BEAN SPROUTS, LLC (2) - Laserfiche WebLink

Home Browse Search

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ARIZONA ALCOHOL- AND DRUG -FREE WORKPLACE PREMIUM CREDIT ENDORSEMENT Policy Number: 59 WEC AC9055 Endorsement Number: Effective Date: 07/03/20 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: BAY SPROUTS LLC 655 S MAIN ST STE 200-317 ORANGE CA 92868 This endorsement applies only to the insurance provided by the policy because Arizona is shown in Item 3.A. of the Policy Information Page. This endorsement provides notice that premium for your policy may be affected by the Arizona Alcohol -and Drug - Free Workplace Premium Credit Program. You may qualify for a 5% premium credit if you have established and maintain a qualifying alcohol- and drug - free workplace program in accordance with Title 23, Chapter 2, Article 14 of Arizona Statutes. We will determine your eligibility for this premium credit after total premium has been paid for the policy period and may be revised at the time your final premium audit is processed. The determination that you have a qualifying program must be made each year that you receive the premium credit. To implement a premium credit program, the following guidelines must be established: 1. Insurers offering the premium credit program may apply a 5% premium credit to qualifying employers. 2. To receive the premium credit, you must: a. Provide a written statement to the insurer prior to or within 30 days after the beginning of the policy effective date each year, certifying that the business has implemented a program meeting the requirements of Title 23, Chapter 2, Article 14. b. At any time during the term of the policy, provide additional information to the insurer, as required, to confirm that a qualifying program has been established and is being maintained. Form WC 02 04 01 C Printed in U.S.A Process Date: 05/25/20 c. Comply with the alcohol and drug testing policy requirements in accordance with Title 23, Chapter 2, Article 14. d. Conduct alcohol and drug testing of prospective employees. e. Conduct alcohol and drug testing of an employee after the employee has been injured. f. Allow us to have access to the alcohol and drug testing results under d. and e. above. 3. The determination that you have established and maintain a qualifying program must be made during each policy term that you receive the premium credit. 4. Your certification and any other information relied upon by the insurer in granting the premium credit must be kept in the insurer's underwriting files and made available to the Department of Insurance upon request. 5. The premium credit may be applied after total premium has been paid for the policy period and may be revised at final audit to the employer's policy. The credit is applicable as a supplement to deviated rates and is applied in a multiplicative manner, after the application of the experience modification, and before the application of the premium discount and expense constant. 6. You must reimburse the premium credit if it is determined that you were not in compliance with the provisions of the program. 7. Minimum premium policies are eligible for this premium credit. 8. Residual market employers are eligible to apply for this premium credit. ew cF RAMwagementDMsian Jy/\'x REVIEWED & APPROVED BY.- V"° Policy E _� R.Wjanagementftalpt