._----_._--~_..-_._.......__._------_._---_........._.._-_...-. G;~. ,';~~it!_ ; ~;.,;.;." .DATE,DF,_';~ 'MAN BIi'UIYEE'::,~ DESCfIBE PREVIOUS JOs EXfERENCE , (l.El<1mI OFllME,DllIlES,rn:.} ,-- -..---.-----------------..---.-.-..-..... ---.-----........-.--.---....---.-----..--..--.-.....-- _......__._....__._._.......___....._..M.._..._._.._..~...___ -~-------_..._---_.__.._--_..- --..-..---...----------..----..----..- ---..----------..-..-......----- -....-------..---.------- ---....--..----.--.----..--------... --_.--_.._~_.._--_..__._----_..__..- .~~~=~~_~t~e~~~,;..aJiIs1iWnOti+... . 12. DESClIBE EMPlIJYEE11WNING PROGRAM _..__......._..... .._-_._-_....------_....~....~..-._------_...__.._-_.__._-_......- --.--------.----.---...----- ----..-..--..---.--..-...-------------..- _...___.______.._____.________..__._~_M__.___...._____~.._.. ...___..__.__...__~____._..__._.__..______..___________._..__._.._.._____..~...M_..__...___... --.----..--.-.--.-..--..-----.-------..---.--....--.-.-..-.----------..-.-..--------.. -----------------..---..------..---...--.----.- ... usr CllIlPDIUUE 0fRCEIIS ~~~~f~I~~~~~~g~,,:~ -, .:~~~~~1ll~r~ ~~:l~~l~~~t[f;~L~{~l[!!~~'::,r~~~ :~~~~~:;;~r DYES Ow DYES 0110 0... 0"" .---- ---_._--_._-_..~_..- -------- ,Q.!!L_,o ~. 0... \If 0FACEIlS ARE to BE EXa.1JIlED (MD, FA DR VAl, PlEASE 1lrTAI:H IIEJECllON IETTBI, CAIlO OR SIGNED AFR1lAVlI) 0110 UF-15184J99 2 . ""..IF COVERAGE IS DESIRED FOR SOLE PROPRIETORS OR PARTNERs, COMPlETE THE FOlLOWINIi.GIVE DETAILS FOR ANY "YES" ANSWERS BElOW. DOES Nat APPlY IN INDIANA-l'lEASE COMPB.lf WC8025A. -JlIllllll'ES llASAPI'llCNlI'.... _DISMIlSlAS - ~THUESUliofM ....~ lSN'I'UCNll PIlESENIIY &aIIG 1R&tf!DfoR Nfl 'lIl.IIlm"_ ....APl'UCANTEVEIl IWlANYIftAIJIl DR _........ce CANCEUElI OR DEQ.JNED? $ DYES DNO M_"_~~___h,,,_~___"__'_'___H""H"'''_'''___'''_"''''____'..'___M'" ..----...._..._......._ DYES ON(} DYES Ow DYES DNO DYES DYES DICl DND ...____.___......__._._.._._...._..___. M_""_'___'_"" _........._..._.____.......___.___...._........_._......' --.......-.-.-... ............-..------...." ....-.--......-...- DYES DND DYES DYES DNO DNO -.-...--..-.....---.---...----....... .-...--......--.--... .......----.......-..----....---..--.........-..-..... .........-.--.--..-.--. -..---.-.....----. -........--....--.....-... DYES 0.. DYES Ow DNG DYES EXPI.AIN Rrf "YES- ANSWERS HEN: ___.....__._ --...---.-.-....--.-.-..--..---...-----...--..................--....-.-.-...............-..---.. --_...---_.._-_.._......_----_..._.._--~--~.-..~----~._----_..-.-..---..--.-...--..-----------......~--..-~...--..-....--.-..-....- ----.-..-.---.-----..---.----...-..-.--..--.---..-.......--.-..-~_..__..._--_.._-_.._..__.._.._.._-.........-_..._--_....-. 15. PlfASEANSWER AU. QUESIIOft$. GIVE DETAILS FDRAIt/ "YES" ANSWERS BaDW. ... III ... .. (&) My~und<<'8or_lIllI65? (h) In.......,...~.._mebl...""'_,c1I1:mlceJs,....? (e) Inemplopes........,..IIII__ (II) In empIoJea 8lqIllI8lI......-.._7 (.) Do em........... or... eny _or WIIIen:raIl'I 111 In empIajees' JoIls l_geable7 (g) My_perlDImed...baJvos._or_ (h) In empI_ 8lqIllI8lIl81derlho I/.S, LllngsllOl8m8ll's end _ _Aclorllle FedBr81 E1nplojell' U1b111lYAcl? ~ Ars lI1eI8 pert"'"'- or -' 8IIIpkl!8Bl ID My___UlIlI~or_'51eet? '~:-. lI<l ~.I1lrm8I..feIy_lnllp8lltJon'/ 1II1sIhoreenywl_or_lebor? (m) Ars_eny__far_lceppOdpersannel'ln ''Y....lndlcale__.t__lC8IIeml__pl1M\I8lL (II) Doemp"""'".....outofstele? {oj Do ""'... ooat- employment physicalS In a particular 11iI_ n..,..,"llstlhocl_catkIn8. lIl)In_amp/oy8ll? q)lnCarlltlc8l88ofl_requlrad? (~ 1s.__In.1lac:t? IS) In empI..... peJd... piece workllasls7 10 Nos. physicians penel been__ ~:::j" _~~:".,~~~~:,,';::ii~~~~~~iti~~~.~t~~:!:,!~J,~'~f~[1.:r(i~~~~~~;~;::::i~:'~;(f~.:~:J~~:'~l'~i-,:~':r::{; EXPlAIN AItt"YB-ANSWER$HEIE______...___..__.______________________.__.._..___...-"-'---' -..----..-.-.--.-----...--..-----.-.-------------..-..----------........-.....-...---.-----.-..--. .._-------~-_...._--_...__..__....._.._-_.._--_.._-_...__......_._-.-..-..--....--- -..-----....--.-------.......---.---...-...------...-..--..-..----,,,-"-"--'-----""''''--'''-'''-'''-''-'''''-'''- -_._~.__._-_.._--_.._._---_._--_....__.__...._-_._._.._---_..-----..-----.--....---.....-..-....--....---.-.--. .-.-.-----.-.-.----.-....-....---..---...------....------------...__.._......__...._.-~.._.._--_.__....-._. ._.._.-.....__._-_..-~-._------------_._----_.._--_.-..__.._--.-..---..----....----..-.-.--....-..-.. --.---...---.---...--.-----.-----..-..--.---..-------.......--.-- ----.------.--..-.--.-----------..-.---..----....-..--.---.-.--..-.-.......-...---.-..-.--....--...-. ~~:;~i;:~~~,~~t~~i.~f :~!~f~~;j~5~E.~f:..~~~;;:~:~~~~~~!~:~.ij,;;,ii:i,:~~ .I,;"" -,:~~L."~__. __1[~'<', ::~Dm.t/,: ---- -..-.-.-.---.- -...----.-...----. -..-...---.--.--..--...---...--........-.-...-..---.. .....--....-.---.. .-..---....... ---..-----.-- .-------.- ...---....--...--............-.---...........-..--..-----..... -..-.--....--....- ,.. FPllUCY EFRCTIYE DlIE1lIFFERENTTIWlPOUCl'...._..... PUASEEXPWt UF.1518 4199 3 .-11oIUF.ocaJJ!IlT PAYIIB/T1IlEllEIl'/E . . f7. Is ,Managed Qwe Program In effect? Dyes DNo rf -Ves,M p/ease dtacrlbe: ..__..__.._~___............~_"M"M..._MM'M'_'"___"".-.....--...-.--.- __~_._._M._____.___._._..___.__.._.,_~..__.____.~._,__--.....-.....-..---..-------.---.---..--.-.----.....----.----.--.-.----.-..---.,. $ _.._..._____.__.__. .....___.__...._.__M._.......____....___._____.__._.___________.......___________._____.___ -..--.---.......-....--.-.----- ...._._______..._._. _____..._._____....._______._..._._.______._.______._____.____.M......._________._.__.__ ...______.__...._.__._.__.___ _______.____.. ___.M..__.__.__..__.__......___.........__._._._.__._______.----...---...----..-.-- ---------.-.-.--.---.-----. _.-_.~_.__._-_._._.._---".~"...._.__._._---------"_.~-..-------.-..--.-- -.-.--.--.--.--.----. 11. Has any Wortters Camp. Instnnte been cancelled or dedined'? (PnrvIous carrten I'!qUeSt thI1 COVI!!P be ~ fnlm another company Is the same lIS being cancened or declined) U'tes 0 N~ "'"YeS.. explain and glvt reason. 21,0... ""'___,_wl1IlERIFI O'es 0.. tf"Yes,- underwtlatnarne1.__......___....__._____.._....____ Polley No(s). --..-..--......--.......... ,..............,......-... 22. ....... rIs'~""'" wl1IllIame 0lfI0e7 DYes 0 o. u......by""""" ...._......_.....____.._........._.._......._...__.... 21 Wasllllsrlsl<.....""'by_S_or.DlstrlctsaJesM_ 0"" 0.. U'Yes,.bywllon17 ..--...-...........--..-. AGENT, 1lD",,_lI1lson_lorlsl<? ~.. Do. .... III lilt bind riIIrI UIIt......... CIIICIOIlI or ......... rwmnd. leertlfythatltmo!orndtD aD quutlonsultleyllRlprintadDnlhtsappllcdan. IbthercerVfrthltlblve DyIlleAppIIcanL AQont'S rD. Ha: IJIJ'Womn Comp. InsurmcI been cenceJled lor IlDII-pIJIMl1t afpremlum? 0'.. 0.. ......."""_""'"'0., IF -m.. COIITACT 1IIIlEIIWRI11ft IEFDRE REWRlTlIIS M. ADDITIONAL UNDERWRmNG INFORMAl1Ott: N011CE OFINSURaNC:E INFORMATION PRACT1CES: We WOI.lki lcelolnlcrm you I'Ild as patt d OJI P'OC8dUJeIol' processing yourlnsdnce appIcetion an ~ Consunar Report may be prepered. PerIonII nb'mation in this ~ II obtained tl'\rQJgh \nIerVIeW8 \lWItl your neIghbcn. Mends 01 ethers vriIh whom:ttlU.. 8CQuainhid I1ld may inck.de ~ as ID}I(U character. general NPuta1ic)'l. pnoneI charIlcterisIic.-Kt mode 01 toling."'tbul'rWlyrequesttobelnteNlewed InccnnecliDnMh 1tIIsrepart. NoimlrmalXlnfrcmourl'ieswill be$livenlD ~withOIAyourMil:len ocnsenI ucepl as allowed by IIw In 0I'der 10 conduct ou" bushess. 'rt:lu hlll/8 the r1ghllO knOW Ih8 kind 01 Hormaaon we h8W' In ycu fie. 10 heve access Ie that i"ItlrmJtia1. 10 ~ II copy 01 aI ~ HotrnItiCI'l. 8'ld 10 request correction d IntorrneMon you beIeYIl Is Nccl.nte. Wewll prcMde II mcnt dIltBIled descriptior'I oIourlF1lonnatlon practices., yaJ lJOf8QUeStThis notice IS givIln PLOL*ttoPWllc Law 91.508llnd llJlpIicabIt 1II!81aw. .....1: II.. ClllJElD PRDVIDEfAISE. 0II_1.DDB1G IIFDIMAlIDITDIII_RlRlIIE PURPDSEGFD&UlDlIIC1IItIllSUREltG."" D1HaI PERSD" PBIIDIESIICLa _--.r...... FUIEI. II ADIIITIDII,AI....IIAT BYIIISIIlAICE BEFItS IF FllSEIIIFIIIIW1D1ILOE1l1AU.Y RB.UIDlD. CUlM WAS PIfMDID 1Y1IIEAPPIJCUt . All PBSOI.... WITH III1U1 TO IERlAUD OR .....1HII' lIE: IS FaJtATDIG A FIWID AIWIIST AllIIISURSI. SUlIIIIS AI APPUCA110I GR ALES. CUlM COITAIIIII . rALIE CIII DEC8'IIIIITIIEMBIT. ClUUT OF IISURMCE FMIIl. AllfPIEIIDI WIlD ~ AID 1IITII1DdT1O IIEfUIID Mf -.ucE.CIIIPUI' DlII'nIEI PEIISOII RLD IIlP1'lJCmDIIFDI.IllSURAlCEGII SlJO"EMEJIT OF aAIIIc:GllllllnllllfllA1illWJ.TFlUE........ GI COIICEILIRJII m ....,..1f1lllLUllalG,1IIFIRIIA.. COICElUHCMY FACT IUTERW. TIIERm COlI11II'S' FlUDllllUllrIdNlCl ACT. waDlISI CIa... IiUIJECJIlHI PERSGllO CllllllW.MI CimL PEJIAlJI!S. 11'.. ClUlETDaow-.rPllDllDEFlLIE" IICIIIPI.EIE II.~ IIIFOIIUIIDI. IIffPlRlTlO A W8RlEI'S COMPEIIS.IJ1OI TlLlllSACJIOI FOIl m PURPOSE IF _11_ FlUUD.PEJIlUIES IIICWDE ........,..fIIIEI AIIJ DElllALDfIBlURAllCEIEllERIS. 11'.. ClIME 11 ~ .1UMDI......IICO..lEIE DR MIIlIlDIIIG DIRIIIIU1IDI.....1IISUIWICE COIIPMf FGR THE PlIlPOSE IF DUIlMIDIIG TJlECOIII'IIR'. PBWJlElJIII.UDE M'IIIIOIIIEIfJ, fWD lJIII DEJIIIL ....IIISURAIICE IEIIDnS. .lIlY P!IlIDIWH, IlmllnElTlD DIFMUD OR UDIfIIG 'nIIr HE IS FAaUIAJIIG A fRAUD AUlIS'T "_SUIIIR,SUIMfJS AN ~ GR fILES. CLAIM ClUtlIDIC I FA1a.. DBEP'IIVE ItIJEIIEIfT IS GIIIJY OF IlSUUICE FUDD. WE _to.....u. DIIIs:IU' 1Y1B.EPII8E18 ERIE IlWRllCEIllWP'lIIEAIIUTc:u. DfFICf. WE AUnIOIIIZE 'DUE IISUIWfCE GlIU 10.. MD fILE lIE.-urmrsFlllS1'IIIPOIII'DFIlJUJlYRtIIII WI11I1HEIIOIIIEItI'CGIII'!IIUnGI~DlatIIIlBWf. I tbIt I bill .... m. a.. ~..... ta 1M quatJonllD tIIIt .ppllcatIoa. N'PUCAIlT'SSlGHA7l.OlE .._ Cl... 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WHERE TO LOOK IN YOUR POLICY GENERAL SECTION ,..,.....,',.........,.""""",.,.."""".""., 2 PART ONE- WORKERS COMPENSATION INSURANCE ',......".."".",."".." 2 PARTTWO-EMPLOYERSLIABILITYINSURANCE .""""..""""""'.""" 3 PART THREE- OTHER STATES INSURANCE. . . , , , . . . , . . . . , , . , . . . , , , , . . , , , , , . , ., 5 PART FOURnYOUR DUTIES IF INJURY OCCURS .,..,....."""..""".,..".,. 5 PART FIVE--PREMIUM .......'.,",.........'."..,..",....""...,.,.,. 5 PART SIX--CONDITIONS ....,.,..........,..'.'...,...'.,...,.".,..,'.'.. 6 PART SEVEN--ADDITIONAL ERIE DEFINITIONS ,.".......",.,.,.""...,'...... 7 PART EIGHTnADDITIONAL ERIE CONDITIONS ..,.".,...""'.....,'.",.,.",, 7 In return for the paymen1 of premium and subject to all 1he terms of mis policy, we agree with you as follows: GENERAL SECTION A. The Policy This policy includes at its effective date the Informa- tion Page and all endorsements and schedules listed mere. 11 is a contract of insurance between you (the employer named in hem 1. of me Informa1ion Page) and us (the insurer named on the Informa1ion Page). The only agreemen1s relating to this insurance are stated in this policy. The terms of mis policy may not be changed or waived except by endorsemen1 issued by us 10 be part of 1his policy, B. Who Is Insured You are insured if you are an employer named in hem 1. of 1he Information Page, If ma1 employer is a partnership, and if you are one of hs partners, you are insured, but only in your capacity as an employer of the partnership's employees. C. Workers Compensation Law Workers Compensa1ion law means the workers or workmen's compensation law and occupational disease law of each s181e or 1erritory named in item 3.A. of the Informa1ion Page. It includes any amendments 10 mat law which are in effect during me policy period. It does not include any federal workers or workmen's compensation law, any federal occupational disease law or 1he provisions of any law 1hat provide nonoccupational disabilhy benefi1s, D, State State means any state of the U nhed States of America, and the District of Columbia. E, Locations This policy covers all of your workplaces listed in hems 1. or 4. of the Informa1ion Page; and h covers all other workplaces in item 3,A. s1a1es unless you have other insurance or are self-insured for such workplaces. PART ONE - WORKERS COMPENSATION INSURANCE A. How This Insurance Applies This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting deam. 1. Bodily injury by accident must occur during the policy period. 2. Bodily injury by disease must be caused or aggravated by me conditions of your employ- ment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. We Will Pay We will pay promptly when due benefi1s required of you by the workers compensation law. C. We Will Defend We have me right and duty to defend a1 our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have me right 10 investigate and settle these claims, proceedings or suhs. We have no duty to defend a claim, pro- ceeding or suit that is n01 covered by this insurance. D. We Will Also Pay We will also pay these costs in addition to other amounts payable under mis insurance, as part of any claim, proceeding or suh we defend: 1. reasonable expenses incurred at our request, bu1 not loss of earnings; 2. premiums for bonds to release at18chmen1s and for appeal bonds in bond amounts up to the amount payable under mis insurance; 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we mcur. E. Other Insurance We will not pay more than our share of benefits and costs covered by this insurance and other insurance or self-insurance. Subjec1 to any limits of liability mat may apply, all shares will be equal until 1he loss is paid, If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid, F. Paymeuts You Must Make You are responsible for any payments in excess of me benefits regularly provided by me workers com- pensation law including those required because: 1. of your serious and willful misconduct; 2. you knowingly employ an employee in violation of law; 3. you fail to comply wi1h a health or safe1y law or regulation; or 4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law. Copyr.ight 1991 National Council on Compensation Insurance 2 If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G, Recovery From Others We have your rights, and the rights of persons enti- tled to the benefits of this insurance, to recover our paymen1s from anyone liable for the injury. You will do everything necessary to protec1 those rights for us and to help us enforce them. H. Statutory Provisiuns These statements apply where they are required by law. 1. As between an injured worker and us, we have notice of the injury when you have notice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our duties under this insurance after an injury occurs. 3. We are directly and primarily liable to any person entitled to the benefits payable by this insurance. Those persons may enforce OUf duties; so may an agency authorized by law. Enforcement may be against us or against you and us. 4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law subject to the provisions of this policy that are n01 in conflict with that law. 5. This insurance conforms to the parts of the workers compensation law that apply to: a. benefits payable by this insurance; b. special taxes, payments into security or other special funds, and assessments payable by us under that law. 6. Terms of this insurance tha1 conflict with the workers compensa1ion law are changed by this statemen1 to conform to that law. Nothing in these paragraphs relieves you of your duties under this policy. PART TWO - EMPLOYERS LIABILITY INSURANCE A. How This Insurance Applies This Employers Liabilhy Insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or incidental to your work in a state or territory listed in item 3.A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employ- ment. The employee's last day of last exposure to the condhions causing or aggravating such bodily injury by disease must occur during the policy period. 5, If you are sued, the original suit and any related legal actions for damages for bodily injury by acciden1 or by disease must be brought in the United States of America, its territories or pos- sessions, or Canada. B, We Will Pay We will pay all sums you legally must pay as damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers Liability Insurance, The damages we will pay, where recovery is per- mitted by law, include damages: 1. for which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against such third party as a result of injury to your employee; 2. for care and loss of services; and 3. for consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee; provided that these damages are the direc1 consequence of bodily injury that arises out of and in the course of the injured employ- ee's employment by you; and 4. because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer. e. Exclusions This insurance does not cover: 1. liability assumed under a contract. This exclu- sion does not apply to a warranty that your work will be done in a workmanlike manner; 2. punitive or exemplary damages because of bodily injury to an employee employed in violation of lawj 3. bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers; 4. any obligation imposed by a workers compen- sation, occupational disease, unemployment compensation, or disability benefits law, or any similar law; 5. bodily injury intentionally caused or aggravated by you; Copyright 1991 National Council on Compensalion Insurance 3 6. bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury 10 a citizen or resident of the United States of America or Canada who is tem- poraroy outside these countries; 7, damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimi- nation against or termination of any employee, or any personnel practices, policies, acts or omis~ sians; 8. bodily injury to any person in work subject to the Longshore and Harbor Workers Compen- sation Act (33 USC Sections 901-950), the Non- appropriated Fund Instrumentalities Act (5 USC Sections 8171-8173), the Outer Continental Shelf Lands Act (43 USC Sections 1331-1356), the Defense Base Act (42 USC Sections 1651-1654), the Federal Coal Mine Health and Safe1y Act of 1969 (30 USC Sections 901-942) any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws; 9. bodily injury 10 any person in work subject to the Federal Employers' Liability Act (45 use Sections 51-60), any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws; 10. bodily injury to a mas1er or member of the crew of any vessel; II. fmes or penalties imposed for violation of federal or state law; 12. damages payable under the Migrant and Sea- sonal Agricultural Worker Protection Ac1 (29 use Sections 1801-1872) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments 10 those laws. D. We Will Defend We have the right and dU1y to defend, at our expense, any claim, proceeding or suit against you for damages payable by 1his insurance. We have the right to investigate and settle these claims, pro- ceedings and suits. We have no duty to defend a claim, proceeding or suit tha1 is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. E. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend; I. reasonable expenses incurred at our request, but not loss of earnings; 2, premiums for bonds 10 release attachments and for appeal bonds in bond amounts up 10 the limit of our liabili1y under this insurance; 3. litigation costs taxed against you; 4, interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. F. Other Insurance We will not pay more 1han our share of damages and costs covered by this insurance and other insur- ance or self-insurance. Subjec1 to any limits of liahili1y that apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance and self. insurance will be equal until the loss is paid. G. Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in item 3.B. of the Infor- mation Page. They apply as explained below. I. Bodily Injury by Accident. The limit shown for "bodily injury by acciden1neach accident" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in anyone accident. A disease is not bodily injury by acciden1 unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease, The limit shown for "bodily injury by disease--policy limit" is the most we will pay for all damages covered by this insurance and arising ou1 of bodily injury by disease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for "bodily injury by diseaseneach employee" is the most we will pay for all damages because of bodily injury by disease to anyone employee. Bodily injury by disease does not include disease that results directly from a bodily injury by acci. dent. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance. H. Recovery From Others We have your rights to recover our payment from anyone liable for an injury covered by this insurance, You will do everything necessary to protect those rights for us and 10 help us enforce them. I. Actions Against Us There will be no right of action against us under this insurance unless: I. you have complied with all the 1erms of this policy; and 2. the amount you owe has been de1ermined with our consent or by actual trial and fmal judg- ment. Copyright 1991 National Council on Compensation Insurance 4 This insurance does not give anyone the right to add us as a defendant in an action against you to deter- mine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obli- gations under this Part. PART THREE - OTHER STATES INSURANCE A How This Insurance Applies \. This other states insurance applies only if one or more states are shown in item 3.C. of the Infor- mation Page. 2. If you begin work in anyone of those states after the e!fecti ve date of this policy and are not insured or self-insured for such work all pro- visions of the policy will apply as though that state were listed in item 3.A. of the Information Page. 3. We will reimburse you for the benefi1s required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have work on the effective date of this policy in any state not listed in item 3.A of the Information Page, coverage will not be afforded for that state unless we are notified within thirty days. Tell us at once if you begin work in any sta1e listed in item 3.C. of the Information Page. PART FOUR--YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here. \. Provide for immediate medical and other services required by the workers compensation law. 2. Give us or our Agent the names and addresses of the injured persons and of witnesses, and other information we may need. 3, Promptly give us notices, demands and legal papers related to the injury, claim, proceeding or suit. 4, Cooperate and assis1 us, as we may request, in the investiga1ion, settlement or defense of any claim, proceeding or suit. 5. Do nothing after an injury occurs that would interfere with our right to recover from others. 6. Do not voluntarily make payments, assume obli- gations or incur expenses, except at your own cost, PART FIVE-PREMIUM A. Manuals All premium for this policy will be determined by our manuals of rules, rates, rating plans and classi- fications. We may change our manuals and apply the changes to this policy if authorized by law or a governmental agency regulating this insurance. B, Classifications Item 4. of the Information Page shows the rate and premium basis for certain business or work classifica- tions. These classifications were assigned based on an estimate of the exposures you would have during the policy period. If your actual exposures are not properly described by those classifications, we will assign proper classifications, rates and premium basis by endorsemen1 10 this policy. C, Remuneration Premium for each work classification is determined by multiplying a rate times a premium basis. Remuneration is the most common premium basis, This premium basis includes payroll and all other remuneration paid or payable during the policy period for the services of: \. all your officers and employees engaged in work covered by this policy; and 2. all other persons engaged in work that could make us liable under Part One (Workers Com- pensation Insurance) of this policy, If you do n01 have payroll records for these persons, the contract price for their services and materials may be used as the premium basis, This para- graph (2) will n01 apply if you give us proof that the employers of these persons lawfully secured their workers compensation obligations. Copyright I 99 I National Council on Compensation Insurance 5 D, Premium Payments You will pay all premium when due. You will pay the premium even if part or all of a workers com- pensation law is not valid, E. Final Premium The premium shown on the Information Page, schedules, and endorsements is an estimate. The fmal premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates tha1 lawfully apply to the business and work covered by this policy. If the fmal premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The fmal premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, fmal premium will be deter- mined in the following way unless our manuals provide otherwise. \. If we cancel, fmal premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. 2. If you cancel, fmal premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short rate cancellation table and procedure. Final premium will n01 be less than the minimum premium. F. Records You will keep records of information needed to compute premium, You will provide us with copies of those records when we ask for them. G. Audit You will let us examine and audit all your records that relate to this policy, These records include ledgers, journals, registers, vouchers, contracts, tax reports, payroll and disbursement records, and pro- grams for storing and retrieving data. We may conduct the audits during regular business hours during the policy period and within three years after the policy period ends. Information developed by audit will be used to determine fmal premium. Insurance rate service organizations have the same rights as we have under this provision. PART SIX-CONDITIONS A. Inspection We have the right, but are not obliged to inspeC1 your workplaces at any time. Our inspections are n01 safety inspections. They rela1e only to the insurability of 1he workplaces and the premiums to be charged. We may give you reports on the condi- tions we fmd. We may also recommend changes, While 1hey may help reduce losses, we do not under- 1ake to perform the duty of any person to provide for 1he heal1h or safe1y of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regu- lations, codes or standards. Insurance ra1e service organizations have the same rights we have under this provision. B, Long Term Policy If the policy period is longer than one year and sixteen days. all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. C. Transfer of Your Rights and Duties Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days after your death, we will cover your legal represen- tative as insured. D, Cancellation 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2. We may cancel this policy. We must mail or deliver to you not less than ten days advance written notice stating when the cancellation is to 1ake effect. Mailing that notice to you a1 your mailing address shown in item \. of the Informa- tion Page will be sufficient to prove notice. 3, The policy period will end on the day and hour slated in the cancellation n01ice. 4. Any of 1hese provisions that conflic1 with a law that controls the cancellation of the insurance in this policy is changed by this s1atement to comply with that law, E. Sole Representative The insured fIrst named in item \. of the Informa- tion Page will act on behalf of all insureds to change this policy. receive return premium and give or receive notice of cancellation. Copyright 1991 National Council on Compensation Insurance 6 PART SEVEN-ADDITIONAL ERIE DEFINITIONS DEFINITIONS The following words used in PAR T EIGHT--ADDITIONAL ERIE CONDITIONS have this special meaning in policies issued by Erie Insurance Exchange. . "Subscriber" means the person, partnership, fIrm or corporation that signed the application for this policy. . "We," "us" and "our" means the Subscribers at Erie Insurance Exchange as represented by their common At1orney-in-Fac1, Erie Indemnity Company. . "You," "your" and "named Insured" mean the Sub- scriber and others named under "Named Insured" on the Information Page. The following words used in PAR T EIGHT--ADDITIONAL ERIE CONDITIONS have this special meaning in policies issued by Erie Insurance Company or Erie Insurance Property and C=lty Company. . "We," "us" and "our" means Erie Insurance Company or Erie Insurance Property and C=lty Company, whichever is stated on the Information Page. . "You," .. your" and "named Insured" means the persons named under "Named Insured" on the Information Page. PART EIGHT--ADDITIONAL ERIE CONDITIONS Addi1ional Conditions applying to policies issued by Erie Insurance Exchange. A. No Contingent Liability You will not be assessed for the losses of Sub- scribers. B. Acconnting Erie Indemnity Company, as at1orney-in-fact, may keep up to 25% of the premium in return for agreeing to represent you. This amount will be used to pay expenses of management, including sales commissions, salaries, and other employment costs, the cost of supplies, and other administrative costs. The rest of the premium will be placed on the books of the Erie Insurance Exchange. We will deposit or inves1 this amount as permit1ed by law. This amount will be used to pay losses, adjustment expenses, legal expenses, court costs and reinsurance. The remainder, if any, will be used for purposes Erie Indemnity Company decides are to the advantage of the Subscribers, C. Dividends Dividends to Policyholders may be paid at the end of a policy period, at the discretion of the Board of Directors of Erie Indemnity Company. The divi- dends will be applied to reduce your premium for further insurance. If this policy is not continued for another policy period, any dividend will be sent to you, D. Not a Partnership or Mutual No term or condition of this policy is intended to create, or does create, or shall be construed to create a partnership, or mutual insurance associatiOllj or to give rise 10 or create any joint or general liability. E. Suits Against Us To avoid multiplicity of suits, you agree that all actions or suits a1 law or in equity, by you or on your behalf because of any claims arising under this policy against us will be brought against Erie Indem- ni1y Company, At1orney-in-Fact for Subscribers at Erie Insurance Exchange. The At1orney-in-Fac1 is authorized to receive and admit service of process on behalf of Subscribers in any such suit or other pro- ceeding. F. Reciprocal Agreement Your signing the power of attorney permits Erie Indemnity Company to represent you and to arrange reciprocal insurance contracts between you and the other Subscribers. Your responsibility as a Subscriber is determined by this policy alone. You cann01 be held responsible for the liability of the other Subscribers. This agreement is made in reliance on the facts you have given us. Additional Conditions applying to policies issued by Erie Insurance Company. A. Dividends Dividends to Policyholders may be paid a1 1he end of a policy period, at the discretion of our Board of Directors. The dividends will be applied to reduce your premium for further insurance. If this policy is not continued for another policy period, any divi- dend will be sen1 to you, B. Agreement Our agreement with you is made in reliance on 1he facts you have given us. Copyright 199 J National Council on Compensation Insurance 7 Additional Condition applying to policies issued by Erie Insurance Exchange, Erie Insurance Company. and Erie Insurance Property and Casually Company. A. Automatic Renewal Policy Your policy will be au10matically renewed at 1:I1e end of the policy period, unless terminated by you or us in accordance with 1:I1e steps explained in 1:I1e Cancel- lation Condition. Each year, we will send you a Renewal Certificate which shows the premium due for the next policy period. This is a service 1hat we provide for you so that your insurance protection does not stop, If you do n01 wan1 the renewal policy, you must mail our Agent or us written notice in advance of 1:I1e new policy period, If you do not notify us, your policy remains in effect. You must pay us the earned premium due us for this time. This policy has been signed on our behalf at Erie, Pennsylvania, by our President and Secretary. If required by law, it has been countersigned on the information page by our authorized Agent. ~c? 9Lf~~ Secretary ~idC::~ WC UF-8129 (Ed. 4/92) III ~ ERIE. ERIE INSURANCE GROUP Home Office. 100 Erie Insurance Place' Erie, PA 16530 . (814) 870-2000 Visit our Website at www.erieinsuranc8_com Copyright 1991 National Council on Compensation Insurance 8 DMB407 08 B002 MILK TRANSP 051839C016 INFORMATION PAGE PRIOR POLICY NUMBER - Q88 7300009 H AA7401 CARL L CRAMER INS. LLC ERIE INSURANCE COMPANY 14664 Q88 7300009 H B002 MILK TRANSPORT INC 1099 RIDGE RD SHIPPENSBURG PA 17257-9714 RENEWAL CERTIFICATE CORPORATION CUMBERLAND CO OTHER WORKPLACES NOT SHOWN ABOVE - AS SCHEDULED RISK IDENTIFICATION NUMBER - 002168547 FED ID # 23-7922246 ITEM 2. THE POLICY PERIOD IS FROM 04/23/03 TO 04/23/04 AT THE INSUREDS MAILING ADDRESS. ITEM 3.A. WORKERS COMPENSATION INSURANCE- PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE- PA. ITEM 3.B. EMPLOYERS LIABILITY INSURANCE- PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3.A, THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE ITEM 3.C. STATES, IF DESIGNATED OTHER STATES INSURANCE- PART ANY, LISTED HERE- ALL STATES IN ITEM 3.A., THREE OF THE POLICY APPLIES TO THE EXCEPT ND, OH, WA, WV, WY, STATES ITEM 3.D. SEE ATTACHED ENDORSEMENT SCHEDULE ITEM 4. 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. CODE 0938 SEE ATTACHED SCHEDULE OF OPERATIONS EXPENSE CONSTANT TOTAL ESTIMATED ANNUAL PREMIUM DEPOSIT PREMIUM .0337 PA EMPLOYER ASSESSMENT TOTAL AMOUNT 17,045 140 $17,185 $17,185 $579 $17,764 MINIMUM PREMIUM $845 PA RATES, MIN. PREM. AND/OR DEVIATIONS MAY CHANGE 060407 08 BOOZ MILK TRANSP 051839C016 ** S C H E D U LEO FOP ERA T ION S ** ITEM 4. ST LOC CODE NO CLASSIFICATIONS PREM BASIS RATE TOTAL-EST PER $100 ANN REMUN REMUN EST ANNUAL PREMIUM PA 001 0953 CLERICAL OFFICE EMPLOYEES IF ANY .45 $0 0805 MILK HAULING BY CONTRACTOR 274,200 7.05 $19,331 SUB-TOTAL 19,331 9898 EXPERIENCE MOD, EFF 04/23/03, USING FACTOR .9580 812 C 0063 PREMIUM DISCOUNT ENDORSEMENT 1,474 C 0032 LOSS CONSTANT 0 TOTAL FOR PENNSYLVANIA $17,045 TOTAL SCHEDULE OF OPERATIONS PREMIUM $17,045 ** SCHEDULE OF PRIMARY AND ADDITIONAL LOCATIONS ** LOC 001 199 BOOZ RD, SHIPPENSBURG, PA 17257 ** END 0 R S E MEN T S C H E D U L E ** THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES- WC-A4/92, WC-000403* (PA) , WC-370601 (PA) , WC-370603A (PA) , WC-UF9574* (PA) , WC-UF3001* (PA) , WC-UF3228* (PA) , WC-370602 (PA) , WC-000419* (PA) , WC-000420* (PA) , WC-990602 (PA). DMB407 08 B002 MILK TRANSP 051839C016 INFORMATION PAGE PRIOR POLICY NUMBER - Q88 7300009 H AA7401 CARL L CRAMER INS. LLC ERIE INSURANCE COMPANY 14664 Q88 7300009 H B002 MILK TRANSPORT INC 1099 RIDGE RD SHIPPENSBURG PA 17257-9714 AMENDMENT 01 *** EFFECTIVE 04/23/03 *** ATTACH THIS TO YOUR POLICY REASON FOR AMENDMENT- AMENDED EXPERIENCE MODIFICATION FACTOR CORPORATION CUMBERLAND CO OTHER WORKPLACES NOT SHOWN ABOVE - AS SCHEDULED FED ID # 23-7922246 RISK IDENTIFICATION NUMBER - 002168547 ITEM 2. THE POLICY PERIOD IS FROM 04/23/03 TO 04/23/04 AT THE INSUREDS MAILING ADDRESS. ITEM 3.A. WORKERS COMPENSATION INSURANCE- PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE- PA. ITEM 3.B. EMPLOYERS LIABILITY INSURANCE- PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE ITEM 3.C. STATES, IF DESIGNATED OTHER STATES INSURANCE- PART ANY, LISTED HERE- ALL STATES IN ITEM 3 .A. , THREE OF THE POLICY APPLIES TO THE EXCEPT ND, OH, WA, WV, WY, STATES ITEM 3.D. SEE ATTACHED ENDORSEMENT SCHEDULE ITEM 4. 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. CODE 0938 SEE ATTACHED SCHEDULE OF OPERATIONS EXPENSE CONSTANT TOTAL ESTIMATED ANNUAL PREMIUM DEPOSIT PREMIUM .0337 PA EMPLOYER ASSESSMENT TOTAL AMOUNT AMOUNT FOR REMAINDER OF POLICY PERIOD 16,925 140 $17,065 $17,065 $575 $17,640 $124.00 C MINIMUM PREMIUM $845 CHANGE IN TOTAL PA RATES, MIN. PREM. AND/OR DEVIATIONS MAY CHANGE 060407 08 BOOZ MILK TRANSP 051839C016 ** S C H E D U LEO FOP ERA T ION S ** ITEM 4. ST LOC CODE NO CLASSIFICATIONS PREM BASIS RATE TOTAL-EST PER $100 ANN REMUN REMUN EST ANNUAL PREMIUM PA 001 0953 0805 9898 0063 0032 CLERICAL OFFICE EMPLOYEES IF ANY MILK HAULING BY CONTRACTOR 274,200 SUB-TOTAL EXPERIENCE MOD, EFF 04/23/03, USING FACTOR PREMIUM DISCOUNT ENDORSEMENT LOSS CONSTANT TOTAL FOR PENNSYLVANIA .45 7.05 $0 $19,331 19,331 947 C 1,459 C o $16,925 .9510 TOTAL SCHEDULE OF OPERATIONS PREMIUM $16,925 ** SCHEDULE OF PRIMARY AND ADDITIONAL LOCATIONS ** LOC 001 199 BOOZ RD, SHIPPENSBURG, PA 17257 ** END 0 R S E MEN T S C H E D U L E ** THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES- WC-A4/92, WC-000403 (PA) , WC-370601 (PA) , WC-370602 (PA) , WC-370603A (PA) , WC-UF9574 (PA) , WC-UF3001 (PA) , WC-UF3228 (PA) , WC-000419 (PA) , WC-000420 (PA) , WC-990602 (PA). DMB407 08 B002 MILK TRANSP 051839C016 INFORMATION PAGE PRIOR POLICY NUMBER - Q88 7300009 H AA7401 CARL L CRAMER INS. LLC ERIE INSURANCE COMPANY 14664 Q88 7300009 H B002 MILK TRANSPORT INC 1099 RIDGE RD SHIPPENSBURG PA 17257-9714 RE-ISSUED POLICY REASON FOR AMENDMENT- DUE TO RATE CHANGE CORPORATION CUMBERLAND CO OTHER WORKPLACES NOT SHOWN ABOVE - AS SCHEDULED RISK IDENTIFICATION NUMBER - 002168547 FED ID # 23-7922246 ITEM 2. THE POLICY PERIOD IS FROM 04/23/03 TO 04/23/04 AT THE INSUREDS MAILING ADDRESS. ITEM 3.A. WORKERS COMPENSATION INSURANCE- PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE- PA. ITEM 3.B. EMPLOYERS LIABILITY INSURANCE- PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE ITEM 3.C. STATES, IF DESIGNATED OTHER STATES INSURANCE- PART ANY, LISTED HERE- ALL STATES IN ITEM 3 .A. , THREE OF THE POLICY APPLIES TO THE EXCEPT ND, OH, WA, WV, WY, STATES ITEM 3.D. SEE ATTACHED ENDORSEMENT SCHEDULE ITEM 4. 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. SEE ATTACHED SCHEDULE OF OPERATIONS 18,483 EXPENSE CONSTANT 140 MINIMUM PREMIUM $907 TOTAL ESTIMATED ANNUAL PREMIUM $18,623 DEPOSIT PREMIUM $18,623 CODE 0938 .0280 PA EMPLOYER ASSESSMENT $521 TOTAL AMOUNT $19,144 CHANGE IN PREMIUM FOR REMAINDER OF POLICY PERIOD $1,504.00 PAYMENT $5,039.00 C BALANCE $14,105.00 060407 08 BOOZ MILK TRANSP 051839C016 ** S C H E D U LEO FOP ERA T ION S ** ITEM 4. ST LOC CODE NO CLASSIFICATIONS PREM BASIS RATE TOTAL-EST PER $100 ANN REMUN REMUN EST ANNUAL PREMIUM PA 001 0953 CLERICAL OFFICE EMPLOYEES IF ANY 0805 MILK HAULING BY CONTRACTOR 274,200 SUB-TOTAL 9898 EXPERIENCE MOD, EFF 04/23/03, USING FACTOR 9740 TERRORISM RISK INSURANCE ACT OF 2002 - CERTIFIED LOSSES 0063 PREMIUM DISCOUNT ENDORSEMENT 0032 LOSS CONSTANT TOTAL FOR PENNSYLVANIA .46 $0 7.67 $21,031 21,031 .9510 1,031 C .043 118 1,635 C o $18,483 TOTAL SCHEDULE OF OPERATIONS PREMIUM $18,483 ** SCHEDULE OF PRIMARY AND ADDITIONAL LOCATIONS ** LOC 001 199 BOOZ RD, SHIPPENSBURG, PA 17257 ** END 0 R S E MEN T S C H E D U L E ** THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES- WC-A4/92, WC-000403* (PA) , WC-370601 (PA) , WC-370602 (PA) , WC-370603A (PA) , WC-UF9574* (PA) , WC-UF3001* (PA) , WC-UF3228* (PA) , WC-000419* (PA) , WC-000420* (PA) , WC-990602 (PA). DMB407 08 BOOZ MILK TRANSP 051839C016 INFORMATION PAGE PRIOR POLICY NUMBER - Q88 7300009 H AA7401 CARL L CRAMER INS. LLC ERIE INSURANCE COMPANY 14664 Q88 7300009 H BOOZ MILK TRANSPORT INC 1099 RIDGE RD SHIPPENSBURG PA 17257-9714 AMENDMENT 02 *** EFFECTIVE 04/23/03 *** ATTACH THIS TO YOUR POLICY REASON FOR AMENDMENT- AMENDED REMUN DUE TO AUDIT CORPORATION CUMBERLAND CO OTHER WORKPLACES NOT SHOWN ABOVE - AS SCHEDULED FED ID # 23-7922246 RISK IDENTIFICATION NUMBER - 002168547 ITEM 2. THE POLICY PERIOD IS FROM 04/23/03 TO 04/23/04 AT THE INSUREDS MAILING ADDRESS. ITEM 3.A. WORKERS COMPENSATION INSURANCE- PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE- PA. ITEM 3.B. EMPLOYERS LIABILITY INSURANCE- PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE ITEM 3.C. STATES, IF DESIGNATED OTHER STATES INSURANCE- PART ANY, LISTED HERE- ALL STATES IN ITEM 3 .A., THREE OF THE POLICY APPLIES TO THE EXCEPT ND, OH, WA, WV, WY, STATES ITEM 3.D. SEE ATTACHED ENDORSEMENT SCHEDULE ITEM 4. 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. CODE 0938 SEE ATTACHED SCHEDULE OF OPERATIONS EXPENSE CONSTANT TOTAL ESTIMATED ANNUAL PREMIUM DEPOSIT PREMIUM .0280 PA EMPLOYER ASSESSMENT TOTAL AMOUNT AMOUNT FOR REMAINDER OF POLICY PERIOD 27,251 140 $27,391 $27,391 $767 $28,158 $9,014.00 MINIMUM PREMIUM $907 CHANGE IN TOTAL 060407 08 BOOZ MILK TRANSP 051839C016 ** S C H E D U LEO FOP ERA T ION S ** ITEM 4. ST LOC CODE NO CLASSIFICATIONS PREM BASIS RATE TOTAL-EST PER $100 ANN REMUN REMUN PA 001 **** CLASS 0953 CHANGED EFF 04/23/03 0953 CLERICAL OFFICE EMPLOYEES IF ANY **** CLASS 0805 CHANGED EFF 04/23/03 0805 MILK HAULING BY CONTRACTOR 408,200 SUB-TOTAL 9898 EXPERIENCE MOD, EFF 04/23/03, USING FACTOR 9740 TERRORISM RISK INSURANCE ACT OF 2002 - CERTIFIED LOSSES 0063 PREMIUM DISCOUNT ENDORSEMENT 0032 LOSS CONSTANT TOTAL FOR PENNSYLVANIA TOTAL SCHEDULE OF OPERATIONS PREMIUM ** SCHEDULE OF PRIMARY AND ADDITIONAL LOCATIONS ** LOC 001 199 BOOZ RD, SHIPPENSBURG, PA 17257 ** END 0 R S E MEN T S C H E D U L E ** EST ANNUAL PREMIUM .46 $0 7.67 $31,309 31,309 .9510 1,534 C .043 176 2,700 C 0 $27,251 $27,251 THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES- WC-A4/92, WC-000403 (PA) , WC-370601 (PA) , WC-370602 (PA) , WC-370603A (PA) , WC-UF9574 (PAl, WC-UF3001 (PA) , WC-UF3228 (PA) , WC-000419 (PA) , WC-000420 (PA) , WC-990602 (PAl. DMB407 08 B002 MILK TRANSP 051839C016 INFORMATION PAGE PRIOR POLICY NUMBER - Q88 7300009 H AA7401 CARL L CRAMER INS. LLC ERIE INSURANCE COMPANY 14664 Q88 7300009 H B002 MILK TRANSPORT INC 1099 RIDGE RD SHIPPENSBURG PA 17257-9714 AMENDMENT 03 *** EFFECTIVE 04/23/03 *** ATTACH THIS TO YOUR POLICY REASON FOR AMENDMENT- SLIDING SCALE DIVIDEND APPLIED CORPORATION CUMBERLAND CO OTHER WORKPLACES NOT SHOWN ABOVE - AS SCHEDULED FED ID # 23-7922246 RISK IDENTIFICATION NUMBER - 002168547 ITEM 2. THE POLICY PERIOD IS FROM 04/23/03 TO 04/23/04 AT THE INSUREDS MAILING ADDRESS. ITEM 3.A. WORKERS COMPENSATION INSURANCE- PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE- PA. ITEM 3.B. EMPLOYERS LIABILITY INSURANCE- PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE ITEM 3.C. STATES, IF DESIGNATED OTHER STATES INSURANCE- PART THREE OF THE POLICY APPLIES TO THE ANY, LISTED HERE- ALL STATES EXCEPT ND, OH, WA, WV, WY, STATES IN ITEM 3 .A., ITEM 3.D. SEE ATTACHED ENDORSEMENT SCHEDULE ITEM 4. 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. SEE ATTACHED SCHEDULE OF OPERATIONS 27,251 EXPENSE CONSTANT 140 MINIMUM PREMIUM $907 TOTAL ESTIMATED ANNUAL PREMIUM $27,391 DEPOSIT PREMIUM $27,391 CODE 0938 .0280 PA EMPLOYER ASSESSMENT $767 TOTAL AMOUNT $28,158 CHANGE IN TOTAL AMOUNT FOR REMAINDER OF POLICY PERIOD $0.00 SLIDING SCALE DIVIDEND 20.00% BASED ON A LOSS RATIO OF .00% $4,604.00 C 060407 08 B002 MILK TRANSP 051839C016 ** S C H E D U LEO FOP ERA T ION S ** ITEM 4. ST LOC CODE NO CLASSIFICATIONS PREM BASIS RATE TOTAL-EST PER $100 ANN REMUN REMUN EST ANNUAL PREMIUM PA 001 0953 CLERICAL OFFICE EMPLOYEES IF ANY 0805 MILK HAULING BY CONTRACTOR 408,200 SUB-TOTAL 9898 EXPERIENCE MOD, EFF 04/23/03, USING FACTOR 9740 TERRORISM RISK INSURANCE ACT OF 2002 - CERTIFIED LOSSES 0063 PREMIUM DISCOUNT ENDORSEMENT 0032 LOSS CONSTANT TOTAL FOR PENNSYLVANIA .46 $0 7.67 $31,309 31,309 .9510 1,534 C .043 176 2,700 C o $27,251 TOTAL SCHEDULE OF OPERATIONS PREMIUM $27,251 ** SCHEDULE OF PRIMARY AND ADDITIONAL LOCATIONS ** LOC 001 199 B002 RD, SHIPPENSBURG, PA 17257 ** END 0 R S E MEN T S C H E D U L E ** THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES- WC-A4/92, WC-000403 (PA) , WC-370601 (PA) , WC-370602 (PA) , WC-370603A (PA) , WC-UF9574 (PA) , WC-UF3001 (PA) , WC-UF3228 (PA) , WC-000419 (PA) , WC-000420 (PA) , WC-990602 (PA). . EXPERIENCE RATING CALCULATION PENNSYLVANIA COMPENSATION RATING BUREAU uf Q887300009H 2168547 BOOZ LEE N MILK TRANSPORT POLICY NUNIlER FILE NO, 1099 RIDGE RD 371 4/23/03 SHIPPENSBURG PA 17257 CUMBERLAND CO. CARR, EFF OT OF RATING POLICY E R RTE LOSSES AS USED YEAR INDEMNITY MEDICAL TOT AL (A) PART I EXHIBIT OF ACTUAL LOSSES TOTAL POLICY CLAIM MULl. I!,YPE LOSSES AS LOSSES AS YEAR NUMBER ACC. INJ. REPORTED USED PART II EXHIBIT OF LOSSES SUBJECT TO LIMITING VALUES ISSUE DATE TOTAL 2/04/03 '1 - EAT - PER T T L'3 - A 4 - I R' - T PRARY CLASS POLICY PAYROLLS EXPECTED EXPECT~~, AUTHORIZED AUTHORIZED CODE YEAR LOSS FACTOR LOSSES E CLASSES RATING VALUES 99 143,872 3.56 5,122 00 145,400 3.25 4,726 01 214,218 2.68 5,741 805 503,490 15,589 805 5.29 PART III 951 .65 EXHIBIT 953 .29 OF PAYROLLS. EXPECTED LOSSES. AUTHORIZED CLASSES AND RATING 1 VALUES 6 ?~f, 03- v ACTUAL LOSSES PART IV - RATING PROCEDURE E EXPECTED LOSSES C:EDIBIL!TY L1MI T CHARGE 11. OOO-C I 15,589 .026 .925 ((A' C + E . (L . C) + E (1.000 - C)) / E) . M A EXP. MOO M .951 01/24/2004 .... .... ..~RI~IN$URA"'CtGROUp. . . . WORKEIlS'.COiio!PENSATION A(/ono ASSIGNMENT COMPUTER-RATED PAGE 1 AUDIT COMPANY, GOD ASSOCIATES , DATE DUE: 06/22/2004 TYPE, PROFESSIONAL AGENT: AA7401, CARL L CRAMER INSURANCE LLC 833 W, KING STREET SHIPPENSBURG PA 17257-9201 (717) 530-8600 POLICY, 08B 7300009 08 H POLICY PERIOD: 04/23/2003 TO 04/23/2004 LEGAL ENTITY: CORPORATION POLICYHOLDER, BOOZ MILK TRANSPORT INC 1099 RIDGE RD SHIPPENSBURG PA 17257-9714 COUNTY: CUMBERLAND CO REe'D FES 05 2004 LOC DESCRIPTION 001 199 BOOZ RD, SHIPPENSBURG, PA ..................................1............................................................................................. ST LDC PA 001 PA 001 ESTIMATED EXPOSUllE IF ANY 40B.200 CHANGE EFFECTIVE DATE CODE 0953A oa05A CLASSIFICATION CLERICAL OFFICE EMPLOYEES MILK HAULING BY CONTRACTOR MISCELLANEOUS AUDIT INFOhMATION NAME: ERICK BOOZ PHONE:(7 I 7)423-5740 SCHEDUlE OF ENDORSEMENTS ST NUMBER PA 000403 DESCRIPTION EFF DATE EXP DATE EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT 04/23/2003 JACKET EDITION DATE 04/2312003 04/2312004 04/23/2004 PA A4/92 AUDIT FOR POLICY ff: 088 7300009 08 H ~ ~ ~ ~ Q..... \ DMB INFORMATION PAGE PRIOR POLICY NUMBER - Q88 7300009 H AA7401 CARL L CRAMER INS. LLC ERIE INSURANCE COMPANY 14664 Q88 7300009 H B002 MILK TRANSPORT INC 1099 RIDGE RD SHIPPENSBURG PA 17257-9714 RENEWAL CERTIFICATE CORPORATION CUMBERLAND CO OTHER WORKPLACES NOT SHOWN ABOVE - AS SCHEDULED RISK IDENTIFICATION NUMBER - 002168547 FED ID # 23-7922246 ITEM 2. THE POLICY PERIOD IS FROM 04/23/04 TO 04/23/05 AT THE INSUREDS MAILING ADDRESS. ITEM 3.A. WORKERS COMPENSATION INSURANCE- PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE- PA. ITEM 3.B. EMPLOYERS LIABILITY INSURANCE- PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE ITEM 3.C. STATES, IF DESIGNATED OTHER STATES INSURANCE- PART ANY, LISTED HERE- ALL STATES IN ITEM 3.A., THREE OF THE POLICY APPLIES TO THE EXCEPT NO, OH, WA, WV, WY, STATES ITEM 3.D. SEE ATTACHED ENDORSEMENT SCHEDULE ITEM 4. 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. CODE 0938 SEE ATTACHED SCHEDULE OF OPERATIONS EXPENSE CONSTANT TOTAL ESTIMATED ANNUAL PREMIUM DEPOSIT PREMIUM .0236 PA EMPLOYER ASSESSMENT TOTAL AMOUNT BALANCE FROM LAST YEAR 29,995 140 $30,135 $30,135 $711 $30,846 $17,113.00 MINIMUM PREMIUM $986 PAGE 01 HOME OFFICE 02/14/04 SEE REVERSE SIDE ** S C H E D U LEO FOP ERA T ION S ** ITEM 4. ST LOC CODE NO CLASSIFICATIONS WFS PREM BASIS RATE TOTAL-EST PER $100 ANN REMUN REMUN EST ANNUAL PREMIUM PA 001 0953 CLERICAL OFFICE EMPLOYEES IF ANY 0805 MILK HAULING BY CONTRACTOR 408,200 SUB-TOTAL 9898 EXPERIENCE MOD, EFF 04/23/04, USING FACTOR 9740 TERRORISM RISK INSURANCE ACT OF 2002 - CERTIFIED LOSSES 0063 PREMIUM DISCOUNT ENDORSEMENT 0032 LOSS CONSTANT TOTAL FOR PENNSYLVANIA TOTAL SCHEDULE OF OPERATIONS PREMIUM ** SCHEDULE OF PRIMARY AND ADDITIONAL LOCATIONS ** LOC 001 199 BOOZ RD, SHIPPENSBURG, PA 17257 ** END 0 R S E MEN T S C H E D U L E ** .55 $0 8.46 $34,534 34,534 .9510 1,692 C .046 188 3,035 C 0 $29,995 $29,995 THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES- WC-A4/92, WC-000403* (PA) , WC-370601 (PA) , WC-370602 (PA) , WC-370603A (PA) , WC-UF9574* (PA) , WC-UF3001* (PA) , WC-UF3228* (PA) , WC-000419* (PA) , WC-000420* (PA) , WC-990602 (PA). Q88 7300009 DMB INFORMATION PAGE PRIOR POLICY NUMBER - Q88 7300009 H AA7401 CARL L CRAMER INS. LLC ERIE INSURANCE COMPANY 14664 Q88 7300009 H BOOZ MILK TRANSPORT INC 1099 RIDGE RD SHIPPENSBURG PA 17257-9714 REVISED POLICY CORPORATION OTHER WORKPLACES NOT RISK IDENTIFICATION CUMBERLAND CO SHOWN ABOVE - AS SCHEDULED NUMBER - 002168547 FED ID # 23-7922246 ITEM 2. THE POLICY PERIOD IS FROM 04/23/04 TO 04/23/05 AT THE INSUREDS MAILING ADDRESS. ITEM 3.A. WORKERS COMPENSATION INSURANCE- PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE- PA. ITEM 3.B. EMPLOYERS LIABILITY INSURANCE- PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJl~Y BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE ITEM 3.C. STATES, IF DESIGNATED OTHER STATES INSURANCE- PART ANY, LISTED HERE- ALL STATES IN ITEM 3 .A., THREE OF THE POLICY APPLIES TO THE EXCEPT ND, OH, WA, WV, WY, STATES ITEM 3.D. SEE ATTACHED ENDORSEMENT SCHEDULE ITEM 4. 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. CODE 0938 SEE ATTACHED SCHEDULE OF OPERATIONS EXPENSE CONSTANT TOTAL ESTIMATED ANNUAL PREMIUM DEPOSIT PREMIUM .0236 PA EMPLOYER ASSESSMENT TOTAL AMOUNT 25,687 140 $25,827 $25,827 $610 $26,437 MINIMUM PREMIUM $986 PAGE 01 HOME OFFICE 02/24/04 SEE REVERSE SIDE AFDPLP ** S C H E D U LEO FOP ERA T ION S ** ITEM 4. ST LOC CODE NO CLASSIFICATIONS PREM BASIS RATE TOTAL-EST PER $100 ANN REMUN REMUN EST ANNUAL PREMIUM PA 001 0953 CLERICAL OFFICE EMPLOYEES IF ANY .55 $0 0805 MILK HAULING BY CONTRACTOR 408,200 8.46 $34,534 SUB-TOTAL 34,534 9898 EXPERIENCE MOD, EFF 04/23/04, USING FACTOR .8110 6,527 C 9740 TERRORISM RISK INSURANCE ACT OF 2002 - .046 188 CERTIFIED LOSSES 0063 PREMIUM DISCOUNT ENDORSEMENT 2,508 C 0032 LOSS CONSTANT 0 TOTAL FOR PENNSYLVANIA $25,687 TOTAL SCHEDULE OF OPERATIONS PREMIUM $25,687 ** SCHEDULE OF PRIMARY AND ADDITIONAL LOCATIONS ** LOC 001 199 BOOZ RD, SHIPPENSBURG, PA 17257 ** END 0 R S E MEN T S C H E D U L E ** THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES- WC-A4/92, WC-000403* (PA) , WC-370601 (PA) , WC-370602 (PA) , WC-370603A (PA) , WC-UF9574* (PA) , WC-UF3001* (PA) , WC-UF3228* (PA) , WC-000419* (PA) , WC-000420* (PA) , WC-990602 (PA). Q88 7300009 L5S407 08 BOOZ MILK TRANSP 051839C016 INFORMATION PAGE PRIOR POLICY NUMBER - Q88 7300009 H AA7401 CARL L CRAMER INS. LLC ERIE INSURANCE COMPANY 14664 Q88 7300009 H BOOZ MILK TRANSPORT INC 1099 RIDGE RD SHIPPENSBURG PA 17257-9714 RENEWAL CERTIFICATE CORPORATION CUMBERLAND CO OTHER WORKPLACES NOT SHOWN ABOVE - AS SCHEDULED RISK IDENTIFICATION NUMBER - 002168547 FED ID # 23-7922246 ITEM 2. THE POLICY PERIOD IS FROM 04/23/03 TO 04/23/04 AT THE INSUREDS MAILING ADDRESS. ITEM 3.A. WORKERS COMPENSATION INSURANCE- PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE- PA. ITEM 3.B. EMPLOYERS LIABILITY INSURANCE- PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE ITEM 3.C. STATES, IF DESIGNATED OTHER STATES INSURANCE- PART THREE OF THE POLICY APPLIES TO THE ANY, LISTED HERE- ALL STATES EXCEPT ND, OH, WA, WV, WY, STATES IN ITEM 3 .A., ITEM 3.D. SEE ATTACHED ENDORSEMENT SCHEDULE ITEM 4. 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. CODE 0938 SEE ATTACHED SCHEDULE OF OPERATIONS EXPENSE CONSTANT TOTAL ESTIMATED ANNUAL PREMIUM DEPOSIT PREMIUM .0337 PA EMPLOYER ASSESSMENT TOTAL AMOUNT 17,045 140 $17,185 $17,185 $579 $17,764!'.-i MINIMUM PREMIUM $845 PA RATES, MIN. PREM. AND/OR DEVIATIONS MAY CHANGE L5S407 08 BOOZ MILK TRANSP 051839C016 INFORMATION PAGE PRIOR POLICY NUMBER - Q88 7300009 H AA7401 CARL L CRAMER INS. LLC ERIE INSURANCE COMPANY 14664 Q88 7300009 H BOOZ MILK TRANSPORT INC 1099 RIDGE RD SHIPPENSBURG PA 17257-9714 AMENDMENT 01 *** EFFECTIVE 04/23/03 *** ATTACH THIS TO YOUR POLICY REASON FOR AMENDMENT- AMENDED EXPERIENCE MODIFICATION FACTOR CORPORATION CUMBERLAND CO OTHER WORKPLACES NOT SHOWN ABOVE - AS SCHEDULED FED ID # 23-7922246 RISK IDENTIFICATION NUMBER - 002168547 ITEM 2. THE POLICY PERIOD IS FROM 04/23/03 TO 04/23/04 AT THE INSUREDS MAILING ADDRESS. ITEM 3.A. WORKERS COMPENSATION INSURANCE- PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE- PA. ITEM 3.B. EMPLOYERS LIABILITY INSURANCE- PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE ITEM 3.C. STATES, IF DESIGNATED OTHER STATES INSURANCE- PART THREE OF THE POLICY APPLIES TO THE ANY, LISTED HERE- ALL STATES EXCEPT ND, OH, WA, WV, WY, STATES IN ITEM 3 .A., ITEM 3.D. SEE ATTACHED ENDORSEMENT SCHEDULE ITEM 4. 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. SEE ATTACHED SCHEDULE OF OPERATIONS 16,925 EXPENSE CONSTANT 140 MINIMUM PREMIUM $845 TOTAL ESTIMATED ANNUAL PREMIUM $17,065 DEPOSIT PREMIUM $17,065 CODE 0938 .0337 PA EMPLOYER ASSESSMENT $575 TOTAL AMOUNT $17,640 CHANGE IN TOTAL AMOUNT FOR REMAINDER OF POLICY PERIOD $124.00 C PA RATES, MIN. PREM. AND/OR DEVIATIONS MAY CHANGE L5S407 08 BOOZ MILK TRANSP 051839C016 INFORMATION PAGE PRIOR POLICY NUMBER - Q88 7300009 H AA7401 CARL L CRAMER INS. LLC ERIE INSURANCE COMPANY 14664 BOOZ MILK TRANSPORT INC 1099 RIDGE RD SHIPPENSBURG PA 17257-9714 RE-ISSUED POLICY REASON FOR AMENDMENT- DUE TO RATE CHANGE CORPORATION CUMBERLAND CO OTHER WORKPLACES NOT SHOWN ABOVE - AS SCHEDULED RISK IDENTIFICATION NUMBER - 002168547 Q88 7300009 H FED ID # 23-7922246 ITEM 2. THE POLICY PERIOD IS FROM 04/23/03 TO 04/23/04 AT THE INSUREDS MAILING ADDRESS. ITEM 3.A. WORKERS COMPENSATION INSURANCE- PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE- PA. ITEM 3.B. EMPLOYERS LIABILITY INSURANCE- PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE ITEM 3.C. STATES, IF DESIGNATED OTHER STATES INSURANCE- PART ANY, LISTED HERE- ALL STATES IN ITEM 3 .A. , THREE OF THE POLICY APPLIES TO THE EXCEPT ND, OH, WA, WV, WY, STATES ITEM 3.D. SEE ATTACHED ENDORSEMENT SCHEDULE ITEM 4. 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. SEE ATTACHED SCHEDULE OF OPERATIONS EXPENSE CONSTANT MINIMUM PREMIUM $907 TOTAL ESTIMATED ANNUAL PREMIUM DEPOSIT PREMIUM CODE 0938 .0280 PA EMPLOYER ASSESSMENT TOTAL AMOUNT CHANGE IN PREMIUM FOR REMAINDER OF POLICY PERIOD PAYMENT BALANCE 18,483 140 $18,623 $18,623 $521 $19,144 $ ! /'~ 1,504.00L' $5,039.00 C $14,105.00 L5S407 08 BOOZ MILK TRANSP 051839C016 INFORMATION PAGE PRIOR POLICY NUMBER - Q88 7300009 H AA7401 CARL L CRAMER INS. LLC ERIE INSURANCE COMPANY 14664 Q88 7300009 H BOOZ MILK TRANSPORT INC 1099 RIDGE RD SHIPPENSBURG PA 17257-9714 AMENDMENT 02 *** EFFECTIVE 04/23/03 *** ATTACH THIS TO YOUR POLICY REASON FOR AMENDMENT- AMENDED REMUN DUE TO AUDIT CORPORATION CUMBERLAND CO OTHER WORKPLACES NOT SHOWN ABOVE - AS SCHEDULED FED ID # 23-7922246 RISK IDENTIFICATION NUMBER - 002168547 ITEM 2. THE POLICY PERIOD IS FROM 04/23/03 TO 04/23/04 AT THE INSUREDS MAILING ADDRESS. ITEM 3.A. WORKERS COMPENSATION INSURANCE- PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE- PA. ITEM 3.B. EMPLOYERS LIABILITY INSURANCE- PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE ITEM 3.C. STATES, IF DESIGNATED OTHER STATES INSURANCE- PART THREE OF THE POLICY APPLIES TO THE ANY, LISTED HERE- ALL STATES EXCEPT ND, OH, WA, WV, WY, STATES IN ITEM 3 .A., ITEM 3.D. SEE ATTACHED ENDORSEMENT SCHEDULE ITEM 4. 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. CODE 0938 SEE ATTACHED SCHEDULE OF OPERATIONS EXPENSE CONSTANT TOTAL ESTIMATED ANNUAL PREMIUM DEPOSIT PREMIUM .0280 PA EMPLOYER ASSESSMENT TOTAL AMOUNT AMOUNT FOR REMAINDER OF POLICY PERIOD 27,251 140 $27,391 $27,391 $767 $28,158 $9,014.00l~ MINIMUM PREMIUM $907 CHANGE IN TOTAL L5S407 08 BOOZ MILK TRANSP 051839C016 INFORMATION PAGE PRIOR POLICY NUMBER - Q88 7300009 H AA7401 CARL L CRAMER INS. LLC ERIE INSURANCE COMPANY 14664 Q88 7300009 H BOOZ MILK TRANSPORT INC 1099 RIDGE RD SHIPPENSBURG PA 17257-9714 AMENDMENT 03 *** EFFECTIVE 04/23/03 *** ATTACH THIS TO YOUR POLICY REASON FOR AMENDMENT- SLIDING SCALE DIVIDEND APPLIED CORPORATION CUMBERLAND CO OTHER WORKPLACES NOT SHOWN ABOVE - AS SCHEDULED FED ID # 23-7922246 RISK IDENTIFICATION NUMBER - 002168547 ITEM 2. THE POLICY PERIOD IS FROM 04/23/03 TO 04/23/04 AT THE INSUREDS MAILING ADDRESS. ITEM 3.A. WORKERS COMPENSATION INSURANCE- PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE- PA. ITEM 3.B. EMPLOYERS LIABILITY INSURANCE- PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE ITEM 3.C. STATES, IF DESIGNATED OTHER STATES INSURANCE- PART ANY, LISTED HERE- ALL STATES IN ITEM 3 .A., THREE OF THE POLICY APPLIES TO THE EXCEPT ND, OH, WA, WV, WY, STATES ITEM 3.D. SEE ATTACHED ENDORSEMENT SCHEDULE ITEM 4. 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. SEE ATTACHED SCHEDULE OF OPERATIONS 27,251 EXPENSE CONSTANT 140 MINIMUM PREMIUM $907 TOTAL ESTIMATED ANNUAL PREMIUM $27,391 DEPOSIT PREMIUM $27,391 CODE 0938 .0280 PA EMPLOYER ASSESSMENT $767 TOTAL AMOUNT $28,158 CHANGE IN TOTAL AMOUNT FOR REMAINDER OF POLICY PERIOD $0.00 SLIDING SCALE DIVIDEND 20.00% BASED ON A LOSS RATIO OF .00% $4,604.00 C L5S INFORMATION PAGE PRIOR POLICY NUMBER - Q88 7300009 H AA7401 CARL L CRAMER INS. LLC ERIE INSURANCE COMPANY 14664 Q88 7300009 H BOOZ MILK TRANSPORT INC 1099 RIDGE RD SHIPPENSBURG PA 17257-9714 RENEWAL CERTIFICATE CORPORATION CUMBERLAND CO OTHER WORKPLACES NOT SHOWN ABOVE - AS SCHEDULED RISK IDENTIFICATION NUMBER - 002168547 FED ID # 23-7922246 ITEM 2. THE POLICY PERIOD IS FROM 04/23/04 TO 04/23/05 AT THE INSUREDS MAILING ADDRESS. ITEM 3.A. WORKERS COMPENSATION INSURANCE- PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THE STATES LISTED HERE- PA. ITEM 3.B. EMPLOYERS LIABILITY INSURANCE- PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE ITEM 3.C. STATES, IF DESIGNATED OTHER STATES INSURANCE- PART ANY, LISTED HERE- ALL STATES IN ITEM 3 .A., THREE OF THE POLICY APPLIES TO THE EXCEPT ND, OH, WA, WV, WY, STATES ITEM 3.D. SEE ATTACHED ENDORSEMENT SCHEDULE ITEM 4. 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. CODE 0938 SEE ATTACHED SCHEDULE OF OPERATIONS EXPENSE CONSTANT TOTAL ESTIMATED ANNUAL PREMIUM DEPOSIT PREMIUM .0236 PA EMPLOYER ASSESSMENT TOTAL AMOUNT BALANCE FROM LAST YEAR 29,995 140 $30,135 $30,135 $711 . $ .., 30,8461:- ~ $17,113.00 MINIMUM PREMIUM $986 [RID] PENNSYLVANIA COMPENSATION RATING BUREAU 0 -, EXPERIENCE RATING CALCULATION ;rrt Q887300009H 2168547 BOOZ LEE N MILK TRANSPORT POLICY NUMBER fILE NO. 1099 RIDGE RD 377 4/23/04 SHIPPENSBURG PA 17257 CUHBERLAND CO. CARR. Eff OT Of RATING POLICY LOSSE A REP RTEO LOSSES AS USED YEAR INDEMNITY IIEOICAL TOTAL (A) PART I EXHIBIT Of ACTlIAL LOSSES TOTAL POLICY CLAIII MULT. yp, LOSSES AS LOSSES AS YEAR NUMBER ACC. IN~ REPORTED USED PART II EXHIBIT Of LOSSES SlIB~ECT TO LIIIITING VALlIES ISSlIE DATE TOTAL 2/11/04 . - DEA - TDTAL'3 - A R' 4 - NI R' 5 - TEN RARY CLASS POLICY PAYROLLS EXPECTED EXPECTED AUTHORIZED AlITHORIZED CODE YEAR LOSS fACTOR LOSSES' IE \ a.ASSES RATING VALlIES 00 145,400 3.45 5,016' 01 214,218 3.27 7,005 02 408,238 2.67 10,900 805 767,856 22,921 805 5.56 PART In 951 .70 EXHIBIT 953 .33 Of PAYROLLS, j)'Jqlo.ft EXPECTED LOSSES, AlITHORIZED CLASSES AND' RATING VALUES ACTUAL LOSSES PART IV - RATING PROCEDURE EXPECTED LOSSES CREDIBILITY LINIT CHARGE l.000-C Ind. NOD final 1100 A E C 22,921 .324 LoC .135 .676 .811 .811 [(A' C + E . (L . C) + E (1.000 - C)) / E] = Ind. 1100. f1nal 1100 = Ind. MOO Capped to +/- 25% of Prior MOO ~J PENNSYLVANIA COMPENSATION RATING BUREAU I!I'l!!II!!J EXPERIENCE RATING CALCULATION Q887300009H 2168547 BOOZ LEE N IULK TRANSPORT POLICY NUMBER fILE NO. 1099 RIDGE RD 377 4/23/05 SHIPPENSBURG PA 17257 CUHBERLAND CO. CARR. Eff DT Of RATING POLICY LOSSE S REP RTEO LOSSES AS USED YEAR INDEMNITY MEDICAL TOTAL (A) PART I 03 501 501 501 EXHIBIT OF ACTUAL LOSSES TOTAL 501 501 501 POLICY CLAIM MlILT. YP LOSSES AS LOSSES AS YEAR NlIIlBER Ace. I~* REPORTED USED PART II EXHIBIT Of LOSSES SlIB~ECT TO LINITING VALUES CLASS CODE TOTAL *1 - 0 AT . 2 - PERM POLICY PAYROLLS YEAR ISSlIE DATE 1/31/05 TDTA '3 - EXPECTED LOSS FACTOR R' 4 - MI EXPECTED LOSSES E R' 5 - RARY AUTHORIZED CLASSES AUTHORIZED RATING VALlIES 01 02 03 214,218 408,238 431,576 1,054,032 3.54 3.23 2.60 7,583 13,186 11,221 31,990 805 951 5.64 805 PART In EXHIBIT OF PAYROLLS. EXPECTED LOSSES. AlITHORIZED CLASSES AND 953 .67 .33 RATING VALlIES PART IV - RATING PROCEDURE ACTlIAL LOSSES EXPECTED LOSSES CREDIBILITY LIMIT CHARGE l.oo0-C Ind. MOD Final MOD A 501 E C 31,990 .364 L*C .161 .636 .803 .803 [(A * C + E * (L * C) + E (1.000 - C)) 1 EJ = Ind. NOD. Final MOD = Ind. MOD Capped to +1- 25% of Prior MOD , vJ c{~, v'} f /11/ 71101 AUDIT WORKSHEET AND SUMMARY ,I' ~p \m POLICY INFORMATION Ins. Co ERIE Insured BOOZ MILK TRANSPORT INC. Ins Phone 717 423-5740 Polic Number QBB730000907H Address 1099 RIDGE ROAD '" Ci , State, ZI Policy Period 4/23/02 - 4/23/03 SHIPPENSBURG PA 17257 Aud It Period 5/1/02-5/1/03 A ent Name CARL L CRAMER INS LLC A ent Phone 717-530-8600 Th;.ket No. 73987 Ins Contact ERICK BOOZ Contact Phone 717-423-5740 Policy Type WC Endorslother Ent; CORPORATION FEIN Number 25-1867316 Auditor 72 6 Date Completed 10/28/03 AUDIT SUMMARY - PAYROLL tate PA PA t er NO EMPL 7FT7PT EMPL ass Icat on escr t on CLERICAL OFFICE EMPLOYEES MILK HAULING CONTRACTOR o e 953 805 U Ie o 27 200 o 408 238 DESCRIPTION OF OPERATION ~ FED . STATE OWNER/OFFICER DETAIL TOTAL 382 586 -119 099 109 272 35 479 40B 238 408,238 INSURED IS A CONTRACT MILK HAULER. INSURED PICKS UP MILK AT DAIRY FARMS IN THE SURROUNDING SODTHCENTRAL PENNSYLVANIA AREA, AND DELIVERS THE MILK TO VARIOUS MILK PROCESSORS ON THE EAST COAST. NO OTHER TYPES OF HAULING WERE DONE IN THIS AUDIT PERIOD. R 2002 JAN APR 02 03 APR 03 SubtotaJ Title PRES ID NT VICE PRES SEC TREA Name LARRY BOOZ ER I BOOZ MARTHA OOZ Dulles SEE NO'l'ES SEE NOTES SEE NOTES Code EXCL 8 EXCL Actua' Char eable o 0 39 398 39 398 o D AUDIT DETAIL - PAYROLL NAME DESC CODE TO'l'AL YR 2002 JAN-APR02 QTR 1 03 APR 03 ERI"<;l: BOOZ VP 805 39 398 45 568 -14 864 7 711 983 MILK HAULING 805 368 840 337 018 -104 235 101 561 34 496 CLERICAL OFFICE 953 0 0 0 0 0 Sii'B-~'OTAL 408 238 382 586 -119 099 109 272 35 479 ADJUSTED TOTAL 408 238 AUDIT REFLECTS RECORDS VIEWED 0 Bonuses 0 Aircraft 181 Payroll 0 Job Costs 0 Commissions 0 Subcontractors 0 Disbursements 0 Check Book 0 Board + Lodging 0 ContractlDay Labor 181 General Ledger 0 0 Overtime 0 Non-Sa! Relatives P+L 0 Tips 181 Cooperation Good 0 Cash Receipts 0 Sales Tax 401 K1CAFE: 0 Yes 181 No 181 Other W2S,941S 0 1120 NOV ) 4 7003 ~o .'/' ( ilL) 1"7 (tlL) \~) GDDASSOCIATES, /NC, PLAINTJFF'S EXHIBIT c Page 1 of 2 I POLICY INFORMATION Ins. Co Polic Number Polley Period ER1E Q88730000907H 4/23/02 - 4/23/03 Insured Address BOOZ MILK TRANSPORT INC. 1099 RIDGE ROAO Ticket No. 73987 Tf:T-J POINT QUALITY CONTROL CHECK LIST N/A OK o r8I Description of Operations justified all classes shown and clarifies governing class o r8I Officers/Owners: Gross, duties, code and limitations r8I 0 Standard exceptions realistic o t8I Customer special requirements o r8I Calculations; Recap; Verification o t8I Exposure increase/decrease or other clarifying notes t8I 0 SlIbcontractor detail; Relationship/terminology o t8I No single figures; if any, source explained o t8I Audit period within 16 days of policy expiration, or documented why o t8I All worksheet blocks completed including signature AUDIT NOTES DISCUSSED WITH VP ERICK BOOZ OFFICERS' DUTIES, DESCRIPTION OF OPERATIONS, AND EMPLOYEES' DUTIES. EXPOSURE NOTES AUDIT WASN'T DONE PER EMPLOYEE- MORE THAN 10. NO STANDARD EXCEPTIONS. CODE 805 EXPOSURE WAS MORE THAN 20% ABOVE ESTIMATE AS A RESULT OF SIGNIFICANT BUSINESS GROWTH DURING THIS AUDIT PERIOD. OFFICER NOTES PRES LARRY BOOZ AND SECITREAS MARTHA BOOZ WERE INACTIVE, SO THEY WERE EXCLUDED. VP ERICK BOOZ (805) MADE MANAGEMENT DECISIONS, SCHEDULED THE DRIVERS, 'FILLED IN' AS A DRIVER ON OCCASION (DROVE ONE DAY IN THE PAST 3 WKSj, AND DID MAINTENANCE WORK ON THE MILK-HAULING TANK TRUCKS. NO OTHER OFFICERS. GDD ASSOC/ATES, INC. Page 2 of 2 <0 \.. ~ -~:YJ ()~ '- ~ ",-j(UDIT WORKSHEET AND SUMMARY CP--flV ~ AA7JfO / POLICY INFORMATION Ins, Co Potic Number PoUc Period Audit Period Ticket No. Polley Type Entl BOOZ MILK TRANSPORT. 1099 RIDGE ROAD SHIPPENBURG PA 17257 CARL L CRAMER INS LLC ERICK BOOZ Ins Phone 717 423-5740 A entPhone 717-530-8600 Contact Phone 717-423-5740 . . . INSURED IS A CONTRACT MILK HAULER. INSURED PICKS UP MILK AT DAIRY FARMS IN THE SURROUNDING SOUTHCENTRAL PENNSYLVANIA AREA, AND DELIVERS THE MILK TO ARIOUS MILK PROCESSORS ON THE EAST COAST. NO OTHER TYPES OF HAULING WERE DONE IN THIS AUDIT PERIOD. YR 2003 ROUNDING tal 431 574 2 431 576 TOTAL 431,576 OWNER/OFFICER DETAIL EXCL o 37 783 o Char ..ble o 37 783 o Name LARRY B Z ERICK BOOZ MARTHA Z Dul EE N N EE N TE TES Code EXCL Actu. AUDIT DETAIL. PAYROLL N1IME DESC CODE 'l'OTAlo YR 2003 ERICK BOOZ VP 805 37 783 37 783 JAMES COHICK 805 11 499 11 499 ALAN WENGER 805 52. 112 52 112 TOM MCGOWAN 805 26 122 26 122 TOVAR EUTZY 805 1 360 1 360 ABRAM BYERS JR 805 30 551 30 551 AARON BAER 805 5 684 5 684 DAN WISER 805 8 838 8 838 GREG MORRIS 805 21 707 21 707 CHAS TRUET JR 805 9 736 9 736 GERALD DAVIDSON B05 7 383 7.383 RYAN TRAIN! 805 41 063 41 063 MYLES WORTHINGTO 805 18 987 18 987 KEN HOCKENBERRY 805 30.530 30.530 WILLIAM HAlBERT 805 15 123 15 123 RYAN !(ANN 805 305 305 JASON NEGLE Y 805 221 221 RON COLLINS 805 32.880 32 880 DAVE SHIVES 805 32 909 32 909 ROBERT RHINE JR 805 46 783 46 783 CLERICAL OFFICE 953 0 0 SOB-TOTAL 431 576 431 576 ADJUSTED TOTAL 431 576 'JIb '8W7 4JC- rnel. fj-"TOf GDD ASSOCIATES, INC. ,75/ Page 1 of 2 AUG 1 0 7004 POI..ICY INfORMATION - Ins. Co PolI~ Number Policy Period ERIE QB8730000908H 4/23/03 - 4/23/04 Insured Address BOOZ MILK TRANSPORT. 1099 RIDGE ROAD Ticket No. 80725 , AUDIT REFLECTS RECORDS VIEWED 0 Bonuses 0 Aircraft 181 Payroll 0 Job Costs 0 Commissions 0 Subcontractors 0 Disbursements 0 Check Book 0 Board + Lodging 0 ContracVDay Labor 0 General Ledger 0 P+L 0 Overtime 0 Non-Sal Relatives 0 Tips 181 Cooperation Good 0 Cash Raceipts 0 Sales Tax 4D1K1CAfE: 0 Ves 181 No 181 Other W2S 0 1120 TEN POINT QUALITY CONTROL CHECK LIST N/A OK o 181 Description of Operations justified all classes shown and clarifies goveming class o 181 Officers/Owners: Gross, duties, code and limilalions 181 0 Standard exceptions realistic o 181 Customer special requirements o 181 Calclllations; Recap; Verification o 181 Exposure Increase/decrease or other clarifying notes 181 0 Subcontractor detail; Relationship/terminology o 181 No single figllres; If Bny, sOllrce explained o 181 Audit period within 16 days of policy expiration, or documented why o 181 All worksheet blocks compleled Including signature AUDIT NOTES DISCUSSED WITH VP ERICK BOOZ OFFICERS: DUTIES, DESCRIPTION OF OPERATIONS, AND EMPLOYEES' DUTIES. EXPOSURE NOTES AUDIT WAS DONE PER EMPLOYEE. THERE WERE NO STANDARD EXCEPTION EMPLOYEES.vI AUDIT HAD TO BE DONE FOR CALENDAR YEAR 2003. AUDIT CONTACT (VP ERICK BOOZ) HAD THE PAYROLL RECORDS FOR YEAR 2003. HOWEVER, THE YEAR 2004 PAYROLL RECORDS WERE WITH THE PRESIDENT LARRY BOOZ, WHO RESIDES IN NEW HAMPSHIRE. LARRY WAS TO SEND THE YEAR 2004 PAYROLL RECORDS TO ERICK, BUT HAS FAILED TO DO SO (ERICK ADVISED THAT YOUR COMPANY WOULDN'T RENEW THE WORKERS COMP POLICY FOR POLICY YEAR 2004- 2005. HE SAID THAT LARRY WASN'T HAPPY ABOUT THAT AND WAS 'IN NO HURRY' TO SEND THE YR 2004 PAYROLL RECORDS TO ERICK.). I WAITED AND WAITED FOR LARRY TO SEND THE YEAR 2004 PAYROLL RECORDS TO ERICK, BUT LARRY HAS FAILED TO DO SO, SO, I WAS FORCED TO DO THE AUDIT FOR CALENDAR YEAR 2003. OFFICER NOTES PRES LARRY BOOZ AND SECITREAS MARTHA BOOZ WERE INACTIVE, SO THEY WERE EXCLUDED. VP ERICK BOOZ (80S) MADE MANAGEMENT DECISIONS, SCHEDULED THE DRIVERS, FILLED IN AS A DRIVER OCCASIONALLY, AND DID MAINTENANCE WORK ON THE MILK-HAULING TANK TRUCKS. NO OTHER OFFICERS. GDD ASSOCIATES, INC. Page 2 of 2 DMB407 08 BOOZ MILK TRANSP 051839C016 FINAL AUDIT STATEMENT AA7401 CARL L CRAMER INS. LLC ERIE INSURANCE COMPANY 14664 Q88 7300009 H BOOZ MILK TRANSPORT INC 1099 RIDGE RD SHIPPENSBURG PA 17257-9714 WHEN THIS POLICY WAS ISSUED, THE PREMIUM WAS BASED ON AN 'ESTIMATED' PAYROLL. RECENTLY, WE RECEIVED AN AUDIT WHICH GAVE US THE 'ACTUAL' PAYROLL. BELOW WE SHOW THE INFORMATION FROM THE AUDIT AND WE INDICATE THE 'ACTUAL' PREMIUM AND THE 'ESTIMATED' PREMIUM AND HOW THE 'CHANGE IN PREMIUM' AFFECTS YOUR ACCOUNT. AUDIT PERIOD 04/23/03 TO 04/23/04 ST LOC CODE CLASSIFICATIONS AUDITED RATE NO PAYROLL PER $100 PREMIUM PA 001 0953 CLERICAL OFFICE EMPLOYEES NIL .46 0 0805 MILK HAULING BY CONTRACTOR 431,576 7.67 $33,102 9898 EXPERIENCE MOD, EFF 04/23/03, USING FACTOR .9510 1,622 C 9740 TERRORISM RISK INSURANCE ACT OF 2002 - .043 186 CERTIFIED LOSSES 0063 PREMIUM DISCOUNT ENDORSEMENT 2,886 C LOSS CONSTANT 0 EXPENSE CONSTANT 140 ACTUAL PREMIUM 28,920 0938 ACTUAL EMPLOYER ASSESSMENT 2.80% 810 ESTIMATED PREMIUM 27,391 0938 ESTIMATED EMPLOYER ASSESSMENT 2.80% 767 CHANGE IN PREMIUM DUE TO AUDIT $1,572 ,__mom L5S407 08 BOOZ MILK TRANSP 051839C016 FINAL AUDIT STATEMENT AA7401 CARL L CRAMER INS. LLC ERIE INSURANCE COMPANY 14664 Q88 7300009 H I BOOZ MILK TRANSPORT INC 1099 RIDGE RD SHIPPENSBURG PA 17257-9714 WHEN THIS POLICY WAS ISSUED, THE PREMIUM WAS BASED ON AN 'ESTIMATED' PAYROLL. RECENTLY, WE RECEIVED AN AUDIT WHICH GAVE US THE 'ACTUAL' PAYROLL. BELOW WE SHOW THE INFORMATION FROM THE AUDIT AND WE INDICATE THE 'ACTUAL' PREMIUM AND THE 'ESTIMATED' PREMIUM AND HOW THE 'CHANGE IN PREMIUM' AFFECTS YOUR ACCOUNT. AUDIT PERIOD 04/23/03 TO 04/23/04 ST LOC CODE CLASSIFICATIONS AUDITED RATE NO PAYROLL PER $100 PREMIUM PA 001 0953 CLERICAL OFFICE EMPLOYEES NIL .46 0 0805 MILK HAULING BY CONTRACTOR 431,576 7.67 $33,102 9898 EXPERIENCE MOD, EFF 04/23/03, USING FACTOR .9510 1,622 C 9740 TERRORISM RISK INSURANCE ACT OF 2002 - .043 186 CERTIFIED LOSSES 0063 PREMIUM DISCOUNT ENDORSEMENT 2,886 C LOSS CONSTANT 0 EXPENSE CONSTANT 140 ACTUAL PREMIUM 28,920 0938 ACTUAL EMPLOYER ASSESSMENT 2.80% 810 ESTIMATED PREMIUM 27,391 0938 ESTIMATED EMPLOYER ASSESSMENT 2.80% 767 CHANGE IN PREMIUM DUE TO AUDIT $1,572 (i. 060407 OL5S00Z MILK TRANSP 014971B230 FINAL AUDIT STATEMENT AA7401 CARL L CRAMER INS. LLC ERIE INSURANCE COMPANY 14664 Q88 7300009 H BOOZ MILK TRANSPORT INC 1099 RIDGE RD SHIPPENSBURG PA 17257-9714 WHEN THIS POLICY WAS ISSUED, THE PREMIUM WAS BASED ON AN 'ESTIMATED' PAYROLL. RECENTLY, WE RECEIVED AN AUDIT WHICH GAVE US THE 'ACTUAL' PAYROLL. BELOW WE SHOW THE INFORMATION FROM THE AUDIT AND WE INDICATE THE 'ACTUAL' PREMIUM AND THE 'ESTIMATED' PREMIUM AND HOW THE 'CHANGE IN PREMIUM' AFFECTS YOUR ACCOUNT. AUDIT PERIOD 04/23/02 TO 04/23/03 ST LOC CODE CLASSIFICATIONS NO AUDITED PAYROLL RATE PER $100 PREMIUM PA 001 0953 CLERICAL OFFICE EMPLOYEES 0805 MILK HAULING BY CONTRACTOR NIL 408,238 .41 0 6.41 $26,168 9898 EXPERIENCE MOD, EFF 04/23/02, USING FACTOR .9580 0063 PREMIUM DISCOUNT ENDORSEMENT LOSS CONSTANT EXPENSE CONSTANT 1,099 C 2,188 C o 140 0938 .0337 ACTUAL PREMIUM ACTUAL EMPLOYER ASSESSMENT 23,021 776 0938 .0337 ESTIMATED PREMIUM ESTIMATED EMPLOYER ASSESSMENT 15,688 529 $ 7, 580 II CHANGE IN PREMIUM DUE TO AUDIT ~ ERIE ~ INSURANCE ERIE. GROUP DATE: Policyholder: BOOZ MILK TRANSPORT INC 04107/06 Account No. Q887300009 A!lent # AA7401 Tvoe work comp PREMIUM AND CASH TRANSACTIONS BALANCE DATE TRANSACTION CHARGES CREDITS 1 04/23/04 renewal $17,764.00 2 04123/04 endorsement -124.00 3 04/23/04 endorsement $1,504.00 4 04/23/06 endorsement $9,014.00 5 04/23/04 dividends -4,604.00 6 04/23/04 audit $1,572.00 7 04/23/04 audit $7,580.00 04/22/03 oaid -1,522.50 05/02/03 oaid -1,741.00 05/13/03 oaid -3,344.00 06/23/03 oaid -534.50 07/13/03 Daid -1,241.00 08/25/03 oaid -1,542.00 10/02/03 oaid -1,778.00 10/23/03 "aid -1,845.00 12/03/03 Daid -3,159.00 02/02/04 oaid -1,295.00 02/09/04 naid -623.00 04/23/04 end of oolicv 0.00 $37,434.00 -23,353.00 14081.00 8 04/23/04 renewal $30,846.00 03/30/04 oaid .$2,891.00 04/23/04 old balance ***** $14,081.00 04/23/04 endorsement -4,409.00 05/09/04 oaid -$3,086.00 06/05/04 cancelled -23,014.00 $44,927.00 -$33,400.00 11 ,527.00 PLAINTIFF'S I EXHIBIT D I ACCOUNT SUMMARY ***It.. ep due p -f,g. ;d ~ lf1 \\- 'r\- Crt UI '".::i ~ \) ~ f ~ ( E +- ~ . .', n t' I h reby certify that the above names are correct and Precise Busi ess Address of the judgment creditor is Address 100 Erie Insurance Place Erie PA 16530 Address of Defendant 199 B002 Road Shippensburg PA 17257-9726 MORRI BY: IDENT P.O. Philo. (215) & ADELMAN, P.C. AMES W. ADELMAN, ESQUIRE ATTORNEY FOR PLAINTIFF FICATION #02604 ox 30477 Erie Insurance Company elphia, Pennsylvania 19103-8477 568-5621 Erie 100 E Erie nsurance Company ie Insurance Place A 16530 COURT OF COMMON PLEAS CUMBERLAND COUNTY CIVIL DIVISION vs. B002 ilk Transport Inc. 199 B 02 Road Shippe sburg PA 17257-9726 NO. 06-2444 ORDER FOR ENTRY OF JUDGMENT AND ASSESSMENT OF DAMAGES TO THE PROTHONOTARY: En and ag above- file a er judgment in favor of the Plaintiff, Erie Insurance Company, inst the Defendant(s), B002 Milk Transport Inc., in the nti tled proceeding in the sum of $12,997.39 for failure t,o Answer, and assess damages as follows: AS ABOVE: .C. unt of Claim In erest from April 23, 2004 TO AL JAMES W. ADELMA , ESQUIRE Attorneys For P]aintiff JWA0608.2 & ADELMAN, P.C. AMES W. ADELMAN, ESQUIRE FICATION #02604 ox 30477 elphia, PA 19103-8477 568-5621 MORRI BY: IDENT P.O. Phila (215) ATTORNEY FOR PLAINTIFF Erie Insurance Company COURT OF COMMON PLEAS CUMBERLAND COUNTY CIVIL DIVISION nsurance Company ie Insurance Place A 16530 Erie 100 E Erie vs. ilk Transport Inc. 02 Road nsburg PA 17257-9726 Booz 199 B Shipp 06-2444 NO. CERTIFICATION I hereby certify that I sent a Notice Of Intention to file a defau t judgment to Defendant(s) by mail pursuant to Pa. R.C.P. 237.1, a true and correct copy of which is attached hereto as Exhibit "A". P.C. ES W. ADELMAN, torneys For PIa' JWA0608.2 . MORRI BY: IDENT P.O. Phila (215) & ADELMAN, P.C. AMES W. ADELMAN, ESQUIRE ATTORNEY FOR PLAINTIFF FICATION #02604 ox 30477 Erie Insurance Company elphia, Pennsylvania 19103-8477 568-5621 Erie 100 E Erie nsurance Company ie Insurance Place A 16530 COURT OF COMMON PLEAS CUMBERLAND COUNTY CIVIL DIVISION vs. Booz 199 B Shipp ilk Transport Inc. oz Road nsburg PA 17257-9726 NO. 06-2444 TO: Booz Milk Transport Inc. 199 Bo02 Road Shippensburg PA 17257-9726 DATE IMPORTANT NOTICE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN NCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE OUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST NLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND LOSE YOU SHOULD TAKE THIS PAPER TO YOU LAWYER AT ONCE. IF YOU AVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION IRING A LAWYER. IF YOU CAN NOT AFFORD TO HIRE A LAWYER, THIS MAY BE ABLE TO PROVIDE INFORMATION ABOUT AGENCIES THAT MAT EGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. NOTICE: June 2, 2006 YOU AR APPEA COURT YOU. NOTICE YOU MA DON'T OFFICE ABOUT OFFICE OFFER LAWYER REFERENCE SERVICE Cumber and County Bar Associatl 2 Libe ty Av Carlis e PA 17013 717/24 -3166 ature of Plai tiff or Attorney) jwa0525.2 ~7i~~ ~~~~ ~ ~ ~~ ...~ ..1::- ~ -\:-, .~\.. J:;' r;:;~ {') c;> '::.-n 0.... .-\ <-.- :r:-n ~;:"~ rn e. -~~ ~c:~ .- .,"" l._ 0) '--l; ~~::\ 'l :::~ '2 c:~\ _'" ::.-.rT1 U, '::: -,.... <1:..1 0) ~ 0-' , . OFFICE OF THE PROTHONOTARY COURT OF COMMON PLEAS CUMBERLAND COUNTY t.,-- ; TO: BOOZ MILK TRANSPORT INC. 199 Booz Road Shippensburg, P A 17257 SURANCE COMPANY ,e Insurance .Place " 16530 COURT OF COMMON PLEAS CUMBERLAND COUNTY CIVIL DIVISION vs. BOO MILK TRANSPORT INC. 199 B zRoad Shipp sburg, PA 17257 NO. 06-2444 NOTICE Pursuant to Rule 236 of the Supreme Court of Pennsylvania, you are hereby notified that a Jud ent has been entered against you in the above proceeding as' . cat I () Judgment Against Garnishee () Complaint (Confession ofJudgment) ~II~ /O(p () Judgment transferred from another jurisdiction (X) Judgment by Default () Money Judgment () Judgment in Replevin () Judgment for Possession () Judgment on Award of Arbitrators () Judgment on Verdict () Judgment on Court Findings HAVE ANY QUESTIONS CONCERNING TillS NOTICE, PLEASE CALL: JAMES W. ADELMAN, ESQUIRE At thi telephone nwnber: 215-568-5621 MORRIS & ADELMAN, P.C. BY: JAMES W. ADELMAN, ESQUIRE ATTORNEY FOR PLAINTIFF IDENTIFICATION #02604 Erie Insurance Company P.O. Box 30477 Philadelphia, Pennsylvania 19103-8477 (215) 568-5621 Erie Insurance Company 100 Erie Insurance Place Erie PA 16530 COURT OF COMMON PLEAS CUMBERLAND COUNTY CIVIL DIVISION vs. Booz Milk Transport Inc. 199 Booz Road Shippensburg PA 17257-9726 NO. 06-2444 ORDER TO SATISFY JUDGMENT TO THE PROTHONOTARY: Please mark the judgment in the above-entitled case satisfied upon payment of your costs only. So Ordered As Above: JAMES W. ADEL Attorneys For Prothonotary JWA0817.2 2 ':.S- -0 t~P n'Hl ~/' th,,' -< .' r;;:,c -~:li~_. 7('::- Z 2 l ~ = C' ~ G"1 N c- ~ :; ~ ~:!1 ""'~ :u 0.) ~-1-r\ -f--rt ~o ,-en 9 ~ r:-? c- -l . , IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA ERIE INSURANCE COMPANY 100 Erie Insurance Place Erie, PA 16530 NO. 06-2444 vs. BOOZ MILK TRANSPORT INC. 199 Booz Road Shippensburg, P A 17257 and ORRSTOWN BANK, Garnishee PRAECIPE FOR WRIT OF EXECUTION TO THE PROTHONOTARY: Issue Writ of Execution in the above matter. (1) directed to the Sheriff of Cumberland County (2) against BOOZ MILK TRANSPORT INC. , defendant; and (3) against ORRSTOWN BANK , garnishee; (4) and index this writ (A) against , defendant and (B) against , as garnishee, as a lis pendens against real property of the defendant in name of garnishee as follows: All accounts, funds, deposits, debts, or other items of personal property standing in the name of the defendant. (5) Amount Due: $ 12.997.39 Attorney's Commission Interest from 6/16/06 ~ + b Q::J ~ l .... t' . t ~ ~ , (') ~1 ~ l.a..J f~ ~~ f/) 6 t () ~~ ~ ~-l::~ ,.. ~ ..o~ w Vt i... ~ 6 ~ ~ '''1 -tODO ~() I j I \' r.:::, it! ~ ~ ~ : ~ .. .. ~:.~'E ,,, V-f{:- WRIT OF EXECUTION and/or ATTACHMENT . , COMMONWEALTH OF PENNSYLVANIA) COUNTY OF CUMBERLAND) NO 06-2444 Civil CIVIL ACTION - LAW TO THE SHERIFF OF CUMBERLAND COUNTY: To satisfy the debt, interest and costs due ERIE INSURANCE COMPANY, Plaintiff (s) From BOOZ MILK TRANSPORT INC., 199 BOOZ ROAD, SHIPPENSBURG, P A 17257 (I) You are directed to levy upon the property of the defendant (s)and to sell . (2) You are also directed to attach the property of the defendant(s) not levied upon in the possession of ORRSTOWN BANK, 77 E. KING STREET, SHIPPENSBURG, PA 17257 - ALL ACCOUNTS, FUNDS, DEPOSITS, DEBTS, OR OTHER ITEMS OF PERSONAL PROPERTY STANDING IN THE NAME OF THE DEFENDANT GARNISHEE(S) as follows: and to notify the garnishee(s) that: (a) an attachment has been issued; (b) the garnishee(s) 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; (3) If property of the defendant(s) not levied upon an subject to attachment is found in the possession of anyone other than a named garnishee, you are directed to notify him/her that he/she has been added as a garnishee and is enjoined as above stated. Amount Due $12,997.39 Interest FROM 6/16/06 Atty's Comm % Atty Paid $126.34 Plaintiff Paid Date: JULY 21, 2006 L.L. $.50 Due Prothy $1.00 Other Costs (Seal) Prothonotary By: Deputy REQUESTING PARTY: Name JAMES W. ADELMAN, ESQillRE Address: MORRIS & ADELMAN, P. C. 1920 CHESTNUT STREET, S/300 P.O.BOX 30477 PHILADLEPHIA, PA 19103-8477 Attorney for: PLAINTIFF Telephone: 215-568-5621 Supreme Court ID No. 02604 MORRIS & ADELMAN, P.C. BY: JAMES W. ADELMAN, ESQUIRE IDENTIFICATION #02604 P.O. Box 30477 Philadelphia, Pennsylvania (215) 568-5621 ATTORNEY FOR PLAINTIFF Erie Insurance Company 19103-8477 Erie Insurance Company 100 Erie Insurance Place Erie PA 16530 COURT OF COMMON PLEAS CUMBERLAND COUNTY CIVIL DIVISION vs. Bo02 Milk Transport Inc. 199 Bo02 Road Shippensburg PA 17257-9726 and Orrstown Bank Garnishee NO. 06-2444 ORDER TO DISCONTINUE ATTACHMENT TO THE PROTHONOTARY: Kindly discontinue the attachment against the garnishee, Orrstown Bank, only in the above-captioned matter. N, ESQ laintiff So Ordered as above: Prothonotary JWA0817.2 ~ t ~ ,-.' () ('~:--=' C~) (). C:.J-... ~ ~ (:) I ~ p: --.:; ~ ~ ~ - " . . L- "-~# --! SHERIFFIS RETURN - REGULAR CASE NO: 2006-02444 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND ERIE INSURANCE COMPANY VS BOOZ MILK TRANSPORT INC MICHAEL BARRICK , Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon BOOZ MILK TRANSPORT INC the DEFENDANT , at 1707:00 HOURS, on the 9th day of May , 2006 at 199 BOOZ ROAD SHIPPENSBURG, PA 17257-9726 by handing to NICK ALSPAUGH, EMPLOYEE, ADULT IN CHARGE a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge (\ ';/..l ..d 0 <{ -~ 18.00 15.84 .00 10.00 .00 43.84 So Answers: .-r~~~:~-(. ~J , I R. Thomas Kline day of 05/10/2006 MORRIS & ADELMAN #' //'----;J BY~~~.. . Deputy Sheriff """ Sworn and Subscribed to before me this A.D. Prothonotary T~oma~ ~line, Sheriff, who being p9~~~~~~!ppaw, states thIS wnt IS returned STAYED. "PL ...,.. [11H.iT'r, p,~ Sheriffs Costs: ZOUb JUl 28 AA&r>>@e Costs: 380.54 Sheriffs Costs: 354.88 $ 25.66 Docketing Poundage Advertising Law Library Prothonotary Mileage Surcharge Levy Certified Mail Post Pone Sale Garnishee Postage TOTAL $ 18.00 230.54 .50 1.00 15.84 40.00 40.00 Refunded to Atty on 08/30/06 9.00 354.88 / q -1I-oC, CJ- ~~~ R. Thomas Kline, Sheriff ~ CJ o.ndi~ J3,(luDb~ By Claudia A. Brewbaker o " ).J ...c. 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Y'1- NOl.L:)Y '1IAD HAD f'f'f'Z-90 ON (QNYT~EI8:Wn:) dO AlNflO:) (YINY A '1ASNNtId dO Hl'1Y3:M.NOWWO:) .LNJ:WH;)V.L.LV.lO/PUU NO'lLfl;)ID(J:""O' .LIlIA\. SHERIFF'S RETURN - GARNISHEE CASE NO: 2006-02444 P COMMONWEALTH OF PENNSLYVANIA COUNTY OF CUMBERLAND ERIE INSURANCE COMPANY VS BOOZ MILK TRANSPORT INC And now RICHARD SMITH ,Sheriff or Deputy Sheriff of Cumberland County of Pennsylvania, who being duly sworn according to law, at 0010:24 Hours, on the 2nd day of August , 2006, attached as herein commanded all goods, chattels, rights, debts, credits, and moneys of the within named DEFENDANT BOOZ MILK TRANSPORT INC , in the hands, possession, or control of the within named Garnishee ORRSTOWN BANK 77 E. KING ST SHIPPENSBURG, PA 17257 Cumberland County, Pennsylvania, by handing to PAT KARPER (TELLER) personally three copies of interogatories together with 3 true and attested copies of the within WRIT OF EXECUTION and made the contents there of known to Her . Sheriff's Costs: Docketing Service Affidavit Surcharge .00 .00 .00 .00 .00 .00./9-1'I-o{,'7L-. 08/08/2006 So an~~~~, . ~ ',.~- ~ R. Thomas Kline Sheriff of Cumberland County before me this day of By Sworn and Subscribed to A.D