Preview
CAUSE NO. 21-03-03046
AMTRUST INSURANCE COMPANY IN THE DISTRICT COURT
OF KANSAS, INC.
PLAINTIFF,
vs. JUDICIAL DISTRICT
ONETURN, L.L.C.
DEFENDANTS. MONTGOMERYCOUNTY, TEXAS
PLAINTIFF'S XHIBITLIST
siness Record Affidavit
Workers’ Compensation Application
Policy PremiumNotice Final Premium Audit
Plaintiff’s Documents and Proof of Performance
Policy History
Workers’ Compensation and Employers’ LiabilityInsurance Policy
Attorney Fees Breakdown
Any Exhibits Defendant Introduces
Plaintiff reserves the right to supplement Exhibit List.
espectfully submitted
ARNETT & GARCIA
A Professional Limited Liability Company
3821 Juniper Trace, Suite 108
Austin, Texas 78738
TELEPHONE: (512) 266
FACSIMILE: (512) 266
/s/ Sean S.V. Homrig
Sean S. V. Homrig
State Bar No. 2406278
sean@barnettgarcia.co
rence J. Falli
State Bar No. 24068702
Matias Eduardo Garcia
State Bar No. 24012675
Ian A. McCarthy
State Bar No. 24078960
ATTORNEYS FOR PLAINTIFF
CERTIFICATE OF SERVICE
I certify that a true and correct copy of the above was forwarded to opposing unsel by
ervice, or by certified mail, return receipt requested and regular mail on this the 11th day of
February
/s/ Sean S.V. Homrig
Sean S.V. Homrig
James B. Jameson
2525 Robinhood, Suite 100
Houston, Texas 77005
Email: jbjameson@jamesonlaw.net
November 11, 2020
Page 1
FORWARD CASE
Barnett & Garcia, PLLC
Matt Garcia
3821 Juniper Trace, Suite 108
Austin TX 78738
Re: Plaintiff: AmTrust Insurance mpany of Kansas, Inc.
Insured: OneTurn LLC
Policy No. KWC1119313 Eff02/22/18 – 02/22/19
Amt. Owed: $16,242.00
File No. 06301
Policy No. KWC1156167 Eff02/22/19 – 10/08/19
Amt. Owed: $9,646.00
File No. 01945
Total Amt. Due: $25,888.00
17.5%
$550.00
National List
AmTrust Insurance Company of Kansas, Inc.
A Stock Insurance Company
PO Box 655028
Dallas, TX 75251
WORKERS COMPENSATION WC 00 00 01 A
AND EMPLOYERS LIABILITY
INSURANCE POLICY INFORMATION PAGE
Insured: Policy Number: KWC1119313
OneTurn, LLC
397 North Sam Houston Pkwy East, Suite 400
Houston, TX 77060 Federal Tax ID: 464303976
Other workplaces not shown above: Board File Number:
See Extension of Information Page Renewal Of: KWC1078584
Producer: Entity: Limited Liability Company
U.S. Risk, LLC Interim Adjustment: Annual
8401 N Central Expwy., Suite 1000 Ncci Code: 68405
Dallas, TX 75225 SIC Code:
The policy period is from 2/22/2018 to 2/22/2019 12:01 a.m. at the insured’s mailing address.
Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed
here: Oklahoma
Employers Liability Insurance: Part Two of the policy applies to work in each stated listed in item 3.A. The limits of our
liability under Part Two are:
Bodily Injury by Accide 1,000,000 each accident
Bodily Injury by Disease 1,000,000 policy limit
Bodily Injury by Disease 1,000,000 each employee
Other States Insurance: Part Three of the policy applies to the states, if any, listed here: ll states except ND, OH, WA, WY
and State(s) Designated in Item 3A.
This policy includes these endorsements and schedules:
See attached 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.
See Extension of Information Page
TOTAL ESTIMATED ANNUAL PREMIUM 7,471
STATE ASSESSMENT
TOTAL ESTIMATED COST 7,471
Minimum Premium
Deposit Premium
Issue Date: 1/29/2018 Countersigned By:
Authorized Representative
AmTrust Insurance Company of Kansas, Inc. is required by law to provide its policyholders with certain
accident prevention services as required by Oklahoma HB 1002, Section 11, Subsection b, at no additional cost.
if you would like additional information, contact AmTrust Insurance Company of Kansas, Inc. Loss Control
Department at 1-877--7878.
Site Address
1 1315 SE 29th St
AmTrust Insurance Company of Kansas, Inc. WC 00 00 01 A
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE
Insured: OneTurn, LLC Policy Number: KWC1119313
EXTENSION OF INFORMATION PAGE
ENDORSEMENT SCHEDULE
Form Number Description
WC000000C DECLARATIONS COVER LETTER
WC000001A DECLARATIONS PAGE
WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT
WC000404 PENDING RATE CHANGE ENDORSEMENT
WC000406A PREMIUM DISCOUNT ENDORSEMENT
WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT
WC000419 PREMIUM DUE DATE ENDORSEMENT
WC000421D CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT
WC000422B TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE
ENDORSEMENT
WC000424 AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT
WC000425 EXPERIENCE RATING MODIFICATION FACTOR REVISION ENDORSEMENT
WC350302 OKLAHOMA EMPLOYERS LIABILITY AMENDED COVERAGE ENDORSEMENT
WC350303 OKLAHOMA EMPLOYERS LIABILITY INTENTIONAL TORT EXCLUSION ENDORSEMENT
WC350601F OKLAHOMA CANCELLATION, NONRENEWAL AND CHANGE ENDORSEMENT
WC350603 OKLAHOMA FRAUD WARNING ENDORSEMENT
WC350604 OKLAHOMA ELECTION OF COVERAGE NOTIFICATION ENDORSEMENT
WcOkLc OK LOSS CONTROL NOTICE TO POLICYHOLDER
WcOkLc1 OK LOSS CONTROL NOTICE TO POLICYHOLDERS
0 3632 241,371
Premium to Equal Increased Limits Minimum Charge 9848
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00
Ed.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLIC
In return for the payment of the premium and subject to PART ONE
all terms of this policy, we agree with you as follows: WORKERS COMPENSATION INSURANCE
How This Insurance Applies
GENERAL SECTION This workers compensation insurance applies to
bodily injury by accident or bodily injury by disease.
The Policy Bodily injury includes resulting death.
This policy includes at its effective date the Info Bodily injury by accident must occur during the
mation Page and all endorsements and schedules policy period.
listed there. It is a contract of insurance between Bodily injury by disease must be caused or a
you (the employer named in Item 1 of the Info gravated by the conditions of your employment.
mation Page) and us (the insurer named on the I The employee’s last day of last exposure to the
formation Page). The only agreements relating to conditions causing or aggravating such bodily i
this insurance are stated in this policy. The terms of jury by disease must occur during the policy
this policy may not be changed or waived except period.
by endorsement issued by us to be part of this
policy.
We Will Pay
We will pay promptly when due the benefits required
Who is Insured
of you by the workers compensation law.
You are insured if you are an employer named in
Item 1 of the Information Page. If that employer is a
We Will Defend
partnership, and if you are one of its partners, you
are insured, but only in your capacity as an e We have the right and duty to defend at our e pense
ployer of the partnership’s employees. any claim, proceeding or suit against you for ben fits
payable by this insurance. We have the right to i
vestigate and settle these claims, proceedings or
Workers Compensation Law suits.
Workers Compensation Law means the workers or We have no duty to defend a claim, proceeding or
workmen’s compensation law and occupational suit that is not covered by this insurance.
disease law of each state or territory named in Item
3.A. of the Information Page. It includes any
We Will Also Pay
amendments to that law which are in effect during
the policy period. It does not include any federal We will also pay these costs, in addition to other
workers or workmen’s compensation law, any fe amounts payable under this insurance, as part of
eral occupational disease law or the provisions of any claim, proceeding or suit we defend:
any law that provide nonoccupational disability easonable expenses incurred at our request,
benefits. but not loss of earnings;
remiums for bonds to release attachments and
State for appeal bonds in bond amounts up to the
State means any state of the United States of amount payable under this insurance;
America, and the District of Columbia. itigation costs taxed against you;
nterest on a judgment as required by law until
Locations we offer the amount due under this insurance;
This policy covers all of your workplaces listed in
Items 1 or 4 of the Information Page; and it covers xpenses we incur.
all other workplaces in Item 3.A. states unless you
have other insurance or are self insured for such Other Insurance
workplaces.
We will not pay more than our share of benefits and
costs covered by this insurance and other
1 of 6
Copyright 20 National Council on Compensation Insurance, Inc. All Rights Reser
WC 00 00 00 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
Ed.
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 enefits payable by this insurance;
the loss is paid. If any insurance or sel insurance
pecial taxes, payments into security or ot
is exhausted, the shares of all remaining insurance
er special funds, and assessments pay ble
will be equal until the loss is paid.
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 statement to conform to that law.
the benefits regularly provided by the workers Nothing in these paragraphs relieves you of your d
compensation law including those required ties under this policy.
because:
f your serious and willful misconduct;
ou knowingly employ an employee in violation PART TWO
of law; EMPLOYERS LIABILITY INSURANCE
ou fail to comply with a health or safety law or
regulation; or How This Insurance Applies
ou discharge, coerce or otherwise discrimi This employers liability insurance applies to bodily
against any employee in violation of the workers injury by accident or bodily injury by disease. Bodily
compensation law. injury includes resulting death.
If we make any payments in excess of the benefits The bodily injury must arise out of and in the
regularly provided by the workers compensation course of the injured employee’s employment by
law on your behalf, you will reimburse us promptly. you.
The employment must be necessary or inc
dental to your work in a state or territory listed in
Recovery From Others
Item 3.A. of the Information Page.
We have your rights, and the rights of persons ent Bodily injury by accident must occur during the
tled to the benefits of this insurance, to recover our
policy period.
payments from anyone liable for the injury. You will
do everything necessary to protect those rights for Bodily injury by disease must be caused or a
us and to help us enforce them. gravated by the conditions of your employment.
The employee’s last day of last exposure to the
conditions causing or aggravating such bodily i
Statutory Provisions jury by disease must occur during the policy
These statements apply where they are required by period.
law. If you are sued, the original suit and any related
As between an injured worker and us, we have legal actions for damages for bodily injury by a
notice of the injury when you have notice. cident or by disease must be brought in the
Your default or the bankruptcy or insolvency of United States of America, its territories or po
you or your estate will not relieve us of our d sessions, or Canada.
ties under this insurance after an injury occurs.
We are directly and primarily liable to any pe We Will Pay
son entitled to the benefits payable by this i We will pay all sums that you legally must pay as
surance. Those persons may enforce our duties; damages because of bodily injury to your emplo
so may an agency authorized by law. Enforc ees, provided the bodily injury is covered by this
ment may be against us or against you and us. Employers Liability Insurance.
Jurisdiction over you is jurisdiction over us for The damages we will pay, where recovery is permi
purposes of the workers compensation law. We ted by law, include damages:
are bound by decisions against you under that For which you are liable to a third party by re
law, subject to the provisions of this policy that
on of a claim or suit against you by that third
are not in conflict with that law.
party to recover the damages claimed against
This insurance conforms to the parts of the
2 of 6
Copyright 20 National Council on Compensation Insurance, Inc. All Rights Reserved.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00
Ed.
such third party as a result of injury to your Bodily injury to any person in work subject to the
ployee; Federal Employers’ Liability Act (45 U
For care and loss of services; tions 51 et seq.), any other federal laws obliga
ing an employer to pay damages to an emplo ee
For consequential bodily injury to a spouse, due to bodily injury arising out of or in the course
child, parent, brother or sister of the injured e
of employment, or any amendments to those
ployee; provided that these damages are the d
laws
rect cons quence of bodily injury that arises out
of and in the course of the injured employee’s Bodily injury to a master or member of the crew
employment by you; and of any vessel, and does not cover punitive da
ages related to your duty or obligation to provide
Because of bodily injury to your employee that transportation, wages, maintenance, and cure
arises out of and in the course of employment, under any applicable maritime law;
claimed against you in a capacity other than as
employer. Fines or penalties imposed for violation of fede al
or state law; and
Exclusions Damages payable under the Migrant and Se
This insurance does not cover: sonal Agricultural Worker Protection Act (29
Sections 1801 et seq.) and under any
Liability assumed under a contract. This excl other federal law awarding damages for violation
sion does not apply to a warranty that your work of those laws or regulations issued thereunder,
will be done in a workmanlike manner; and any amen ments to those laws.
Punitive or exemplary damages because of bod
ly injury to an employee employed in viol tion of We Will Defend
law;
We have the right and duty to defend, at our e
Bodily injury to an employee while employed in pense, any claim, proceeding or suit against you for
violation of law with your actual knowledge or the damages payable by this insurance. We have the
actual knowledge of any of your executive offi
right to investigate and settle these claims, procee
ers;
ings and suits.
Any obligation imposed by a workers compens
We have no duty to defend a claim, proceeding or
tion, occupational disease, unemployment co
suit that is not covered by this insurance. We have
pensation, or disability benefits law, or any sim
no duty to defend or continue defending after we
lar law;
have paid our applicable limit of liability under this
Bodily injury intentionally caused or aggravated insurance.
by you;
Bodily injury occurring outside the United States
We Will Also Pay
America, its territories or possessions, and
da. This exclusion does not apply to bodily We will also pay these costs, in addition to other
injury to a citizen or resident of the United States amounts payable under this insurance, as part of
of Amer ca or Canada who is temporarily outside any claim, proceeding, or suit we defend:
these countries; Reasonable expenses incurred at our request,
Damages arising out of coercion, criticism, d but not loss of earnings;
motion, evaluation, reassignment, discipline, Premiums for bonds to release attachments and
defamation, harassment, humiliation, discrimin for appeal bonds in bond amounts up to the limit
tion against or termination of any employee, or of our liability under this insurance;
any personnel practices, policies, acts or omi Litigation costs taxed against you;
sions;
Interest on a judgment as required by law until
Bodily injury to any person in work subject to th we offer the amount due under this insurance;
Longshore and Harbor Workers’ Compensation
Act (33 U Sections 901 et seq.), the No
propriated Fund Instrumentalities Act (5 Expenses we incur.
Sections 8171 et seq.), the Outer Continental
Shelf Lands Act (43 U Sections 1331
seq.), the Defense Base Act (42 U tions
1654), the Federal Mine Safety and Health
Act (30 U Sections 801 et seq. and 901
), any other federal workers or workmen’s
compensation law or other federal occupational
disease law, or any amendments to these laws;
3 of 6
Copyright 20 National Council on Compensation Insurance, Inc. All Rights Reserved
WC 00 00 00 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
Ed. 1
Other Insurance The amount you owe has been determined with
We will not pay more than our share of damages our consent or by actual trial and final judgment.
and costs covered by this insurance and other i This insurance does not give anyone the right to add
surance or self insurance. Subject to any limits of l us as a defendant in an action against you to dete
ability that apply, all shares will be equal until the mine your liability. The bankruptcy or insolvency of
loss is paid. If any insurance or self surance is e you or your estate will not relieve us of our oblig
hausted, the shares of all remaining insurance and tions under this Part.
self insurance will be equal until the loss is paid
PART THREE
Limits of Liability OTHER STATES INSURANCE
Our liability to pay for damages is limited. Our limits
of liability are shown in Item 3.B. of the Information How This Insurance Applies
Page. They apply as explained below. This other states insurance applies only if one or
Bodily Injury by Accident. The limit shown for more states are shown in Item 3.C. of the Info
bodily injury by accident each accident” is the tion Page.
most we will pay for all damages covered by this If you begin work in any one of those states after
insurance because of bodily injury to one or the effective date of this policy and are not i
more employees in any one accident. sured or are not self insured for such work, all
A disease is not bodily injury by accident unless provisions of the policy will apply as though that
it results directly from bodily injury by accident. state were listed in Item 3.A. of the Information
Bodily Injury by Disease. The limit shown for Page.
bodily injury by disease policy limit” is the We will reimburse you for the benefits required
most we will pay for all damages covered by this by the workers compensation law of that state if
insurance and arising out of bodily injury by di we are not permitted to pay the benefits directly
ease, regardless of the number of employees to persons entitled to them.
who sustain bodily injury by disease. The limit If you have work on the effective date of this po
shown for “bodily injury by disease each e icy in any state not listed in Item 3.A. of the I
oyee” is the most we will pay for all damages formation Page, coverage will not be afforded for
because of bodily injury by disease to any one that state unless we are notified within thirty
employee. days.
Bodily injury by disease does not include di
ease that results directly from a bodily injury by Notice
accident. Tell us at once if you begin work in any state listed in
We will not pay any claims for damages after we Item 3.C. of the Information Page
have paid the applicable limit of our liability u
der this insurance. PART FOUR
YOUR DUTIES IF INJURY OCCURS
Recovery From Others
We have your rights to recover our payment from Tell us at once if injury occurs that may be covered
anyone liable for an injury covered by this insurance. by this policy. Your other duties are listed here.
You will do everything necessary to protect those Provide for immediate medical and other se
rights for us and to help us enforce them. vices required by the workers compensation law.
Give us or our agent the names and addresses
Actions Against Us of the injured persons and of witnesses, and
There will be no right of action against us under this other information we may need.
insurance unless: Promptly give us all notices, demands and legal
You have complied with all the terms of this pol
; and
4 of 6
Copyright National Council on Compensation Insurance, Inc. All Rights Reserved
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00
Ed. 1
papers related to the injury, claim, procee ing Premium Payments
or suit. You will pay all premium when due. You will pay the
Cooperate with us and assist us, as we may r premium even if part or all of a workers compens
quest, in the investigation, settlement or defense tion law is not valid.
of any claim, proceeding or suit.
Do nothing after an injury occurs that would i Final Premium
terfere with our right to recover from others. The premium shown on the Information Page,
Do not voluntarily make payments, assume obl schedules, and endorsements is an estimate. The
gations or incur expenses, except at your own final premium will be determined after this policy
st. ends by using the actual, not the estimated, prem
um basis and the proper classifications and rates
that lawfully apply to the business and work covered
PART FIVE
by this policy. If the final premium is more than the
PREMIUM premium you paid to us, you must pay us the ba
ance. If it is less, we will refund the balance to you.
Our Manuals The final premium will not be less than the highest
All premium for this policy will be determined by our minimum premium for the classifications covered by
manuals of rules, rates, rating plans and classific this pol cy.
tions. We may change our manuals and apply the If this policy is canceled, final premium will be d
changes to this policy if authorized by law or a go termined in the following way unless our manuals
ernmental agency regulating this insurance. provide otherwise:
If we cancel, final premium will be calculated pro
Classifications rata based on the time this policy was in force.
Item 4 of the Information Page shows the rate and Final premium will not be less than the pro rata
premium basis for certain business or work classif share of the minimum premium.
cations. These classifications were assigned based If you cancel, final premium will be more than
on an estimate of the exposures you would have pro rata; it will be based on the time this policy
during the policy period. If your actual exposures are was in force, and increased by our short rate
not properly described by those classifications, we cancelation table and procedure. Final premium
will assign proper classifications, rates and premium will not be less than the minimum premium.
basis by endorsement to this policy.
Remuneration
You will keep records of information needed to co
Premium for each work classification is determined pute premium. You will provide us with copies of
by multiplying a rate times a premium basis. Rem those records when we ask for them.
neration is the most common premium basis. This
premium basis includes payroll and all other rem
neration paid or payable during the policy period for Audit
the services of: You will let us examine and audit all your records
that relate to this policy. These records include led
ll your officers and employees engaged in work
ers, journals, registers, vouchers, contracts, tax r
covered by this policy; and
ports, payroll and disbursement records, and pr
ll other persons engaged in work that could grams for storing and retrieving data. We may co
make us liable under Part One (Workers Co duct the audits during regular business hours during
pensation Insurance) of this policy. If you do not the policy period and within three years after the po
have payroll records for these persons, the co icy period ends. Information developed by audit will
tract price for their services and materials may be used to determine final premium. Insurance rate
be used as the premium basis. This paragraph 2 service organizations have the same rights we have
will not apply if you give us proof that the e under this provision.
ployers of these persons lawfully secured their
workers compensation obligations.
5 of 6
Copyright 20 National Council on Compensation Insurance, Inc. All Rights Reserved
WC 00 00 00 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
Ed.
If you die and we receive notice within thirty days a
PART SIX ter your death, we will cover your legal represent
tive as insured.
CONDITIONS
Inspection Cancelation
We have the right, but are not obliged to inspect You may cancel this policy. You must mail or d
your workplaces at any time. Our inspections are not liver advance written notice to us stating when
fety inspections. They relate only to the insurabi the cancelation is to take effect.
ity of the workplaces and the premiums to be We may cancel this policy. We must mail or d
charged. We may give you reports on the conditions liver to you not less than ten days advance wri
we find. We may also recommend changes. While ten notice stating when the cancelation is to take
they may help reduce losses, we do not undertake fect. Mailing that notice to you at your mailing
to perform the duty of any person to provide for the address shown in Item 1 of the Information Page
health or safety of your employees or the public. We will be sufficient to prove notice.
do not warrant that your workplaces are safe or The policy period will end on the day and hour
healthful or that they comply with laws, regulations, stated in the cancelation notice.
codes or standards. Insurance rate service organiz
tions have the same rights we have under this Any of these provisions that conflict with a law
provision. that controls the cancelation of the insurance in
this policy is changed by this statement to co
ply with the law.
Term Policy
If the policy period is longer than one year and Sole Representative
days, all provisions of this policy will apply as
though a new policy were issued on each annual The insured first named in Item 1 of the Information
annive sary that this policy is in force. Page will act on behalf of all insureds to change this
policy, receive return premium, and give or receive
notice of cancelation.
Transfer of Your Rights and Duties
Your rights or duties under this policy may not be
transferred without our written consent.
6 of 6
Copyright 20 National Council on Compensation Insurance, Inc. All Rights Reserved
AmTrust Insurance Company of Kansas, Inc. WC 00 00 01 A
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE
Insured: OneTurn, LLC Policy Number: KWC1119313
PAYMENT SCHEDULE
Payment Premium Surcharge
Due Date Description Fees Total Due
2/22/2018 Downpayment $748.00 $0.00 $0.00 $748.00
3/31/2018 Installment 1 of 9 $747.00 $0.00 $0.00 $747.00
4/30/2018 Installment 2 of 9 $747.00 $0.00 $0.00 $747.00
5/31/2018 Installment 3 of 9 $747.00 $0.00 $0.00 $747.00
6/30/2018 Installment 4 of 9 $747.00 $0.00 $0.00 $747.00
7/31/2018 Installment 5 of 9 $747.00 $0.00 $0.00 $747.00
8/31/2018 Installment 6 of 9 $747.00 $0.00 $0.00 $747.00
9/30/2018 Installment 7 of 9 $747.00 $0.00 $0.00 $747.00
10/31/2018 Installment 8 of 9 $747.00 $0.00 $0.00 $747.00
11/30/2018 Installment 9 of 9 $747.00 $0.00 $0.00 $747.00
Totals $7,471.00 $0.00 $0.00 $7,471.00
Your Installments will be billed in 9 invoices based on the Schedule above.
Payment of each Installment is due to the Company on or before the due date indicated. You will receive an
installment invoice for each of the Installments shown above. No invoice will be sent for the Downpayment.
To avoid cancellation of your coverage, please make sure that our payment is received by the specified due date.
The company may process a Notice of Cancellation if payment is not received by the Company on or before the
due date. Postmark is not sufficient. If your check is returned by the bank for insufficient funds or for any reason, a
Notice of Cancellation will be immediately processed and an Nsf fee of $25 will be charged.
If your policy cancels for late payment or because of an item returned by the bank, you may be assessed a
Reinstatement Fee of $25 to reinstate your coverage.
All payments received will first be applied to fees assessed against the account and then to premium due.
Checks should be made payable to Amtrust North America, Inc. and can be mailed to:
Amtrust North America, Inc.
P.O. Box 6939
Cleveland, OH 44101-1939
Do not mail certified, overnight, or express mail to our P.O. Box. Any such mail can be sent to:
Amtrust North America, Inc.
800 Superior Avenue East, 21st Floor
Cleveland, OH 44114
Printed: 1/29/2018
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 08
(Ed. 4 84)
PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT
The policy does not cover bodily injury to any person described in the Schedule.
The premium basis for the policy does not include the remuneration of such persons.
You will reimburse us for any payment we must make because of bodily injury to such persons.
Schedule
Partners Officers Others
Chad Turner
Cody Turner
Lonnie Smith
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
Endorsement Effective 2/22/2018 Policy No. KWC1119313 Endorsement No.
Insured OneTurn, LLC Premium $7,471
Insurance Company AmTrust Insurance Company of Kansas, Inc.
Countersigned by
1999 National Council on Compensation Insurance.
Endorsement Effective 2/22/2018 Policy No. KWC1119313 Endorsement No. 0
Premium $ 7471
$10,000 $190,000 $1,550,000
10.9% 12.6%
2. Average percentage discount: 3.7 %
3. Other policies:
4. If there are no entries in Items 1, 2 and 3 of the Schedule, see the Premium Discount Endorsement attached to
Endorsement Effective 2/22/2018 P
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CAUSE NO. 21-03-03046 AMTRUST INSURANCE COMPANY IN THE DISTRICT COURT OF KANSAS, INC. PLAINTIFF, vs. JUDICIAL DISTRICT ONETURN, L.L.C. DEFENDANTS. MONTGOMERYCOUNTY, TEXAS PLAINTIFF'S XHIBITLIST siness Record Affidavit Workers’ Compensation Application Policy PremiumNotice Final Premium Audit Plaintiff’s Documents and Proof of Performance Policy History Workers’ Compensation and Employers’ LiabilityInsurance Policy Attorney Fees Breakdown Any Exhibits Defendant Introduces Plaintiff reserves the right to supplement Exhibit List. espectfully submitted ARNETT & GARCIA A Professional Limited Liability Company 3821 Juniper Trace, Suite 108 Austin, Texas 78738 TELEPHONE: (512) 266 FACSIMILE: (512) 266 /s/ Sean S.V. Homrig Sean S. V. Homrig State Bar No. 2406278 sean@barnettgarcia.co rence J. Falli State Bar No. 24068702 Matias Eduardo Garcia State Bar No. 24012675 Ian A. McCarthy State Bar No. 24078960 ATTORNEYS FOR PLAINTIFF CERTIFICATE OF SERVICE I certify that a true and correct copy of the above was forwarded to opposing unsel by ervice, or by certified mail, return receipt requested and regular mail on this the 11th day of February /s/ Sean S.V. Homrig Sean S.V. Homrig James B. Jameson 2525 Robinhood, Suite 100 Houston, Texas 77005 Email: jbjameson@jamesonlaw.net November 11, 2020 Page 1 FORWARD CASE Barnett & Garcia, PLLC Matt Garcia 3821 Juniper Trace, Suite 108 Austin TX 78738 Re: Plaintiff: AmTrust Insurance mpany of Kansas, Inc. Insured: OneTurn LLC Policy No. KWC1119313 Eff02/22/18 – 02/22/19 Amt. Owed: $16,242.00 File No. 06301 Policy No. KWC1156167 Eff02/22/19 – 10/08/19 Amt. Owed: $9,646.00 File No. 01945 Total Amt. Due: $25,888.00 17.5% $550.00 National List AmTrust Insurance Company of Kansas, Inc. A Stock Insurance Company PO Box 655028 Dallas, TX 75251 WORKERS COMPENSATION WC 00 00 01 A AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Insured: Policy Number: KWC1119313 OneTurn, LLC 397 North Sam Houston Pkwy East, Suite 400 Houston, TX 77060 Federal Tax ID: 464303976 Other workplaces not shown above: Board File Number: See Extension of Information Page Renewal Of: KWC1078584 Producer: Entity: Limited Liability Company U.S. Risk, LLC Interim Adjustment: Annual 8401 N Central Expwy., Suite 1000 Ncci Code: 68405 Dallas, TX 75225 SIC Code: The policy period is from 2/22/2018 to 2/22/2019 12:01 a.m. at the insured’s mailing address. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: Oklahoma Employers Liability Insurance: Part Two of the policy applies to work in each stated listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accide 1,000,000 each accident Bodily Injury by Disease 1,000,000 policy limit Bodily Injury by Disease 1,000,000 each employee Other States Insurance: Part Three of the policy applies to the states, if any, listed here: ll states except ND, OH, WA, WY and State(s) Designated in Item 3A. This policy includes these endorsements and schedules: See attached 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. See Extension of Information Page TOTAL ESTIMATED ANNUAL PREMIUM 7,471 STATE ASSESSMENT TOTAL ESTIMATED COST 7,471 Minimum Premium Deposit Premium Issue Date: 1/29/2018 Countersigned By: Authorized Representative AmTrust Insurance Company of Kansas, Inc. is required by law to provide its policyholders with certain accident prevention services as required by Oklahoma HB 1002, Section 11, Subsection b, at no additional cost. if you would like additional information, contact AmTrust Insurance Company of Kansas, Inc. Loss Control Department at 1-877--7878. Site Address 1 1315 SE 29th St AmTrust Insurance Company of Kansas, Inc. WC 00 00 01 A WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Insured: OneTurn, LLC Policy Number: KWC1119313 EXTENSION OF INFORMATION PAGE ENDORSEMENT SCHEDULE Form Number Description WC000000C DECLARATIONS COVER LETTER WC000001A DECLARATIONS PAGE WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT WC000404 PENDING RATE CHANGE ENDORSEMENT WC000406A PREMIUM DISCOUNT ENDORSEMENT WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT WC000419 PREMIUM DUE DATE ENDORSEMENT WC000421D CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT WC000422B TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT WC000424 AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT WC000425 EXPERIENCE RATING MODIFICATION FACTOR REVISION ENDORSEMENT WC350302 OKLAHOMA EMPLOYERS LIABILITY AMENDED COVERAGE ENDORSEMENT WC350303 OKLAHOMA EMPLOYERS LIABILITY INTENTIONAL TORT EXCLUSION ENDORSEMENT WC350601F OKLAHOMA CANCELLATION, NONRENEWAL AND CHANGE ENDORSEMENT WC350603 OKLAHOMA FRAUD WARNING ENDORSEMENT WC350604 OKLAHOMA ELECTION OF COVERAGE NOTIFICATION ENDORSEMENT WcOkLc OK LOSS CONTROL NOTICE TO POLICYHOLDER WcOkLc1 OK LOSS CONTROL NOTICE TO POLICYHOLDERS 0 3632 241,371 Premium to Equal Increased Limits Minimum Charge 9848 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 Ed. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLIC In return for the payment of the premium and subject to PART ONE all terms of this policy, we agree with you as follows: WORKERS COMPENSATION INSURANCE How This Insurance Applies GENERAL SECTION This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. The Policy Bodily injury includes resulting death. This policy includes at its effective date the Info Bodily injury by accident must occur during the mation Page and all endorsements and schedules policy period. listed there. It is a contract of insurance between Bodily injury by disease must be caused or a you (the employer named in Item 1 of the Info gravated by the conditions of your employment. mation Page) and us (the insurer named on the I The employee’s last day of last exposure to the formation Page). The only agreements relating to conditions causing or aggravating such bodily i this insurance are stated in this policy. The terms of jury by disease must occur during the policy this policy may not be changed or waived except period. by endorsement issued by us to be part of this policy. We Will Pay We will pay promptly when due the benefits required Who is Insured of you by the workers compensation law. You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a We Will Defend partnership, and if you are one of its partners, you are insured, but only in your capacity as an e We have the right and duty to defend at our e pense ployer of the partnership’s employees. any claim, proceeding or suit against you for ben fits payable by this insurance. We have the right to i vestigate and settle these claims, proceedings or Workers Compensation Law suits. Workers Compensation Law means the workers or We have no duty to defend a claim, proceeding or workmen’s compensation law and occupational suit that is not covered by this insurance. disease law of each state or territory named in Item 3.A. of the Information Page. It includes any We Will Also Pay amendments to that law which are in effect during the policy period. It does not include any federal We will also pay these costs, in addition to other workers or workmen’s compensation law, any fe amounts payable under this insurance, as part of eral occupational disease law or the provisions of any claim, proceeding or suit we defend: any law that provide nonoccupational disability easonable expenses incurred at our request, benefits. but not loss of earnings; remiums for bonds to release attachments and State for appeal bonds in bond amounts up to the State means any state of the United States of amount payable under this insurance; America, and the District of Columbia. itigation costs taxed against you; nterest on a judgment as required by law until Locations we offer the amount due under this insurance; This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers xpenses we incur. all other workplaces in Item 3.A. states unless you have other insurance or are self insured for such Other Insurance workplaces. We will not pay more than our share of benefits and costs covered by this insurance and other 1 of 6 Copyright 20 National Council on Compensation Insurance, Inc. All Rights Reser WC 00 00 00 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Ed. 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 enefits payable by this insurance; the loss is paid. If any insurance or sel insurance pecial taxes, payments into security or ot is exhausted, the shares of all remaining insurance er special funds, and assessments pay ble will be equal until the loss is paid. 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 statement to conform to that law. the benefits regularly provided by the workers Nothing in these paragraphs relieves you of your d compensation law including those required ties under this policy. because: f your serious and willful misconduct; ou knowingly employ an employee in violation PART TWO of law; EMPLOYERS LIABILITY INSURANCE ou fail to comply with a health or safety law or regulation; or How This Insurance Applies ou discharge, coerce or otherwise discrimi This employers liability insurance applies to bodily against any employee in violation of the workers injury by accident or bodily injury by disease. Bodily compensation law. injury includes resulting death. If we make any payments in excess of the benefits The bodily injury must arise out of and in the regularly provided by the workers compensation course of the injured employee’s employment by law on your behalf, you will reimburse us promptly. you. The employment must be necessary or inc dental to your work in a state or territory listed in Recovery From Others Item 3.A. of the Information Page. We have your rights, and the rights of persons ent Bodily injury by accident must occur during the tled to the benefits of this insurance, to recover our policy period. payments from anyone liable for the injury. You will do everything necessary to protect those rights for Bodily injury by disease must be caused or a us and to help us enforce them. gravated by the conditions of your employment. The employee’s last day of last exposure to the conditions causing or aggravating such bodily i Statutory Provisions jury by disease must occur during the policy These statements apply where they are required by period. law. If you are sued, the original suit and any related As between an injured worker and us, we have legal actions for damages for bodily injury by a notice of the injury when you have notice. cident or by disease must be brought in the Your default or the bankruptcy or insolvency of United States of America, its territories or po you or your estate will not relieve us of our d sessions, or Canada. ties under this insurance after an injury occurs. We are directly and primarily liable to any pe We Will Pay son entitled to the benefits payable by this i We will pay all sums that you legally must pay as surance. Those persons may enforce our duties; damages because of bodily injury to your emplo so may an agency authorized by law. Enforc ees, provided the bodily injury is covered by this ment may be against us or against you and us. Employers Liability Insurance. Jurisdiction over you is jurisdiction over us for The damages we will pay, where recovery is permi purposes of the workers compensation law. We ted by law, include damages: are bound by decisions against you under that For which you are liable to a third party by re law, subject to the provisions of this policy that on of a claim or suit against you by that third are not in conflict with that law. party to recover the damages claimed against This insurance conforms to the parts of the 2 of 6 Copyright 20 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 Ed. such third party as a result of injury to your Bodily injury to any person in work subject to the ployee; Federal Employers’ Liability Act (45 U For care and loss of services; tions 51 et seq.), any other federal laws obliga ing an employer to pay damages to an emplo ee For consequential bodily injury to a spouse, due to bodily injury arising out of or in the course child, parent, brother or sister of the injured e of employment, or any amendments to those ployee; provided that these damages are the d laws rect cons quence of bodily injury that arises out of and in the course of the injured employee’s Bodily injury to a master or member of the crew employment by you; and of any vessel, and does not cover punitive da ages related to your duty or obligation to provide Because of bodily injury to your employee that transportation, wages, maintenance, and cure arises out of and in the course of employment, under any applicable maritime law; claimed against you in a capacity other than as employer. Fines or penalties imposed for violation of fede al or state law; and Exclusions Damages payable under the Migrant and Se This insurance does not cover: sonal Agricultural Worker Protection Act (29 Sections 1801 et seq.) and under any Liability assumed under a contract. This excl other federal law awarding damages for violation sion does not apply to a warranty that your work of those laws or regulations issued thereunder, will be done in a workmanlike manner; and any amen ments to those laws. Punitive or exemplary damages because of bod ly injury to an employee employed in viol tion of We Will Defend law; We have the right and duty to defend, at our e Bodily injury to an employee while employed in pense, any claim, proceeding or suit against you for violation of law with your actual knowledge or the damages payable by this insurance. We have the actual knowledge of any of your executive offi right to investigate and settle these claims, procee ers; ings and suits. Any obligation imposed by a workers compens We have no duty to defend a claim, proceeding or tion, occupational disease, unemployment co suit that is not covered by this insurance. We have pensation, or disability benefits law, or any sim no duty to defend or continue defending after we lar law; have paid our applicable limit of liability under this Bodily injury intentionally caused or aggravated insurance. by you; Bodily injury occurring outside the United States We Will Also Pay America, its territories or possessions, and da. This exclusion does not apply to bodily We will also pay these costs, in addition to other injury to a citizen or resident of the United States amounts payable under this insurance, as part of of Amer ca or Canada who is temporarily outside any claim, proceeding, or suit we defend: these countries; Reasonable expenses incurred at our request, Damages arising out of coercion, criticism, d but not loss of earnings; motion, evaluation, reassignment, discipline, Premiums for bonds to release attachments and defamation, harassment, humiliation, discrimin for appeal bonds in bond amounts up to the limit tion against or termination of any employee, or of our liability under this insurance; any personnel practices, policies, acts or omi Litigation costs taxed against you; sions; Interest on a judgment as required by law until Bodily injury to any person in work subject to th we offer the amount due under this insurance; Longshore and Harbor Workers’ Compensation Act (33 U Sections 901 et seq.), the No propriated Fund Instrumentalities Act (5 Expenses we incur. Sections 8171 et seq.), the Outer Continental Shelf Lands Act (43 U Sections 1331 seq.), the Defense Base Act (42 U tions 1654), the Federal Mine Safety and Health Act (30 U Sections 801 et seq. and 901 ), any other federal workers or workmen’s compensation law or other federal occupational disease law, or any amendments to these laws; 3 of 6 Copyright 20 National Council on Compensation Insurance, Inc. All Rights Reserved WC 00 00 00 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Ed. 1 Other Insurance The amount you owe has been determined with We will not pay more than our share of damages our consent or by actual trial and final judgment. and costs covered by this insurance and other i This insurance does not give anyone the right to add surance or self insurance. Subject to any limits of l us as a defendant in an action against you to dete ability that apply, all shares will be equal until the mine your liability. The bankruptcy or insolvency of loss is paid. If any insurance or self surance is e you or your estate will not relieve us of our oblig hausted, the shares of all remaining insurance and tions under this Part. self insurance will be equal until the loss is paid PART THREE Limits of Liability OTHER STATES INSURANCE Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.B. of the Information How This Insurance Applies Page. They apply as explained below. This other states insurance applies only if one or Bodily Injury by Accident. The limit shown for more states are shown in Item 3.C. of the Info bodily injury by accident each accident” is the tion Page. most we will pay for all damages covered by this If you begin work in any one of those states after insurance because of bodily injury to one or the effective date of this policy and are not i more employees in any one accident. sured or are not self insured for such work, all A disease is not bodily injury by accident unless provisions of the policy will apply as though that it results directly from bodily injury by accident. state were listed in Item 3.A. of the Information Bodily Injury by Disease. The limit shown for Page. bodily injury by disease policy limit” is the We will reimburse you for the benefits required most we will pay for all damages covered by this by the workers compensation law of that state if insurance and arising out of bodily injury by di we are not permitted to pay the benefits directly ease, regardless of the number of employees to persons entitled to them. who sustain bodily injury by disease. The limit If you have work on the effective date of this po shown for “bodily injury by disease each e icy in any state not listed in Item 3.A. of the I oyee” is the most we will pay for all damages formation Page, coverage will not be afforded for because of bodily injury by disease to any one that state unless we are notified within thirty employee. days. Bodily injury by disease does not include di ease that results directly from a bodily injury by Notice accident. Tell us at once if you begin work in any state listed in We will not pay any claims for damages after we Item 3.C. of the Information Page have paid the applicable limit of our liability u der this insurance. PART FOUR YOUR DUTIES IF INJURY OCCURS Recovery From Others We have your rights to recover our payment from Tell us at once if injury occurs that may be covered anyone liable for an injury covered by this insurance. by this policy. Your other duties are listed here. You will do everything necessary to protect those Provide for immediate medical and other se rights for us and to help us enforce them. vices required by the workers compensation law. Give us or our agent the names and addresses Actions Against Us of the injured persons and of witnesses, and There will be no right of action against us under this other information we may need. insurance unless: Promptly give us all notices, demands and legal You have complied with all the terms of this pol ; and 4 of 6 Copyright National Council on Compensation Insurance, Inc. All Rights Reserved WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 Ed. 1 papers related to the injury, claim, procee ing Premium Payments or suit. You will pay all premium when due. You will pay the Cooperate with us and assist us, as we may r premium even if part or all of a workers compens quest, in the investigation, settlement or defense tion law is not valid. of any claim, proceeding or suit. Do nothing after an injury occurs that would i Final Premium terfere with our right to recover from others. The premium shown on the Information Page, Do not voluntarily make payments, assume obl schedules, and endorsements is an estimate. The gations or incur expenses, except at your own final premium will be determined after this policy st. ends by using the actual, not the estimated, prem um basis and the proper classifications and rates that lawfully apply to the business and work covered PART FIVE by this policy. If the final premium is more than the PREMIUM premium you paid to us, you must pay us the ba ance. If it is less, we will refund the balance to you. Our Manuals The final premium will not be less than the highest All premium for this policy will be determined by our minimum premium for the classifications covered by manuals of rules, rates, rating plans and classific this pol cy. tions. We may change our manuals and apply the If this policy is canceled, final premium will be d changes to this policy if authorized by law or a go termined in the following way unless our manuals ernmental agency regulating this insurance. provide otherwise: If we cancel, final premium will be calculated pro Classifications rata based on the time this policy was in force. Item 4 of the Information Page shows the rate and Final premium will not be less than the pro rata premium basis for certain business or work classif share of the minimum premium. cations. These classifications were assigned based If you cancel, final premium will be more than on an estimate of the exposures you would have pro rata; it will be based on the time this policy during the policy period. If your actual exposures are was in force, and increased by our short rate not properly described by those classifications, we cancelation table and procedure. Final premium will assign proper classifications, rates and premium will not be less than the minimum premium. basis by endorsement to this policy. Remuneration You will keep records of information needed to co Premium for each work classification is determined pute premium. You will provide us with copies of by multiplying a rate times a premium basis. Rem those records when we ask for them. neration is the most common premium basis. This premium basis includes payroll and all other rem neration paid or payable during the policy period for Audit the services of: You will let us examine and audit all your records that relate to this policy. These records include led ll your officers and employees engaged in work ers, journals, registers, vouchers, contracts, tax r covered by this policy; and ports, payroll and disbursement records, and pr ll other persons engaged in work that could grams for storing and retrieving data. We may co make us liable under Part One (Workers Co duct the audits during regular business hours during pensation Insurance) of this policy. If you do not the policy period and within three years after the po have payroll records for these persons, the co icy period ends. Information developed by audit will tract price for their services and materials may be used to determine final premium. Insurance rate be used as the premium basis. This paragraph 2 service organizations have the same rights we have will not apply if you give us proof that the e under this provision. ployers of these persons lawfully secured their workers compensation obligations. 5 of 6 Copyright 20 National Council on Compensation Insurance, Inc. All Rights Reserved WC 00 00 00 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Ed. If you die and we receive notice within thirty days a PART SIX ter your death, we will cover your legal represent tive as insured. CONDITIONS Inspection Cancelation We have the right, but are not obliged to inspect You may cancel this policy. You must mail or d your workplaces at any time. Our inspections are not liver advance written notice to us stating when fety inspections. They relate only to the insurabi the cancelation is to take effect. ity of the workplaces and the premiums to be We may cancel this policy. We must mail or d charged. We may give you reports on the conditions liver to you not less than ten days advance wri we find. We may also recommend changes. While ten notice stating when the cancelation is to take they may help reduce losses, we do not undertake fect. Mailing that notice to you at your mailing to perform the duty of any person to provide for the address shown in Item 1 of the Information Page health or safety of your employees or the public. We will be sufficient to prove notice. do not warrant that your workplaces are safe or The policy period will end on the day and hour healthful or that they comply with laws, regulations, stated in the cancelation notice. codes or standards. Insurance rate service organiz tions have the same rights we have under this Any of these provisions that conflict with a law provision. that controls the cancelation of the insurance in this policy is changed by this statement to co ply with the law. Term Policy If the policy period is longer than one year and Sole Representative days, all provisions of this policy will apply as though a new policy were issued on each annual The insured first named in Item 1 of the Information annive sary that this policy is in force. Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancelation. Transfer of Your Rights and Duties Your rights or duties under this policy may not be transferred without our written consent. 6 of 6 Copyright 20 National Council on Compensation Insurance, Inc. All Rights Reserved AmTrust Insurance Company of Kansas, Inc. WC 00 00 01 A WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Insured: OneTurn, LLC Policy Number: KWC1119313 PAYMENT SCHEDULE Payment Premium Surcharge Due Date Description Fees Total Due 2/22/2018 Downpayment $748.00 $0.00 $0.00 $748.00 3/31/2018 Installment 1 of 9 $747.00 $0.00 $0.00 $747.00 4/30/2018 Installment 2 of 9 $747.00 $0.00 $0.00 $747.00 5/31/2018 Installment 3 of 9 $747.00 $0.00 $0.00 $747.00 6/30/2018 Installment 4 of 9 $747.00 $0.00 $0.00 $747.00 7/31/2018 Installment 5 of 9 $747.00 $0.00 $0.00 $747.00 8/31/2018 Installment 6 of 9 $747.00 $0.00 $0.00 $747.00 9/30/2018 Installment 7 of 9 $747.00 $0.00 $0.00 $747.00 10/31/2018 Installment 8 of 9 $747.00 $0.00 $0.00 $747.00 11/30/2018 Installment 9 of 9 $747.00 $0.00 $0.00 $747.00 Totals $7,471.00 $0.00 $0.00 $7,471.00 Your Installments will be billed in 9 invoices based on the Schedule above. Payment of each Installment is due to the Company on or before the due date indicated. You will receive an installment invoice for each of the Installments shown above. No invoice will be sent for the Downpayment. To avoid cancellation of your coverage, please make sure that our payment is received by the specified due date. The company may process a Notice of Cancellation if payment is not received by the Company on or before the due date. Postmark is not sufficient. If your check is returned by the bank for insufficient funds or for any reason, a Notice of Cancellation will be immediately processed and an Nsf fee of $25 will be charged. If your policy cancels for late payment or because of an item returned by the bank, you may be assessed a Reinstatement Fee of $25 to reinstate your coverage. All payments received will first be applied to fees assessed against the account and then to premium due. Checks should be made payable to Amtrust North America, Inc. and can be mailed to: Amtrust North America, Inc. P.O. Box 6939 Cleveland, OH 44101-1939 Do not mail certified, overnight, or express mail to our P.O. Box. Any such mail can be sent to: Amtrust North America, Inc. 800 Superior Avenue East, 21st Floor Cleveland, OH 44114 Printed: 1/29/2018 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 08 (Ed. 4 84) PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT The policy does not cover bodily injury to any person described in the Schedule. The premium basis for the policy does not include the remuneration of such persons. You will reimburse us for any payment we must make because of bodily injury to such persons. Schedule Partners Officers Others Chad Turner Cody Turner Lonnie Smith This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement Effective 2/22/2018 Policy No. KWC1119313 Endorsement No. Insured OneTurn, LLC Premium $7,471 Insurance Company AmTrust Insurance Company of Kansas, Inc. Countersigned by 1999 National Council on Compensation Insurance. Endorsement Effective 2/22/2018 Policy No. KWC1119313 Endorsement No. 0 Premium $ 7471 $10,000 $190,000 $1,550,000 10.9% 12.6% 2. Average percentage discount: 3.7 % 3. Other policies: 4. If there are no entries in Items 1, 2 and 3 of the Schedule, see the Premium Discount Endorsement attached to Endorsement Effective 2/22/2018 P