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16-2023-CA-001847-XXXX-MA Div: CV-A
Filing # 168900416 E-Filed 03/16/2023 04:00:56 PM
IN THE CIRCUIT COURT OF THE FOURTH JUDICIAL CIRCUIT
IN AND FOR DUVAL COUNTY, FLORIDA
AMERICAN BUILDERS INSURANCE
COMPANY, a foreign corporation, CASE NO:
Plaintiff,
vs.
FGC, INC.,
Defendant.
NOTICE OF FILING
Plaintiff, AMERICAN BUILDERS INSURANCE COMPANY, by and through its
undersigned attorney, hereby gives notice of the following insurance policies at issue:
1 Exhibit “1:” WCV-0276670 01 (Count I of Plaintiff's Complaint)
2. Exhibit “2:” WCV-0276670 02 (Count II of Plaintiff's Complaint)
Dated this 16" day of March, 2023.
4s/ Cesery L. Bullard
Cesery L. Bullard, Esquire
BULLARD LAW
219 East Marks Street
Orlando, Florida 32803
Florida Bar No. 793361
cbullard@pbullard-law.com
T: (407) 648-9530
Attomey for Plaintiff
ACCEPTED: DUVAL COUNTY, JODY PHILLIPS, CLERK, 03/20/2023 03:28:42 PM
INSURED
MAILER PAGE
Reference: 0022WCV027667001
FC INC
TH 69
4. BEACH, FL 32082
FL NOTICE OF COMPLIANCE POSTER
©8
EXHIBIT
im. vO 01
American Builders Insurance Company Builders INVOICE
A Stock Company Insurance
P.O. Box 723099 Group* Date: 05/29/2020
Atlanta, GA 31139-0099
POLICY HOLDER AGENCY
FGC INC Sihle Insurance Group Inc.
830-13 A1A NORTH #169 P.O. Box 160398
PONTE VEDRA BEACH, FL 32082 Altamonte Springs, FL 32716
Phone: Phone: 407-869-0962
Policy Type: Workers Compensation
Policy #: WCV 0276670 01 Policy Term: 07/24/2020 - 07/24/2021 Pay Plan: MSR 25% Deposit
Current Policy Balance Last Payment Received Current Due Date Payment Due
$6,781.00 $0.00 08/31/2020 $477.00
Payments received after the cancellation date will be posted to the policy-holder's account. This in no way obligates
American Builders Insurance Company to reinstate or extend coverage. Any refund due to the insured will be issued
after the cancellation audit has been processed.
If payment is not received by the due date, a late fee will be assessed and in addition, coverage may expire
or a notice of cancellation may be issued. For your convenience, you may make a payment by calling
866-40-SUPPORT (866-407-8776), or pay securely online at www.bldrs.com.
INSTALLMENT INVOICE DATE TRANSACTION AMOUNT
07/24/2020 Expense Constant 160.00
07/24/2020 State Assessment 67.00
05/28/2020 Blanket Waiver of Subrogation 250.00
Please detach and return the bottom portion with your payment
Billing: 678-309-4000 option 5 or 866-40-SUPPORT (866-407-8776)
Make Check Payable to Amarican Builders insurance Company and please include your Policy Number on your check.
Please contact your Agent if you have Policy Number: WCV 0276670 01
any changes related to your Name,
Address or Phone Number.
Payment Due: $477.00
Due Date: 08/31/2020
Total Remitted:
Please Remit Payment To:
FGC INC American Builders Insurance Company
830-13 A1A NORTH #169 A Stock Company
PONTE VEDRA BEACH, FL 32082 P.O. Box 723099
Atlanta, GA 31139-0099
HM Mi EENUE UU UEDA USOT EDA OMT ED
Builders
Insurance
Group*
TO: Builders Insurance Group Pelicyholder
FROM: Builders Insurance Group
RE: Renewal Coverage for Workers’ Compensation Insurance
Enclosed, please find complete renewal information for your Workers' Compensation coverage provided through Builders
Insurance Group. Please forward this information to the individual responsible for maintaining your insurance coverage.
Builders Insurance Group delivers Workers' Compensation and General Liability insurance products tailored to the needs
of the home building community. We are the largest commercial property and casually company domesticated in Georgia
and a leading underwriter of Workers’ Compensation insurance in the Southeast. Member companies of Builders
insurance Group include Builders Insurance (A Mutua! Captive Company), American Builders Insurance Company, and
National Builders Insurance Company
Included in this renewal package is:
+ Your policy information
+ Your estimated premium and premium invoice
+ Fraud Posting Notice
. Instructions on how to file a claim
. Cost Management program information
. First Report of Injury forms and Wage Statement
. important payment Information
+ Privacy Notice of the Builders Insurance Group companies
+ Official Posting Notice (if required)
Generally, renewal policies are issued using current year estimated payrolls. Your pay plan may be revised due to a
decrease in premium. |f you are eligible for experience rating, the most current experience modification from the National
Council on Compensation Insurance (NCCI) has been applied. Unless you notify Builders Insurance Group to the
contrary in writing on or before your renewal date, you will be subject to the renewal premium.
Builders Insurance Group is committed to providing you with opportunities to save money through competitive rates,
interest-free payment plans and superior claims and safety management services. A Drug-Free Workplace Credit and/or
a Deductible Plan may be available for policyholders that qualify.
We greatly appreciate the opportunity to deliver products and services to meet your insurance needs and look forward to
our continued partnership for years to come. If you have any questions, please call your focal independent insurance
agent, or Builders Insurance Group at 678-309-4000 or 1-800-883-9305.
Thank you for allowing us to serve your business.
P.O. Box 723099 * Atlanta, GA 31139-0099 * 678-309-4000 * 800-883-9305 * 678-309-4077 * www.bidrs.com
Builders
Insurance
Group*
DE: Asegurado de Builders Insurance Group
PARA: Builders Insurance Group
ASUNTO: Renovacién de la Cobertura del Seguro de Compensacién para el Trabajador
Sirvase revisar el paquete de informacién sobre la renovacion de la cobertura de su Seguro de Compensacién para el
Trabajador que estamos adjuntando a esta carta, asegurese de que la informacién llegue a la persona responsable de
administrar la cobertura de su seguro.
Builders Insurance Group cuenta con productos de seguros para compensacién del trabajador y de responsabilidad civil
general disefiados especificamente para satisfacer las necesidades de la comunidad de constructores de viviendas.
Somos la empresa de seguros de propiedad comercial y contra siniestros mas grande en el estado de Georgia y
proveedor lider en el mercado de compensacién al trabajador en el sureste del pais. Entre las empresas miembros de
Builders Insurance Group estan Builders Insurance (una Empresa de Mutual Captive), American Builders Insurance
Company y National Builders Insurance Company.
Este paquete de renovacién de péliza contiene:
* La informacion sobre su pdliza
» La prima estimada junto con su factura
» Aviso de Comision de Fraudes
+ Instrucciones para solicitar una indemnizacion
+ Informacién sobre el programa de Administracién de Costos
+ Formularios de Primer Reporte de Lesion y Declaracisn de Salario
* Aviso de Privacidad de las empresas miembros de Builders Insurance Group
* Aviso de Publicacién Oficial (si es necesario)
En general, las politicas de renovacién se expiden sobre la base del afio en curso. Es posible que su plan sea revisado
debido @ una disminucién en la prima. Si usted cumple los requisitos para la evaiuacién basada en datos historicos
(experience rating) se aplicaran las modificaciones mas recientes hechas en este renglén por el Consejo Nacional de
Compensacién de Seguros (NCCI, por sus siglas en inglés). Su pdliza sera renovada automaticamente a menos que
Builders Insurance Group reciba una notificacién por escrito indicando lo contrario antes de la fecha de renovacion
programada.
El compromiso de Builders Insurance Group siempre sera ofrecerle oportunidades de ahorrar recursos, a través de
tarifas competitivas, planes de pago sin intereses y excelentes servicios de indemnizacion y administracién de seguridad.
Tenemos disponibles ademas un Crédito para Empresas Libres de Drogas y/o un Plan de Deducibles para los
asegurados que llenen los requisitos.
Le agradecemos la oportunidad de ofrecerie productos y servicios para satisfacer sus necesidades de aseguramiento y
esperamos que nuestra sociedad dure por un largo tiempo. Péngase en contacto con nuestros agentes independientes o
con Builders insurance Group al 678-309-4000 o al 1-800-883-9305 si tiene cualquier pregunta acerca de esta
informacion.
Gracias por permitimos atenderle..
P.O. Box 723099 * Atlanta, GA 31139-0099 * 678-309-4000 * 800-883-9305 * 678-309-4077 * www.bidrs.com
Builders
Insurance
Group’
TO: Our Valued Policyholder
FROM: Builders Insurance Group
RE: Renewal Payment Terms Notice
THIS IS AN IMPORTANT NOTICE. PLEASE READ THIS CAREFULLY.
Dear Valued Policyholder:
We are providing you with a copy of your renewal policy and advance notice of a change in the policy payment terms for
your renewal policy. No coverage is provided by this change and this notice does not amend or replace any provisions of
your policy or endorsements. You should read this notice carefully to understand the changes. Your policy is scheduled to
renew soon.
Enclosed is a copy of the renewal of your Policy # WCV 0276670 01 and installment schedule (if applicable). The
renewal of this policy will become effective on 07/24/2020 if the initial invoice is paid in full by the specified due
date.
TO RENEW YOUR POLICY:
To continue your policy with no lapse in coverage, please pay the initial invoice total no later than 07/24/2020 by
remitting a check to: P.O. Box 723099, Atlanta, GA 31139, or you may elect the convenience of our fast and
simple online payment tool at www.bldrs.com. Please have your policy information handy for quick reference.
TO CANCEL YOUR RENEWAL:
If you do NOT wish to renew this Policy or if you have placed coverage with another carrier,please contact your
Agent: Sihle Insurance Group Inc.
407-869-0962
Piease send us a courtesy email at renewalsupport@bldrs.com after you contact your insurance agent and
include your policy information.
if we do not receive your initial premium payment by 07/24/2020, your Policy will NOT be renewed and your
coverage will expire on the last day of your current Policy term.
Thank you and we appreciate your business.
Builders Insurance Group
BIG PHN CXRN 02 12
ti
Builders
Insurance
Group’
POLICY NUMBER: WCV 0276670 01
INSURED: FGC INC
American Builders Insurance Company
A Stock Company
2410 Paces Ferry Road, Suite 300
Atlanta, GA 30339
WORKERS COMPENSATION & EMPLOYERS LIABILITY INSURANCE POLICY
For: FGC INC By: Sihle Insurance Group Inc.
830-13 ATA NORTH #169 P.O, Box 160398
PONTE VEDRA BEACH, FL 32082 Altamonte Springs, FL 32716
IN WITNESS WHEREOF, American Builders Insurance Company has caused this policy to be
executed and attested, and, if required by State law, this policy shall not be valid unless
countersigned by our authorized representative.
Sol [AM
President
t. bey Secretary
For Inquiry purposes, coverage information and complaint assistance, please contact your
agent or call:
1-800-883-9305
or
678-309-4000
WC 09 00 00 B 03 16
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Insurer: NCCI Carrier Code 25496 Producer: 0001356
American Builders Insurance Company Sihle Insurance Group Inc.
A Stock Company P.O. Box 160398
P.O. Box 723099 Altamonte Springs, FL 32716
Atlanta, GA 31139-0099
41. The Insured and Mailing Address: Policy #:. WCV 0276670 01
FGC INC Prior Policy # 0276670
830-13 A1A NORTH #169 Type of Business: CORPORATION
PONTE VEDRA BEACH, FL 32082
Fein: 272700711
Risk ID:
Other workplaces not shown above: See the Schedule of Workplaces for this policy.
The Policy Period is from 12:01 a.m. on 07/24/2020 to 12:01 a.m. on 07/24/2021 at the Insured's mailing address.
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states
listed here: Florida
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A.
The timits 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: Part Three of the policy applies to the states, if any, listed here:
Alabama Arizona Colorado Georgia Indiana Maryland Mississippi North Carolina Oklahoma Pennsylvania
South Carolina Tennessee Virginia
D. This policy includes these endorsements and schedules: See endorsement schedule.
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 No. Premium Basis Rate Per Estimated
Total Estimated $100 of Annual
Annual Remuneration Remuneration Premium
SEE SCHEDULE OF OPERATIONS
Total Estimated Annual Premium $6,714 Expense Constant $160
FL Workers Comp Insurance $67
Minimum Premium $969 Guaranty Assoc. Surcharge
Total Cost $6,781
COUNTERSIGNED BY.
hand Af
WC 00 00 01 A 0919
includes copyright material of the National Council on Compensation Insurance, inc., used with its permission
©2019 National Council on Compensation Insurance Inc. All Rights Reserved.
WORKERS COMPENSATION & EMPLOYERS LIABILITY
American Builders Insurance Company INSURANCE POLICY
A Stock Company Policy Number: WCV 0276670 01
P.O. Box 723099
Atlanta, GA 31139 Named Insured: FGC INC
Agent: SIHLE INSURANCE GROUP INC. 0001356.
SCHEDULE OF OPERATIONS
EXTENSION OF INFORMATION PAGE, ITEM 4
Premium Basis Rate Per Estimated
Code Classification Description Total Est. Annual $100 of Annual
No. Remuneration Remuneration Premium
Florida
Rating Period 07/24/2020 through 07/24/2021
Site 00001
5403 CARPENTRY NOC 7,200 8.0900 582.00
5606 CONTRACTOR-EXECUTIVE SUPERVISOR/SUPERINTENDENT 357,800 1.3500 4,830.00
8810 CLERICAL OFFICE EMPLOYEES-NOC 408,633 0.1700 695.00
Site 90001 Total 6,107.00
9812 INCREASED LIMITS OF EMPLOYERS LIABILITY 6,107 0.0140 85.00
0930 BLANKET WAIVER OF SUBROGATION 6,107 0.0200 250,00
9848 TO EQUAL MINIMUM PREMIUM (E L) 35.00
0063 PREMIUM DISCOUNT 6,477 0.00
0300 EXPENSE CONSTANT 160.00
9740 TERRORISM ACT SURCHARGE 773,633 0.0100 77.00
9684 FLORIDA WC INS GUARANTY ASSOC 6,714 0.0100 67.00
Rating Period Total 6,781.00
Total Estimated Premium 6,781.00
State Total 6,781.00
Policy Total 6,781.00
Issued Date: 05/29/2020
WC 09 06 52 0919 Page 1 of 1
WORKERS COMP & EMPLOYERS LIABILITY
Builders American Builders Insurance
INSURANCE POLICY
Insurance Company Policy Number: WCv 0276670 01
Group" A Stock Company
P.O. Box 723099 Named Insured: FGC INC
Atlanta, GA 31139
Agent: SIHLE INSURANCE GROUP INC. 0001356
SCHEDULE OF WORKPLACES
EXTENSION OF INFORMATION PAGE, ITEM 1
Site 1
FGC INC
830-13 A1A NORTH #169
PONTE VEDRA BEACH, FL 32082
issued Date: 05/29/2020
WC 09 06 53 0919 Page 1 of 1
WORKERS COMP & EMPLOYERS LIABILITY
Builders American Builders Insurance
INSURANCE POLICY
Insurance Company Policy Number: wCv 0276670 01
Group’ A Stock Company
P.O, Box 723099 Named Insured: FGC INC
Atlanta. GA 34139
Agent: SIHLE INSURANCE GROUP INC. 0001356
NAMED INSURED SCHEDULE
EXTENSION OF INFORMATION PAGE, ITEM 1.
FGC INC
830-13 A1A NORTH #169
PONTE VEDRA BEACH, FL 32082
FEIN: 272700711
Issued Date: 05/29/2020
WC 09 06 51 0919 Page 1 of 1
WORKERS COMP & EMPLOYERS LIABILITY
Builders American Builders Insurance
INSURANCE POLICY
Insurance Company Policy Number: WCv 0276670 01
Group® A Stock Company
P.O. Box 723089 Named Insured: FGC INC
Atlanta, GA 31139
Agent: SIHLE INSURANCE GROUP INC. 0001356
ENDORSEMENT SCHEDULE
EXTENSION OF INFORMATION PAGE, ITEM 3.D.
It is hereby understood and agreed that the following forms and
endorsements are attached to and are part of this policy.
State Form Nbr Ed. Date Description
US ‘wcoo0000c (1/18) WC AND EMPLOYERS LIAB INS POL
US WC000313 (4/84) WAIVER OF OUR RIGHT TO RECOVER
US WC000414A (1/19) NOTIFICATION OF CHANGE IN OWNE
US wc000419 (101) PREMIUM DUE DATE ENDORSEMENT
FL FORMOSANOT (1/20) FL TERRORISM RISK PENDING CHG
FL WC000406A (7/95) PREMIUM DISCOUNT ENDORSEMENT
FL WC080303 (8/05) FL EMPLOYERS LIABILITY COVERAG
FL ‘wc090401 (6/87) FL CONTRACTING CLASS PREM ADJ
FL wcos0402A (5/17) FL EXPERIENCE RATING MOD FACTO.
FL 'WC090403B (4/15) FL TERRORISM RISK INS ACT ENDT
FL wc090407 (7/13) FL NON-COOP AUDIT ENDT
FL WC090408A, (7/19) FL INSUFFICIENT FUNDS ENDT
FL wcos0606 (10/98) FL EMPLOYMENT & WAGE INFO REL
FL WC090607A (719) FL GUARANTY ASSOC SURCH ENDT
Issued Date: 05/29/2020
WC 09 06 50 0919 Page 1 of 1
xxxeKA ATTEN TION******
Online Monthly Self Reporting (MSR) Payment Plan Guidelines
Enclosed is the policy detail pertaining to your Workers compensation coverage for the current term. Based upon the
Underwriting information supplied, your policy has qualified for our Online Monthly Self Reporting (MSR) payment
program. Enrollment in this flexible payment option means that you have agreed to the terms of the payment plan and
understand that you are required to electronically submit your Monthly (calendar) payroll detail, uninsured subcontractor
exposure, as well as alert us to any class code changes, timely and accurately. You further understand that the
transmittal of this MSR data is an immediate endorsement of your actual premium and is due upon receipt.
- You MUST file an online report for each monthly period for your account to be credited properly.
- Failure to submit a Monthly Self Report (MSR) and make the corresponding premium payment
will result in a late notice and/or cancellation of your Policy.
Instructions for enrolling online for MSR reporting and payment:
Please go to our Web page at www.bidrs.com
. Under the "FOR POLICHOLDERS*" section, CLICK "Monthly Self Reporting".
. This will direct you to our SAFE AND SECURE policyholder Support Center for processing.
a First Time users will need to Click Enroll. Returning Users can Click Login.
Enrolling - as easy as 1-2-3
. You will need your Policy number and corresponding FEIN (tax |.D.) to enroll. This information is contained in this
policy packet.
Simply select the "Workers Compensation" pull down menu option.
Enter your 7 (seven) digit Policy number in the field after the WCV identifier (i.e. WCV 1234567 00).
Enter your FEIN (Federal Employee [D Number). Click NEXT.
Enter your Valid Email address as the User ID (to receive Email confirmations) .
Select a unique password and Submit. Print the password reference page.
Login - It's fast and secure
. Enter your User ID (Hint: Your email address) and Password.
. Click on the "Policy Information Center" link and see your policy detail page.
. Click "Create a Monthly Self Report" to access your MSR summary page and follow the simple online filing
instructions to process your MSR.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
American Builders Insurance Company po, Box 723099
Atlanta, GA 31139-0099
(A Stock Company)
QUICK REFERENCE
Beginning
on Page
Beginning
INFORMATION PAGE on Page
PART TWO - EMPLOYERS
GENERAL SECTION. LIABILITY INSURANCE (con't)
The Policy... H. Recovery From Others.
Who is Insure ' Actions Against Us....
Workers Compensation Law
State.. PART THREE -
Location: OTHER STATES INSURANCE
A. How This Insurance App!
PART ONE - WORKERS B. Notice.
COMPENSATION
INSURANCE PART FOUR - YOUR DUTIES
How This Insurance Applies iF INJURY OCCURS.
We Will Pay...
We Will Defen PART FIVE - PREMIUM
We Will also Pay. Our Manuals.
Other Insurance.. Classification:
Payments You Must Make. Remuneration
Recovery From Other: Premium Payment
Statutory Provisions.. Final Premiu
Record.
PART TWO - EMPLOYERS Audit
LIABILITY INSURANCE..
How This Insurance pp PART SIX - CONDITIONS
We Will Pay. . Inspection.
Exclusions... Long Term Policy.
We Will Defen Transfer of Your Rights and Dutie:
We Will Also Pay. Cancellation......
Other Insurance Sole Representative.
Limits of Liability.
These Policy Provisions with the Information Page and Endorsements,
if any, issued to form a part thereof, complete this policy.
PLEASE READ THIS POLICY CAREFULLY
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 0000 C
(Ed. 1-45)
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
In return for the payment of the premium and subject to all PART ONE
terms 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
The Policy injury by accident or bodily injury by disease. Bodily
This policy includes at its effective date the injury includes resulting death.
Information Page and all endorsements and schedules
4 Bodily injury by accident must occur during the
listed there. It is a contract of insurance between you
policy period.
(the employer named in Item 1 of the Information
Page) and us (the insurer named on the Information 2. Bodily injury by disease must be caused or
Page). The only agreements relating to this insurance aggravated by the conditions of your employment.
are stated in this policy. The terms of this policy may The employee's last day of last exposure to the
not be changed or waived except by endorsement conditions causing or aggravating such bodily
issued by us to be part of this policy. injury by disease must occur during the policy
period.
Who is Insured
We Will Pay
You are insured if you are an employer named in Item
1 of the Information Page. H that employer is a We will pay promptly when due the benefits required
partnership, and if you are one of its partners, you are of you by the workers compensation law.
insured, but only in your capacity as an employer of
the partnership’s employees.
We Will Defend
We have the right and duty to defend at our expense
Workers Compensation Law any claim, proceeding or suit against you for benefits
Workers Compensation Law means the workers or payable by this insurance. We have the right to
workmen's compensation law and occupational investigate and settle these claims, proceedings or
disease law of each state or territory named in Item suits.
3.4. of the Information Page. It includes any We have no duty to defend a claim, proceeding or suit
amendments to that law which are in effect during the that is not covered by this insurance.
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 We Will Also Pay
that provide nonoccupational disability benefits.
We will also pay these costs, in addition to other
amounts payable under this insurance, as part of any
State claim, preceeding or suit we defend:
4 reasonable expenses incurred at our request, but
State means any state of the United States of
America, and the District of Columbia. not loss of earnings;
2 premiums for bonds to release attachments and
for appeal bonds in bend amounts up to the
Locations amount payable under this insurance;
This policy covers all of your workplaces listed in Items litigation costs taxed against you:
1 or 4 of the Information Page; and it covers ail other
workplaces in Item 3.A. states unless you have other interest on a judgment as required by taw until we
insurance or are self-insured for such workplaces. offer the amount due under this insurance; and
expenses we incur.
Other Insurance
We will not pay more than our share of benefits and
costs covered by this insurance and other
10f 6
@ Convtloht 2043 National Council an Compansation Innurance inc. All Riahts Reserved.
WC 00 00 00¢ WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
(Ed. 1-15)
insurance or self-insurance. Subject to any limits of workers compensation law that apply to:
liability that may apply, all shares will be equal until the a. benefits payable by this insurance;
loss is paid. If any insurance or self-insurance is
exhausted, the shares of all remaining insurance will b. special taxes, payments into security or other
be equal until the loss is paid. special funds, and assessments payable by
us under that law.
Terms of this insurance that conflict with the
Payments You Must Make workers compensation law are changed by this
You are responsible for any payments in excess of the statement fo conform to that law.
benefits regularly provided by the workers Nothing in these paragraphs relieves you of your
compensation Jaw including those required because: duties under this policy.
4 of your serious and willful misconduct;
2. you knowingly employ an employee in violation of PART TWO
law; EMPLOYERS LIABILITY INSURANCE
you fail to comply with a health or safety law or How This Insurance Applies
regulation; or
This employers liability insurance applies to bodily
you discharge, coerce or otherwise discriminate injury by accident or bodily injury by disease. Bodily
against any employee in violation of the workers injury includes resulting death.
compensation law.
1 The bodily injury must arise out of and in the
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 you.
on your behalf, you will reimburse us promptly.
The employment must be necessary or incidental
to your work in a state or territory listed in Item
Recovery From Others 3.A. of the Information Page.
We have your rights, and the rights of persons entitled Bodily injury by accident must occur during the
to the benefits of this insurance, to recover our policy period.
payments from anyone liable for the injury. You will do Bodily injury by disease must be caused or
everything necessary to protect those rights for us and aggravated by the conditions of your employment.
to help us enforce them. The employee’s last day of last exposure to the
conditions causing or aggravating such bodily
injury by disease must occur during the policy
Statutory Provisions
period.
These statements apply where they are required by
If you are sued, the original suit and any related
Jaw.
fegal actions for damages for bodily injury by
4 As between an injured worker and us, we have accident or by disease must be brought in the
notice of the injury when you have notice. United States of America, its territories or
2. Your default or the bankruptcy or insolvency of possessions, or Canada.
you or your estate will not relieve us of our duties
under this insurance after an injury occurs.
B. We Will Pay
We are directly and primarily liable to any person
We will pay all sums that you legally must pay as
entitled to the benefits payable by this insurance.
Those persons may enforce our duties; so may an damages because of bodily injury to your employees,
provided the bodily injury is covered by this Employers
agency authorized by law. Enforcement may be
against us or against you and us. Liability Insurance.
Jurisdiction over you is jurisdiction over us for The damages we will pay, where recovery is
permitted by law, include damages:
purposes of the workers compensation law. We
are bound by decisions against you under that 1 For which you are liable to a third party by reason
law, subject to the provisions of this policy that are ofa claim or suit against you by that third party to
not in conflict with that law. tecover the damages claimed against
This insurance conforms to the parts of the
2of 6
© Conveiaht 2043 National Council an Comnansation insurance ine. All Riahts Rasarved.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C
(Ed. 1-15)
such third party as a result of injury to your and 901-944), any other federal workers or
employee; workmen's compensation law or other federal
occupational disease law, or any amendments to
For care and loss of services; and these laws;
For consequential bodily injury to a spouse, child, Bodily injury to any person in work subject to the
parent, brother or sister of the injured employee: Federai Employers’ Liability Act (45 U.S.C.
provided that these damages are the direct other federal laws
Sections 51 et seq.), any
consequence of bodily injury that arises out of and
obligating an employer to pay damages to an
in the course of the injured employee's employee due to bodily injury arising out of or in
employment by you; and the course of employment, or any amendments to
Because of bodily injury to your employee that those laws;
arises out of and in the course of employment,
10. Bodily injury to a master or member of the crew of
claimed against you in a capacity other than as any vessel; and does not cover punitive damages
employer. telated to your duty or obligation to provide
transportation, wages, maintenance, and cure
Cc. Exclusions under any appli-cable maritime law;
This insurance does not cover: 1 Fines or penalties imp
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16-2023-CA-001847-XXXX-MA Div: CV-A Filing # 168900416 E-Filed 03/16/2023 04:00:56 PM IN THE CIRCUIT COURT OF THE FOURTH JUDICIAL CIRCUIT IN AND FOR DUVAL COUNTY, FLORIDA AMERICAN BUILDERS INSURANCE COMPANY, a foreign corporation, CASE NO: Plaintiff, vs. FGC, INC., Defendant. NOTICE OF FILING Plaintiff, AMERICAN BUILDERS INSURANCE COMPANY, by and through its undersigned attorney, hereby gives notice of the following insurance policies at issue: 1 Exhibit “1:” WCV-0276670 01 (Count I of Plaintiff's Complaint) 2. Exhibit “2:” WCV-0276670 02 (Count II of Plaintiff's Complaint) Dated this 16" day of March, 2023. 4s/ Cesery L. Bullard Cesery L. Bullard, Esquire BULLARD LAW 219 East Marks Street Orlando, Florida 32803 Florida Bar No. 793361 cbullard@pbullard-law.com T: (407) 648-9530 Attomey for Plaintiff ACCEPTED: DUVAL COUNTY, JODY PHILLIPS, CLERK, 03/20/2023 03:28:42 PM INSURED MAILER PAGE Reference: 0022WCV027667001 FC INC TH 69 4. BEACH, FL 32082 FL NOTICE OF COMPLIANCE POSTER ©8 EXHIBIT im. vO 01 American Builders Insurance Company Builders INVOICE A Stock Company Insurance P.O. Box 723099 Group* Date: 05/29/2020 Atlanta, GA 31139-0099 POLICY HOLDER AGENCY FGC INC Sihle Insurance Group Inc. 830-13 A1A NORTH #169 P.O. Box 160398 PONTE VEDRA BEACH, FL 32082 Altamonte Springs, FL 32716 Phone: Phone: 407-869-0962 Policy Type: Workers Compensation Policy #: WCV 0276670 01 Policy Term: 07/24/2020 - 07/24/2021 Pay Plan: MSR 25% Deposit Current Policy Balance Last Payment Received Current Due Date Payment Due $6,781.00 $0.00 08/31/2020 $477.00 Payments received after the cancellation date will be posted to the policy-holder's account. This in no way obligates American Builders Insurance Company to reinstate or extend coverage. Any refund due to the insured will be issued after the cancellation audit has been processed. If payment is not received by the due date, a late fee will be assessed and in addition, coverage may expire or a notice of cancellation may be issued. For your convenience, you may make a payment by calling 866-40-SUPPORT (866-407-8776), or pay securely online at www.bldrs.com. INSTALLMENT INVOICE DATE TRANSACTION AMOUNT 07/24/2020 Expense Constant 160.00 07/24/2020 State Assessment 67.00 05/28/2020 Blanket Waiver of Subrogation 250.00 Please detach and return the bottom portion with your payment Billing: 678-309-4000 option 5 or 866-40-SUPPORT (866-407-8776) Make Check Payable to Amarican Builders insurance Company and please include your Policy Number on your check. Please contact your Agent if you have Policy Number: WCV 0276670 01 any changes related to your Name, Address or Phone Number. Payment Due: $477.00 Due Date: 08/31/2020 Total Remitted: Please Remit Payment To: FGC INC American Builders Insurance Company 830-13 A1A NORTH #169 A Stock Company PONTE VEDRA BEACH, FL 32082 P.O. Box 723099 Atlanta, GA 31139-0099 HM Mi EENUE UU UEDA USOT EDA OMT ED Builders Insurance Group* TO: Builders Insurance Group Pelicyholder FROM: Builders Insurance Group RE: Renewal Coverage for Workers’ Compensation Insurance Enclosed, please find complete renewal information for your Workers' Compensation coverage provided through Builders Insurance Group. Please forward this information to the individual responsible for maintaining your insurance coverage. Builders Insurance Group delivers Workers' Compensation and General Liability insurance products tailored to the needs of the home building community. We are the largest commercial property and casually company domesticated in Georgia and a leading underwriter of Workers’ Compensation insurance in the Southeast. Member companies of Builders insurance Group include Builders Insurance (A Mutua! Captive Company), American Builders Insurance Company, and National Builders Insurance Company Included in this renewal package is: + Your policy information + Your estimated premium and premium invoice + Fraud Posting Notice . Instructions on how to file a claim . Cost Management program information . First Report of Injury forms and Wage Statement . important payment Information + Privacy Notice of the Builders Insurance Group companies + Official Posting Notice (if required) Generally, renewal policies are issued using current year estimated payrolls. Your pay plan may be revised due to a decrease in premium. |f you are eligible for experience rating, the most current experience modification from the National Council on Compensation Insurance (NCCI) has been applied. Unless you notify Builders Insurance Group to the contrary in writing on or before your renewal date, you will be subject to the renewal premium. Builders Insurance Group is committed to providing you with opportunities to save money through competitive rates, interest-free payment plans and superior claims and safety management services. A Drug-Free Workplace Credit and/or a Deductible Plan may be available for policyholders that qualify. We greatly appreciate the opportunity to deliver products and services to meet your insurance needs and look forward to our continued partnership for years to come. If you have any questions, please call your focal independent insurance agent, or Builders Insurance Group at 678-309-4000 or 1-800-883-9305. Thank you for allowing us to serve your business. P.O. Box 723099 * Atlanta, GA 31139-0099 * 678-309-4000 * 800-883-9305 * 678-309-4077 * www.bidrs.com Builders Insurance Group* DE: Asegurado de Builders Insurance Group PARA: Builders Insurance Group ASUNTO: Renovacién de la Cobertura del Seguro de Compensacién para el Trabajador Sirvase revisar el paquete de informacién sobre la renovacion de la cobertura de su Seguro de Compensacién para el Trabajador que estamos adjuntando a esta carta, asegurese de que la informacién llegue a la persona responsable de administrar la cobertura de su seguro. Builders Insurance Group cuenta con productos de seguros para compensacién del trabajador y de responsabilidad civil general disefiados especificamente para satisfacer las necesidades de la comunidad de constructores de viviendas. Somos la empresa de seguros de propiedad comercial y contra siniestros mas grande en el estado de Georgia y proveedor lider en el mercado de compensacién al trabajador en el sureste del pais. Entre las empresas miembros de Builders Insurance Group estan Builders Insurance (una Empresa de Mutual Captive), American Builders Insurance Company y National Builders Insurance Company. Este paquete de renovacién de péliza contiene: * La informacion sobre su pdliza » La prima estimada junto con su factura » Aviso de Comision de Fraudes + Instrucciones para solicitar una indemnizacion + Informacién sobre el programa de Administracién de Costos + Formularios de Primer Reporte de Lesion y Declaracisn de Salario * Aviso de Privacidad de las empresas miembros de Builders Insurance Group * Aviso de Publicacién Oficial (si es necesario) En general, las politicas de renovacién se expiden sobre la base del afio en curso. Es posible que su plan sea revisado debido @ una disminucién en la prima. Si usted cumple los requisitos para la evaiuacién basada en datos historicos (experience rating) se aplicaran las modificaciones mas recientes hechas en este renglén por el Consejo Nacional de Compensacién de Seguros (NCCI, por sus siglas en inglés). Su pdliza sera renovada automaticamente a menos que Builders Insurance Group reciba una notificacién por escrito indicando lo contrario antes de la fecha de renovacion programada. El compromiso de Builders Insurance Group siempre sera ofrecerle oportunidades de ahorrar recursos, a través de tarifas competitivas, planes de pago sin intereses y excelentes servicios de indemnizacion y administracién de seguridad. Tenemos disponibles ademas un Crédito para Empresas Libres de Drogas y/o un Plan de Deducibles para los asegurados que llenen los requisitos. Le agradecemos la oportunidad de ofrecerie productos y servicios para satisfacer sus necesidades de aseguramiento y esperamos que nuestra sociedad dure por un largo tiempo. Péngase en contacto con nuestros agentes independientes o con Builders insurance Group al 678-309-4000 o al 1-800-883-9305 si tiene cualquier pregunta acerca de esta informacion. Gracias por permitimos atenderle.. P.O. Box 723099 * Atlanta, GA 31139-0099 * 678-309-4000 * 800-883-9305 * 678-309-4077 * www.bidrs.com Builders Insurance Group’ TO: Our Valued Policyholder FROM: Builders Insurance Group RE: Renewal Payment Terms Notice THIS IS AN IMPORTANT NOTICE. PLEASE READ THIS CAREFULLY. Dear Valued Policyholder: We are providing you with a copy of your renewal policy and advance notice of a change in the policy payment terms for your renewal policy. No coverage is provided by this change and this notice does not amend or replace any provisions of your policy or endorsements. You should read this notice carefully to understand the changes. Your policy is scheduled to renew soon. Enclosed is a copy of the renewal of your Policy # WCV 0276670 01 and installment schedule (if applicable). The renewal of this policy will become effective on 07/24/2020 if the initial invoice is paid in full by the specified due date. TO RENEW YOUR POLICY: To continue your policy with no lapse in coverage, please pay the initial invoice total no later than 07/24/2020 by remitting a check to: P.O. Box 723099, Atlanta, GA 31139, or you may elect the convenience of our fast and simple online payment tool at www.bldrs.com. Please have your policy information handy for quick reference. TO CANCEL YOUR RENEWAL: If you do NOT wish to renew this Policy or if you have placed coverage with another carrier,please contact your Agent: Sihle Insurance Group Inc. 407-869-0962 Piease send us a courtesy email at renewalsupport@bldrs.com after you contact your insurance agent and include your policy information. if we do not receive your initial premium payment by 07/24/2020, your Policy will NOT be renewed and your coverage will expire on the last day of your current Policy term. Thank you and we appreciate your business. Builders Insurance Group BIG PHN CXRN 02 12 ti Builders Insurance Group’ POLICY NUMBER: WCV 0276670 01 INSURED: FGC INC American Builders Insurance Company A Stock Company 2410 Paces Ferry Road, Suite 300 Atlanta, GA 30339 WORKERS COMPENSATION & EMPLOYERS LIABILITY INSURANCE POLICY For: FGC INC By: Sihle Insurance Group Inc. 830-13 ATA NORTH #169 P.O, Box 160398 PONTE VEDRA BEACH, FL 32082 Altamonte Springs, FL 32716 IN WITNESS WHEREOF, American Builders Insurance Company has caused this policy to be executed and attested, and, if required by State law, this policy shall not be valid unless countersigned by our authorized representative. Sol [AM President t. bey Secretary For Inquiry purposes, coverage information and complaint assistance, please contact your agent or call: 1-800-883-9305 or 678-309-4000 WC 09 00 00 B 03 16 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Insurer: NCCI Carrier Code 25496 Producer: 0001356 American Builders Insurance Company Sihle Insurance Group Inc. A Stock Company P.O. Box 160398 P.O. Box 723099 Altamonte Springs, FL 32716 Atlanta, GA 31139-0099 41. The Insured and Mailing Address: Policy #:. WCV 0276670 01 FGC INC Prior Policy # 0276670 830-13 A1A NORTH #169 Type of Business: CORPORATION PONTE VEDRA BEACH, FL 32082 Fein: 272700711 Risk ID: Other workplaces not shown above: See the Schedule of Workplaces for this policy. The Policy Period is from 12:01 a.m. on 07/24/2020 to 12:01 a.m. on 07/24/2021 at the Insured's mailing address. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: Florida B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A. The timits 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: Part Three of the policy applies to the states, if any, listed here: Alabama Arizona Colorado Georgia Indiana Maryland Mississippi North Carolina Oklahoma Pennsylvania South Carolina Tennessee Virginia D. This policy includes these endorsements and schedules: See endorsement schedule. 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 No. Premium Basis Rate Per Estimated Total Estimated $100 of Annual Annual Remuneration Remuneration Premium SEE SCHEDULE OF OPERATIONS Total Estimated Annual Premium $6,714 Expense Constant $160 FL Workers Comp Insurance $67 Minimum Premium $969 Guaranty Assoc. Surcharge Total Cost $6,781 COUNTERSIGNED BY. hand Af WC 00 00 01 A 0919 includes copyright material of the National Council on Compensation Insurance, inc., used with its permission ©2019 National Council on Compensation Insurance Inc. All Rights Reserved. WORKERS COMPENSATION & EMPLOYERS LIABILITY American Builders Insurance Company INSURANCE POLICY A Stock Company Policy Number: WCV 0276670 01 P.O. Box 723099 Atlanta, GA 31139 Named Insured: FGC INC Agent: SIHLE INSURANCE GROUP INC. 0001356. SCHEDULE OF OPERATIONS EXTENSION OF INFORMATION PAGE, ITEM 4 Premium Basis Rate Per Estimated Code Classification Description Total Est. Annual $100 of Annual No. Remuneration Remuneration Premium Florida Rating Period 07/24/2020 through 07/24/2021 Site 00001 5403 CARPENTRY NOC 7,200 8.0900 582.00 5606 CONTRACTOR-EXECUTIVE SUPERVISOR/SUPERINTENDENT 357,800 1.3500 4,830.00 8810 CLERICAL OFFICE EMPLOYEES-NOC 408,633 0.1700 695.00 Site 90001 Total 6,107.00 9812 INCREASED LIMITS OF EMPLOYERS LIABILITY 6,107 0.0140 85.00 0930 BLANKET WAIVER OF SUBROGATION 6,107 0.0200 250,00 9848 TO EQUAL MINIMUM PREMIUM (E L) 35.00 0063 PREMIUM DISCOUNT 6,477 0.00 0300 EXPENSE CONSTANT 160.00 9740 TERRORISM ACT SURCHARGE 773,633 0.0100 77.00 9684 FLORIDA WC INS GUARANTY ASSOC 6,714 0.0100 67.00 Rating Period Total 6,781.00 Total Estimated Premium 6,781.00 State Total 6,781.00 Policy Total 6,781.00 Issued Date: 05/29/2020 WC 09 06 52 0919 Page 1 of 1 WORKERS COMP & EMPLOYERS LIABILITY Builders American Builders Insurance INSURANCE POLICY Insurance Company Policy Number: WCv 0276670 01 Group" A Stock Company P.O. Box 723099 Named Insured: FGC INC Atlanta, GA 31139 Agent: SIHLE INSURANCE GROUP INC. 0001356 SCHEDULE OF WORKPLACES EXTENSION OF INFORMATION PAGE, ITEM 1 Site 1 FGC INC 830-13 A1A NORTH #169 PONTE VEDRA BEACH, FL 32082 issued Date: 05/29/2020 WC 09 06 53 0919 Page 1 of 1 WORKERS COMP & EMPLOYERS LIABILITY Builders American Builders Insurance INSURANCE POLICY Insurance Company Policy Number: wCv 0276670 01 Group’ A Stock Company P.O, Box 723099 Named Insured: FGC INC Atlanta. GA 34139 Agent: SIHLE INSURANCE GROUP INC. 0001356 NAMED INSURED SCHEDULE EXTENSION OF INFORMATION PAGE, ITEM 1. FGC INC 830-13 A1A NORTH #169 PONTE VEDRA BEACH, FL 32082 FEIN: 272700711 Issued Date: 05/29/2020 WC 09 06 51 0919 Page 1 of 1 WORKERS COMP & EMPLOYERS LIABILITY Builders American Builders Insurance INSURANCE POLICY Insurance Company Policy Number: WCv 0276670 01 Group® A Stock Company P.O. Box 723089 Named Insured: FGC INC Atlanta, GA 31139 Agent: SIHLE INSURANCE GROUP INC. 0001356 ENDORSEMENT SCHEDULE EXTENSION OF INFORMATION PAGE, ITEM 3.D. It is hereby understood and agreed that the following forms and endorsements are attached to and are part of this policy. State Form Nbr Ed. Date Description US ‘wcoo0000c (1/18) WC AND EMPLOYERS LIAB INS POL US WC000313 (4/84) WAIVER OF OUR RIGHT TO RECOVER US WC000414A (1/19) NOTIFICATION OF CHANGE IN OWNE US wc000419 (101) PREMIUM DUE DATE ENDORSEMENT FL FORMOSANOT (1/20) FL TERRORISM RISK PENDING CHG FL WC000406A (7/95) PREMIUM DISCOUNT ENDORSEMENT FL WC080303 (8/05) FL EMPLOYERS LIABILITY COVERAG FL ‘wc090401 (6/87) FL CONTRACTING CLASS PREM ADJ FL wcos0402A (5/17) FL EXPERIENCE RATING MOD FACTO. FL 'WC090403B (4/15) FL TERRORISM RISK INS ACT ENDT FL wc090407 (7/13) FL NON-COOP AUDIT ENDT FL WC090408A, (7/19) FL INSUFFICIENT FUNDS ENDT FL wcos0606 (10/98) FL EMPLOYMENT & WAGE INFO REL FL WC090607A (719) FL GUARANTY ASSOC SURCH ENDT Issued Date: 05/29/2020 WC 09 06 50 0919 Page 1 of 1 xxxeKA ATTEN TION****** Online Monthly Self Reporting (MSR) Payment Plan Guidelines Enclosed is the policy detail pertaining to your Workers compensation coverage for the current term. Based upon the Underwriting information supplied, your policy has qualified for our Online Monthly Self Reporting (MSR) payment program. Enrollment in this flexible payment option means that you have agreed to the terms of the payment plan and understand that you are required to electronically submit your Monthly (calendar) payroll detail, uninsured subcontractor exposure, as well as alert us to any class code changes, timely and accurately. You further understand that the transmittal of this MSR data is an immediate endorsement of your actual premium and is due upon receipt. - You MUST file an online report for each monthly period for your account to be credited properly. - Failure to submit a Monthly Self Report (MSR) and make the corresponding premium payment will result in a late notice and/or cancellation of your Policy. Instructions for enrolling online for MSR reporting and payment: Please go to our Web page at www.bidrs.com . Under the "FOR POLICHOLDERS*" section, CLICK "Monthly Self Reporting". . This will direct you to our SAFE AND SECURE policyholder Support Center for processing. a First Time users will need to Click Enroll. Returning Users can Click Login. Enrolling - as easy as 1-2-3 . You will need your Policy number and corresponding FEIN (tax |.D.) to enroll. This information is contained in this policy packet. Simply select the "Workers Compensation" pull down menu option. Enter your 7 (seven) digit Policy number in the field after the WCV identifier (i.e. WCV 1234567 00). Enter your FEIN (Federal Employee [D Number). Click NEXT. Enter your Valid Email address as the User ID (to receive Email confirmations) . Select a unique password and Submit. Print the password reference page. Login - It's fast and secure . Enter your User ID (Hint: Your email address) and Password. . Click on the "Policy Information Center" link and see your policy detail page. . Click "Create a Monthly Self Report" to access your MSR summary page and follow the simple online filing instructions to process your MSR. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY American Builders Insurance Company po, Box 723099 Atlanta, GA 31139-0099 (A Stock Company) QUICK REFERENCE Beginning on Page Beginning INFORMATION PAGE on Page PART TWO - EMPLOYERS GENERAL SECTION. LIABILITY INSURANCE (con't) The Policy... H. Recovery From Others. Who is Insure ' Actions Against Us.... Workers Compensation Law State.. PART THREE - Location: OTHER STATES INSURANCE A. How This Insurance App! PART ONE - WORKERS B. Notice. COMPENSATION INSURANCE PART FOUR - YOUR DUTIES How This Insurance Applies iF INJURY OCCURS. We Will Pay... We Will Defen PART FIVE - PREMIUM We Will also Pay. Our Manuals. Other Insurance.. Classification: Payments You Must Make. Remuneration Recovery From Other: Premium Payment Statutory Provisions.. Final Premiu Record. PART TWO - EMPLOYERS Audit LIABILITY INSURANCE.. How This Insurance pp PART SIX - CONDITIONS We Will Pay. . Inspection. Exclusions... Long Term Policy. We Will Defen Transfer of Your Rights and Dutie: We Will Also Pay. Cancellation...... Other Insurance Sole Representative. Limits of Liability. These Policy Provisions with the Information Page and Endorsements, if any, issued to form a part thereof, complete this policy. PLEASE READ THIS POLICY CAREFULLY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 0000 C (Ed. 1-45) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all PART ONE terms 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 The Policy injury by accident or bodily injury by disease. Bodily This policy includes at its effective date the injury includes resulting death. Information Page and all endorsements and schedules 4 Bodily injury by accident must occur during the listed there. It is a contract of insurance between you policy period. (the employer named in Item 1 of the Information Page) and us (the insurer named on the Information 2. Bodily injury by disease must be caused or Page). The only agreements relating to this insurance aggravated by the conditions of your employment. are stated in this policy. The terms of this policy may The employee's last day of last exposure to the not be changed or waived except by endorsement conditions causing or aggravating such bodily issued by us to be part of this policy. injury by disease must occur during the policy period. Who is Insured We Will Pay You are insured if you are an employer named in Item 1 of the Information Page. H that employer is a We will pay promptly when due the benefits required partnership, and if you are one of its partners, you are of you by the workers compensation law. insured, but only in your capacity as an employer of the partnership’s employees. We Will Defend We have the right and duty to defend at our expense Workers Compensation Law any claim, proceeding or suit against you for benefits Workers Compensation Law means the workers or payable by this insurance. We have the right to workmen's compensation law and occupational investigate and settle these claims, proceedings or disease law of each state or territory named in Item suits. 3.4. of the Information Page. It includes any We have no duty to defend a claim, proceeding or suit amendments to that law which are in effect during the that is not covered by this insurance. 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 We Will Also Pay that provide nonoccupational disability benefits. We will also pay these costs, in addition to other amounts payable under this insurance, as part of any State claim, preceeding or suit we defend: 4 reasonable expenses incurred at our request, but State means any state of the United States of America, and the District of Columbia. not loss of earnings; 2 premiums for bonds to release attachments and for appeal bonds in bend amounts up to the Locations amount payable under this insurance; This policy covers all of your workplaces listed in Items litigation costs taxed against you: 1 or 4 of the Information Page; and it covers ail other workplaces in Item 3.A. states unless you have other interest on a judgment as required by taw until we insurance or are self-insured for such workplaces. offer the amount due under this insurance; and expenses we incur. Other Insurance We will not pay more than our share of benefits and costs covered by this insurance and other 10f 6 @ Convtloht 2043 National Council an Compansation Innurance inc. All Riahts Reserved. WC 00 00 00¢ WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) insurance or self-insurance. Subject to any limits of workers compensation law that apply to: liability that may apply, all shares will be equal until the a. benefits payable by this insurance; loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will b. special taxes, payments into security or other be equal until the loss is paid. special funds, and assessments payable by us under that law. Terms of this insurance that conflict with the Payments You Must Make workers compensation law are changed by this You are responsible for any payments in excess of the statement fo conform to that law. benefits regularly provided by the workers Nothing in these paragraphs relieves you of your compensation Jaw including those required because: duties under this policy. 4 of your serious and willful misconduct; 2. you knowingly employ an employee in violation of PART TWO law; EMPLOYERS LIABILITY INSURANCE you fail to comply with a health or safety law or How This Insurance Applies regulation; or This employers liability insurance applies to bodily you discharge, coerce or otherwise discriminate injury by accident or bodily injury by disease. Bodily against any employee in violation of the workers injury includes resulting death. compensation law. 1 The bodily injury must arise out of and in the 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 you. on your behalf, you will reimburse us promptly. The employment must be necessary or incidental to your work in a state or territory listed in Item Recovery From Others 3.A. of the Information Page. We have your rights, and the rights of persons entitled Bodily injury by accident must occur during the to the benefits of this insurance, to recover our policy period. payments from anyone liable for the injury. You will do Bodily injury by disease must be caused or everything necessary to protect those rights for us and aggravated by the conditions of your employment. to help us enforce them. The employee’s last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy Statutory Provisions period. These statements apply where they are required by If you are sued, the original suit and any related Jaw. fegal actions for damages for bodily injury by 4 As between an injured worker and us, we have accident or by disease must be brought in the notice of the injury when you have notice. United States of America, its territories or 2. Your default or the bankruptcy or insolvency of possessions, or Canada. you or your estate will not relieve us of our duties under this insurance after an injury occurs. B. We Will Pay We are directly and primarily liable to any person We will pay all sums that you legally must pay as entitled to the benefits payable by this insurance. Those persons may enforce our duties; so may an damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers agency authorized by law. Enforcement may be against us or against you and us. Liability Insurance. Jurisdiction over you is jurisdiction over us for The damages we will pay, where recovery is permitted by law, include damages: purposes of the workers compensation law. We are bound by decisions against you under that 1 For which you are liable to a third party by reason law, subject to the provisions of this policy that are ofa claim or suit against you by that third party to not in conflict with that law. tecover the damages claimed against This insurance conforms to the parts of the 2of 6 © Conveiaht 2043 National Council an Comnansation insurance ine. All Riahts Rasarved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) such third party as a result of injury to your and 901-944), any other federal workers or employee; workmen's compensation law or other federal occupational disease law, or any amendments to For care and loss of services; and these laws; For consequential bodily injury to a spouse, child, Bodily injury to any person in work subject to the parent, brother or sister of the injured employee: Federai Employers’ Liability Act (45 U.S.C. provided that these damages are the direct other federal laws Sections 51 et seq.), any consequence of bodily injury that arises out of and obligating an employer to pay damages to an in the course of the injured employee's employee due to bodily injury arising out of or in employment by you; and the course of employment, or any amendments to Because of bodily injury to your employee that those laws; arises out of and in the course of employment, 10. Bodily injury to a master or member of the crew of claimed against you in a capacity other than as any vessel; and does not cover punitive damages employer. telated to your duty or obligation to provide transportation, wages, maintenance, and cure Cc. Exclusions under any appli-cable maritime law; This insurance does not cover: 1 Fines or penalties imp