Laserfiche WebLink
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) <br />PREMIUM ENDORSEMENT <br />Policy Number: 59 WEC AC9055 Endorsement Number: <br />Effective Date: 07/03/20 Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address: BAY SPROUTS LLC <br />655 S MAIN ST STE 200-317 <br />ORANGE CA 92868 <br />This endorsement is notification that your insurance <br />carrier is charging premium to cover the losses that <br />may occur in the event of a Catastrophe (other than <br />Certified Acts of Terrorism) as that term is defined <br />below. Your policy provides coverage for workers <br />compensation losses caused by a Catastrophe (other <br />than Certified Acts of Terrorism). This premium <br />charge does not provide funding for Certified Acts of <br />Terrorism contemplated under the Terrorism Risk <br />Insurance Program Reauthorization Act Disclosure <br />Endorsement (WC 00 04 22 B), attached to this <br />policy. <br />For purposes of this endorsement, the following <br />definitions apply: <br />o Catastrophe (other than Certified Acts of <br />Terrorism): Any single event, resulting from an <br />Earthquake, Noncertified Act of Terrorism, or <br />Catastrophic Industrial Accident, which results in <br />aggregate workers compensation losses in <br />excess of $50 million. <br />o Earthquake: The shaking and vibration at the <br />surface of the earth resulting from underground <br />movement along a fault plane or from volcanic <br />activity. <br />o Noncertified Act of Terrorism: An event that is not <br />certified as an Act of Terrorism by the Secretary <br />State <br />WI <br />NC <br />AZ <br />of Treasury pursuant to the Terrorism Risk Insurance <br />Act of 2002 (as amended) but that meets all of the <br />following criteria: <br />a. It is an act that is violent or dangerous to human <br />life, property, or infrastructure; <br />b. The act results in damage within the United <br />States, or outside of the United States in the case <br />of the premises of United States missions or air <br />carriers or vessels as those terms are defined in <br />the Terrorism Risk Insurance Act of 2002 (as <br />amended); and <br />c. It is an act that has been committed by an <br />individual or individuals as part of an effort to <br />coerce the civilian population of the United States <br />or to influence the policy or affect the conduct of <br />the United States Government by coercion. <br />o Catastrophic Industrial Accident: A chemical release, <br />large explosion, or small blast that is localized in <br />nature and affects workers in a small perimeter the <br />size of a building. <br />The premium charge for the coverage your policy <br />provides for workers compensation losses caused by a <br />Catastrophe (other than Certified Acts of Terrorism) is <br />shown in Item 4 of the Information Page or in the <br />Schedule below. <br />Schedule <br />Rate <br />0.010000 <br />0.020000 <br />0.010000 <br />Form WC 00 04 21 D Printed in U.S.A. <br />Process Date: 05/25/20 Policy <br />Premium <br />$0 <br />$48 <br />cF RAMmWmentDMsian <br />REVIEWED & APPROVED BY.- <br />v <br />mwd <br />--� Risk janagement Analyst <br />