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DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED <br /> WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> (Ed. 1-15) <br /> insurance or self-insurance. Subject to any limits of workers compensation law that apply to: <br /> liability that may apply, all shares will be equal until <br /> the loss is paid. If any insurance or self-insurance is a. benefits payable by this insurance; <br /> exhausted,the shares of all remaining insurance will b. special taxes, payments into security or other <br /> be equal until the loss is paid. special funds, and assessments payable by us <br /> under that law. <br /> F. Payments You Must Make <br /> You are responsible for any payments in excess of 6. Terms of this insurance that conflict with the <br /> the benefits regularly provided by the workers workers compensation law are changed by this <br /> compensation law including those required because: statement to conform to that law. <br /> 1. of your serious and willful misconduct; Nothing in these paragraphs relieves you of your duties <br /> under this policy. <br /> 2. you knowingly employ an employee in violation <br /> of law; PART TWO <br /> 3. you fail to comply with a health or safety law or EMPLOYERS LIABILITY INSURANCE <br /> regulation; or A. How This Insurance Applies <br /> 4. you discharge, coerce or otherwise discriminate This employers liability insurance applies to bodily <br /> against any employee in violation of the workers injury by accident or bodily injury by disease. Bodily <br /> compensation law. injury includes resulting death. <br /> If we make any payments in excess of the benefits 1. The bodily injury must arise out of and in the <br /> regularly provided by the workers compensation law course of the injured employee's employment by <br /> on your behalf, you will reimburse us promptly. you, <br /> 2. The employment must be necessary or incidental <br /> G. Recovery From Others to your work in a state or territory listed in Item 3.A. <br /> We have your rights, and the rights of persons of the Information Page. <br /> entitled to the benefits of this insurance, to recover 3. Bodily injury by accident must occur during the <br /> our payments from anyone liable for the injury. You policy period. <br /> will do everything necessary to protect those rights 4. Bodily injury by disease must be caused or <br /> for us and to help us enforce them. aggravated by the conditions of your employment. <br /> H. Statutory Provisions The employee's last day of last exposure to the <br /> conditions causing or aggravating such bodily <br /> These statements apply where they are required by <br /> injury by disease must occur during the policy <br /> law. period. <br /> 1. As between an injured worker and us,we have 5. If you are sued, the original suit and any related <br /> notice of the injury when you have notice. legal actions for damages for bodily injury by <br /> 2. Your default or the bankruptcy or insolvency of accident or by disease must be brought in the <br /> you or your estate will not relieve us of our United States of America, its territories or <br /> duties under this insurance after an injury occurs. possessions, or Canada. <br /> 3. We are directly and primarily liable to any B.We Will Pay <br /> person entitled to the benefits payable by this <br /> insurance. Those persons may enforce our We will pay all sums that you legally must pay as <br /> duties; so may an agency authorized by law. damages because of bodily injury to your employees, <br /> Enforcement may be against us or against you provided the bodily injury is covered by this Employers <br /> and us. Liability Insurance. <br /> 4. Jurisdiction over you is jurisdiction over us for The damages we will pay, where recovery is permitted <br /> purposes of the workers compensation law. We by law, include damages: <br /> are bound by decisions against you under that 1. For which you are liable to a third party by reason <br /> law, subject to the provisions of this policy that of a claim or suit against you by that third party to <br /> are not in conflict with that law. recover the damages claimed <br /> 5. This insurance conforms to the parts of the <br /> Ed.1-15 6 of 24 <br /> Copyright 2013 National Council on Compensation Insurance,Inc.Ail Rights Reserved. <br />