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Information Page, coverage will not be afforded for B. Notice <br /> that state unless we are notified within thirty days. Tell us at once if you begin work in any state listed in <br /> Item 3.C. of the Information Page. <br /> PART FOUR -YOUR DUTIES IF INJURY OCCURS <br /> Tell us at once if injury occurs that may be covered by 4. Cooperate with us and assist us, as we may <br /> this policy. Your other duties are listed here. request, in the investigation, settlement or <br /> 1 Provide for immediate medical and other services defense of any claim, proceeding or suit. <br /> required by the workers compensation law. 5. Do nothing after an injury occurs that would <br /> 2. Give us or our agent the names and addresses of interfere with our right to recover from others. <br /> the injured persons and of witnesses, and other 6. Do not voluntarily make payments, assume <br /> information we may need. obligations or incur expenses, except at your own <br /> 3. Promptly give us all notices, demands and legal cost. <br /> papers related to the injury, claim, proceeding or <br /> suit. <br /> PART FIVE v PREMIUM <br /> A. Our Manuals 2. all other persons engaged in work that could <br /> All premium for this policy will be determined by our make us liable under Part One (Workers <br /> manuals of rules, rates, rating plans and Compensation Insurance) of this policy. If you do <br /> classifications. We may change our manuals and not have payroll records for these persons, the <br /> apply the changes to this policy if authorized by law or contract price for their services and materials <br /> a governmental agency regulating this insurance. may be used as the premium basis. This <br /> paragraph 2 will not apply if you give us proof <br /> B. Classifications that the employers of these persons lawfully <br /> Item 4 of the Information Page shows the rate and secured their workers compensation obligations. <br /> premium basis for certain business or work D. Premium Payments <br /> classifications. These classifications were assigned <br /> based on an estimate of the exposures you would You will pay all premium when due. You will pay the <br /> have during the policy period. If your actual premium even if part or all of a workers <br /> exposures are not properly described by those compensation law is not valid. <br /> classifications, we will assign proper classifications, E. Final Premium <br /> rates and premium basis by endorsement to this The premium shown on the Information Page, <br /> policy. schedules, and endorsements is an estimate. The <br /> C. Remuneration final premium will be determined after this policy ends <br /> Premium for each work classification is determined by by using the actual, not the estimated, premium basis <br /> multiplying a rate times a premium basis. and the proper classifications and rates that lawfully <br /> Remuneration is the most common premium basis. apply to the business and work covered by this <br /> This premium basis includes payroll and all other <br /> policy. If the final premium is more than the premium <br /> you paid to us, you must pay us the balance. If it is <br /> remuneration paid or payable during the policy period less, we will refund the balance to you. The final <br /> for the services of: premium will not be less than the highest minimum <br /> 1. All your officers and employees engaged in work premium for the classifications covered by this policy. <br /> covered by this policy; and <br /> Form WC 00 00 00 C Printed in U.S.A. Page 5 of 6 <br />