Legal Document: SECURITY NATIONAL INSURANCE COMPANY VS ADVANCED PANEL SYSTEMS LLC

On July 14, 2022 a ClientDecCourtJudgment was filed involving a dispute between Security National Insurance Company, and Advanced Panel Systems Llc, in the District Court of Kern County.

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DocuSign Envelope ID: 41883220-9421-473E-A57F-94D84486FC9A

1 Timothy Carl Aires, Esq. (138169)
AIRES LAW FIRM
2 6 Hughes, Suite 205
Irvine, California 92618
3 (949) 718-2020
(949) 718-2021 FAX
4
Attorneys for Plaintiff,
5 SECURITY NATIONAL INSURANCE COMPANY

8 SUPERIOR COURT (UNLIMITED) OF THE STATE OF CALIFORNIA

9 COUNTY OF KERN

10
11 SECURITY NATIONAL INSURANCE ) Case No. BCV-22-101762
COMPANY, )
12 ) DECLARATION OF JAMES BULLER IN
Plaintiff, ) SUPPORT OF ENTRY OF COURT
13 ) JUDGMENTBYDEFAULT
~ )
14 ) [C.C.P. §585(d)]
ADVANCED PANEL SYSTEMS LLC; and )
15 DOES 1 through 100, inclusive, )
)
16
______________ Defendants. )
)
17

19 Plaintiff Security National Insurance Company, by and through its counsel of record, hereby

20 submits the Declaration of James Buller in Support of Entry of Court Judgment by Default, as

21 follows:

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DEC RE: COURT JUDGMENT
DocuSign Envelope ID: 41883220-9421-473E-A57F-94D84486FC9A

1 DECLARATION OF JAMES BULLER

3 I, JAMES BULLER, hereby declare:

5 1. The following facts are true of my own personal, first-hand knowledge, except as

6 those matters stated on information and belief, which I believe to be true, and if called and sworn

7 to testify thereto, I could and would competently do so.

9 2. I am the Vice President of Cash Operations for AmTrust North America Inc., the

10 operating company for Security National Insurance Company, and as such am fully familiar with

11 the facts and circumstances of this matter and have authority to act on behalf of Security National

12 Insurance Company in the commercial liability and workers compensation insurance coverage to

13 businesses. My tasks include collecting and overseeing the collection of premiums due on insurance

14 policies Security National Insurance Company writes which are administered by my employer.

16 3. In my employment capacity, I am a custodian of records for Security National

17 Insurance Company. I am familiar with the methods used in making database entries and maintaining

18 the records of the insurance policies we write as well as the accounts receivables and other

19 documents reflecting the agreements and contracts of Security National Insurance Company which

20 are made or entered into in the regular course of business, and are made at or near the time of the

21 occurrence of the transactions which are recorded or otherwise documented. I can and do testify to

22 the identity of said records and documents and their mode of preparation and maintenance. The

23 records and documents accompanying this declaration were created, executed and/or received by our

24 employees in the regular course ofbusiness and are maintained in the files ofmy employer. Those

25 records include certain policies of insurance and supporting documentation, including applications

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2 DEC RE: COURT JUDGMENT
DocuSign Envelope ID: 41883220-9421-473E-A57F-94D84486FC9A

1 and policies issued, maintained and/or serviced by Security National Insurance Company, as well

2 as the results of audits performed to determine premiums due on the policies we write, as well as

3 promissory notes reflecting subsequent agreements to pay unpaid premiums over time.

5 4. This is a collection case. Through the complaint, my employer seeks to collect unpaid

6 WorkersCompensationandEmployersLiabilityinsurancepremiums. On Policy No. SWC1242724

7 for the period ofl 0/3/2018 through 10/3/2019, my employer seeks the principal sum of$286,913 .31,

8 together with prejudgment interest of$57,834.88 (based on $78.58 per day from September 9, 2020

9 through September 15, 2022 [736 days] using the legal rate of 10% per annum). In addition, my

10 employer seeks costs of suit totaling $535.00 [complaint fee $435.00; service of process fee

11 $100.00]. In total, my employer seeks $345,283.19.

13 5. The records ofmy employer show that on or about October 3, 2018, Plaintiff upon

14 the request of Defendants for Workers Compensation and Employers Liability Insurance coverage,

15 providedDefendantswithanlnsurancePolicyNo. SWC1242724fortheperiodof10/3/2018through

16 10/3/2019, which was subject to an audit and recomputation of its premium (the "2018 Policy"). A

17 true and correct copy of which is attached as Exhibit "A".

19 The 2018 Policy, in part, provides:

21 PART FIVE - PREMIUM [i1lB. Classifications [4,r]
Item 4 of the

22 information page shows the rate and premium basis for certain

23 business or work classifications. These classifications were assigned

24 based on an estimate of the exposures you would have during the

25 policy period. If your actual exposures are not properly described by

26 those classifications, we will assign proper classifications, rates and

27 premium basis by endorsement to this policy. [,r] C. Remuneration

28 [1] Premium for each work classification is determined by

3 DEC RE: COURT JUDGMENT
DocuSign Envelope ID: 41883220-9421-473E-A57F-94D84486FC9A

1 multiplying a rate times a premium basis period. Remuneration is the

2 most common premium basis. This premium basis includes payroll

3 and all other remuneration paid or payable during the policy period

4 for the services of: [,r]1. All your officer and employees engaged in

5 work covered by this policy; and [in 2. All other persons engaged in

6 work that would make us liable under Part One 0Norkers
7 Compensation Insurance) of this policy period. If you do not have

8 payroll records for these persons, the contract price for their services

9 and materials may be used as the premium basis. This paragraph 2

10 will not apply if you give us proof that the employers of these persons

11 lawfully secured their workers compensation obligation. [ii] E. Final

12 Premium. The premium shown on the Information Page, schedules

13 and endorsements is an estimate. The final premium will be

14 determined after this policy ends by using the actual, and not the

15 estimated, premium basis and the proper classifications and rates that

16 lawfully apply to the business and work covered by this policy. Ifthe

17 final premium is more than the premium you paid us, you must pay

18 us the balance. If it is less, we will refund the balance to you. The

19 final premium will not be less than the highest minimum premium for

20 the classifications covered by this policy.... [in F. Records. y OU will
21 keep records of information needed to compute premium. You will

22 provide us with copies of those records when we ask for them. [ii] G.

23 Audit. You will let us examine and audit all your records that relate

24 to this policy. These records include ledgers, journals, registers,

25 vouchers, contracts, tax reports, payroll and disbursement records,

26 and programs for storing and retrieving data. We may conduct the

27 audits during regular business hours during the policy period and

28 within three years after the policy period ends. Information

4 DEC RE: COURT JUDGMENT
DocuSign Envelope ID: 41883220-9421-473E-A57F-94D84486FC9A

1 developed by audit will be used to determine final premmm.

2 Insurance rate service organizations have the same rights we have

3 under this provision.

5 6. The 2018 Policy is an audited premium policy providing statutorily-mandated

6 workers compensation and employers liability insurance. Premium audit adjustment is necessary

7 after expiration, cancellation or at intervals specified in any insurance policy which has a variable

8 premium base. An audit is performed after the policy expires to gather the actual basis of premium,

9 which is used to correctly adjust the premium for the coverage. Examples of coverages which

10 require an adjustment are: workers' compensation, general liability, premises operations liability,

11 products completed operations, garage liability, and automobile liability. Since these types of

12 insurance coverages are based upon variable estimates at the inception of the policy, adjustment at

13 expiration or cancellation is necessary to determine the correct classifications and exposures for the

14 coverages provided. The insured pays only for the coverages provided - no more, no less.

16 7. My employer periodically generates audit reports and invoices/endorsements for

17 premiums due for insurance provided by my employer to our various insureds, as well as invoices

18 for deductibles due on claims. I am familiar with the mode of preparation of these audit reports and

19 the maintenance of those records after invoices/endorsements are generated and sent to our insureds.

20 Data integrity is maintained throughout our billing process to insure that a particular insured is only

21 billed for premiums due by that particular insured. After the premium due is calculated for our

22 various insureds, or deductibles are determined to be due on claims, this data is used in generating

23 invoices/endorsements for each insured through our computerized accounting system. Once the

24 invoices/endorsements are generated, the invoices/endorsements are placed in addressed, sealed

25 envelopes, postage prepaid, and then mailed to the various insureds. Copies of

26 invoices/endorsements are then maintained in our records in either hard-copy of electronic form, as

27 the case may be. Those copies are stored in our accounting files. My employer's records

28 demonstrate that an audit was subsequently performed on the effective policy period for the 2018

5 DEC RE: COURT JUDGMENT
DocuSign Envelope ID: 418B3220-9421-473E-A57F-94D84486FC9A

1 Policy. The audit found the premium basis estimate provided by the Defendants to be inaccurate and

2 found the actual audited total premium and fees for the effective policy period for the 2018 Policy

3 to be an additional $286,913.31, which became fixed or readily ascertainable on September 9, 2020,

4 as evidenced by a premium audit invoice, a true and correct copy of which is attached hereto as

5 Exhibit "B".

7 8. Defendants refused to make any further payments toward the policy premium due for

8 the 2018 Policy. Thus, the complaint seeks money, based on a breach of contract, for unpaid

9 insurance premiums due after demand as set forth on written invoice, as shown on Exhibit "B".

IO There is no instrument to "cancel" under California Rules of Court, Rule 3.1806.

12 9. Thus, through its complaint, my employer seeks to collect unpaid workers

13 compensation and employers liability insurance premiums on Policy No. SWC1242724 for the

14 period of 10/3/2018 through 10/3/2019, in the principal sum of $286,913.31, together with

15 prejudgment interest of $57,834.88 (based on $78.58 per day from September 9, 2020 through

16 September 15, 2022 [736 days] using the legal rate of 10% per annum), plus my employer seeks

17 costs of suit totaling $535.00 [clerk's filing fee: $435.00; process server's fees: $100.00] are

18 requested. Attorney's fees, if any, due under the contract are hereby waived. In total, my

19 employer seeks $345,283.19.

21 I declare under penalty of perjury under the laws of the State of California that the foregoing

22 is true and correct and that this Declaration was executed on this day of September, 2022 at
Cl eve1and, Oh10. . 9/14/2022 I 09 : 11 : 00 PDT
23

25
Tfm:LER
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6 DEC RE: COURT JUDGMENT
SECURITY NATIONAL INSURANCE COMPANY
2711 Centerville Road, Suite
[ 400 ]
Wilmington, DE 19808

WORKERS' COMPENSATION
and
EMPLOYERS’ LIABILITY INSURANCE POLICY

In Witness Whereof, we have caused this policy to be executed and attested.

[ ] [ ]

[ Stephen Ungar, Secretary ] [ Barry Dov Zyskind, President ]

To obtain information, please contact your agent or Security National Insurance
Company at 877-528-7878. You may also write Security National Insurance Company
Consumer Relations at:

800 Superior Avenue East, 21st Floor
Cleveland, OH 44114

WC 99 00 00 B

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective 10/3/2018 Policy No. SWC1242724 Endorsement No. 0

Insured Advanced Panel Systems LLC Premium $ 127556

Insurance Company Security National Insurance Company EXHIBIT A
PN049901D
(Ed. 01-11)

POLICYHOLDER NOTICE
YOUR RIGHT TO RATING AND DIVIDEND INFORMATION
I. Information Available to You
A. Information Available from Us – Security
.
National Insurance Company
(1) General questions regarding your policy should be directed to your agent.
(2) Dividend Calculation. If this is a participating policy (a policy on which a dividend may be paid), upon payment or
non-payment of a dividend, we shall provide a written explanation to you that sets forth the basis of the dividend
calculation. The explanation will be in clear, understandable language and will express the dividend as a dollar amount
and as a percentage of the earned premium for the policy year on which the dividend is calculated.
(3) Claims Information. Pursuant to Sections 3761 and 3762 of the California Labor Code, you are entitled to receive
information in our claim files that affects your premium. Copies of documents will be supplied at your expense during
reasonable business hours.
For claims covered under this policy, we will estimate the ultimate cost of unsettled claims for statistical purposes
eighteen months after the policy becomes effective and will report those estimates to the Workers' Compensation
Insurance Rating Bureau of California (WCIRB) no later than twenty months after the policy becomes effective. The cost
of any settled claims will also be reported at that time. At twelve-month intervals thereafter, we will update and report to
the WCIRB the estimated cost of any unsettled claims and the actual final cost of any claims settled in the interim. The
amounts we report will be used by the WCIRB to compute your experience modification if you are eligible for experience
rating.

B. Information Available from the Workers’ Compensation Insurance Rating Bureau of California
(1) The WCIRB is a licensed rating organization and the California Insurance Commissioner’s designated statistical agent.
As such, the WCIRB is responsible for administering the California Workers’ Compensation Uniform Statistical
Reporting Plan—1995 (USRP) and the California Workers’ Compensation Experience Rating Plan—1995 (ERP).
Contact information for the WCIRB is: WCIRB, 525 Market Street, Suite 800, San Francisco, California 94105-2767,
Attention: Customer Service. You may also contact WCIRB Customer Service at 1 888 229 2472, by fax at 415-778-
7272, or via the Internet at the WCIRB’s website: http://www.wcirbonline.org. The regulations contained in the USRP
and the ERP are available for public viewing through the WCIRB’s website.

(2) Policyholder Information. Pursuant to California Insurance Code (CIC) Section 11752.6, upon written request, you
are entitled to information relating to loss experience, claims, classification assignments, and policy contracts as well as
rating plans, rating systems, manual rules, or other information impacting your premium that is maintained in the records
of the WCIRB. Complaints and Requests for Action requesting policyholder information should be forwarded to: WCIRB,
525 Market Street, Suite 800, San Francisco, California 94105-2767, Attention: Custodian of Records. The Custodian of
Records can be reached by telephone at 415-777-0777 and by fax at 415-778-7272.

(3) Experience Rating Form. Each experience rated risk may receive a single copy of its current Experience Rating Form
free of charge by completing a Policyholder Rate Sheet Request Form on the WCIRB’s website at
https://wcirbonline.org/ratesheet. The Experience Rating Form will include a Loss-Free Rating, which is the experience
modification that would have been calculated of $0 (zero) actual losses were incurred during the experience period.
This hypothetical rating calculation is provided for information purposes only.
II. Dispute Process
You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1.
A. Our Dispute Resolution Process.
If you are aggrieved by our decision adopting a change in a classification assignment that results in increased premium, or
by the application of our rating system to your workers’ compensation insurance, you may dispute these matters with us. If
you are dissatisfied with the outcome of the initial dispute with us, you may send us a written Complaint and Request for
Action as outlined below.

You may send us a written Complaint and Request for Action requesting that we reconsider a change in a classification
assignment that results in an increased premium and/or requesting that we review the manner in which our rating system
has been applied in connection with the insurance afforded or offered you. Written Complaints and Requests for Action
should be forwarded to:
CT Corporation Phone – (213) 627-8252
c/o Jere Keprios Fax – (213) 614-8632
818 West Seventh Street
Los Angeles, California 9001
After you send your Complaint and Request for Action, we have 30 days to send you a written notice indicating whether or
not your written request will be reviewed. If we agree to review your request, we must conduct the review and issue a

1 of 2 EXHIBIT A
PN049901D
(Ed. 01-11)

decision granting or rejecting your request within 60 days after sending you the written notice granting review. If we decline
to review your request, if you are dissatisfied with the decision upon review, or if we fail to grant or reject your request or
issue a decision upon review, you may appeal to the insurance commissioner as described in paragraph II.C., below.

B. Disputing the Actions of the WCIRB. If you have been aggrieved by any decision, action, or omission to act of the
WCIRB, you may request, in writing, that the WCIRB reconsider its decision, action, or omission to act. You may also
request, in writing, that the WCIRB review the manner in which its rating system has been applied in connection with the
insurance afforded or offered you. For requests related to classification disputes, the reporting of experience, or coverage
issues, your initial request for review must be received by the WCIRB within 12 months after the expiration date of the policy
to which the request for review pertains, except if the request involves the application of the Revision of Losses rule. For
requests related to your experience modification, your initial request for review must be received by the WCIRB within 6
months after the issuance, or 12 months after the expiration date, of the experience modification to which the request for
review pertains, whichever is later, except if the request for review involves the application of the Revision of Losses rule. If
the request involves the Revision of Losses rule, the time to state your appeal may be longer. (See Section VI, Rule 14 of
the ERP).

You may commence the review process by sending the WCIRB a written Inquiry. Written Inquiries should be sent to:
WCIRB, 525 Market Street, Suite 800, San Francisco, California 94105-2767, Attention: Customer Service. Customer
Service can be reached by telephone at 1-888-229-2472, and by fax at 415-778-7272.
If you are dissatisfied with the WCIRB’s decision upon an Inquiry, or if the WCIRB fails to respond within 90 days after
receipt of the Inquiry, you may pursue the subject of the Inquiry by sending the WCIRB a written Complaint and Request for
Action. After you send your Complaint and Request for Action, the WCIRB has 30 days to send you written notice indicating
whether or not your written request will be reviewed. If the WCIRB agrees to review your request, it must conduct the review
and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If
the WCIRB declines to review your request, if you are dissatisfied with the decision upon review, or if the WCIRB fails to
grant or reject your request or issue a decision upon review, you may appeal to the insurance commissioner as described in
paragraph II.C., below. Written Complaints and Requests for Action should be forwarded to: WCIRB, 525 Market Street,
Suite 800, San Francisco, California 94105-2767, Attention: Complaints and Reconsiderations. The WCIRB's telephone
number is 1-888-229-2472, and the fax number is 415-371-5204.

C. California Department of Insurance – Appeals to the Insurance Commissioner. If, after you follow the appropriate
dispute resolution process described above, we or the WCIRB decline to review your request, if you are dissatisfied with the
decision upon review, or if we or the WCIRB fail to grant or reject your request or issue a decision upon review, you may
appeal to the insurance commissioner pursuant to CIC Sections 11737, 11752.6, 11753.1 and Title 10, California Code of
Regulations, Section 2509.40 et seq. You must file your appeal within 30 days after we or the WCIRB send you the notice
rejecting review of your Complaint and Request for Action or the decision upon your Complaint and Request for Action. If no
written decision regarding your Complaint and Request for Action is sent, your appeal must be filed within 120 days after you
sent your Complaint and Request for Action to us or to the WCIRB. The filing address for all appeals to the insurance
commissioner is:

Administrative Hearing Bureau
California Department of Insurance
1221 Broadway
Suite 900
Oakland, CA 94612
You have the right to a hearing before the insurance commissioner, and our action, or the action of the WCIRB, may be
affirmed, modified, or reversed.
III. Resources Available to You in Obtaining Information and Pursuing Disputes
A. Policyholder Ombudsman. Pursuant to California Insurance Code Section 11752.6, a policyholder ombudsman is
available at the WCIRB to assist you in obtaining and evaluating the rating, policy, and claims information referenced in I.A.
and I.B., above. The ombudsman may advise you on any dispute with us, the WCIRB, or on an appeal to the insurance
commissioner pursuant to Section 11737 of the Insurance Code. The address of the policyholder ombudsman is WCIRB, 525
Market Street, Suite 800, San Francisco, California 94105-2767, Attention: Policyholder Ombudsman. The policyholder
ombudsman can be reached by telephone at 415-778-7159 and by fax at 415-371-5288.

B. California Department of Insurance – Information and Assistance. Information and assistance on policy questions can
be obtained from the Department of Insurance Consumer HOTLINE, 1-800-927-HELP (4357) or http://www.insurance.ca.gov.
For questions and correspondence regarding appeals to the Administrative Hearing Bureau, see the contact information in
paragraph II.C.
This notice does not change the policy to which it is attached.

2 of 2 EXHIBIT A
PN049902B
(Ed. 05-02)

POLICYHOLDER NOTICE

CALIFORNIA WORKERS’ COMPENSATION
INSURANCE RATING LAWS

Pursuant to Section 11752.8 of the California Insurance Code, we are providing you with an explanation of the California
workers’ compensation rating laws.

1. We establish our own rates for workers’ compensation. Our rates, rating plans, and related information are filed with
the insurance commissioner and are open for public inspection.

2. The insurance commissioner can disapprove our rates, rating plans, or classifications only if he or she has
determined after public hearing that our rates might jeopardize our ability to pay claims or might create a monopoly in
the market. A monopoly is defined by law as a market where one insurer writes 20% or more of that part of the
California workers’ compensation insurance that is not written by the State Compensation Insurance Fund. If the
insurance commissioner disapproves our rates, rating plans, or classifications, he or she may order an increase in the
rates applicable to outstanding policies.

3. Rating organizations may develop pure premium rates that are subject to the insurance commissioner’s approval. A
pure premium rate reflects the anticipated cost and expenses of claims per $100 of payroll for a given classification.
Pure premium rates are advisory only, as we are not required to use the pure premium rates developed by any rating
organization in establishing our own rates.
4. We must adhere to a single, uniform experience rating plan. If you are eligible for experience rating under the plan,
we will be required to adjust your premium to reflect your claim history. A better claim history generally results in a
lower experience rating modification; more claims, or more expensive claims, generally result in a higher experience
rating modification. The uniform experience rating plan, which is developed by the insurance rating organization
designated by the insurance commissioner, is subject to approval by the insurance commissioner.

5. A standard classification system, developed by the insurance rating organization designated by the insurance
commissioner, is subject to approval by the insurance commissioner. The standard classification system is a method
of recognizing and separating policyholders into industry or occupational groups according to their similarities and/or
differences. We can adopt and apply the standard classification system or develop and apply our own classification
system, provided we can report the payroll, expenses, and other costs of claims in a way that is consistent with the
uniform statistical plan or the standard classification system.

6. Our rates and classifications may not violate the Unruh Civil Rights Act or be unfairly discriminatory.
7. We will provide an appeal process for you to appeal the way we rate your insurance policy. The process requires us
to respond to your written appeal within 30 days. If you are not satisfied with the result of your appeal, you may appeal
our decision to the insurance commissioner.

California Workers’ Compensation Insurance
Notice of Nonrenewal

Section 11664 of the California Insurance Code requires us, in most instances, to provide you with a notice of
nonrenewal. Except as specified in paragraphs 1 through 6 below, if we elect to nonrenew your policy, we are required to
deliver or mail to you a written notice stating the reason or reasons for the nonrenewal of the policy. The notice is required
to be sent to you no earlier than 120 days before the end of the policy period and no later than 30 days before the end of
the policy period. If we fail to provide you the required notice, we are required to continue the coverage under the policy
with no change in the premium rate until 60 days after we provide you with the required notice.

1 of 2

EXHIBIT A
PN049902B
(Ed. 05-02)

We are not required to provide you with a notice of nonrenewal in any of the following situations:

1. Your policy was transferred or renewed without a change in its terms or conditions or the rate on which the premium
is based to another insurer or other insurers who are members of the same insurance group as us.

2. The policy was extended for 90 days or less and the required notice was given prior to the extension.

3. You obtained replacement coverage or agreed, in writing, within 60 days of the termination of the policy, to obtain that
coverage.

4. The policy is for a period of no more than 60 days and you were notified at the time of issuance that it may not be
renewed.

5. You requested a change in the terms or conditions or risks covered by the policy within 60 days prior to the end of the
policy period.

6. We made a written offer to you to renew the policy at a premium rate increase of less than 25 percent.
(A) If the premium rate in your governing classification is to be increased 25 percent or greater and we intend to
renew the policy, we shall provide a written notice of a renewal offer not less than 30 days prior to the policy
renewal date. The governing classification shall be determined by the rules and regulations established in
accordance with California Insurance Code Section 11750.3(c).

(B) For purposes of this Notice, “premium rate” means the cost of insurance per unit of exposure prior to the
application of individual risk variations based on loss or expense considerations such as scheduled rating and
experience rating.

This notice does not change the policy to which it is attached.

2 of 2

EXHIBIT A
PN049903

(Ed. 11-99)

NOTICE REQUIRED BY LAW−CALIFORNIA

Since our offer to renew your coverage reflects a premium rate increase of 25 percent or more in your governing
classification, California law (Insurance Code section 11664) requires us to send you a “notice of nonrenewal”, even
though we do intend to renew your policy. This constitutes the required notice. For purposes of this Notice, premium
rate means the cost of insurance per unit of exposure prior to the application of individual risk variations based on loss
or expense considerations such as scheduled rating and experience rating.

Insured Advanced Panel Systems LLC Date of Notice 10/3/2018

Policy No. SWC1242724 Policy Period 10/3/2018 - 10/3/2019

EXHIBIT A
PN049904
(Ed. 12-04)

POLICYHOLDER NOTICE

CALIFORNIA INSURANCE GUARANTEE ASSOCIATION (CIGA) SURCHARGE

Companies writing property and casualty insurance business in California are required to participate in the California
Insurance Guarantee Association. If a company becomes insolvent, the California Insurance Guarantee Association
settles unpaid claims and assesses each insurance company for its fair share.

California law requires all companies to surcharge policies to recover these assessments. If your policy is surcharged,
“CA Surcharge” or “CA Surcharge (CIGA Surcharge)” with an amount will be displayed on your premium notice.

This notice does not change the policy to which it is attached.

EXHIBIT A
PN049906
(Ed. 1-08)

POLICYHOLDER NOTICE

PAYROLL RECORD REQUIREMENTS FOR
DUAL WAGE CONSTRUCTION OR ERECTION CLASSIFICATIONS

Dual wage classifications are pairs of classifications that describe the same construction or erection operation yet are
assigned based upon whether the employee’s hourly wage is above or below a specified threshold. Each pair of dual
wage classifications contains one “high wage” classification that is assignable to payrolls earned by employees whose
regular hourly wage equals or exceeds a specified wage threshold and one “low wage” classification that is assignable to
payrolls earned by employees whose regular hourly wage is less than the specified threshold.
Your policy includes one or more dual wage construction or erection classifications. The assignment of a high wage
classification to any non-salaried employee is contingent on verifying that employee’s hourly wage by reconciling the total
number of hours the employee actually worked during the policy period against the employee’s time cards or time sheets
that document the operations performed, the daily start and stop times and the total hours worked each day for that
employee.

The non-salaried employee’s regular hourly wage shall be determined by dividing that employee’s total remuneration by
the hours worked, irrespective of whether the employee is paid on an hourly, piecework, production or commission basis.

The payroll earned by any non-salaried employees for whom we are unable to verify the total number of hours worked
will be assigned to the low wage classification that describes the operations performed.

The regular hourly wage of salaried employees is determined by dividing the total annual remuneration by 2000
hours. If an employee is salaried for less than 12 months, the regular hourly wage for the salaried period is
calculated on a prorated basis.

EXHIBIT A
Provide 24/7 Toll-Free Claim Reporting
For ALL States
Phone: (866) 272-9267
Fax: (775) 908-3724 or (877) 669-9140
Email: Amtrustclaims@qrm-inc.com
Online: www.amtrustfinancial.com (Must Register)

Information Required for All Claims reported.

1. Name of the insured and policy number
2. Date, Time & Place of Accident
3. Description of accident or incident
4. Name, phone and/or e-mail of person making the report

Additional Information Required for Specific Claim Types

A. For Workers’ Compensation
1. MUST have the injured employee’s social security number as it is required by law
2. Description of injury

B. For Property Claims
1. Physical address of the loss
2. If more than one building on property must have specific building(s) involved
3. Type of loss, i.e., Fire, Theft, etc.
4. Description of loss or damage

C. For Motor Vehicle (Auto) Claims
1. Name, address and contact information of ALL parties involved.
2. Make, model and VIN of the insured vehicle
3. Make, model of all other vehicles involved
4. Current location of all vehicles
5. Name and contact information for each driver and all passengers
6. Name and contact information any known witnesses

D. For General Liability Claims
1. Physical address of where the loss occurred
2. Name, address and contact information for all persons claiming injury or damage
3. Name and contact information any known witnesses

EXHIBIT A
Reporte De Reclamo Gratuito 24/7
Para todos los Estados - Demanda Informes Sólo
Teléfono: (866) 272-9267
Fax: (775) 908-3724 o (877) 669-9140
Correo electrónico: Amtrustclaims@qrm-inc.com
En línea: www.amtrustfinancial.com (deben registrarse)

Información necesaria para todos los reclamos registrados.

1. Nombre de la cantidad asegurada y la política
2. Fecha, hora y lugar del accidente
3. Descripción del accidente o incidente
4. Nombre, teléfono y/o correo electrónico de la persona que hace el informe

Información adicional requerida para los tipos de demanda específica

A. Para la compensación
1. Debe tener número de seguro social del empleado lesionado como es requerido por la
ley
2. Descripción de la lesión

B. Para reclamos de propiedad
1. Dirección física de la pérdida
2. Si más de un edificio en propiedad debe tene

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Document for SECURITY NATIONAL INSURANCE COMPANY VS ADVANCED PANEL SYSTEMS LLC

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