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7632-C-6049
TIIIBY non . TIIIBY
BYI Daniel J. Allan
I4entifiaation HOI 02612
suite 3100
1818 Market street
Philadelphia, PA 1'103
(215) SU-4141
Attorney fori Plaintiff
LUMBERMENS MUTUAL CASUALTY CO.
25 DeForest Avenue
Summit, New Jersey 07901
COURT OF COMMON PLEAS
v.
MECHANICSBURG GF INVESTORS
HOLIDAY INN - MECHANICSBURG
5401 Carlisle Pike
Mechanicsburg, PA 17055
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COMPLAIlfT
1. The Plaintiff, Lumbermens Mutual Casualty Company, is a
corporation duly organized under the laws of the State of Illinois,
lice~Bed tc d~ businaca i~ the ct~tes af ~ew Jersey and Pennsylvania
with an office located at 25 DeForest Avenue, Summit, New Jersey
07901.
2. The Defendant, Mechanicsburg GF Investors, Holiday Inn,
Mechanicsburg is a corporation and conducts business at 5401 Carlisle
Pike, Mechanicsburg, Pennsylvania 17055.
3. On or about August 3, 1991, Plaintiff issued to Defendant
a policy of insurance titled Workers Compensation and Employers
Liability POlicy, policy number 3BA001447, effective from August 3,
1991 to August 3, 1992. The original policy ot insurance is in the
possession ot the Defendant and cannot be attached her.eto. However,
a specimen ot the policy and copy of the declaration of coverage of
said policy are attached hereto and marked Exhibit "A".
4. The policy ot insurance issued to Detendant, in Part Five
entitled "Premium" spelled out in detail all provisions relating to
the charge ot premium and payment of premium including but not limited
to an audit pr.ovision and explained that the initial premium was an
estimate with the final premium to be determined after the policy
ends. See Part Five, Subsection E entitled "Final Premium of the
Policy of Insurance" which is Exhibit "A".
5. The policy of insurance issued to Defendant, in Part Five
entitled "Premium", Subsection G entitled "Audit" provides:
"'lou will let us examine and audit all your
records that relate to this policy. .. Information
developed by audit will be used to determine
final premium."
6. plaintiff, pursuant to the "Audit provision" of said policy,
did audit the books and records of the Defendant and as a result of
the audit, it was determined that the total earned premium was
$88.221.00 of Which Defendant, at the time the policy was issued, paid
the sum of $83,250.00 leaving a balance due and owing upon completion
of the audit the sum of $4,971.00. See copy of the Results of Audit
attached hereto and marked Exhibit "B".
7. Plaintiff admits that the Defendant, following the audit,
did make payment of $4,911.00.
8. Subsequent to the additional
$4,971.00, in accordance with the law
payment by Defendant
of the Commonwea 1 th
of
of
, .
Pennsylvania, the Pennsylvania compensation Rating Bureau reviewed the
entire records pertaining to the policy and to the calculation of the
total premium and determined that one of the classifications used by
the Plaintiff, Class 951, was not authorhed.
The Pennsylvania
compensation Rating Bureau then directed Plaintiff to recalculate the
total premium due using the proper classiflcation.
See letter of
pennsylvAnia Compensation Rating Bureau attached hereto and marked
Exhibit "C".
9. As a result of the recalculation of the total premium due
in accordance with the directive of the Pennsylvania Compensation
Rating Bureau, it was determined that the total earned premium for
said policy was $90,093.00. See copy of audit dated June 10, 1993
attached hereto and marked Exhibit "0".
10. As the Defendant had made payments of $88,221.00, there is
a balance still due and owing in the amount of $1,872.00.
11. Defendant, in spite of being billed and requested to pay the
additional premium, has failed to make p~yment to Plaintiff.
12. Defendant has breached the contract which it entered into
with Plaintiff.
WHEREFORE, Plaintiff, Lumbermens Mutual Casualty company, demands
judgment against Defendant in the amount of $1,872.00 together with
interest and costs, including but not limited to attorney~ fees.
TIMBY BROWN & TIMBY
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By: . !-(hut lltl.. III,)
DANIEL J. ALLAN, ESQUIRE
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Attorney for'Plaintiff
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VIRIrICATJ:OII
The undersigned hereby states that he
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of Lumbermens Mutual Casualty Company, plaintitf herein, and verities
that the statements made in the foregoing civil Action complaint are
true and correct to the best of his knowledge, information and belief
and understands that the statements herein are made subject to the
penalties of 18 Pa. C.S. S4~04 relating to unsworn falsification to
authorities.
LUMBERMENS MUTUAL CASUALTY co.
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'In relurn for the paymenl of lhor premium md ~ublecl to olllterm~ of th" policy, we olgree wilh you al follow~.
GINERAI, SECTION
A. The Policy
This policy Includel at ill orHectlve dale the Information
PI.e and IlIendo"ementl and Ichedul..lllled lhere, It
II I contrlct of ,nlurance belween you Ilhe employer
nlmed In 111m 1 of the Information Page) and UI (the
Inlurer nlmed on the Information Page). The only
Igreemenll relallng to thillnsurance are Italed in tnll
policy, The lerm~ of Ihll policy may not be cholnBed or
w.lved e.cepl by endo"ement IlIued by u~ 10 be part
of lhl~ policy,
I. Who t.lnlured
You are Insured If you are an employer namltd In Item 1
of lhe Informallon Page, If that employer il a partner.
Ihlp, and If you are one of ill partner!, you are inlured,
but only in your capacity al an employer of the partner.
shlp'l employeel,
C. Workell Campen.allon Law
Worke" Compensallon Law means tne worker! or
workmen'l compenlatlon law and occupational dlleale
I.w of each Ilolte or lerrltory named In item 3,A, of the
Information page, It Includorl any amendmentllo lhat
I.w which are In effect during lhe policy period. It doe~
not Include the provllions of any law lhat provide non-
occupational dllolbillty beneflll,
D. Slale
Slale melnl Iny Ilolte of the United State~ of America,
.nd the Dlmlct of Columbia.
I. Location.
Thll policy covell all of your workplacellllted In Items 1
or 4 of lhe Information Page; and It covell all other
workplacel In Item lA. Itatel unlell you have other
Inlurance or are lelf.lnlured for luch workplacel,
PART ONE - WORKERS COMPENSATION INSURANCE
A. How Thl.lnlurance Applies
This workerl compenlation inlurance applies to bodily
Injury by aCCident or bodily injury by dlseale, Bodily
Injury Includel relulting death.
1. 1I0dily Injury by Iccldent must occur during the
policy period.
2. Bodily injury by dileale mUlt be cauled or ag-
gravatord by the conditIOns of your employment The
flmployee'llall day of lalt expolure to the condilions
causing or aggravlting luch bodily injury by dllease
mUll occur during the policy period,
I. We Will PlY
We will pay promptly when due the benefits required
of you by lhe workers compenlatlon law.
C. We Will Defend
We hav.. lhe right and duty to defend at our expense
any cla,m, proceed,ng or luit agaInst you for benefits
C.",.,tr.1 "IJ ~.lIjol,,1 Cl)ufttil on C:Orftp.llwUon lnlu""u.
payable by thillnlurance, We have the rignllo Invel-
ligate and leltle thele c1alml, proceedings or IUItS.
We have no dUlY to defend a c1alm, proceeding or IUIt
thaI il nor covered by In.s insurance,
D. We Will Alia Pay
We will allo pay Ihele COIIS, In addition to other
amounll payable under thll Insurance, 15 part of allY
c1aim, proceedlng, or lult we defend:
1. realonable e'penses incurred at our requelt, bUI nOI
1011 of earningl;
2, premium, for bOllds 10 relealt allacnmenls and for
appeal bondl in bond amounlS up to lhe amounl
payable under Ihis Inlurance;
3, litigation COlli taxed against you;
~, interelt on a judgmenl al required by law un III we
oHer lhe amounl due under Ihil Inlurance; and
5, expensel we incur,
E. Olher Inll.ranee
We will nOl pay more than our share 0/ benefltl and
COSIS covered by this Insurance and olher Inlurance or
lel/-inlurance. Sublect to any limits of liability that may
apply, alllharel will be equal until tne 1011 Is paid. If any
Insurance or lelf.insurance II exnaulted. the Ihares of all
remaining Insurance will be equal until the 1011 Is paid.
F. Paymenls You MUll Make
You are responllble for any paymen15 In excell of the
benefltl regularly provided by the workers compensa-
tion law Including thOle required because:
1. of your serioul and willful mllconduct;
2. you knowingly employ an employee In violation of
law;
3, you fail 10 comply with a health or safelY law or
regulation; or
4, you discharge, coerce or olherwlse dllcrlmlnate
against any employee in violation of the workers
compensation law,
If we make any paymenls In excell of the benefltl regu-
larly provided by lhe workers compensation law on
your behalf, you will reimburse UI promptly.
G. Recovery From Others
We nave your rightl, and the rignll of persons entllled
to the benefitl of this Insurance, to recover our pay-
mentl from anyone liable for lhe Injury. You will do
everyth,ng necellary to p,'otect those righlS for us and
10 help UI enforce them.
H. Statulory Pr"vllions
These Ilatemenll apply wnere lhey are required by law,
1, AI between an injured worker and UI, we have
notice or the injury when you have notice.
2. Your default or the bankruptcy or insolvency of you
or your eltate 1'1111 not relieve us of our dUlies under
thiS InsurJnce after an injury occurs.
1 at S
3. We ~re dlrectl~ ~nd prlm~rlly liable to ~ny perlon
er,lIlled 10 the benefltl payable by thil Imuranct,
Thole perlom may enforce our dutlel; 10 may an
agenq lulhorlZed by law, Enforcemenl may be
agaimt UI or aga'nll you and UI,
4. Iurlldictlon over vou II jurildlction over UI for
purpolel of the workerl compematlon law. We are
bound by dedl.on, agalmt you under tharlaw, lub-
ject to the provlllonl of thll policy that are not In
conflict with that law,
S, Thll inlurance conforml to Ihe pam of the workerl
compematlon law Ihat ~pply 10:
.. beneflrl payable by thlllnlurance;
b, Ipeclallaxel, paymenll inlo lecurllY or other Ipe-
clal fundI, and allellmentl payable by UI under
that :aw,
6. Terml of thll Imurance thaI conflict with the
workerl compenlallon law ~re changed by thil mte-
ment 10 conform 10 Ihallaw,
Nothing In thele paragraphl rellevel you of your dutlel
under thil policy,
PART TWO - EMPLOYERS LIABILITY INSURANCE
A. How Thlllnlllrance Appllel
Thil employer! liabllllY Imurance appliel to bodily In-
jury by accldenl or bodily Injury by dlleale. Bodily
Injury includel relultlng death.
1. The bodily injury mUlt arlle out of and In the COUrle
of the injured employee'l employment by you,
2. The employmenl mUll be necenary or Incidental to
your work In a Itale or territory lilted In Item 3.A. of
the Information Page.
3. Bodily Injury by accident mUll occur during the
policy period.
4. Bodily injury by dlseale mUll be cauled or ag-
gravated by the condltiom of your employment. The
employee'llall day of lalt expolure to the condltlonl
caullng or asgravaling luch bodily Injury by dlleale
mUll occur during the polley period,
S. If you 3re lued, the original lull and any related legal
actlonl for damagel for bodily Injury by accident or
by dlleale mUlt be brought In the United Sratel of
America, itl terrltorlel or pOllelliom, or Canada,
.. We Will Pay
We will pav all lums you legally mUll pay al damagel
beeaule of bodily inJury 10 your employees. provided
the bodily injury II covered by Ihis Employer! Liability
Inlurance.
The damages we will pav, where recovery II permitted
by law, include damage\:
1. for which you ~re liable to a third party by rea.on of a
claim or luit agalnlt you by that third party to recover
the damages cla,med against luch third party al a
relull of ,njury to your employee:
2. for care and 1011 of le"icel; and
3. for consequential bodily :nlur:, 10 a IpOUle, ch.ld,
parent, brother or Illter of the Injured employee;
eo"rip. 1"1 .....tlo".1 (lJunell,)" C<>n'lp."ulio" l",unnn.
prolllded that thele dam~gel are the dirllct come-
qUlln,e of bodily injury Ihat arile, \Jul of and In the
courlll of the injured empl(J~ell'l employmllnt by yo\"
and
4, be,ause of bodllv injury 10 your employee thar arllel
OUI of and in the course of employment, claimed
agai"'t you In a c~paclty other than alemployer,
C. bcllllions
This Imurance does nol cOlier:
1. liability a>lumed under a contract. Thll exclullon
does not apply to a warranty rhat your work will be
done in a workmanllkll manner;
2, punitive or e,emplary damages because of bodily
Injury to an Ilmployee emploJ~ed In lIiolatlon of law;
3, bodily Injury to an employee while employed In
IIlolatlon of law wllh your aClual knowledge or the
aClual knowledge of any of your executllle office,,;
4. any obligation imposed by a workers compenlallon,
occupational dlleale, unemployment compema-
tlon, or disability benefits law, or any Ilmllar law;
5, bodily Injury Intllntlonally cauled or aggrallated by
you;
6, bodily injury occurring oUlside the United States of
America. III terrltorlel or pOI\esslonl, and Canada,
This exclusion does nOI apply 10 bodily Injury to a
cltl~en or resident of the Unlled Stales of America or
Canada who 15 temporarily outside these counlrles;
7. damages arlllng OUI of the dllcharge of, coercion of,
or discrimination agalnll any employeol In IIlolatlon
of law,
D. We will Defend
We have the right and dUlY to defend. al our expeme,
any c1alm, proceeding or suit agalnlt YOIl for damag"
payable by this Insurance. We have the rlghlto Inv,,-
ligale and sellle thele claims. proceedlngl and lulu,
We halle no dUlY to defend a claim. proceeding or luit
thallI nol covered by thillnsurance, We halle no duty
10 defend or continue defending afler we have paid our
applicable limit of liability under thil inlurance.
E. We Will Also Pay
We will also pay these com, In addlllon to other
amounts payable under this Imurance. al part of any
claim, proceeding, or luit we defend:
1, reasonable expenses incurred at our request; but not
lOll of earning\:
2, premiums for bondl to releale attachmenls and for
appeal bonds In bond amountl up 10 lhe limit of our
liability under Ihls Imurance;
3, litigation com taxed against you;
4, interelt on a judgment as required by law until we
offer Ihe amount due under thIS inlurance; and
5. expenses we incur.
f. Other InlurOlnce
We will not pall more 'h~n our ,hare of dama~el and COlli
cOllered by Ihll inlu"nce and o'her insurance or self-
2 of 5
Inlurlnce, SubJect to Iny Iimln ollilbllity rhlt Ipply, III
Ihlrll will be equII unlllthe Ion II plld, If any Insurance
or "II-Insurance Is exhaulled. the shares 01 all remain-
Inl Insurance Ind self .insurance will be equal untlllhe
101111 paid.
G. Umlta of liability
Our liability 10 PlY for damages islimlled, Our limin of
IlabllllY Ire Ihown In item ),8. of the Inlormallon Page.
They apply II explained below.
1. Bodilr Injury by Accident. The I.mlt shown for
'bod I r injury by accidenl.each accldent'lsthe mosl
we wll pay for all damages covered by this insurance
because of bodily injury to one or more employees
In anyone Iccldent
A dlselse Is not bodily injury by acddenl unless It
resulu directly Irom bodily Injury by accident.
2. Bodily Injury by Dlseille, The ilmitshown for 'bodily
Injury by disuse-policy limit. Is Ihe mosl we will pay
for all damlges covered by this Insurance and arising
out 01 bodily Injury by dlsease, regardless 01 Ihe
number of employees who sustain bodily Injury by
disease. The limit shown for 'bodily Injury by
dlsease-elch employee'lslhe most we will pay lor all
damages because 01 bodily Injury by disease 10 any
one employee.
Bodily injury by disease does not Include disease
lhat results directly from a bodily Injury by accident.
3, We will nOI pay any claims lor damages alter we ha....
paid the Ippllcable limit 01 our liability under Ihls
Insurance.
H. Recovery From Othen
We have your rlghn to recover our payment Irom
.nyone liable for an Injury covered by this Insurance.
You will do everything necessary 10 protect those
rllhtslor uSlnd to help us enlorce them.
t. Actlons Alalnsl Us
There will be no right of Ictlon against us under this
insurance unless:
1. you have compiled wilh all the terms of this policy;
and
2, the amount you owe has been determined with our
consent or by actual trial and final judgment
This Insurance does not give anyone the righlto add us
as a delendant In an action against you to determine
your liability.
PART THREE - OTHER STATES INSURANCE
A. How This Insurance Applies
1. This other lIates insurance applies only if one or
more swes are shown in item 3.C. of the Informalion
Page,
2. If you begin work 'n Iny one of thos~ stites and are
not'n5ured or are nOI self',nsured lor such work, the
policy will apply as though that lIate were listed in
item 3,A, of the Inlormation Page.
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3. We will reimburse you lor rhe benelill required by
the workers compensalion law 01 IhatItate il we Ire
not permllted to pay Ihe benefits directly 10 perlons
enlitled 10 them,
B. Nollce
Teil us at once II you begin work In any stale lilted In
Ilem 3,(' of Ihe Inform,lllon Page.
PART FOUR - YOUR DUTIES IF INJURY OCCURS
Teil us al once if Injury occurslhat may be covered by
this polley, Your olner duties are lilted here,
1. Provide for Immediate medical and other services
required by the workers compensation law.
2. Clve us or our agent the names and addresses of the
Injured personslnd o( wllnelles, and other Inlor.
mallon we may need.
3. Promptly give us all nOllces, demands and legal
papers related 10 the Injury, claim, proceeding or
suit.
4, Cooperate wllh us a"d alllst US, as we may request,ln
the investigallon, settlement or delense 01 any claim,
proceeding or suil.
5. Do nothing alter an Injury occurslhat would Inter.
lere with our right 10 recover from others.
6. Do not volunlarlly make payments, assume obllga<
tlons or Incur expenses, except at your own cost.
PART FIVE - PREMIUM
A. Our Manuals
All premium lor this policy will be determined by our
manuals 01 rules. rates, rating plans and clanl/leatlons.
We may change our manuals and apply the changes to
this policy II authorized by law or a governmental
agency regulating this Insurance.
B. Clasll/lcatlons
lIem 4 of the Information Page shows the rate and
premium basis for certain business or work clasolllca.
lions. These classilicallons were alligned based on an
estimate of the exposures you would have during the
policy period. II your actual exposures are not properly
described by those classllications, we will assign proper
classllications. rates and premium basis by endorse-
ment to this policy.
C. Remunerallon
Premium for each work classlllcation Is determined by
multiplying a rate times a premium basis. Remunerallon
is the most common premium basis. This premium basis
includes payroll and all olher remuneration paid or
payable during the polley period (or the services 01:
1. all your officers and employees engaged in work
covered by this polley; and
2. all other persons engaged in work that could make
us liable under Part One (Workers Compensation
Insurance) 01 this policy, II you do nOI have payroll
records lor these persons, the contract price lor
3 of 5
Ihelr ,er.ICIl,and mat~rlal, may be uled al the pre-
mium balll. Thl, paragraph 2 will nOI apply If you
II.e UI proof Ihal Ihe employerl 01 thele perlonl
Ilwfully lecured Iheir worker! compenlatlon obliga-
tions,
D. Premium paymentl
You will pay III premium whon due. You will pay Ihe
premium e.en II part or III of I workerl compeMlltlon
law II nOI vllld.
I. final Premium
The premium shown on Ihe Informltlon Page,
tehedulel, Ind endorlementl II an eltlmale. The final
premium will be determined afler thll policy endl by
ullna Ihe IClual, nOI the elllmaled, premium balll and
the proper r.!llIlflcluon'lnd ralel Ihal lawfully Ipply to B.
Ihe bUllnellllld work cOllered by Ihll policy. If the final
premium Is morelhln the premium you paid to UI, you
mUll PlY us Ihe ballnce. If Itlllell, we will refund Ihe
ballnce to you. The flnll premium will nOI be lellthan
the hlahllll minimum premium for Ihe clalllflclrlons
cOllered by Ihll policy.
If Ihll policy II canceled, final premium will be deter-
mined In the following way unlell our manuall pro. Ide
otherwlll!.
1. If we cancel, final premium will be calculaled IJro
rate blll!d on the lime thll policy wal In force. Final
premium will nOI be lell than the pro rala Ihare of
the minimum premium.
1. II you clncel, final premium will be more than pro
ratl; It will be ballld on Ihe time thll policy was In
loree, Ind Increlll!d by our short rate cancelltlon
table Ind procedure. Flnll premium will not be lell
thin Ihe minimum premium.
.. Records
You will keep recordl of Information needed to
compute premium. You will provide UI with caples of
those recordl when we ask for them,
G. Audll
YOlj will let UI examine and audlllll your recordllhal
relate 10 thll policy. Thllle recordl Include ledgers,
journall, reslllerl, voucherl, contraCll, tax reportl,
'Payroll and dllburlllment recordl, and programs for
Itorlng and retrlevlns dala. We may conductlhe audlll
durlns resular bUllnel1 hOUr! during the policy period E.
and within three yearl alter Ihe policy period endl.
Information developed by audll will be ullld to deter-
mine final premium. Inlurance rate IIlrlllce organiza-
tions have the lame rlghtl we have under thll pro-
1Illlon.
Co"ri,"1 "'1 .llIj"llon,,1 Council on Comp.nwflon '"'Uflnn. .. of 5
PART SIX - CONDITIONS
A. tnlpedlon
We havO! Ihe rlShl, bUI are nOI obliged 10 Inlpect YOllr
workplacel al any IIml!, Our Inspecllons lie notlllety
Inspectlonl. They relall! only 10 Ihe Insurability of the
workplacl!l and Ihe premluml 10 be charsed. We may
gllle you repom on Ihe conditlonl we find. We may alIa
recommend chansel. While Ihey may help reduce
101l1ll, we do not undertake 10 perform the dUlY of any
perlon 10 provide for Ihe health or IIfety 01 your
employeel or the public. We do not warrantlhat your
workplacel are life or heallhful or that Ihey comply
with lawl, regulatlonl, codes or Ilandardl, Inlurance
rate ler.lce orsanlullonl halle the lime rlghtl we halle
under thll pro.lllon.
LonB Term Policy
II the polley period Illonser Ihan one year and Ilxteen
daYl, all pro.lllonl of Ihll policy will apply as Ihough a
new policy were III1Ied on each annualannl",rllry that
Ihll policy II In force.
C. Transfer 01 Your Rights ,and Dulles
Your rlghtl or dutlel under thll policy may not be tranl-
ferred wllhout our written comenl,
If you die and we recel'll notice within Ihlrty daYlalter
your dealh, we will cover your legal reprelentatllle as
Inlured,
D. Caneelallon
1. You may cancel thll policy. You mUlt mall or dellller
ad.ance written notice to UI stating when the can-
celation II to take eHect.
2. We may cancel thll policy. We mUlt mall or deliller to
you not lell Ihan ten days adllance written notice
IlItlng when the cancelation II to lake effect.
Mailing Ihat notice to you at your mailing addresl
Ihown In Ilem 1 of Ihe Information pase will be
lufflcienl to prove notice.
3. The policy period will end on the day and hour
Ita led In the cancelallon nOllce,
4 Any of these prolllllonl thai confllctl with a taw that
conlrols Ihe cancelation of the Inlurance In Ihll
policy II changed by this statement to comply with
that law,
Sole Representative
The inlured flm named In Ilem 1 of the Information
Pase will act on behalf of all imuredl to chanse Ihll
polley, receive relurn premium, and gl.e or receive
nOllce of cancelation.
AI re,peclllhe company prevloUlly dellgnated, the following (orrelallve provllion forml a part ollhil policy:
Mutual Policy Condltlonl. LUMBERMENS MUTUAL AMERICAN MANUfACTURERS
CASUALTY COMPANY MUTUAL INSURANCE COMPANY
Thll II a perpetual mUlual corporal Ion owned by and operated tor Ihe beneflr of ill members, Thil II a non.
IlItllable. participating pollq under which Ihe Board 01 Dlrectorlln 'tl dllcretlon may delermlne and pay unablorbed
premium depoIl1 refundl (dividendI) 10 the Insured,
AI rtlpectl Ihe Stare of Te.al. luch provlllon II amended to read H followl:
MutuIII-Membenhlp and Votlnll NollCl, The Insured II notified lhat by virtue of thll policy he II a member 01 rhe
company 10 dellgnated, and II enllrled to vale either In person or by pro.y ar any and all meetlngl 01 laid company, The
Annual Meetlnll' are held In Irl Home OHlce at the place and time Itated on lhe front cover,
Mutuals-Parllclpallon Clause Without Conllnllenl Liability. No Contlnllenr L1ablllry: Thll policy II non-mellable. The
policyholder Is a member of luch company ~nd Ihall partlclpate, to the e.tent and upon the conditions fixed Ind
determined by the Board of Directors In accordance with the provlllons of law, In Ihe dlmlbutlon of tilvldendl 10 Ilxed
and determined.
Dividends.
AMERICAN MOTORISTS AMERICAN PROTECTION
tNSURANCE COMPANY INSURANCE COMPANY
The Inlured Ihall participate In Ihe earnlngl of the company to luch exrenl and upon luch condlllonl al Ihall be
determined by rhe Board of Directors of the company In accordance with Law and al made applicable to thll policy
provided the Inlured Ihall have complied with all of the terml of thil policy with relpectlO the paymenr 01 premium.
As respectl the State of Texal. luch provlllon II amended to read al followI:
Dividend Provision-Participating Companies. The named Inlured Ihall be entitled to partlcip.lle In a dlmlbutlon of rhe
surplul of the company,al determined by It I Board of Directors from time to time, afrer approval in accordance with Ihe
provlllonl of the Texallnlurance Code. of 19S 1, al amended,
The Mutual Policy Conditions Ind the DividendI Condition are lupplemented by the following paragraph:
Parttclpatlnll Provision: Clllfornla-Under C.ll1fornla Law It II unlawful for an inlurer to prom lIe the future payment of
dividendi under an unexpired workers compenlation policy or 10 mlsreprelent the conditions for dividend payment.
DividendI are payaole only pUlluant to condltlonl det~rmlned by the Board of Directors or other governing board of the
Company following policy explrltion,
Oregon-It II unlawful in Oregon for an insurer to promile to pay policyholder dividendI for any unexpired portion of
the policy term or to mlsreprelent the conditions for dividend payment. DividendI will be due Ind payable only for a
polley period that hal expired or. If a policy II illued for a period in excesl of one yelr and a premium il payable at each
annlverlary, for an anniversary period that hal ..x pi red I and only if declared by Ind under the condltionl prelcribed by
the Board of Directors of the insurer,
South Carolina- The Inlured Ihall participate in the elrnlngl of the company only in accordance with law and a plan and
any amendmenrltheretoappliclble to thil policy which have been flied with the Chief Insurance Commllsloner of South
Carolina. provided thelnlured hal complied with all the terml of thil policy with relpect to the payment of premium.
Neither dividends nor any factor in their calculation may be guaranteed. By purchallng thil policy. the inlured obtalnl no
contractual right to a dividend. DividendI are declared In the lole dllcretion of the governing body of the inlurer. Any
reprtlentatlonlto the contrary are faile,
IN WITNESS WHEREOF, the company dellgnated on the Information Page hal cauled thil policy to be Ilgned by irl
Prelldent and Secretary, but this policy Ihall nor be valid unlell countersigned on the Information Page by a duly
authorized reprelentatlve of the company,
lUMIERMENS MUTUAL CASUALTY COMPANY
AMIRtCAN MOTORISTS INSURANCE COMPANY
AMIRICAN MANUfACTURERS MUTUAL INSURANCE COMPANY
~~
AMERICAN PROTECTION INSURANCE COMPANY
Secrerary
~.~,Yf~ '-r@~
President Secrerary
fL
s: ~""{ "'~
President
....(1101...
eM: :001).1 I ,rMll 15M
5 of 5
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I"OL.LCY NlJi'tIiEI'oI' JBA 00144 ,-QQ
'\. ,. f'L. ,.:
NAMe: AND ADDRESS IJF INGURED
1. HOLIDAY INN MECHAI'oIl:C5f1URC;.
~401 CARLI3LE PIKE
MECHANICSBURG. F'A
170e;~
ISSUE I)An::: 08/U5/91
LOCA TIO 5. AUl,IIU.1 ''''D'~ pl~v~ 'I' 11'1. 'Mil"" ~I 'lr !film whld, .jplt"II!)"1 ("....t.d by tl'1I1 JlQlif;y ... (cnlluClliJ Il' IqCllt1l u Ih. IbOlI. .dd,eu unl... oth.rw... ftlt.d hlt'ln,
SEE EXl'EN6ION OF INFORMATION PAGE
ENTITY OF INSI:RED - CCRPIJRAHON
2. POLICY PEIUOD- 08/C3/'i'1 TO 013/03/9:1 i~. C 1. AM SfANCARD TIME ,'IT
THE ..\DD"'::S~l GF THE INSURE;) r;~3 S r,~TI::D liE"'CIN,
3A. PART CNE 0;::' THIS POL.ICY ,~PPI..IES Tfj TI-:! \oleRI!I::!"!,:: COMI:'!::NSAnC~'1 1..,,1.1 ill'/!)
ANY fJCCUPIHICNAL. DISEASE '-''IW OF EAC:~ OF 'T~E F~:"1..0',jING STA I ES-
FA.
: 31:1. PART
WORK
TWO Of' T:-II8 I~CI..ICY APPLIES TO E~::'1..0YEr,::;
IN EACH !3TAfE I..ISTED IN ITEM 3A:
BODIl.Y INJURY BY ACCIDENT $:'500, OO() E~CH ArXIOt::NT
BODIL Y INJURY BY DISEASE 11:.';00, 000 E~CH EMPI_OYEE
BODILY INJURY BY DISEASE '~OO.OOO POLICY L.IMIT
PART THREE OF THIS F'OLICY APF'LIES TO OTHER STATES INSUR,~NCE
LOWING GTATES- NOT APPLICABLE.
L rAI<:'UT"( rNSUr;:r-.,~r;I:: n)r~
3e.
FOR THE FOL-
3D. SEE F.XTENSION OF UlF'ORMATION PAGE I=OR ENDORSEMENTS FORMING PART OF
THIS POLICY,
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
4. THE PREMIUM FOR THIS POLICY WILL. BE Di::TERMINED BY OUR MANUALS OF RULES.
CLASSIFICATIONS. RATES, AND RATING PLANS. AL.L INFORMATION REQUIRED BELOW
19 SUBJECT TO VERIFICATION AND CHANGE BY AUDIT,
ADJUSTMENT OF PREMIUM SHALL BE MADE ANNUALLY.
CLASSIFICATION OF OPERATIONS" ~ST RATE EST
LOC CODE TYP TOT-ANN PER .100 ANNUAL
NO RSK REMUN REMUN PREMIUM
SEE EXTENSION OF INFORMATION PAGE
MINIMUM F'REMIUM $76:5 EXPF.:NGE CONS'fANT
nJTAl. ESTIMATED COST
DE:F'r:lS IT AMOlJN'f
83,110
140
.e3.::!:50
'83.250
: "ENTRIES INfHIS !rEM, EXCl'::':PT (~S SPECIFICALL. Y
I" DO NOT MODIFY ANY OF THE OTHER PROVISIONS OF
I; ~ODllCER INFO~MATION: 0323033
; CCHEN-SEL TZER INC
PROVIDE:D I:!LSEWHERE IN THIS POLICV.
THIS POLICV
COUNTERSIGNATU~E:
BOX 7e2:i
FORT WASHINGTONPA 19034
.i9E~vtIING OFFICE: KEMPER GROUP/ ATTN: CLSU MANAGER
II 10 INDEPENDENCE MALL. PHILADELF'HIA, PA
'I
II we 00 00 01A
I
DATE:
1':1 AUGUST 91
19106-1~92
COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE
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NPoME AND ADIJRE';U OF tNSuRL;:D
HOLIDAY INN ~El~I.!ANICSE,IJRG,
::5401 CARU'il.1:: PIKE
ME:CHANICeeIJI\C;, F'i\
,
170~:5
!SGIJl~ .t>ArE:' <,8/1:5/71
L CAnONS. AU u.u.! 1lI0'~ pl"LI" "Ilh. ,nlUlld It or 110m 1lIl'llcn 'lp,,'I,ont co~".d by Itu. policy It. conduc!.d or IOUI.d .llh. .bo~. .dd".. ~nl.u olh."""". 1I.lld h"ltln,
CODE rYF'
NO RSI<
09~3
0973
094:5
9807
9898
u'ijl:H':OU'1E: or- O?ERArr
I,:LI~5GIf:'ICi"nCN (JF CF'I~r.~ATIClt>8
CLEI~ICAL OFF'!C::: E:MF'LO'l'EJ:::3, NCe
HOTELS
HOT~L RESTAURANT
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Tr.;T-o.\i~rl
RI:::Ml;tl
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497,640
710,407
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r;'E'.~, '51(.:'(;
RI~MliN
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6.Sa
~5 .0:3
PREMIUM FOR INCI~. EMF'I_OYERS L.lABILITY .0190
lOTAL PREi1IU11 SUBJECT TO THE E:<PERIENCE MCDIFr.C(\iION
~XPERIe:NCE MOO. EFF 08/03/91. USING FACTOR 1.1~9
I..ES5 F'REHIUM DISCOUNT
rOT,'~L ESiU1ATED 6'TANOARD PRI::I'1IUM I~OR F'E:NNS'l'I_vANIA
TOTAL FOR PENNSYLVANIA
TOTAL SCHEDULE OF
OF'Er,'AnONS F'REMIUM
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f"REMIUM
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12,4:2~
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DIVIIION CO""
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NAME: L IJMPERMEN5 MUTIJAI_
C,~SUAL TY COMf'I1N~
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POLICY NLIMl:lEH'. "m,e, ()Ot44-'-0()
RE r;;WAL OF'. NE
NAME I~Nll ADDRESS <:lI~tNEU~r::O
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MECHANICSEilJRG. rJ.<\
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ISSUE OATr~'. \'8/1.~/'~1
CATIONS. All ~lu.1 .....Olt.. pl'l" "llh. Inl"lId U lI' "om which vptr.tllJ'" (0....,." b., Ihll pOlky ,tt cnnducllQ III IOellld " lh. .bo". add"" un I... olh'MII. tllt.d h".,n,
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DESCRIFTICN
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ENDT. .1 0787 ENDORSEi1EiH 06/0:51'91
WCOO0406 04t~4 PREMIUM DISCOUNT ENDORSEI1ENT 081(,):51'91
WCJ7C601 04134 i'ENN SPECIAL ENDT-INSPEcnON OF MAN. 08/0:5/91
WCOO0316 0'1138 F.MF'LOYERS LIAS:l:LLTY INSURANCE E:ND'r 081'0:5/<;1
WC:570602 0484 PENN NOTICE(CONSULTATION SERV EXEMP) 08/031'91
WCJ7C603 1::87 PENNSYLVANIA ACT 86'-1986 ENor Okl/,):3,91
WCOOI)OOO 04134 PDUC'r ..JAC:<E:T va, ')3, q 1.
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BEECHWOOD AT DE r-ORr,ST
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POLICY NO. 38A 001447 00
PRI10IJr.Hl COOF. 32 303:3
NAI1.. CODE I'IF.Cti
COHEN-S~LT,[R, INe
BOX '~25
FORT I.tIIISHINGTON, PA 1'1034
I'IECHANICGBURG UF !NVF.STORS HOLIDAV
INN /~ECHAtl!CSBURa
POLICY PERIOD 08/03/91 TO 08/03/92
AUDIT PERIOD 09/03/'11 TO 06/03/92
-------------------.--------------------------------------------------------------~,---
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SEE ATTACHFD DETAlL PAGE~
,
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TOTAL [HRNED PREI'I!UI'I
8e.e21.00
DE(>051 r PilE" IUl1
93.i!50.()1)
DIFFERENCE
<1,[171.10
BALANCE DUE CO"PANV
4,~71.00
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'The WIdener lulldlnl - Ith 'Ioor
o One South Penn Squ.r. . Phll'd~IPh'., P. 11107-3577
(2111111-2371 'AJCI211)1'4-4221
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REPLY WUHIN 30 DAYS.
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PLEASE ATTACH COPY OP LETTER WITH REPLY.
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PLEASE SUBKIT A 'c' IEPORT CORRECTING THE SPECIPIED ERRORS.
.:"iPOLICY NO
31.\00144700
STATE SERIAL EPP DATE UP DATE TEIK
37 0-000-0 08/03/91 08/03/92 1
CLASS 951
NOT AUTBOllIZED
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HOTEL RESTAURANT 9~5 ?6i!,?:l3 ~.05 39,'510
CLERICAL OFfICE 953 :123,441 0.'59 1,909
HOTEL 9?3 51e,'551 6.50 31.614
......--...--.....-...
SUB-TOTAL 78,100
INCR E"PLOYERS L[A8CL[TV '1001 1B,II)I) 1.'11)7. t,484
---...--------
"AHlJAL PRE" [U" 1'1,~84
EXPER[ENCE "OO[F[CAT[ON 911911 ?9,3114 I. 16<) 13,430
----..-------
STATE SUB-TOTAL 93,034 .
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TOTAL STANOMO PRE"[Jm 1,6:511,12:5 93,034 ..
PRE"l~ DISCOUNT: 0064 13,001)
PENNSVl VANt A '13,034 13.081)' .....
EXPENSE CONSTANT:
PENNSVlVANIA 0900 140 .
---..-..---....-
TOTAL cas r t ,630,125 '10,09:]
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7632.6049
WILDRAHAM LAWLER & DUDA
By: Daniel J. AUan
Identification No. 02612
1818 Market Street
Philadelphia, PA 19103
(2IS) S64.4141
Attomey forI Plaintiff
v.
: COURT OF COMMON PLEAS
: CUMDERLfND (;OUNTY
: 14-- q g1~
LUMDERMENS MUTUAL CASUALTY
MECHANICSDURG G. F. INVESTORS
HQ.IJJ!AY.INN
: CIVIL ACTION NO. 4896
ORDER TO DISCONTINUE
TO THE PROTHONOTARY:
Please mark the above matter discontinued upon payment of your costs.
WILBRAHAM LAWLER & BUBA
c-,..., .~'
~_)t&. ~~
Daniel J. Allan~