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C72410634PPRGWCADM20240910115657_Insured - Transferred On 09-11-2024 At 06-01-03BEGINNING OF POLICY KINGWOOD TX 77339 19001 VE INSPERITY, INC. WILMINGTON, DE 19803 BEAVER VALLEY ROAD CENTRALIZED OPERATIONS CHUBB GROUPCHUBB WC 90 04 34 (09/22)Page 1 of 2 WORKERS COMPENSATION AND EMPLOYERS’ LIABILITY INSURANCE POLICY TABLE OF CONTENTS AND NOTICE OF IMPORTANT PROVISIONS The Table of Contents below provides information regarding the sections within the Workers Compensation and Employers Liability Policy – WC 00 00 00C. GENERAL SECTION Begins on Page 1 A. The Policy 1 B. Who is Insured 1 C. Workers Compensation Law 1 D. State 1 E. Locations 1 PART ONE – WORKERS COMPENSATION INSURANCE Begins on Page 1 A. How This Insurance Applies 1 B. We Will Pay 1 C. We Will Defend 1 D. We Will Also Pay 1 E. Other Insurance 2 F. Payments You Must Make 2 G. Recover From Others 2 H. Statutory Provisions 2 PART TWO – EMPLOYERS LIABILITY INSURANCE Begins on Page 2 A. How This Insurance Applies 2 B. We Will Pay 3 C. Exclusions 3 D. We Will Defend 3 E. We Will Also Pay 4 F. Other Insurance 4 G. Limits of Liability 4 H. Recovery From Others 4 I. Action Against Us 4 PART THREE – OTHER STATES INSURANCE Begins on Page 4 A. How This Insurance Applies 4 B. Notice 4 PART FOUR – YOUR DUTIES IF INJURY OCCURS Begins on Page 5 WC 90 04 34 (09/22)Page 2 of 2 PART FIVE – PREMIUM Begins on Page 5 A. Our Manuals 5 B. Classifications 5 C. Remuneration 5 D. Premium Payments 5 E. Final Premium 5 F. Records 5 G. Audit 6 PART SIX – CONDITIONS Begins on Page 6 A. Inspection 6 B. Long Term Policy 6 C. Transfer of Your Rights and Duties 6 D. Cancellation 6 E. Sole Representative 6 NOTICE OF IMPORTANT PROVISIONS: THE FORMS AND ENDORSEMENTS LISTED ON THE SCHEDULE OF FORMS AND ENDORSEMENTS ARE IMPORTANT PROVISIONS AND MODIFY COVERAGES OR CONDITIONS UNDER THIS POLICY. PLEASE READ THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CAREFULLY WC 00 01 04A (10/04)Copyright 2004 National Council on Compensation Insurance. FEDERAL EMPLOYERS' LIABILITY ACT COVERAGE Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. FEDERAL EMPLOYERS' LIABILITY ACT COVERAGE ENDORSEMENT This endorsement applies only to the work subject to the Federal Employers' Liability Act (45 USC Sections 51-60) and any amendment to that Act that is in effect during the policy period. G.Limits of Liability of Part Two (Employers Liability Insurance) is replaced by the following: G.Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in the Schedule. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for "bodily injury by accident-each accident" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for "bodily injury by disease-aggregate" is the most we will pay for all damages covered by this insurance because of bodily injury by disease to one or more employees. The limit applies separately to bodily injury by disease arising out of work in each state shown in Item 3.A. of the Information Page or in the Schedule. Bodily injury by disease does not include disease that results directly from bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance. If any state is named in item 2 of the Schedule, Part Two (Employers Liability Insurance) applies in that state to work subject to the Federal Employers' Liability Act as though that state were listed in item 3.A. of the Information Page. Part One (Workers Compensation Insurance) does not apply in a state shown in the Schedule. Part Two (Employers Liability Insurance), C. Exclusions, exclusion 9, does not apply to work subject to the Federal Employers' Liability Act. Schedule 1. Limits of Liability Bodily Injury by Accident $1,000,000 each accident Bodily Injury by Disease $1,000,000 aggregate 2. State IF ANY This endorsement is not applicable in MI. Authorized Representative CKE-3N11a (4/92) Ptd. in U.S.A. Copyright 1983, 1991, National Council on Compensation Insurance.WC 00 01 06A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE ENDORSEMENT This endorsement applies only to work subject to the Longshore and Harbor Workers' Compensation Act in a state shown in the Schedule. The policy applies to that work as though that state were listed in Item 3.A. of the Information Page. General Section C.Workers' Compensation Law is replaced by the following: C.Workers’ Compensation Law Workers' Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page and the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901-950). It includes any amendments to those laws that are in effect during the policy period. It does not include any other federal workers or workmen's compensation law, other federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. Part Two (Employers Liability Insurance), C. Exclusions., exclusion 8, does not apply to work subject to the Longshore and Harbor Workers' Compensation Act. This endorsement does not apply to work subject to the Defense Base Act, the Outer Continental Shelf Lands Act, or the Nonappropriated Fund Instrumentalities Act. Schedule State Longshore and Harbor Workers' Compensation Act Coverage Percentage MASSACHUSETTS The rates for classifications with code numbers not followed by the letter "F" are rates for work not ordinarily subject to the Longshore and Harbor Workers' Compensation Act. If this policy covers work under such classifications, and if the work is subject to the Longshore and Harbor Workers' Compensation Act, those non-F classification rates will be increased by the Longshore and Harbor Workers' Compensation Act Coverage Percentage shown in the Schedule. Authorized Agent WC 00 01 09C (01/15)© Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. OUTER CONTINENTAL SHELF LANDS ACT COVERAGE ENDORSEMENT OUTER CONTINENTAL SHELF LANDS ACT COVERAGE ENDORSEMENT This endorsement applies only to the work described in Item 4 of the Information Page or in the Schedule as subject to the Outer Continental Shelf Lands Act. The policy will apply to that work as though the location shown in the Schedule were a state named in Item 3.A. of the Information Page. General Section C.Workers Compensation Law is replaced by the following: C.Workers Compensation Law Workers Compensation Law means the workers or workmen’s compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page and the Outer Continental Shelf Lands Act (43 U.S.C. Sections 1331 et seq.). It includes any amendments to those laws that are in effect during the policy period. It does not include any other federal workers or workmen’s compensation law, other federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. Part Two (Employers Liability Insurance), C. Exclusions., exclusion 8, does not apply to work subject to the Outer Continental Shelf Lands Act. Schedule Description and Location of Work IF ANY WC 00 01 09C (01/15)© Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. Authorized Representative WC 00 02 01 B (01/15) 1983–2013 National Council on Compensation Insurance, Inc. All Rights Reserved Page 1 of 2 Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. MARITIME COVERAGE ENDORSEMENT MARITIME COVERAGE ENDORSEMENT This endorsement changes how insurance provided by Part Two (Employers Liability Insurance) applies to bodily injury to a master or member of the crew of any vessel. A.How This Insurance Applies is replaced by the following: A.How This Insurance Applies This 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 work described in Item 1 of the Schedule of the Maritime Coverage Endorsement. 3. The bodily injury must occur in the territorial limits of, or in the operation of a vessel sailing directly between the ports of, the continental United States of America, Alaska, Hawaii or Canada. 4. Bodily injury by accident must occur during the policy period. 5. Bodily injury by disease must be caused or aggravated by the conditions of your employment. 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. 6. If you are sued, the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. C.Exclusions is changed by removing exclusion 10 and by adding exclusions 13 and 14. This insurance does not cover: 13. Bodily injury covered by a Protection and Indemnity Policy or similar policy issued to you or for your benefit. This exclusion applies even if the other policy does not apply because of another insurance clause, deductible or limitation of liability clause, or any similar clause. 14. Your duty or obligation to provide transportation, wages, maintenance, and cure. This exclusion does not apply if a premium entry is shown in Item 2 of the Schedule, except that punitive damages related to your duty or obligation to provide transportation, wages, maintenance, and cure under any applicable maritime law are excluded even if a premium is paid for transportation, wages, maintenance, and cure coverage. D.We Will Defend is changed by adding the following statement: We will treat a suit or other action in rem against a vessel owned or chartered by you as a suit against you. G.Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in the Schedule. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for “bodily injury by accident—each accident” is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for “bodily injury by disease—aggregate” is the most we will pay for all damages covered by this insurance because of bodily injury by disease to one or more employees. The limit applies separately to bodily injury by disease arising out of work in each state shown in Item 3.A. of the Information Page. Bodily injury by disease will be deemed to occur in the state of the vessel’s home port. Bodily injury by disease does not include disease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance. WC 00 02 01 B (01/15) 1983–2013 National Council on Compensation Insurance, Inc. All Rights Reserved Page 2 of 2 Schedule 1. Description of work: IF ANY 2. Transportation, Wages, Maintenance, and Cure Premium $ Exclusion:This insurance does not cover punitive damages related to your duty or obligation to provide transportation, wages, maintenance, and cure under any applicable maritime law even if a premium is paid for transportation, wages, maintenance, and cure coverage. 3. Limits of Liability Bodily Injury by Accident $1,000,000 each accident Bodily Injury by Disease $1,000,000 aggregate Authorized Representative WC 00 02 03 (4/84)Copyright 1982-83, National Council on Compensation Insurance Page 1 of 2 VOLUNTARY COMPENSATION MARITIME COVERAGE ENDORSEMENT Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. VOLUNTARY COMPENSATION MARITIME COVERAGE ENDORSEMENT This endorsement adds Voluntary Compensation Maritime Insurance to the Policy. A.How This Insurance Applies This insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury including resulting death. 1.The bodily injury must be sustained by an employee who is a master or member of the crew of a vessel described in the Schedule. 2.The bodily injury must occur in employment that is necessary or incidental to work described in item 2 of the Schedule. 3.The bodily injury must occur in the territorial limits of, or in the operation of a vessel sailing directly between the ports of, the continental United States of America, Alaska, Hawaii or Canada. 4.Bodily injury by accident must occur during the policy period. 5.Bodily injury by disease must be caused or aggravated by the conditions of your employment. The em- ployee'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 an amount equal to the benefits that would be required of you if you and your employees described in item 1 of the Schedule were subject to the workers' compensation law shown in item 1 of the Schedule. We will pay those amounts to the persons who would be entitled to them under that law. C.Exclusions This insurance does not cover: 1.any obligation imposed by a workers compensation or occupational disease law, or any similar law. 2.bodily injury intentionally caused or aggravated by you. D.Before We Pay Before we pay benefits to the persons entitled to them, they must: 1.Release you and us, in writing, of all responsibility for the injury or death. 2.Transfer to us their right to recover from others who may be responsible for the injury or death. 3.Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If the persons entitled to the benefits of this insurance fail to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. WC 00 02 03 (4/84)Copyright 1982-83, National Council on Compensation Insurance Page 2 of 2 E.Recovery From Others If we make a recovery from others, we will keep an amount equal to our expenses of recovery and the benefits we paid. We will pay the balance to the persons entitled to it. If the persons entitled to the benefits of this insurance make a recovery from others, they must reimburse us for the benefits we paid them. Schedule Workers Compensation 1.Employees Law Master and members of the crews of these vessels: [ ANY VESSELS FOR WHICH YOU HAVE A CONTRACT TO PERFORM STATE OF HIRE WORK THEREON 2.Description of work: [ IF ANY Authorized Representative [ WC 00 03 11A (08/91)Page 1 of 2 Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT This endorsement adds Voluntary Compensation Insurance to the policy. A. How This Insurance Applies This insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must be sustained by an employee included in the group of employees described in the Schedule. 2. The bodily injury must arise out of and in the course of employment necessary or incidental to work in a state listed in the Schedule. 3. The bodily injury must occur in the United States of America, its territories or possessions or Canada and may occur elsewhere if the employee is a United States or Canadian citizen temporarily away from those places. 4. Bodily injury by accident must occur during the policy period. 5. Bodily injury by disease must be caused or aggravated by the conditions of your employment. 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 an amount equal to the benefits that would be required of you if you and your employees described in the Schedule were subject to the workers compensation law shown in the Schedule. We will pay those amounts to the persons who would be entitled to them under the law. C. Exclusions This insurance does not cover: 1. any obligation imposed by a workers compensation or occupational disease law, or any similar law. 2. bodily injury intentionally caused or aggravated by you. D. Before We Pay Before we pay benefits to the persons entitled to them, they must: 1. Release you and us, in writing, of all responsibility for the injury or death. 2. Transfer to us their right to recover from others who may be responsible for the injury or death. 3. Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If the persons entitled to the benefits of this insurance fail to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. E. Recovery From Others If we make a recovery from others, we will keep an amount equal to our expenses of recovery and the benefits we paid. We will pay the balance to the persons entitled to it. If the persons entitled to the benefits of this insurance make a recovery from others, they must reimburse us for the benefits we paid them. WC 00 03 11A (08/91)© Copyright 1991 National Council on Compensation Insurance, Inc.Page 2 of 2 F. Employers Liability Insurance Part Two (Employers Liabiity Insurance) applies to bodily injury covered by this endorsement as though the State of Employment shown in the Schedule were shown in Item 3.A. of the Information Page. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Schedule Employee ANY EMPLOYEE EXEMPT FROM THE WORKERS COMPENSATION LAW.NJ & WI ARE EXCLUDED State of Employment ALL STATES LISTED UNDER ITEM 3.A. OF THE INFORMATION PAGE EXCEPT NJ & WI Designated Workers Compensation Law STATE OF HIRE This endorsement is not applicable in the states of CA, HI, and NJ. Authorized Representative WC 00 03 13 (11/05)© Copyright 1983–2017 National Council on Compensation Insurance, Inc. All Rights Reserved. Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us. This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. For the states of CA, UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications. For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. Authorized Agent WC 00 04 14 (7/90)Copyright 1990 National Council on Compensation Insurance.CKE-4255 NOTIFICATION OF CHANGE IN OWNERSHIP Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT Experience rating is mandatory for all eligible insureds. The experience rating modification factor, if any, applicable to this policy, may change if there is a change in your ownership or in that of one or more of the entities eligible to be combined with you for experience rating purposes. Change in ownership includes sales, purchases, other transfers, mergers, consolidations, dissolutions, formations of a new entity and other changes provided for in the applicable experience rating plan manual. You must report any change in ownership to us in writing within 90 days of such change. Failure to report such changes within this period may result in revision of the experience rating modification factor used to determine your premium. This endorsement is not applicable in CA, DE, NJ, and PA. Authorized Representative WC 00 04 22C (01/21)© Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. Page 1 of 3 Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2019. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. “Act” means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto, including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2019. “Act of Terrorism” means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States, as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property, or infrastructure. c. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. “Insured Loss” means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. “Insurer Deductible” means, for the period beginning on January 1, 2021, and ending on December 31, 2027, an amount equal to 20% of our direct earned premiums during the immediately preceding calendar year. Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a calendar year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. Policyholder Disclosure Notice WC 00 04 22C (01/21)© Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. Page 2 of 3 1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses occurring in any calendar year exceed $200,000,000, the United States Government would pay 80% of our Insured Losses that exceed our Insurer Deductible. 2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100,000,000,000. 3. The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in Item 4 of the Information Page or in the Schedule below. WC 00 04 22C (01/21)© Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. Page 3 of 3 Schedule State Rate Premium MA Authorized Representative 08 02 0261 (Ed. 3-12) Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. CIVIL UNIONS OR DOMESTIC PARTNERSHIPS Civil Unions or Domestic Partnerships:All r r n e in the po icy to pou e include a party to a civil union or domestic partnership recognized under the applicable law of the jurisdiction having authority. All other terms and conditions remain unchanged. Authorized Representative WC 99 03 43A (01/08)Page 1 WAR RISK HAZARD Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. WAR RISK HAZARD ENDORSEMENT It is agreed that no premium has been charged in this policy for accidental injury, disease, or death resulting from acts of war for which coverage may be provided under War Hazards Compensation Act (42 USCS Section 1701). Authorized Agent WC 99 03 55 (12/08) CALIFORNIA AMENDATORY ENDORSEMENT Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. UNINTENTIONAL ERRORS AND OMISSIONS PART SIX - CONDITIONS is amended by the addition of the following: F. Unintentional errors or omissions in representations made to us or our agent by you or any other insured before the inception of this policy will not impair your rights under this policy. This endorsement is not applicable in the states of CT, MI, MN, NC, NJ, TN and WI. This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. Authorized Representative WC 99 03 91A (08/13)©Chubb. 2016. All rights reserved.Page 1 of 1 TWO OR MORE POLICIES ISSUED BY US Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. TWO OR MORE POLICIES ISSUED BY US The following paragraph is added to G. Limits of Liability under PART TWO – EMPLOYERS LIABILITY: 4.If this policy and any other policy issued to you by us, or any company affiliated with us, apply to the same accident or disease, the maximum limit of liability under all applicable policies for such accident or disease shall not be greater than the highest applicable limit of liability under any one such policy for Bodily Injury by Accident or Bodily Injury by Disease. This provision does not apply to any policy we, or any company affiliated with us, issue to an insured that by its terms specifically provides coverage that is excess over other applicable insurance. This endorsement is not applicable in the states of AK, AZ, CT, FL, NJ, NY, NC, TN and WI. Authorized Representative WC 99 04 09 (03/05) NOTIFICATION OF PREMIUM ADJUSTMENT Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. NOTIFICATION OF PREMIUM ADJUSTMENT For the states and lines of business in which regulatory approval has been granted for the NCCI Large Risk Alternative Rating Option, the ISO Large Risk Alternative Rating Option, or the independently filed Chubb Large Risk Rating Plan, the premiums for this policy will be adjusted in accordance with the Notice of Election, signed by you. This endorsement is not applicable in the states of CA, FL, NJ, TX, and WI. Authorized Representative -+ ** %) '( ",.$ )/&&# Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. EARLIER NOTICE OF CANCELLATION OR NONRENEWAL PROVIDED BY US A.Under Condition D.Cancellation of Part Six,the time period is amended as follows: We may cancel this policy by mailing or delivering to you written notice of cancellation at least: 1. 10 days before the effective date of cancellation if we cancel for non-payment of premium; or 2. 90 days before the effective date of cancellation if we cancel for any other reason. B.Under Part Six -Conditions of the policy,the following is added: Notice of Nonrenewal When we do not renew this policy, we will mail or deliver to you written notice of the nonrenewal at Least 90 days before the expiration date. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. State Exceptions California Not Applicable Authorized Representative WC 99 07 73 (11/06) TRADE OR ECONOMIC SANCTIONS ENDORSEMENT Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. TRADE OR ECONOMIC SANCTIONS ENDORSEMENT This insurance does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit us from providing insurance, including, but not limited to, the payment of claims. All other terms and conditions of policy remain unchanged. This endorsement is not applicable in: CT, FL, MN, NJ, TN, VA and WI. Authorized Representative WC 99 99 99 A (10/06)Page 1 of 1 EXTENSION OF INFORMATION PAGE SCHEDULE OF NAMED INSURED Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLRNumber:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. SCHEDULE OF NAMED INSURED ITEM 1., NAMED INSURED, OF THE INFORMATION PAGE IS EXTENDED AS FOLLOWS: NAMED INSURED FEIN INSPERITY, INC. 760479645 NORTH SHORE COMMUNITY DEVELOPMENT 042686893 COALITION INC For the state of CA refer to state specific endorsement. Authorized Representative WC 99 99 99 B (10/06)Page 1 of 1 EXTENSION OF INFORMATION PAGE SCHEDULE OF OTHER WORKPLACES Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. SCHEDULE OF OTHER WORKPLACES ITEM 1., OTHER WORKPLACES, OF THE INFORMATION PAGE IS EXTENDED AS FOLLOWS: OTHER WORKPLACES FEIN INSPERITY, INC. 760479645 19001 CRESCENT SPRINGS DRIVE KINGWOOD, TX 77339 NORTH SHORE COMMUNITY DEVELOPMENT 042686893 COALITION INC 96 LAFAYETTE ST SALEM, MA 019703625 For the state of CA refer to state specific endorsement. This endorsement is not applicable in NJ. Authorized Representative WC 99 99 99D INSURED COPY Forms and Endorsements Schedule Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. FORM AND ENDORSEMENT SCHEDULE WC 000000C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 000001A CONTRACT INFORMATION PAGE WC 000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE ENDORSEMENT WC 000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE ENDORSEMENT WC 000109C OUTER CONTINENTAL SHELF LANDS ACT COVERAGE ENDORSEMENT WC 000201B MARITIME COVERAGE ENDORSEMENT WC 000203 VOLUNTARY COMPENSATION MARITIME COVERAGE ENDORSEMENT WC 000311A VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT WC 000313 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT WC 000414 NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT WC 000422C TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT 08020261 CIVIL UNIONS OR DOMESTIC PARTNERSHIPS WC 990302D VOLUNTARY COMPENSATION ENDORSEMENT FOREIGN WC 990343A WAR RISK HAZARD ENDORSEMENT WC 990355 UNINTENTIONAL ERRORS AND OMISSIONS WC 990391A TWO OR MORE POLICIES ISSUED BY US WC 990409 NOTIFICATION OF PREMIUM ADJUSTMENT WC 990645 EARLIER NOTICE OF CANCELLATION OR NONRENEWAL PROVIDED BY US WC 990773 TRADE OR ECONOMIC SANCTIONS ENDORSEMENT WC 999999A SCHEDULE OF NAMED INSURED WC 999999B SCHEDULE OF OTHER WORKPLACES WC 999999D SCHEDULE OF FORMS AND ENDORSEMENTS WC 200301 MA MASSACHUSETTS LIMITS OF LIABILITY ENDORSEMENT WC 200302A MA MASSACHUSETTS ASSESSMENT CHARGE (Authorized Representative) WC 99 99 99D INSURED COPY Forms and Endorsements Schedule Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. FORM AND ENDORSEMENT SCHEDULE WC 200303D MA MASSACHUSETTS NOTICE TO POLICYHOLDER ENDORSEMENT WC 200304D MA MASSACHUSETTS PROFESSIONAL EMPLOYER ORGANISATION (PEO) / EMPLOYEE LEASING ENDORSEMENT WC 200405 MA MASSACHUSETTS PREMIUM DUE DATE ENDORSEMENT WC 200601A MA MASSACHUSETTS CANCELLATION ENDORSEMENT WC 990766A MA DEDUCTIBLE ENDORSEMENT EXPENSE ERODES DEDUCTIBLE STATE OF MASSACHUSETTS (Authorized Representative) WC 20 03 01 (4/84) Ptd. in U.S.A. MASSACHUSETTS LIMITS OF LIABILITY ENDORSEMENT Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. MASSACHUSETTS LIMITS OF LIABILITY ENDORSEMENT This endorsement applies only to the insurance provided by Part Two (Employers Liability Insurance) because Massachusetts is listed in item 3.A of the Information Page. Our liability to you under Section 25 of Chapter 152 of the General Laws of Massachusetts is not subject to the limit of liability that applies to Part Two (Employers Liability Insurance). Authorized Agent WC 20 03 02 A (9/08) Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. MASSACHUSETTS - ASSESSMENT CHARGE Massachusetts General Laws, Chapter 152, Section 65, as amended by Chapter 572 of the Acts of 1985, establishes a workers compensation special fund and a workers compensation trust fund. On behalf of the Department of Industrial Accidents (DIA), the insurance company providing workers compensation coverage is required to bill and collect an assessment charge covering the special and trust funds from insured employers and remit the amounts collected to the State Treasury. The assessment charge, which is determined by applying a rate (subject to annual change) to the DIA’s standard premium, as defined and outlined in 452 CMR 7.00, developed under your policy, is shown as a separate item on the information page of the policy. The rate may be different for private employers and for the Commonwealth and its political subdivisions. The income derived from the assessment charge will be used to fund the operating expenses of the DIA and to fund certain employee benefits as described in Chapter 152. Authorized Representative WC 20 03 03D (08/10)Page 1 of 2 MASSACHUSETTS NOTICE TO POLICYHOLDER ENDORSEMENT Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. MASSACHUSETTS NOTICE TO POLICYHOLDER ENDORSEMENT This endorsement applies only to the insurance provided by the policy because Massachusetts is shown in Item 3.A. of the Information Page. 1. Rates and Premium The policy contains rates and classifications that apply to your type of business. If you have any questions regarding the rates or classifications, please contact your agent or us. You may obtain pertinent rating information by submitting a written request to the Workers’ Compensation Rating and Inspection Bureau of Massachusetts at the address shown in this endorsement or to us at our company address shown on this endorsement. We may require you to pay a reasonable charge for furnishing the information. You may also submit a written request for a review of the method by which your classification, rates, premiums or audit results were determined. If we fail to grant or reject your request within thirty days after it is made or if you are not satisfied by the results of our review, you may submit a written request for review to the Workers’ Compensation Rating and Inspection Bureau of Massachusetts (“WCRIBMA”) at the address shown in this endorsement. If the WCRIBMA fails to grant or reject your request within thirty days after it is made or if you are not satisfied with the results of the WCRIBMA review, you may appeal to the Commissioner of Insurance at the address shown in this endorsement. 2. Reserve or Settlements You may request a loss run, which contains reserve and settlement information for claims that relate to the premium for this policy. Such a request must be in writing and should be sent to our address shown on this endorsement. We will provide you with that information within thirty (30) days of receipt of your request, and at reasonable intervals thereafter. If you have any questions or believe that we set unreasonable reserves or made unreasonable settlements that affected your premiums or losses, you may make a written request through your agent or directly to us for a meeting with our company representative. If you are not satisfied with the results of the meeting, you may make a written appeal to the Insurance Commissioner at the address shown on the endorsement. 3. Named Insured You are responsible for immediately reporting all changes in name or legal status to us in writing at the company address shown in this Endorsement. If you want to add a named insured or replace the named insured with another legal entity on any policy issued through the Massachusetts Assigned Risk Pool you must submit a new Assigned Risk Pool Application, including a Confidential Request for Information Form (ERM), to the Workers’ Compensation Rating and Inspection Bureau of Massachusetts at the address shown in this Endorsement. 4. Insured’s Mailing Address Notices relating to this Policy will be mailed or delivered to your mailing address. Your mailing address is that which is shown in Item 1 of the Information Page or in a change of address Endorsement to the Policy. You are responsible for notifying us in writing at the company address shown in this Endorsement about any change to your mailing address. WC 20 03 03D (08/10)Page 2 of 2 Addresses The Workers’ Compensation Rating and Inspection Bureau of Massachusetts Attention: Customer Service Department 101 Arch Street, 5th Floor Company Address Boston, MA 02110 www.wcribma.org Commissioner of Insurance Division of Insurance Department of Banking and Insurance 1000 Washington St 8th Floor Boston, MA 02118-2218 ACE USA COMPANIES NEW MARKET 55 HADDONFIELD ROAD SUITE 210 CHERRY HILL, NJ 08002 1-800-352-4462 Authorized Representative WC 20 03 04D (01/20)Page 1 of 2 Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. MASSACHUSETTS PROFESSIONAL EMPLOYER ORGANIZATION (PEO) / EMPLOYEE LEASING ENDORSEMENT As used in this endorsement, “employee leasing” shall mean an arrangement, whereby an entity utilizes the services of another entity to provide it with some or all of its workforce for a fee or other compensation under an employee leasing arrangement. The entity providing employee leasing services shall be referred to as the “employee leasing company” or “ELC.” The entity receiving the services shall be referred to as the “client” or “client company.” As used in this endorsement, “professional employer agreement” shall mean a written contract by and between a client and a professional employer organization that establishes the PEO co-employment relationship, identifies covered employees, and allocates employer rights, responsibilities and obligations between the client and the PEO with respect to the covered employees. The entity providing professional employer services shall be referred to as the “professional employer organization” or “PEO.” The entity receiving the services shall be referred to as the “client” or “client company.” Employees provided by either an ELC or a PEO to a client shall herein be referred to as “leased employees” or “leased workers.” This endorsement applies only with respect to those of your workers provided to the client company named in the Schedule below under either an employee leasing arrangement or a professional employer agreement that allocates to the PEO the responsibility of obtaining workers’ compensation insurance. These are arrangements that are long term and not used to provide the client company temporary help services during seasonal or unusual conditions, such as temporary skill shortages or temporary special assignments and projects. Part One (Workers’ Compensation Insurance) and Part Two (Employers’ Liability Insurance) will apply as though the client is the employer and is insured under this policy. The insurance afforded by this endorsement is not intended to satisfy the client company’s duty to secure its obligations under the workers’ compensation law. We will not file evidence of this insurance on behalf of the client with any government agency. We will not ask any other insurer of the client to share with us a loss covered by this endorsement. Premium will be charged for your workers leased to the client company shown below. The policy may be cancelled pursuant to applicable law without need for us to send notice to the client company. It shall be your responsibility to notify the client of the cancellation, by certified mail and within ten days of your receipt of the cancellation notice. The cancellation of this policy shall not affect your rights and obligations as an ELC or PEO with respect to any other workers’ compensation and employers’ liability policy issued to you. Part Four (Your Duty If Injury Occurs) applies to you and the client company shown below. The client company will recognize our right to defend under Part One and Part Two and our right to inspect under Massachusetts law and Part Six (Conditions). The experience of the employees leased to the client company shall be separately maintained. WC 20 03 04D (01/20)Page 2 of 2 Schedule Name of Client Address FEIN NORTH SHORE COMMUNITY 96 LAFAYETTE 042686893 DEVELOPMENT COALITION INC ST;SALEM;MA;019703625 Authorized Representative WC 20 04 05 (10/01) Ptd. in U.S.A. MASSACHUSETTS PREMIUM DUE DATE Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. MASSACHUSETTS PREMIUM DUE DATE ENDORSEMENT Section D. of Part Five of the Policy is replaced by this provision PART FIVE PREMIUM D.Premium Payments is amended to read: You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid.The audit and retrospective premiums shall be paid by the due date indicated on the billing statement. Authorized Agent WC 20 06 01 A (7/08) MASSACHUSETTS CANCELATION Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. MASSACHUSETTS CANCELLATION ENDORSEMENT This endorsement applies only to the insurance provided by the policy because Massachusetts is shown in Item 3.A. of the Information Page. The Cancellation Condition of the policy is replaced by the following: Cancellation 1.You may cancel this policy by mailing or delivering to us advance written notice requesting cancelation. Such cancellation shall not be effective until ten days after written notice is given by us to The Workers' Compensation Rating and Inspection Bureau of Massachusetts (Bureau), or until notice has been received by the Bureau that you have secured insurance from another insurance company, whichever occurs first.Our notice to the Bureau may be given by electronic transmission. 2.We may cancel this policy only if based on one or more of the following reasons: (i) nonpayment of premium; (ii) fraud or material misrepresentation affecting your policy; or (iii) a substantial increase in the hazard insured against. Such cancellation shall not be effective until ten days after written notice is given by us to you and The Workers' Compensation Rating and Inspection Bureau of Massachusetts (Bureau), or until notice has been received by the Bureau that you have secured insurance from another insurance company, whichever occurs first.Our notice to the Bureau may be given by electronic transmission. 3.We will mail or deliver the notice of cancellation to you at your last address, which shall be the mailing address shown in Item 1 of the Information Page or the change of mailing address shown in an Endorsement to the Policy. Pursuant to M.G.L. Chapter 175, Section 187C, a written notice of cancellation shall be deemed effective when mailed by us if we obtain a certificate of mailing receipt from the United States Postal Service showing your name and address as stated in the policy. 4. Any of these provisions that conflict with the law that controls the cancellation of this insurance policy is changed by this statement to comply with the law. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Authorized Agent WC 99 03 02D (01/15)©Chubb. 2016. All rights reserved.Page 1 of 3 VOLUNTARY COMPENSATION ENDORSEMENT FOREIGN Workers' Compensation and Employers' Liability Policy Named Insured INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Endorsement Number Policy Number Symbol:WLR Number:C72410634 Policy Period 10-01-2024 TO 10-01-2025 Effective Date of Endorsement 10-01-2024 Issued By (Name of Insurance Company) INDEMNITY INS. CO. OF NORTH AMERICA Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. VOLUNTARY COMPENSATION ENDORSEMENT FOREIGN This endorsement adds Foreign Voluntary Compensation Insurance to the Policy. A.How this Insurance Applies This insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must be sustained by a person who is your employee included in the group of employees described in the Schedule. 2. The bodily injury must occur in the course of the insured employee's employment by you in the country or countries designated in the Schedule or while being transported to or from the United States of America, its territories or possessions, or Canada, and the employment must be necessary or incidental to work in a country listed in the Schedule. 3. This insurance applies only to employees you hire within the limits of the United States of America while they are traveling or temporarily residing outside the United States of America, its territories or possessions or Canada for a period no longer than thirty days. 4. We will reimburse you for the benefits required by this endorsement if we are not permitted to pay the benefits directly to persons entitled to them. B. We will Pay 1. We will pay an amount equal to the benefits that would be required of you if you and your employees described in the Schedule were subject to the workers' compensation law shown in item 1 of the Schedule. We will pay those amounts to the persons who would be entitled to them under the law. 2. Provided a separate specific premium is charged and indicated, we will pay such additional expenses as reasonably may be incurred over and above normal transportation costs for repatriation of employees suffering from bodily injury or diseases covered by this endorsement (including the bodies of employees injured fatally) from a Designated Country to a destination in the United States of America or Canada provided that such injuries make repatriation necessary in the opinion of competent medical authorities. Our liability is limited to the amount shown in the schedule with respect to any one employee. C. Exclusions This insurance does not cover: 1. Any obligation imposed by a workers compensation or occupational disease law, or any similar law. 2. Bodily injury intentionally caused or aggravated by you. 3. Any obligation imposed by the United States Longshoremen's and Harbor Workers' Compensation Act. 4. Bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation Act (33 U.S.C. Sections 901 et seq), the Non-appropriated Fund Instrumentalities Act (5 U.S.C. Sections 8171 et seq), the Outer Continental Shelf Lands Act (43 U.S.C. Sections 1331 et seq), the Defense Base Act (42 U.S.C. Sections 1651-1654), the Federal Mine Safety and Health Act (30 U.S.C. Sections 801 et seq and 901-944 ) any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws. WC 99 03 02D (01/15)©Chubb. 2016. All rights reserved.Page 2 of 3 5. Bodily injury to any person in work subject to the Federal Employers' Liability Act (45 U.S.C. Sections 51- et seq), 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. 6. Bodily injury to a master or member of the crew of any vessel and does not cover punitive damages related to your duty or obligation to provide transportation, wages, maintenance, and cure under any applicable maritime law; D. Before We Pay Before we pay benefits to the persons entitled to them, they must: 1. Release you and us, in writing, of all responsibility for the injury or death. 2. Transfer to us their right to recover from others who may be responsible for the injury or death. 3. Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If the persons entitled to the benefits of this insurance fail to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. E. Recovery From Others If we make a recovery from others, we will keep an amount equal to our expenses of recovery and the benefits we paid. We will pay the balance to the persons entitled to it. If the persons entitled to the benefits of this insurance make a recovery from others, they must reimburse us for the benefits we paid them. F. Employers Liability Insurance Part Two (Employers Liability Insurance) applies to bodily injury covered by this endorsement as though the country shown in the Schedule were shown in item 3.A of the information Page. WC 99 03 02D (01/15)©Chubb. 2016. All rights reserved.Page 3 of 3 SCHEDULE A. Employees Designated Country and/or Location of Operations Designated Workers' Compensation Law ANY U.S. EMPLOYEE WHILE TEMPORARILY OUTSIDE THE UNITED STATES OR CANADA ANYWHERE ELSE IN THE WORLD UNLESS SUBJECT TO TRADE/ECONOMIC SANCTIONS BY U.S. STATE OF HIRE B. REPATRIATION LIMIT $100,000.00 REPATRIATION PREMIUM $ This endorsement is not applicable in the following states: AZ, MN, NJ, NC, PA, TN and WI. For the states of CA, CT, FL, MI and NY refer to state specific endorsements. Authorized Representative WC 90 03 74A (Rev. 03/2024) Page 2 Who we are Who is providing this notice? The Chubb Group. A list of these companies is located at the end of this document. What we do How does Chubb Group protect my personal information? To protect your personal information from unauthorized access and use, we use security measures that comply with federal law. These measures include computer safeguards and secured files and buildings. We restrict access to personal information to our employees, affiliates’ employees, or others who need to know that information to service the account or to conduct our normal business operations. How does Chubb Group collect my personal information? We collect your personal information, for example, when you §apply for insurance or pay insurance premiums §file an insurance claim or provide account information §give us your contact information We also collect your personal information from others, such as credit bureaus, affiliates, or other companies. Why can’t I limit all sharing? Federal law gives you the right to limit only §sharing for affiliates’ everyday business purposes – information about your creditworthiness §affiliates from using your information to market to you §sharing for nonaffiliates to market to you State laws and individual companies may give you additional rights to limit sharing. See below for more on your rights under state law. Definitions Affiliates Companies related by common ownership or control. They can be financial and nonfinancial companies. §Our affiliates include those with a Chubb name and financial companies, such as Westchester Fire Insurance Company and Great Northern Insurance Company. Nonaffiliates Companies not related by common ownership or control. They can be financial and nonfinancial companies. §Chubb does not share with nonaffiliates so they can market to you. Joint Marketing A formal agreement between nonaffiliated financial companies that together market financial products or services to you. §Our joint marketing partners include categories of companies such as banks. WC 90 03 74A (Rev. 03/2024) Page 3 Other important information For Insurance Customers in AZ, CA, CT, GA, IL, MA, ME, MN, MT, NC, NJ, NV, OH, OR, and VA only:Under state law, under certain circumstances, you have the right to see the personal information about you that we have on file. To see your information, write Chubb Group, Attention: Privacy Inquiries, 202 Hall’s Mill Road, P.O. Box 1600, Whitehouse Station, NJ 08889-1600. Chubb may charge a reasonable fee to cover the costs of providing this information. If you think any of the information is not accurate or if you would like us to delete any of this information, you may write us. We will let you know what actions we take. If you do not agree with our actions, you may send us a statement. If you want a full description of privacy rights that we will protect in accordance with the law in your home state, please contact us and we will provide it. We may disclose information to certain third parties, such as law enforcement officers, without your permission. For Nevada residents only:We may contact our existing customers by telephone to offer additional insurance products that we believe may be of interest to you. Under state law, you have the right to opt out of these calls by adding your name to our internal do-not-call list. To opt out of these calls, or for more information about your opt out rights, please contact our customer service department. You can reach us by calling 1-800-258-2930, emailing us at privacyinquiries@Chubb.com, or writing to Chubb Group, Attention: Privacy Inquiries, 202 Hall’s Mill Road, P.O. Box 1600, Whitehouse Station, NJ 08889-1600. You are being provided this notice under Nevada state law. In addition to contacting Chubb, Nevada residents can contact the Nevada Attorney General for more information about your opt out rights by calling 775-684-1100, emailing bcpinfo@ag.state.nv.us, or by writing to: Office of the Attorney General, Nevada Department of Justice, Bureau of Consumer Protection: 100 North Carson Street, Carson City, NV 89701. For California residents only:Under state law, under certain circumstances, you also have the right to correct, amend, or delete the personal information about you that we have on file by writing to Chubb Group, Attention: Privacy Inquiries, 202 Hall’s Mill Road, P.O. Box 1600, Whitehouse Station, NJ 08889-1600. We will respond to your request within 30 business days. For Vermont residents only:Under state law, we will not share information about your creditworthiness within our corporate family except with your authorization or consent, but we may share information about our transactions or experiences with you within our corporate family without your consent. Chubb Group Companies Providing This Notice This notice is being provided by the following Chubb Group companies to their customers located in the United States: ACE American Insurance Company, ACE Capital Title Reinsurance Company, ACE Fire Underwriters Insurance Company, ACE Insurance Company of the Midwest, ACE Life Insurance Company, ACE Property and Casualty Insurance Company, Agri General Insurance Company, Atlantic Employers Insurance Company, Bankers Standard Insurance Company, Century Indemnity Company, Chubb Custom Insurance Company, Chubb Indemnity Insurance Company, Chubb Insurance Company of New Jersey, Chubb Lloyds Insurance Company of Texas, Chubb National Insurance Company, Executive Risk Indemnity Inc., Executive Risk Specialty Insurance Company, Federal Insurance Company, Great Northern Insurance Company, Illinois Union Insurance Company, Indemnity Insurance Company of North America, Insurance Company of North America, Pacific Employers Insurance Company, Pacific Indemnity Company, Penn Millers Insurance Company, Vigilant Insurance Company, Westchester Fire Insurance Company and Westchester Surplus Lines Insurance Company. OVERTIME In most states, the amount in excess of the straight time pay rate may be deducted, provided it can easily be identified on your records. Overtime must be shown separately by employee and in summary by class of work. DIVISION OF PAYROLL Division of an individual employee's payroll to more than one classification is not permitted, except for construction or erection operations and/or certain executive officer classifications. For construction or erection operations, the payroll of an employee may be allocated to each type of work performed, provided proper records are maintained. If not, the full salary must be charged against the highest rated classification to which the employee is exposed. SUB-CONTRACTORS State Workers' Compensation laws generally hold you responsible for injuries to an employee of an uninsured Sub-Contractor. You may protect your interests by securing a Certificate of Insurance from each Sub-Contractor you use. If certificates are not available at the time of Audit, the Sub- Contractor's exposure must be added to yours which will increase your insurance costs. NOTE: The two (2) preceding paragraphs refer to Workers' Compensation. For General Liability audits, the total cost of sublet work and certificates of the sub-contractor's liability coverage will be required. AUTOMATED RECORDS If your records are Automated, or you plan to Automate in the near future, you can obtain maximum benefits by setting up your programs to include Insurance Requirements. A Chubb Premium Auditor will be pleased to assist you in identifying lnsurance Record Keeping Requirements. Simple questions can be answered by phone or mail. More complex matters may require the services of a Premium Auditor at your premises. In either case, we will be pleased to help you avoid future audit problems, thereby avoiding unnecessary costs. Your agent can request this service for you and we will be pleased to provide it at no cost. AFTER THE AUDIT IS COMPLETED The Auditor will be happy to explain the audit to you. You are entitled to a copy of the worksheets upon request, and the Auditor will provide it or arrange to have it sent to you. We are not allowed to provide anyone else with copies of your Audit results as this information is considered confidential. You may request additional copies at any time and we will send them to your attention for further distribution. The contents of this publication follow general insurance principles. It is not intended to replace or supercede any definitions or conditions contained in your policy. If you have questions concerning your insurance coverage, we recommend you bring them to the attention of your local insurance agent. WC 00 00 00 C (01/15)Copyright 2013 National Council on Compensation Insurance, Inc. Page 1 of 6 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows: GENERAL SECTION A. The Policy This policy includes at its effective date the Information Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Information Page) and us (the insurer named on the Information Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy. B.Who is Insured You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an employer of the partnership's employees. C. Workers Compensation Law Workers Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect during the policy period. It does not include any federal workers or workmen's compensation law, any federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D. State State means any state of the United States of America, and the District of Columbia. E.Locations This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A. states 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 death. 1. Bodily injury by accident must occur during the policy period. 2. Bodily injury by disease must be caused or aggravated by the conditions of your employment. 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 the benefits required of you by the workers compensation law. C.We Will Defend We have the right and duty to defend at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to investigate and settle these claims, proceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. D.Will 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: 1. reasonable expenses incurred at our request, but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable 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. WC 00 00 00 C (01/15)Copyright 2013 National Council on Compensation Insurance, Inc. Page 2 of 6 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. Subject to any limits of liability that may 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 will be equal until the loss is paid. F. Payments You Must Make You are responsible for any payments in excess of the benefits regularly provided by the workers compensation 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 with a health or safety law or regulation; or 4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law. 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 entitled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H. Statutory Provisions 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 our 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 not 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 that conflict with the workers compensation law are changed by this statement 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 liability 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 employment. 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. 5.If you are sued, the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. WC 00 00 00 C (01/15)Copyright 2013 National Council on Compensation Insurance, Inc. Page 3 of 6 B. We Will Pay We will pay all sums that 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 permitted 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 direct consequence of bodily injury that arises out of and in the course of the injured employee'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. C. Exclusions This insurance does not cover: 1. Liability assumed under a contract. This exclusion 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 law; 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 compensation,occupational disease, unemployment compensation, or disability benefits law, or any similar law; 5. Bodily injury intentionally caused or aggravated by you; 6. Bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 7. Damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation,harassment,humiliation, discrimination against or termination of any employee, or any personnel practices, policies, acts or omissions; 8. Bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation Act (33 U.S.C. Sections 901 et seq.), the Non appropriated Fund Instrumentalities Act (5 U.S.C. Sections 8171 et seq.), the Outer Continental Shelf Lands Act (43 U.S.C. Sections 1331 et seq.), the Defense Base Act (42 U.S.C. Sections 1651- 1654), the Federal Mine Safety and Health Act (30 U.S.C. Sections 801 et seq. and 901-944), any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws; 9. Bodily injury to any person in work subject to the Federal Employers' Liability Act (45 U.S.C. Sections 51 et seq.), 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 master or member of the crew of any vessel, and does not cover punitive damages related to your duty or obligation to provide transportation, wages, maintenance, and cure under any applicable maritime law; 11. Fines or penalties imposed for violation of federal or state law; and 12. Damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 U.S.C Sections 1801 et seq.) and under any other federal law awarding damages for violation of those laws or regulations issued there under, and any amendments to those laws. D. We Will Defend We have the right and duty to defend, at our expense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceedings and suits. We have no duty to defend a claim, proceeding or suit that 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. WC 00 00 00 C (01/15)Copyright 2013 National Council on Compensation Insurance, Inc. Page 4 of 6 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: 1. Reasonable expenses incurred at our request, but not loss of earnings; 2. Premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability 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 than our share of damages and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability 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 Information Page. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for "bodily injury by accident-each accident" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident 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 out of bodily injury by disease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for "bodily injury by disease-each employee" is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include disease that results directly from a bodily injury by accident. 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 to help us enforce them. I. Actions Against Us There will be no right of action against us under this insurance unless: 1. You have complied with 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 right to add us as a defendant in an action against you to determine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obligations under this Part. PART THREE – OTHER STATES INSURANCE A. How This Insurance Applies 1. This other states insurance applies only if one or more states are shown in Item 3.C. of the Information Page. 2.If you begin work in any one of those states after the effective date of this policy and are not insured or are not self-insured for such work, all provisions 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 benefits 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. B.Notice Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. WC 00 00 00 C (01/15)Copyright 2013 National Council on Compensation Insurance, Inc. Page 5 of 6 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. 1. 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 all notices, demands and legal papers related to the injury, claim, proceeding or suit. 4. Cooperate with us and assist us, as we may request, in the investigation, 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 obligations or incur expenses, except at your own cost. PART FIVE – PREMIUM A. Our Manuals All premium for this policy will be determined by our manuals of rules, rates, rating plans and classifications. 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 classifications. 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 endorsement to 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: 1. 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 Compensation Insurance) of this policy. If you do not have payroll records for these persons, the contract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the employers of these persons lawfully secured their workers compensation obligations. D. Premium Payments You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. E. Final Premium The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final 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 final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise: 1. If we cancel, final 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, final 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 cancelation table and procedure. Final premium will not 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. WC 00 00 00 C (01/15)Copyright 2013 National Council on Compensation Insurance, Inc. Page 6 of 6 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 programs 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 final premium. Insurance rate service organizations have the same rights we have under this provision. PART SIX – CONDITIONS A. Inspection We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurability of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate 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 representative as insured. D. Cancelation 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation 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 cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancelation notice. 4. Any of these provisions that conflict with a law that controls the cancelation of the insurance in this policy is changed by this statement to comply with the law. E.Sole Representative The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancelation. By signing and delivering the policy to you, we state that it is a valid contract when countersigned by our authorized representative. INDEMNITY INS. CO. OF NORTH AMERICA 436 Walnut Street P.O. Box 1000 Philadelphia, PA 19106 - 3703 Brandon M. Peene, Secretary