Preview
FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022
NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 08/10/2022
EXHIBIT M
FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022
NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 08/10/2022
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE RENEWAL AGREEMENT
Insurer: PRODUCER: Agent# 201
Oriska Insurance Company Freedom Tower Insurance Agency, In
1310 Utica St. P.O. Box 36
P.O. Box 855 Clinton, NY 13323
Oriskany, NY 13424
(Carrier Code: 37265) Carrier Policy #: WC46416010100038
Carrier Prior Policy #: WC46416010100038
1. The Insured: Tov Management Inc a/k/a TOV Management Corp.
Mailing Address: PO Box 190438
Brooklyn, NY 11219
Fein: 043675409
File #: 464000000038004
Other workplaces not shown above: Type of Business: Corporation
NO OTHER WORKPLACES FOR THIS POLICY Risk ID:
2. The policy period is from 12:01 a.m. on 4/01/2019 to 12:01 a.m. on 4/01/2020
at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers
Compensation Law of the states listed here:
NY
B. Employers Liability Insurance: Part Two of the policy applies to work in each
state listed in Item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident $ 1,000,000 each accident
Bodily Injury by Disease $ 1,000,000 policy limit
Bodily Injury by Disease $ 1,000,000 each employee
C. Other States Insurance: N/A
D. This policy includes these endorsements and schedules:
WC000000C(01/15) WC000403(04/84) WC000406A(08/95) WC000414 (07/90) WC000419(01/01)
WC000421D(01/15) WC000422B(01/15) WC310308(04/84) WC310317(07/93) WC310319I(01/18)
WC990602(11/07)
4. The premium for this policy will be determined by our Manuals of Rules,
Classifications, Rates and Rating Plans. All information required below is subject
to verification and change by audit.
Classifications Code Premium Basis Rate Per Estimated
No. Total Estimated $100 of Annual
Annual Remuneration Remuneration Premium
SEE SCHEDULE OF OPERATIONS
Total Estimated Annual Premium $ 1,351.00
Minimum Premium $ 708.20 Expense Constant $ 200.00 Deposit Premium $ .00
WC 00 00 01 C Countersigned by
FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022
NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 08/10/2022
SCHEDULE OF OPERATIONS FOR: PAGE: 1 .
***** PREMIUM INFORMATION FOR NY *****
Tov Management Inc a/k/a TOV Manage Carrier Policy #: WC46416010100038 .
PO Box 190438 Fein: 043675409 .
Brooklyn, NY 11219 .
DIV #: 00000 E/L Number: 0000000001 .
.
.
.
Code Classification Payroll Rate Premium
9028 Building Operation NOC-Dw 28, 800. 00 4 . 62 1, 331. 00
.
Manual Premium 1, 331. 00 .
Standard Premium 1, 331. 00 .
Normal Premium 1, 331. 00
Expense Constant 200. 00
Terrorism Charge . 059 17. 00 .
Catastrophe Charge . 010 3 . OO .
Annual Premium 1, 551. 00 .
NY State Assesment (00932) 12. 6000% 170. 00 .
Total 1, 721. 00 .
WC 00 00 01 C .
FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022
NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 08/10/2022
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C
(Ed. 1-15)
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
In return for the payment of the premium and subject to PART ONE
allterms of this policy,we agree with you as follows: WORKERS COMPENSATION INSURANCE
A. How This Insurance Applies
GENERAL SECTION This workers compensation insurance applies to
bodily injury by accident or bodily injuryby disease.
A. The Policy Bodily injury includes resulting death.
This includes at itseffective date the Infor- 1.. accident must occur the
policy Bodily injury by during
mation Page and allendorsements and schedules policy period.
listed there. Itisa contract of insurance between 2. disease must be caused or ag-
Bodily injury by
you (the employer named in Item 1 of the Infor-
gravated by the conditions of your employment.
mation and us (the insurer named on the In-
Page) The employee's lastday of lastexposure tothe
formation Page). The only agreements relatingto conditions or such in-
causing aggravating bodily
this insurance are stated inthis policy.The terms of disease must occur the
jury by during policy
this policy may not be changed orwaived except period.
by endorsement issued by us to be partof this
policy.
B. We Will Pay
We wilipay promptly when due the benefits required
B. Who is Insured
of you by the workers compensation law.
You are insured if youare an employer named in
Item 1 of the information Page. If thatemployer isa
C. We Will Defend
partnership, and if youare one of itspartners, you
are insured, but only in your capacity as an em- We have the right and duty todefend atour expense
ployer of the partnership's employees. any claim, proceeding or suit against you forbenefits
payable this insurance. We have the right toin-
by
vestigate and settle these claims, proceedings or
CÌ Workers Compensation Law suits.
Workers Compensation Law means the workers or We have no todefend a or
duty claim, proceeding
workmen's compensation law and occupational suitthat isnot covered this insurance.
by
disease law ofeach state or territorynamed in Item
3.A. of the Information Page. Itincludes any
D. We Will Also Pay
amendments to that law which are in effectduring
the period. Itdoes not include federal We willalso pay these costs, inaddition to other
policy any
workers or workmen's compensation fed- amounts payable under this insurance, as part of
law, any
eral occupational disease law or the provisions of any claim, proceeding or suit we defend:
any law that provide nonoccupational disability 1. reasonable expenses incurred at our request,
benefits. but not loss of earnings;
2. premiums for bonds to release attachments and
D. State for appeal bonds in bond amounts up to the
State means state ofthe United States of amount payable under thisinsurance;
any
America, and the Districtof Columbia. 3. litigationcosts taxed against you;
4. interest on a judgment as required by law until
E. Locations we offerthe amount due under thisinsurance;
This covers allof your workplaces listed in and
policy
Items 1 or 4 ofthe Information Page; and it covers 5. expenses we incur.
allother workplaces inItem 3.A. states unless you
have other insurance or are self-insured for such Other
E. Insurance
workplaces.
We willnot pay more than our share of benefits and
costs covered by this insurance and other
1 of 6
© copyright20'l3 National council! on Compensation
Insurance, Inc. All Rights Reserved.
FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022
NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 08/10/2022.
WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
(Ed. 1-15)
insurance or self-insurance. Subject to any limitsof workers compensation law that apply to:
that
liability may apply, allshares willbe equal until a. benefits payable this
by insurance;
the loss ispaid. Ifany insurance or self-insurance
b. special payments into or oth-
is the shares ofall insurance taxes, security
exhausted, remaining
er special funds, and assessments payable
. will
be equal untilthe loss ispaid.
by us under that law.
6. Terms of this insurance thatconflict with the
F. Payments You Must Make workers compensation law are changed this
by
You are responsible forany payments in excess of statement to conform to that law.
the benefits regularly provided by the workers iI these paragraphs relieves you of your du-
Nothing
compensation law including those required ties under this policy.
because:
1. of your serious and willfulmisconduct;
2. you knowingly employ an employee inviolation PART TWO
of law; EMPLOYERS LIABILITY INSURANCE
3. you failto comply with a health or safety law or
or A. How This Insurance Applies
regulation;
This employers insurance
liability applies to bodily
4. you discharge, coerce or otherwise discriminate
injuryby accident or bodily injury by disease. Bodily
against any employee inviolation of the workers
law. injuryincludes resultingdeath.
compensation
1. The bodily injurymust arise out of and inthe
If we make any payments in excess of the benefits
course of the injured employee's employment by
regularly provided by the workers compensation
law on your you willreimburse us promptly. You.
behalf,
2. The employment must be or inci-
necessary
dental to your work in a state or territorylistedin
G. Recovery From Others
Item 3.A. ofthe Information Page.
We have your and the rights of persons enti-
rights, 3. accident must occur the
Bodily injury by during
tied-tothe benefits of thisinsurance, to recover our
po cy perio
payments from anyone liablefor the injury.You will
4. disease must be caused or ag-
do necessary to protect those rightsfor Bodily injury by
everything
gravated by the conditions of your employment.
us and to help us enforce them.
The employee's lastday of lastexposure tothe
conditions or such in-
causing aggravating bodily
H. Statutory Provisions by disease must occur during the policy
jury
These statements apply where they are required by period.
law- 5. If you are sued, the original suitand any related
legal actions for damages for ac-
1. As between an injured worker and us, we have bodily injuryby
notice of the when you have notice. cident or by disease must be brought inthe
injury
United States of itsterritoriesor pos-
2. Your default or the or of America,
bankruptcy insolvency
du- sessions, or Canada.
you or your estate will not relieve us ofour
ties under this insurance after an injury occurs.
3. We are and liableto per- B. We Will Pay
directly primarily any
son entitledto the benefits payable thisin-
by We willpay allsums thatyou legallymust pay as
surance. Those persons may enforce our duties; damages because of toyour employ-
bodilyinjury
so an authorized law. Enforce- covered this
may agency by ees, provided the bodily injury is by
ment may be against us or against you and us. Employers Insurance.
Liability
4. Jurisdiction over you is jurisdictionover us for The damages we will where ispermit-
pay, recovery
purposes ofthe workers compensation law. We ted by law, include damages:
are bouñd by decisions against you under that rea-
1. For which you are liableto a thirdparty by
law, subject to the provisions of thispolicy that
son ofa claim orsuit against you by that third
are not in conflictwith that law.
party to recover the damages claimed against
5. This insurance conforms to the parts of the
2 of 6
© Copyright Insurance, Inc. All Rights Reserved.
2013 National Councl1 on Compensation
FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022
NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 08/10/2022
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C
(Ed. 1-15)
such third as a result of to your em- 9. to person in work subject to the
party injury Bodily injury any
Employers' Sec-
ployee; Federal Act
Liability (45 U.S.C.
tions 51 et seq.), other federal laws obligat-
2. For care and loss of services; and any
ing an employer to pay damages to an employee
3. For consequential bodily injury toa spouse
em- due tobodily injury arising out ofor m the course
child,parent, brother or sister ofthe injured
emPloyment, or any amendments to those
provided thatthese damages are the di-
ployee;
'
rect consequence of bodily injurythat arises out
of and inthe course of the injured employee's 10.Bodily injury to a master or member of the crew
of and does not cover punitive dam-
employment by you; and any vessel,
ages related to your duty orobligation toprovide
4. Because of bodily injuryto your employee that
'transportation, wages, maintenance, and cure
arises out of and inthe course of employment, under any applicable maritime law;
claimed against you in a capacity other than as
11.Fines or penalties imposed for violation of federal
. employer.
or state law; and
12.Damages payable under the Migrant and Sea-
C. Exclusions
sonal Agricultural Worker Protection Act (29
This insurance does not cover:
U.S.C. Sections 1801 et seq.) and under any
1. assumed under a contract.This exclu-
Liability other federal law awarding damages forviolation
sion does not apply to a warranty thatyour work of those laws or regulations issued thereunder,
willbe done ina workmanlike manner; and amendments to those laws.
any
2. Punitive or damages because of bodi-
exemplary
lyinjury to an employee employed inviolation of D. We Will Defend
We have the right and to at our ex-
duty defend,
3. Bodily injury to an employeewhile employed in
pense, any claim, proceeding orsuit against you for
violation of law with your actual knowledge or the
damages payable by this insurance. We have the
actual knowledge of of your executive offic-
any rightto investigate and settlethese proceed-
claims,
ers; ings and suits.
4. obligation imposed a workers compensa-
Any by
com- We have no duty todefend a claim, proceeding or
tion,occupational disease, unemployment
simi- suitthat is notcovered by this insurance. We have
pensation, or disabilitybenefits law, or any no duty to defend or continue defending after we
lar law; have paid our applicable limitof under
liability this
5. Bodily injury intentionally caused or aggravated insurance.
by you;
6. Bodily injury occurring outside the United States
E. We Will Also Pay
of America, itsterritones or possessions, and
Canada. This exclusion does not to We willalso pay these costs, inaddition toother
apply bodily
toa citizen or resident of the United States amounts payable under this insurance, as part of
injury
of America orCanada who is outside any claim, proceeding, or suitwe defend:
temporarily
these countries; 1. Reasonable expenses incurred at our request,
7. Damages out of de·- but not loss of earnings;
arising coercion, criticism,
motion, evaluation, reassignment, discipline, 2. Premiums for bonds to release attachments and
discrimina- for appeal bonds inbond amounts to the limit
defamation, harassment, humiliation, up
tion against or termination ofany employee, or of our under
liability thisinsurance;
personnel acts oromis-
any practices, policies, 3. Litigation costs taxed against you;
sions;
4. Interest on a judgment as required by law until
8. Bodily injuryto any person inwork subject to the the amount under this
Workers' we offer due insurance;
Longshore and Harbor Compensation
and
Act (33 U·.S.C. Sections 901 et seq.), the
5. Expenses we incur.
Nonappropriated Fund Instrumentalities Act (5
U.S.C. Sections 8171 et the Outer Conti-
seq.),
nental Shelf Lands Act (43 U.S.C. Sections 1331
et the Defense Base Act (42 U.S.C. Sec-
seq.),
tions 1651-1654), the Federal Mine Safety and
Health Act (30 U.S.C. Sections 801 et seq. and
other federal workers or work-
901-944), any
men's compensation law or other federal occu-
pational disease or amendments to the-
law, any
se laws;
3 of 6
© Copyright2013 National councli
on CompensationInsurance, Inc. All Rights Reserved.
FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022
NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 08/10/2022
WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
(Ed. 1-15)
F. Other Insurance 2. The amount you owe has been determined with
We will not more than our share of damages our consent or by actual trialand finaljudgment.
pay
and costs covered thisinsurance and other in- This insurance does not give anyone the right toadd
by
surance or self-insurance. Subject to limitsof li- us as a defendant in an action against you to deter-
any
abilitythat apply, allshares willbe equal untilthe mine your liability.
The bankruptcy or insolvency of
loss is paid. If insurance orself-insurance is ex- you oryour estate will not relieve us of our obliga-
any
hausted, the shares of allremaining insurance and tionsunder this Part.
self-insurance willbe equal untilthe loss ispaid.
PART THREE
G. Limits of Liability .
OTHER STATES INSURANCE
Our to
liability pay for damages islimited..Our limits
of are
liability shown in Item 3.B. of the Information A. How This Insurance Applies
Page. They apply as explained below. 1. This other states insurance applies if one or
only
1. Accident. The limitshown for more states are shown in Item 3.C. of the Infor-
Bodily Injuryby
accident"
"bodily injuryby accident-each isthe mation Page.
most we willpay foralldamages covered by this 2. If you begin work in one of those states after
any
insurance because of bodily injury toone or the effective date of this and are not in-
policy
more employees inany one accident. sured or are not self-insured for such all
work,
A disease isnot bodily injuryby accident unless provisions ofthe policy willapply as though that
itresults directly from bodily injury by accident. state were listedin Item 3.A. of the Information
Page.
2. Bodily Injury by Disease. The limitshown for
limit" 3. We willreimburse you for the benefits required
"bodily injury by disease-policy isthe
most we will foralldamages covered this by the workers compensation law ofthat state if
pay by
insurance and out of dis- we are not permitted to pay the benefits directly
arising bodily injury by
regardless of the of employees to persons entitled to them.
ease, number
4. If you have work on the effectivedate of thispol-
who sustain to-dilyinjury by disease. The limit
em- in state not listedin Item 3,A. of the In-
hown for "bodily injuryby disease-each icy any
ployee" formation coverage will not be afforded for
isthe most we will pay for alldamages Page,
because of disease to one that state unless we are notified within thirty
bodilyinjury by any
employee. days.
disease does not include dis-
Bodily injury by
ease that results from a B. Notice
directly bodily injury by
accident. Tell us at once if youbegin work in any state listedin
3. We will not claims for damages after we Item 3.C. of the Information Page.
pay any
have paid the applicable limitof our un-
liability
der this insurance· PART FOUR
YOUR DUTIES IF INJURY OCCURS
H. Recovery From Others
We have your rights torecover our payment from Tell us at once if injuryoccurs thatmay be covered
anyone liablefor an injury covered by this insurance. by this policy.Your other duties are listedhere.
You willdo everything necessary toprotect those 1. Provide for immediate medical and other ser-
rights for us and to help us enforce them. vices required the workers compensation law.
by
2. Give us or our agent the names and addresses
I. Actions Against Us of the injured persons and ofwitnesses, and
There will be no rightof action against us under this other information we may need.
insurance unless: 3. give us allnotices, demands and legal
Promptly
1. You have complied with allthe terms of thispoli-
cy; and
4 of 6
© Copyright Insurance, Inc. AII Rights Reserved.
2013 National Council on compensation
FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022
NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 08/10/2022
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C
(Ed. 1-15)
papers related to the injury, claim, proceeding D. Premium Payments
or suit- You will allpremium when due. You will the
pay pay
4. Cooperate with us and assist as we re- premium even ifpart or allofa workers compensa-
us, may
quest, in the investigation, settlement ordefense tionlaw is not valid.
of any claim, proceeding or suit.
5. Do afteran occurs thatwould in- E. Final Premium
nothing injury
terfere with our rightto recover from others. The premium shown on the Information Page,
6. Do not make assume obli- and endorsements isan estimate. The
voluntarily payments, schedules,
gations or incur expenses, except at your own finalpremium willbe determined afterthis policy
cost. ends the not the premi-
by using actual, estimated,
um basis and the proper classifications and rates
that lawfullyapply to the business and work covered
PART FIVE
by this policy.If thefinalpremium ismore than the
PREMIUM premium you paid to you must us the bal-
us, pay
ance. Ifit is
less,we willrefund the balance to you.
A. Our Manuals The finalpremium willnot be lessthan the highest
Allpremium forthis policywill be determined by our minimum premium forthe classifications covered by
manuals of plans and classifica- thispolicy.
rules, rates,rating
tions.We may change our manuals and
Preview
FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022 NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 08/10/2022 EXHIBIT M FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022 NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 08/10/2022 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE RENEWAL AGREEMENT Insurer: PRODUCER: Agent# 201 Oriska Insurance Company Freedom Tower Insurance Agency, In 1310 Utica St. P.O. Box 36 P.O. Box 855 Clinton, NY 13323 Oriskany, NY 13424 (Carrier Code: 37265) Carrier Policy #: WC46416010100038 Carrier Prior Policy #: WC46416010100038 1. The Insured: Tov Management Inc a/k/a TOV Management Corp. Mailing Address: PO Box 190438 Brooklyn, NY 11219 Fein: 043675409 File #: 464000000038004 Other workplaces not shown above: Type of Business: Corporation NO OTHER WORKPLACES FOR THIS POLICY Risk ID: 2. The policy period is from 12:01 a.m. on 4/01/2019 to 12:01 a.m. on 4/01/2020 at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: NY B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: N/A D. This policy includes these endorsements and schedules: WC000000C(01/15) WC000403(04/84) WC000406A(08/95) WC000414 (07/90) WC000419(01/01) WC000421D(01/15) WC000422B(01/15) WC310308(04/84) WC310317(07/93) WC310319I(01/18) WC990602(11/07) 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration Remuneration Premium SEE SCHEDULE OF OPERATIONS Total Estimated Annual Premium $ 1,351.00 Minimum Premium $ 708.20 Expense Constant $ 200.00 Deposit Premium $ .00 WC 00 00 01 C Countersigned by FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022 NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 08/10/2022 SCHEDULE OF OPERATIONS FOR: PAGE: 1 . ***** PREMIUM INFORMATION FOR NY ***** Tov Management Inc a/k/a TOV Manage Carrier Policy #: WC46416010100038 . PO Box 190438 Fein: 043675409 . Brooklyn, NY 11219 . DIV #: 00000 E/L Number: 0000000001 . . . . Code Classification Payroll Rate Premium 9028 Building Operation NOC-Dw 28, 800. 00 4 . 62 1, 331. 00 . Manual Premium 1, 331. 00 . Standard Premium 1, 331. 00 . Normal Premium 1, 331. 00 Expense Constant 200. 00 Terrorism Charge . 059 17. 00 . Catastrophe Charge . 010 3 . OO . Annual Premium 1, 551. 00 . NY State Assesment (00932) 12. 6000% 170. 00 . Total 1, 721. 00 . WC 00 00 01 C . FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022 NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 08/10/2022 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to PART ONE allterms of this policy,we agree with you as follows: WORKERS COMPENSATION INSURANCE A. How This Insurance Applies GENERAL SECTION This workers compensation insurance applies to bodily injury by accident or bodily injuryby disease. A. The Policy Bodily injury includes resulting death. This includes at itseffective date the Infor- 1.. accident must occur the policy Bodily injury by during mation Page and allendorsements and schedules policy period. listed there. Itisa contract of insurance between 2. disease must be caused or ag- Bodily injury by you (the employer named in Item 1 of the Infor- gravated by the conditions of your employment. mation and us (the insurer named on the In- Page) The employee's lastday of lastexposure tothe formation Page). The only agreements relatingto conditions or such in- causing aggravating bodily this insurance are stated inthis policy.The terms of disease must occur the jury by during policy this policy may not be changed orwaived except period. by endorsement issued by us to be partof this policy. B. We Will Pay We wilipay promptly when due the benefits required B. Who is Insured of you by the workers compensation law. You are insured if youare an employer named in Item 1 of the information Page. If thatemployer isa C. We Will Defend partnership, and if youare one of itspartners, you are insured, but only in your capacity as an em- We have the right and duty todefend atour expense ployer of the partnership's employees. any claim, proceeding or suit against you forbenefits payable this insurance. We have the right toin- by vestigate and settle these claims, proceedings or CÌ Workers Compensation Law suits. Workers Compensation Law means the workers or We have no todefend a or duty claim, proceeding workmen's compensation law and occupational suitthat isnot covered this insurance. by disease law ofeach state or territorynamed in Item 3.A. of the Information Page. Itincludes any D. We Will Also Pay amendments to that law which are in effectduring the period. Itdoes not include federal We willalso pay these costs, inaddition to other policy any workers or workmen's compensation fed- amounts payable under this insurance, as part of law, any eral occupational disease law or the provisions of any claim, proceeding or suit we defend: any law that provide nonoccupational disability 1. reasonable expenses incurred at our request, benefits. but not loss of earnings; 2. premiums for bonds to release attachments and D. State for appeal bonds in bond amounts up to the State means state ofthe United States of amount payable under thisinsurance; any America, and the Districtof Columbia. 3. litigationcosts taxed against you; 4. interest on a judgment as required by law until E. Locations we offerthe amount due under thisinsurance; This covers allof your workplaces listed in and policy Items 1 or 4 ofthe Information Page; and it covers 5. expenses we incur. allother workplaces inItem 3.A. states unless you have other insurance or are self-insured for such Other E. Insurance workplaces. We willnot pay more than our share of benefits and costs covered by this insurance and other 1 of 6 © copyright20'l3 National council! on Compensation Insurance, Inc. All Rights Reserved. FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022 NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 08/10/2022. WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) insurance or self-insurance. Subject to any limitsof workers compensation law that apply to: that liability may apply, allshares willbe equal until a. benefits payable this by insurance; the loss ispaid. Ifany insurance or self-insurance b. special payments into or oth- is the shares ofall insurance taxes, security exhausted, remaining er special funds, and assessments payable . will be equal untilthe loss ispaid. by us under that law. 6. Terms of this insurance thatconflict with the F. Payments You Must Make workers compensation law are changed this by You are responsible forany payments in excess of statement to conform to that law. the benefits regularly provided by the workers iI these paragraphs relieves you of your du- Nothing compensation law including those required ties under this policy. because: 1. of your serious and willfulmisconduct; 2. you knowingly employ an employee inviolation PART TWO of law; EMPLOYERS LIABILITY INSURANCE 3. you failto comply with a health or safety law or or A. How This Insurance Applies regulation; This employers insurance liability applies to bodily 4. you discharge, coerce or otherwise discriminate injuryby accident or bodily injury by disease. Bodily against any employee inviolation of the workers law. injuryincludes resultingdeath. compensation 1. The bodily injurymust arise out of and inthe If we make any payments in excess of the benefits course of the injured employee's employment by regularly provided by the workers compensation law on your you willreimburse us promptly. You. behalf, 2. The employment must be or inci- necessary dental to your work in a state or territorylistedin G. Recovery From Others Item 3.A. ofthe Information Page. We have your and the rights of persons enti- rights, 3. accident must occur the Bodily injury by during tied-tothe benefits of thisinsurance, to recover our po cy perio payments from anyone liablefor the injury.You will 4. disease must be caused or ag- do necessary to protect those rightsfor Bodily injury by everything gravated by the conditions of your employment. us and to help us enforce them. The employee's lastday of lastexposure tothe conditions or such in- causing aggravating bodily H. Statutory Provisions by disease must occur during the policy jury These statements apply where they are required by period. law- 5. If you are sued, the original suitand any related legal actions for damages for ac- 1. As between an injured worker and us, we have bodily injuryby notice of the when you have notice. cident or by disease must be brought inthe injury United States of itsterritoriesor pos- 2. Your default or the or of America, bankruptcy insolvency du- sessions, or Canada. you or your estate will not relieve us ofour ties under this insurance after an injury occurs. 3. We are and liableto per- B. We Will Pay directly primarily any son entitledto the benefits payable thisin- by We willpay allsums thatyou legallymust pay as surance. Those persons may enforce our duties; damages because of toyour employ- bodilyinjury so an authorized law. Enforce- covered this may agency by ees, provided the bodily injury is by ment may be against us or against you and us. Employers Insurance. Liability 4. Jurisdiction over you is jurisdictionover us for The damages we will where ispermit- pay, recovery purposes ofthe workers compensation law. We ted by law, include damages: are bouñd by decisions against you under that rea- 1. For which you are liableto a thirdparty by law, subject to the provisions of thispolicy that son ofa claim orsuit against you by that third are not in conflictwith that law. party to recover the damages claimed against 5. This insurance conforms to the parts of the 2 of 6 © Copyright Insurance, Inc. All Rights Reserved. 2013 National Councl1 on Compensation FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022 NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 08/10/2022 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) such third as a result of to your em- 9. to person in work subject to the party injury Bodily injury any Employers' Sec- ployee; Federal Act Liability (45 U.S.C. tions 51 et seq.), other federal laws obligat- 2. For care and loss of services; and any ing an employer to pay damages to an employee 3. For consequential bodily injury toa spouse em- due tobodily injury arising out ofor m the course child,parent, brother or sister ofthe injured emPloyment, or any amendments to those provided thatthese damages are the di- ployee; ' rect consequence of bodily injurythat arises out of and inthe course of the injured employee's 10.Bodily injury to a master or member of the crew of and does not cover punitive dam- employment by you; and any vessel, ages related to your duty orobligation toprovide 4. Because of bodily injuryto your employee that 'transportation, wages, maintenance, and cure arises out of and inthe course of employment, under any applicable maritime law; claimed against you in a capacity other than as 11.Fines or penalties imposed for violation of federal . employer. or state law; and 12.Damages payable under the Migrant and Sea- C. Exclusions sonal Agricultural Worker Protection Act (29 This insurance does not cover: U.S.C. Sections 1801 et seq.) and under any 1. assumed under a contract.This exclu- Liability other federal law awarding damages forviolation sion does not apply to a warranty thatyour work of those laws or regulations issued thereunder, willbe done ina workmanlike manner; and amendments to those laws. any 2. Punitive or damages because of bodi- exemplary lyinjury to an employee employed inviolation of D. We Will Defend We have the right and to at our ex- duty defend, 3. Bodily injury to an employeewhile employed in pense, any claim, proceeding orsuit against you for violation of law with your actual knowledge or the damages payable by this insurance. We have the actual knowledge of of your executive offic- any rightto investigate and settlethese proceed- claims, ers; ings and suits. 4. obligation imposed a workers compensa- Any by com- We have no duty todefend a claim, proceeding or tion,occupational disease, unemployment simi- suitthat is notcovered by this insurance. We have pensation, or disabilitybenefits law, or any no duty to defend or continue defending after we lar law; have paid our applicable limitof under liability this 5. Bodily injury intentionally caused or aggravated insurance. by you; 6. Bodily injury occurring outside the United States E. We Will Also Pay of America, itsterritones or possessions, and Canada. This exclusion does not to We willalso pay these costs, inaddition toother apply bodily toa citizen or resident of the United States amounts payable under this insurance, as part of injury of America orCanada who is outside any claim, proceeding, or suitwe defend: temporarily these countries; 1. Reasonable expenses incurred at our request, 7. Damages out of de·- but not loss of earnings; arising coercion, criticism, motion, evaluation, reassignment, discipline, 2. Premiums for bonds to release attachments and discrimina- for appeal bonds inbond amounts to the limit defamation, harassment, humiliation, up tion against or termination ofany employee, or of our under liability thisinsurance; personnel acts oromis- any practices, policies, 3. Litigation costs taxed against you; sions; 4. Interest on a judgment as required by law until 8. Bodily injuryto any person inwork subject to the the amount under this Workers' we offer due insurance; Longshore and Harbor Compensation and Act (33 U·.S.C. Sections 901 et seq.), the 5. Expenses we incur. Nonappropriated Fund Instrumentalities Act (5 U.S.C. Sections 8171 et the Outer Conti- seq.), nental Shelf Lands Act (43 U.S.C. Sections 1331 et the Defense Base Act (42 U.S.C. Sec- seq.), tions 1651-1654), the Federal Mine Safety and Health Act (30 U.S.C. Sections 801 et seq. and other federal workers or work- 901-944), any men's compensation law or other federal occu- pational disease or amendments to the- law, any se laws; 3 of 6 © Copyright2013 National councli on CompensationInsurance, Inc. All Rights Reserved. FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022 NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 08/10/2022 WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) F. Other Insurance 2. The amount you owe has been determined with We will not more than our share of damages our consent or by actual trialand finaljudgment. pay and costs covered thisinsurance and other in- This insurance does not give anyone the right toadd by surance or self-insurance. Subject to limitsof li- us as a defendant in an action against you to deter- any abilitythat apply, allshares willbe equal untilthe mine your liability. The bankruptcy or insolvency of loss is paid. If insurance orself-insurance is ex- you oryour estate will not relieve us of our obliga- any hausted, the shares of allremaining insurance and tionsunder this Part. self-insurance willbe equal untilthe loss ispaid. PART THREE G. Limits of Liability . OTHER STATES INSURANCE Our to liability pay for damages islimited..Our limits of are liability shown in Item 3.B. of the Information A. How This Insurance Applies Page. They apply as explained below. 1. This other states insurance applies if one or only 1. Accident. The limitshown for more states are shown in Item 3.C. of the Infor- Bodily Injuryby accident" "bodily injuryby accident-each isthe mation Page. most we willpay foralldamages covered by this 2. If you begin work in one of those states after any insurance because of bodily injury toone or the effective date of this and are not in- policy more employees inany one accident. sured or are not self-insured for such all work, A disease isnot bodily injuryby accident unless provisions ofthe policy willapply as though that itresults directly from bodily injury by accident. state were listedin Item 3.A. of the Information Page. 2. Bodily Injury by Disease. The limitshown for limit" 3. We willreimburse you for the benefits required "bodily injury by disease-policy isthe most we will foralldamages covered this by the workers compensation law ofthat state if pay by insurance and out of dis- we are not permitted to pay the benefits directly arising bodily injury by regardless of the of employees to persons entitled to them. ease, number 4. If you have work on the effectivedate of thispol- who sustain to-dilyinjury by disease. The limit em- in state not listedin Item 3,A. of the In- hown for "bodily injuryby disease-each icy any ployee" formation coverage will not be afforded for isthe most we will pay for alldamages Page, because of disease to one that state unless we are notified within thirty bodilyinjury by any employee. days. disease does not include dis- Bodily injury by ease that results from a B. Notice directly bodily injury by accident. Tell us at once if youbegin work in any state listedin 3. We will not claims for damages after we Item 3.C. of the Information Page. pay any have paid the applicable limitof our un- liability der this insurance· PART FOUR YOUR DUTIES IF INJURY OCCURS H. Recovery From Others We have your rights torecover our payment from Tell us at once if injuryoccurs thatmay be covered anyone liablefor an injury covered by this insurance. by this policy.Your other duties are listedhere. You willdo everything necessary toprotect those 1. Provide for immediate medical and other ser- rights for us and to help us enforce them. vices required the workers compensation law. by 2. Give us or our agent the names and addresses I. Actions Against Us of the injured persons and ofwitnesses, and There will be no rightof action against us under this other information we may need. insurance unless: 3. give us allnotices, demands and legal Promptly 1. You have complied with allthe terms of thispoli- cy; and 4 of 6 © Copyright Insurance, Inc. AII Rights Reserved. 2013 National Council on compensation FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022 NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 08/10/2022 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) papers related to the injury, claim, proceeding D. Premium Payments or suit- You will allpremium when due. You will the pay pay 4. Cooperate with us and assist as we re- premium even ifpart or allofa workers compensa- us, may quest, in the investigation, settlement ordefense tionlaw is not valid. of any claim, proceeding or suit. 5. Do afteran occurs thatwould in- E. Final Premium nothing injury terfere with our rightto recover from others. The premium shown on the Information Page, 6. Do not make assume obli- and endorsements isan estimate. The voluntarily payments, schedules, gations or incur expenses, except at your own finalpremium willbe determined afterthis policy cost. ends the not the premi- by using actual, estimated, um basis and the proper classifications and rates that lawfullyapply to the business and work covered PART FIVE by this policy.If thefinalpremium ismore than the PREMIUM premium you paid to you must us the bal- us, pay ance. Ifit is less,we willrefund the balance to you. A. Our Manuals The finalpremium willnot be lessthan the highest Allpremium forthis policywill be determined by our minimum premium forthe classifications covered by manuals of plans and classifica- thispolicy. rules, rates,rating tions.We may change our manuals and