Orange County NC Website
Browse       Search
DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 21 D <br /> (Ed. 1-15) <br /> CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT <br /> This endorsement is notification that your insurance carrier is charging premium to cover the losses that may occur in <br /> the event of a Catastrophe(other than Certified Acts of Terrorism)as that term is defined below. Your policy provides <br /> coverage for workers compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism). This <br /> premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk <br /> Insurance Program Reauthorization Act Disclosure Endorsement(WC 00 04 22 B), attached to this policy. <br /> For purposes of this endorsement, the following definitions apply: <br /> • Catastrophe(other than Certified Acts of Terrorism): Any single event, resulting from an Earthquake, Noncertified <br /> Act of Terrorism, or Catastrophic Industrial Accident,which results in aggregate workers compensation losses in <br /> excess of$50 million. <br /> • Earthquake: The shaking and vibration at the surface of the earth resulting from underground movement along a <br /> fault plane or from volcanic activity. <br /> o Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary of Treasury <br /> pursuant to the Terrorism Risk Insurance Act of 2002(as amended)but that meets all of the following criteria: <br /> a. It is an act that is violent or dangerous to human life, property, or infrastructure; <br /> b. The act results in damage within the United States, or outside of the United States in the case of the <br /> premises of United States missions or air carriers or vessels as those terms are defined in the Terrorism <br /> Risk Insurance Act of 2002 (as amended); and <br /> c. It is an act that has been committed by an individual or individuals as part of an effort to coerce the civilian <br /> population of the United States or to influence the policy or affect the conduct of the United States <br /> Government by coercion. <br /> • Catastrophic Industrial Accident: A chemical release, large explosion, or small blast that is localized in nature and <br /> affects workers in a small perimeter the size of a building. <br /> The premium charge for the coverage your policy provides for workers compensation losses caused by a <br /> Catastrophe(other than Certified Acts of Terrorism)is shown in Item 4 of the Information Page or in the Schedule <br /> below. <br /> Schedule <br /> State Rate Premium <br /> NC 0.02 $40.00 <br /> This endorsement changes the policy to which It Is attached and is effective on the date issued unless otherwise stated. <br /> (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br /> Endorsement Effective 02/08/2017 Policy No. MWC0106102-01 Endorsement No. <br /> Insured Senior Care of Orange County Inc Premium:$(See Attached) <br /> Insurance Company Markel Insurance Company Countersigned by <br /> WC 00 04 21 A <br /> (Ed.1-15) <br /> c4 Copyright 2015 National Council on Compensation Insurance,Inc.All Rights Reserved, <br /> 16 of 24 <br />