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InformationPage,coeragewillnoteaffordedfor C/Opujdf <br />tat state nless we are notified witin tirty days. <br />Tellsatonceifyoeginworinanystatelistedin <br />Item 3.C. of te Information Page. <br />QBSU!GPVS!.!ZPVS!EVUJFT!JG!JOKVSZ!PDDVST <br />Tellsatonceifinryoccrstatmayecoeredy4.Cooperatewitsandassists,aswemay <br />tis policy.Yor oter dties are listed ere.reest,inteinestigation,settlementor <br />defense of any claim, proceeding or sit. <br />1.Proideforimmediatemedicalandoterserices <br />reired y te worers compensation law..Donotingafteraninryoccrstatwold <br />interfere wit or rigt to recoer from oters. <br />2.Giesororagenttenamesandaddressesof <br />teinredpersonsandofwitnesses,andoter6.Donotolntarilymaepayments,assme <br />information we may need.oligationsorincrepenses,eceptatyorown <br />cost. <br />3.Promptlygiesallnotices,demandsandlegal <br />papersrelatedtoteinry,claim,proceedingor <br />sit. <br />QBSU!GJWF!.!QSFNJVN <br />B/Pvs!Nbovbmt 2.alloterpersonsengagedinwortatcold <br />maeslialenderPartOneWorers <br />Allpremimfortispolicywilledeterminedyor <br />CompensationInsranceoftispolicy.Ifyodo <br />manalsofrles,rates,ratingplansand <br />notaepayrollrecordsfortesepersons,te <br />classifications.Wemaycangeormanalsand <br />contractpriceforteirsericesandmaterials <br />applytecangestotispolicyifatoriedylawor <br />mayesedastepremimasis.Tis <br />a goernmental agency reglating tis insrance. <br />paragrap2willnotapplyifyogiesproof <br />C/Dmbttjgjdbujpot <br />tatteemployersoftesepersonslawflly <br />Item4ofteInformationPagesowsterateand <br />secred teir worers compensation oligations. <br />premimasisforcertainsinessorwor <br />E/Qsfnjvn!Qbznfout <br />classifications.Teseclassificationswereassigned <br />Yowillpayallpremimwende.Yowillpayte <br />asedonanestimateofteeposresyowold <br />premimeenifpartorallofaworers <br />aedringtepolicyperiod.Ifyoractal <br />compensation law is not alid. <br />eposresarenotproperlydescriedytose <br />classifications,wewillassignproperclassifications,F/Gjobm!Qsfnjvn <br />ratesandpremimasisyendorsementtotis <br />TepremimsownonteInformationPage, <br />policy. <br />scedles,andendorsementsisanestimate.Te <br />D/Sfnvofsbujpo finalpremimwilledeterminedaftertispolicyends <br />ysingteactal,notteestimated,premimasis <br />Premimforeacworclassificationisdeterminedy <br />andteproperclassificationsandratestatlawflly <br />mltiplyingaratetimesapremimasis. <br />applytotesinessandworcoeredytis <br />Remneration is te most common premim asis. <br />policy.Iftefinalpremimismoretantepremim <br />Tispremimasisincldespayrollandalloter <br />yopaidtos,yomstpaystealance.Ifitis <br />remnerationpaidorpayaledringtepolicyperiod <br />less,wewillrefndtealancetoyo.Tefinal <br />for te serices of <br />premimwillnotelesstanteigestminimm <br />1.Allyorofficersandemployeesengagedinwor <br />premim for te classifications coered y tis policy. <br />coered y tis policy and <br />Gpsn!XD!11!11!11!D Printed in .S.A.Qbhf6!pg7 <br /> <br />