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HomeMy WebLinkAboutFRIDA CINEMA, THE (12),k.mNCE ON FILE N-2019-189-02 -,r:A 6M PROCEED MAR 2 � 2�21 ,.,.IiiVSlirR2ANCE EXPIRES ...;I. Oh COUNCIL SECOND AMENDMENT TO ARTS AND CULTURE Q : CDO (4 ) CTrayv\ ,t)FR ARTIST GRANT PROGRAM AGREEMENT THIS SECOND AMENDMENT TO ARTS AND CULTURE ARTIST GRANT PROGRAM AGREEMENT is made and entered into this 10th day of February, 2021, by and between the City of Santa Ana, a charter city and municipal corporation, organized and existing under the Constitution and laws of the State of California ("City"), and The Frida Cinema ("Grantee"). RECITALS A. City and Grantee entered into Arts and Culture Artist Grant Program Agreement number N-2019-189, dated August 20, 2019, for the purpose of providing grant funding pursuant to the Investing in the Artist Grant Program ("said Agreement"). B. City and Grantee entered into a First Amendment to said Agreement dated July 6, 2020, for the purpose of extending the Term of said Agreement until June 30, 2021. C. In accordance with the terms and conditions of said Agreement, the parties now desire to amend Section 1 — Term, to extend said Agreement until June 30, 2022. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions of said Agreement, except as herein modified, the parties agree as follows: Section 1, Term, shall be amended to read as follows: "This Agreement shall commence on the date first written above and terminate on June 30, 2022, unless terminated earlier in accordance with this Agreement. The term of this Agreement may be extended upon a writing executed by the City Manager and the City Attorney." 2. Except as hereinabove modified, all terms and conditions of said Agreement shall remain in full force and effect. Page 1 of 2 N-2019-189-02 IN WITNESS WHEREOF, the Parties have executed this Second Amendment to Arts and Culture Artist Grant Program Agreement the date and year first above written. ATTEST: CITY OF SANTA ANA \GE u DAISY COME �. �.�jJR KRISTINE RI GE Clerk of the Council City Manager APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney i lr r By: Ryan O. Hodge Assistant City Attorney RECOMMENDED FOR APPROVAL: GRANTEE: -�::z pC , ANC OW Executive Director The Frida Cinema Page 2 of 2 STEVEN A. MENDOZA Executive Director Community Development Agency Francine R. Villareal Dj1e1ygnetl1b,H.."-RV111-1 o rtm 202103.1617 25 54 -07'M A� ®® CERTIFICATE OF LIABILITY INSURANCE O03/04/2021ATE Y) 03104/2021 _-- THIS -CERTIFICATE -IS ISSUED -AS A -MATTER -OF -INFORMATIONS ONLY -AND CONFERSNORIGHTS UPON -THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER KEIR JONES STATE FARM StateFarm 5150 E COLORADO ST LONG BEACH CA 90814 CONTACT MELISSA WRIGHT NAME: PHONE IN Ext, 562-433-5573 ac No:562-433-5574 ADDRESS: MELISSA@KEIRJONES.COM INSURERS AFFORDING COVERAGE NAIC# INSURER A:SIate Farm General Insurance Company 25151 INSURED THE FRIDA CINEMA INSURER B: 25178 305 E 4TH ST STE 100 INSURER C: SANTA ANA CA 92701 INSURER D: INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDLSUBR INSO me POLICY NUMBER 92-E6-S4883 POLICY EFF (MMIDDWnL 12/08/2020 POLICY EXP flMMuDDNYYY)LIMITS 12108/2021 EACH OCCURRENCE $ 2,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I OCCUR yl Y DAMAGE TO RENTED PREMISES Ea occurrence $ 300,000 MED EXP(Any one person) $ 10,000 PERSONAL S ADV INJURY $ 2,000,000 AGGREGATE LIMIT APPLIES PER: POLICY PRO- ECT OC GENERAL AGGREGATE $ 4,000,000 GEN'L X PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ee accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Par accitlenl ( ) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Peraccldent $ Is UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? ❑NIA STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory In NH) If yes, describe under E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS below NON -FOR -PROFIT ORGANIZATION LIABILITY POLICY INCLUDING EMPLOYMENT PRACTICES LIABILITY COVERAGE DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) City of Santa Ana is named as additionally insured on this policy pursuant to written contract, agreement, or memorandum of understanding. Such insurance as afforded by this policy shall be primary, and any insurance carried by the City shall be excess and non-contributory. If we cancel this policy, we will give written notice as least 10 days before the effective date of cancellation if we cancel for nonpayment of premium or 30 days before effective date of cancellation if we cancel for any other reason. CITY OF SANTA ANA RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLAZA 4TH FLR SANTA ANA CA 92701 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD per- Rlsk MMlrg'amraltDMsicm REVIEWED &APPROVED BY: Risk Management Analyst CA Policy No. 92 E6S488 3 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CMP-4860.1 ADDITIONAL INSURED — DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 92 E6S488 3 Named Insured: THE FRIDA CINEMA C/O LOGAN CROW 1901 E 1ST ST APT 532 SANTA ANA CA 92705-4096 Name And Address Of Additional Insured Person Or Organization CITY OF SANTA ANA ATTN RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLZ FL 4 SANTA ANA CA 92701 4058 CMP-4860.1 Page 1 of 2 1. SECTION II — WHO IS AN INSURED of b. If coverage provided to the additional in - SECTION II — LIABILITY is amended to in- sured is required by a contract or agree- clude, as an additional insured, any person or ment, the insurance provided to the organization shown in the Schedule, but only additional insured will not be broader than with respect to liability for "bodily injury", that which you are required by the con - "property damage", or "personal and advertis- tract or agreement to provide for such ad- ing injury' caused, in whole or in part, by: ditional insured; and a. Premises And Ongoing Operations c. If the contract or agreement between you Your acts or omissions or the acts or and the additional insured is governed by omissions of those acting on your behalf: California Civil Code Section 2782 or 2782.05, the insurance provided to the (1) In connection with your premises; or additional insured is the lesser of that (2) In the performance of your ongoing which: operations; or (1) Is allowed for the satisfaction of a de- b. Products —Completed Operations fense or indemnity obligation by Cali - "Your work" performed for that additional fornia Civil Code Section 2782 or insured and included in the "products- 2782.05 for your sole liability; or completed operations hazard". (2) You are required by contract or However, Paragraph 1. above is subject to the agreement to provide for such addi- following: tional insured. a. The insurance afforded to the additional We have no duty to defend or indemnify the insured only applies to the extent permit- additional insured under this endorsement un- ted by law; til a claim or "suit' is tendered to us. O, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission CONTINUED Risk Manageinad Dlv is tan REVIEWED&APPROVEDBY: ®' Ruk Management Analyst 2. Any insurance provided to the additional in- sured shall only apply with respect to a claim made or a "suit' brought for damages for which you are provided coverage. This endorsement shall not increase the ap- plicable Limits Of Insurance shown in the Declarations. 3. With respect to the insurance afforded to the additional insured, the following is added to SECTION II — LIMITS OF INSURANCE: If coverage provided to the additional insured is required by contract or agreement, the most we will pay on behalf of the additional insured will be the lesser of the amount of insurance: a. Required by the contract or agreement; or b. Available under the applicable Limits Of Insurance shown in the Declarations. This endorsement shall not increase the ap- plicable Limits Of Insurance shown in the Declarations. 4. With respect to the insurance afforded to the additional insured, the following is added to Paragraph 3. Duties In The Event Of Occur- rence, Offense, Claim Or Suit of SECTION II — GENERAL CONDITIONS: The additional insured must: a. See to it that we are notified as soon as practicable of an 'occurrence" or an of- fense which may result in a claim. To the extent possible, notice should include: (1) How, when and where the "occur- rence" or offense took place; (2) The names and addresses of any in- jured persons and witnesses; and CMP-4860.1 Page 2 of 2 (3) The nature and location of any injury or damage arising out of the "occur- rence" or offense; b. Tender the defense and indemnity of any claim or "suit' to us and to all other insur- ers who may have insurance potentially available to the additional insured; and c. Agree to make available any other insur- ance the additional insured has for de- fense or damages for which we would provide coverage under SECTION II — LIABILITY. 5. With respect to the insurance afforded the ad- ditional insured, the following replaces SEC- TION II — LIABILITY of Paragraph 7. Other Insurance of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: a. This insurance is primary to and will not seek contribution from any other insur- ance available to the additional insured, provided that the additional insured is a named insured under such other insur- ance. b. Regardless of any agreement between you and the additional insured, this insur- ance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the additional in- sured has been added as an additional in- sured on other policies. There will be no refund of premium in the event this endorsement is cancelled. All other policy provisions apply. CMP-4860.1 1007042 148020 08-26-2014 O, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission. P.IA MOUganent Division REVIEWED & APPROVED BY. ® f+r a R, V:ILvuP ® Risk Management Analyst CA Policy No. 92 E6S488 3 CMP-4787 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CMP4787 WAIVER OF TRANSFER OF RIGHTS OR RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 92 E6S488 3 Named Insured: THE FRIDA CINEMA C/O LOGAN CROW 1901 E 1ST ST APT 532 SANTA ANA CA 92705-4096 Name And Address Of Person Or Organization: CITY OF SANTA ANA ATTN RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLZ FL 4 SANTA ANA CA 92701 4058 The following is added to Paragraph 10.b. of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: We waive any right of recovery we may have against the person or organization shown in the Schedule because of payments we make for injury or damage arising out of: a. Your ongoing operations; or b. "Your work" done under contract with that person or organization and included in the "products - completed operations hazard". This waiver applies only to the person or organization shown in the Schedule. All other policy provisions apply. CMPA787 ©, Copyright, State Farm Mutual Automobile Insurance Company, 2008 1006225 137715.1 11-19-2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Riele Mu'isgement Division q, REmEwED&APmmm8v: ` Risk Management Analyst SAFETY SERVICES Notice to policy recipient: If you are not the person directly responsible for the accident prevention activities for your company, please direct this Safety Services notice to the person that is directly responsible for them. SAFETY IS OUR CONCERN Thank you for purchasing your insurance from one of the writing companies owned or managed by The Travelers Companies, Inc. We appreciate your business and welcome the opportunity to be of service. An important part of that service concerns safety and accident prevention. Travelers Risk Control department has the experience,resources and capabilities to provide a range of safety services, including site surveys, phone consultations, as well as provide access to numerous safety -related materials. We have experience in a variety of industries, some of which include manufacturing, wholesale and retail businesses, service organizations, technology -related business, oil and gas -based business, and the public sector. Following are some examples of available safety services: Accident Prevention — Our staff can help you identify present and potential hazards in your operations, premis- es and equipment, and recommend measures for reduc- ing or eliminating these hazards. Analysis of Accident Causes — Although you investigate and keep records of accidents, we are available to assist if needed. Safety Consultations — Our Consultants can help you with special problems such as ergonomics and human factors. Industrial Hygiene/Health Services — We have the facilities and resources to answer your questions concern- ing job related industrial hygiene/health issues and to measure exposure to industrial hygiene hazards. Safety Literature and Digital Media — We can provide you with top-notch safety -related literature, CDs, DVDs, and videos to assist in your loss control efforts. Also, we can direct you to several vendors who are able to provide additional safety materials, including brochures, pam- phlets and digital media. Safety Training — We offer face-to-face classroom courses, as well as distance learning programs that explore the risks our policyholders face and ways for them to control losses. Return -To -Work Coordination — We can assist you with several aspects of the post injury management process. Please note: For ALL loss control assistance re- quests, please contact your local office directly, which is listed on one of the following pages. These services are available upon request. See the remainder of this document for the Travelers' Risk Control office nearest you. These phone numbers should not be used for questions regarding your policy or claims. SAFETY IS YOUR CONCERN At Travelers, we are committed to doing all we can to help protect your business. As our customer, you have access to hundreds of safety materials specific to industry, size and complexity to help control hazards and reduce risks of illness or injury — with more than 700 focusing on workers' compensation issues Take advantage of the Risk Control website at travelers.com/riskcontrol. Examples of what you will find include: • Safety checklists, sample programs. • You will find hundreds of resources in our Education Center including schedules of live classroom sessions and online webinars — more then 90 training options for workers' compensation alone. • Alerts and newsletters that can be sent directly to you, to stay informed the latest safety trends and regulatory topics. The loss of a key employee due to an injury can serious- ly impact your business. We can help you to understand the types of accidents that may occur in your business and the steps you can take to help prevent them. These resources can help you improve your workplace safety practices. We like to think of it as protection beyond the policy. Contact Us For more information, please visit travelers.com/riskcontrol. WUNT3B16 © 2015 The Travelers Indemnity Company. All rights reserved. RiskMZMgnnodDWion kev E 6 APPRovm BY: Risk Management Analyst Please call these numbers FOR SAFETY SERVICES ONLY For all other inquiries please contact your agent, underwriter or claim representative ALABAMA CALIFORNIA IDAHO Birmingham San Diego Sacramento, CA 3000 Riverchase Galleria 9325 Sky Park Court, Ste. 220 11070 White Rock Rd, Suite 130 Ste. 600 San Diego, CA 92123 Rancho Cordova, CA 95670 Birmingham, AL 35244 Risk Control: (949) 224-5789 Risk Control: (916) 852-5245 (615)660-6036 Claim: (800) 727-3995 Claims: 1-800-238-6214 ALASKA Portland, OR 4000 SW Kruse Place, Suite 100 Lake Oswego, OR 97035 (916)852-5245 ARIZONA Phoenix 2401 W Peoria Ave., Suite 130 Phoenix, AZ 85029 Risk Control: (720) 200-8355 ARKANSAS St. Louis, MO 940 West Port Plaza, Suite 270 St. Louis, MO 63146 Risk Control: (314) 579-B282 CALIFORNIA Diamond Bar 21688 Gateway Center Drive P.O. Box 6512 Diamond Bar, CA 91765-8512 Risk Control: (949) 224-5789 Claims::(909) 612-3000 CALIFORNIA Glendale 655 N. Central Avenue, #1600 Glendale, CA 91203 Risk Control: (949) 224-5789 Claims:(909) 612-3000 CALIFORNIA Irvine 3333 Michelson Dr. City Blvd. W Suite 1000 Irvine, CA 92612 Risk Control: (949) 224-5789 CALIFORNIA Los Angeles 888 South Figueroa St., Ste. 500 Los Angeles, CA 90017 Risk Control: (949) 224-5789 Claims: (909) 612-3000 CALIFORNIA Sacramento 11070 White Rock Road, Suite 130 Rancho Cordova, CA 95670 Risk Control: (916) 852-5245 Claims:(800) 727-3995 CALIFORNIA Walnut Creek 225 Lennon Lane, Ste. 105 P.O. Box 8090 Walnut Creek, CA 94596-8090 Risk Control: (925) 945-4193 Claims: (800) 842-7354 COLORADO Denver 6060 S. Willow Dr. #300 Greenwood Village, CO 80111 (720)200-8355 Claims: 720-200-8100 CONNECTICUT Hartford 300 Windsor Street Hartford, CT 06120 (860)277-5748 Claims: 1 (877) 828-4110 DELAWARE Philadelphia, PA 10 Sentry Parkway, Suite 300 Blue Bell, PA 19422 (215)274-1610 Claims: 1-800-368-3562 DISTRICT OF COLUMBIA Washington, DC 14200 Park Meadow Dr. Chantilly, VA 20151 (571)287-6285 Claims: 1-800-368-3562 FLORIDA Orlando 2420 Lakemont Dr Orlando, FL 32814 (678) 317-8210 Claims: 407-388-2400 GEORGIA Atlanta 1000 Windward Concourse Alpharetta, GA 30005 (678) 317-8210 Claims: 800-238-6214 HAWAII Irvine, CA 3333 Michelson Drive City Blvd. W Suite 1000 Irvine, CA 92612 (949)224-5789 WUNT3B16 © 2015 The Travelers Indemnity Company. All rights reserved. ILLINOIS Chicago 200 North LaSalle Street Suite 2200 Chicago, IL 60601 (630)961-8074 Claims: 800-842-6172 ILLINOIS Naperville 215 Shuman Boulevard P.O. Box 3208 Naperville, IL 60566 (630)961-8074 Claims: 800-842-6172 INDIANA Indianapolis Suite 300 280 East 96th Street Indianapolis, IN 46240 (317)818-0174 Claims: 800-238-6210 IOWA Des Moines 7101 Vista Dr. West Des Moines, IA 50266-9313 (651)-310-7834 Claims: 800-255-5072 KANSAS Kansas City 7465 West 132nd Overland Park, KS 66213 (314)579-8282 KENTUCKY Louisville Suite 150 303 N Hurstbourne Pkwy Louisville, KY 40222 (248)312-7301 Claims: 800-238-5210 LOUISIANA New Orleans 3838 N. Causeway, Suite 2700 Metairie, LA 70002 P.O. Box 61479 New Orleans, LA 70161-1479 (504)832-7562 Claims: 800-842-2556 MAINE Portland, ME 207 Larrabee Road, Suite 3 Westbrook, ME 04092 (207) IS -2091 olio..®_•Ncec�., Rialt Management Div isi m REVIEWED &gqAP'P'`a`�o/v�m� By. F441.6V1 d r„ h+t&wd r `® Risk Management Analyst Please call these numbers FOR SAFETY SERVICES ONLY For all other inquiries please contact your agent, underwriter or claim representative MARYLAND Kansas City NEW YORK Blue Bell, PA St. Louis Albany 10 Sentry Parkway, Suite 300 940 West Port Plaza, Suite 270 900 Watervliet -Shaker Road Blue Bell, PA 19422 St. Louis, MO 63146 Albany, NY 12205 (215)274-1610 (314)579-8282 (315)424-7231 Claims: 1-800-368-3562 Claims: 800-255-5072 Claims: 800-842-2475 MASSACHUSETTS Missouri Workers' NEW YORK Boston Compensation Plan (MWCP) Buffalo 100 Summer Street, Suite 201A 1000 Walnut Street 60 Lakefront Blvd. Boston, MA 02110 Kansas City, MO 64199 P.O. Box 242 (781) 817-8370 (816) 391-1123 Buffalo, NY 14240-0242 Claims: 800-832-7839 (315) 424-7231 Claims: 800-842-2475 MASSACHUSETTS MONTANA NEW YORK Hudson Sacramento, CA Melville 1 Cabot Road 11070 White Rock Rd, Suite 130 3 Huntington Quadrangle Suite 250 Rancho Cordova, CA 95670 Melville, NY 11747 Hudson, MA 01749 Risk Control: (916) 852-5245 (631) 501-8146 (978) 568-4411 Claims: (800) 727-3995 Claims: 800-842-2475 Claims: 800-832-7839 MASSACHUSETTS NEBRASKA NEW YORK Braintree Omaha New York 350 Granite Street 11516 Miracle Hills Dr., St. 400 485 Lexington Ave . Suite 1201 Omaha, NE 68154 New York, NY 10017-2630 Braintree, MA 02184 1651) 310-7834 (516) 933-3932 (781)817-8373 Claims: 800-255-5072 Claims: 1-800-842-2475 Claims: 800-832-7839 MICHIGAN NEVADA NEW YORK Grand Rapids Las Vegas Rochester 625 Kenmoor Ave 7450 Arroyo Crossing Pkwy 75 Town Centre Drive Suite 213 Suite 200 P.O. Box 23235 Grand Rapids, MI 49546 Las Vegas, NV 89113 Rochester, NY 14692-3235 (248) 312-7301 Risk Control: (720) 200-8355 (315) 424-7231 Claims: 800-238-6210 Claims: 702-479-4200 Claims: 1-800-842-2475 MICHIGAN NEW HAMPSHIRE NEW YORK Troy Portland, ME Syracuse 1301 W. Long Lake Rd., Ste. 300 207 Larrabee Road, Suite 3 440 South Warren Street Troy, MI 48098 Westbrook, ME 04092 P.O. Box 4963 (248) 312-7301 1207) 857-2021 Syracuse, NY 13221-4963 Claims: 800-238-6210 (315) 424-7231 Claims: 800-842-2475 MINNESOTA NEW JERSEY NORTH CAROLINA St. Paul Morristown Charlotte 385 Washington St., MC 104P 445 South Street 11440 Carmel Commons Blvd. St. Paul, MN 55102 Morristown, NJ 07960 P.O. Box 473500 (651)310-7834 (973)631-7015 Charlotte, NC 28247-3500 Claims: 800-842-3073 Claims: 1-800-842-2475 (704) 540-3209 Claims: (704) 544-3500 MISSISSIPPI NEW JERSEY NORTH CAROLINA Jackson Marlton Raleigh 1080 River Oaks Or Lake Center Exec Park Building 30 4504 Emperor Blvd. Ste B-200 Suite 110 Durham, NC 27703 Flowood, MS 39232 Marlton, NJ 08053 (704) 540-3209 (615) 660-6036 (856) 703-2323 Claims: (704) 544-3500 Claims: 1-800-342-4064 Claims: 800-842-2475 MISSOURI St. Louis 940 West Port Plaza, Suite 270 St. Louis, MO 63146 (314)579-8282 Claims: B00-842-9621 NEW MEXICO Phoenix 2401 W Peon Ave., Suite 130 Phoenix, AZ 85029 (720)200-8355 Claims: 602-861-8600 WUNT3B16 © 2015 The Travelers Indemnity Company. All rights reserved. NORTH DAKOTA St. Paul, MN 385 Washington St., MC 104P St. Paul, MN 55102 (651)310-7834 ClainN RiekMvugonartDlvision REVIEWED&APPROVED BY: F.c.t.: Jz. V1.1 Risk Management Malys[ Please call these numbers FOR SAFETY SERVICES ONLY For all other inquiries please contact your agent underwriter or claim representative OHIO Cincinnati Baldwin Center, Suite 500 625 Eden Park Drive Cincinnati, OH 45202(412) 338-3069 Claims: 800-238-6210 OHIO Cleveland 6150 Oak Tree Blvd., Suite 400 Independence, OH 44131 (412)338-3069 Claims: 800-238-6210 OKLAHOMA Tulsa 9820 East 41 st St., Suite 401 P.O Box 3510 Tulsa, OK 74101 (314)579-8282 OREGON Portland 4000 SW Kruse Place, Suite 100 Lake Oswego, OR 97035 Risk Control: (916) 852-5245 Claims: 800-698-6883 PENNSYLVANIA Philadelphia 10 Sentry Parkway, Suite 300 Blue Bell, PA 19422 (215)274-1610 Claims: 800-832-0606 PENNSYLVANIA Pittsburgh 800 Two Chatham Center Pittsburgh, PA 15219-2505 (412) 338-3069 Claims:(412) 338-3000 PENNSYLVANIA Reading 1105 Berkshire Blvd. P.O. Box 13426 Wyomissing, PA 19612-3426 (215)274-1610 Claims: 800-832-0606 RHODE ISLAND Braintree 350 Granite Street Suite 1201 Braintree, MA 02184 (781)817-8370 Claims: 800-832-7839 SOUTH CAROLINA Charlotte 11440 Carmel Commons Blvd. P.O. Box 473500 Charlotte, NC 28247-3500 (704)540-3209 Claims: 704-544-3500 SOUTH DAKOTA St. Paul, MN 385 Washington St. St. Paul, MN 55102 (651)310-7834 Claims: 800-842-3073 TENNESSEE Franklin 6640 Carothers Pkwy, Suite 300 Franklin, TN 37067 (615)660-6036 Claims: (615) 660-6000 TEXAS Dallas 1301 E Collins Blvd., Suite 300 Richardson, TX 75081 (214)570-6627 Claims: 214-570-6000 TEXAS Houston 4650 Westway Park Blvd., Suite 350 Houston, TX 77041 (281)606-8534 Claims: 800-235-3610 UTAH Denver, CO 6060 S. Willow Drive #300 Greenwood Village, CO 80111 (720)200-8355 Claims: 800453-3025 WUNT3B16 © 2015 The Travelers Indemnity Company. All rights reserved. VERMONT Hartford, CT 300 Windsor Street Hartford, CT 06120 (860)954-5190 Claims: (800) 422-3340 VIRGINIA Richmond 9954 Mayland Drive, Suite 6100 Richmond, VA 23233 (571)287-6285 Claims:(804) 330-6000 Washington, DC 14200 Park Meadow Dr. Chantilly, VA 20151 (571)287-6285 Claims: 800-368-3562 WASHINGTON Seattle 1501 4th Avenue, Suite 400 Seattle, WA 98101 Risk Control: (916) 852-5245 WEST VIRGINIA Charleston, WV 119 Virginia St. W . Charleston, WV 25302 (412)338-3069 Claims:(443) 353-1000 WISCONSIN Milwaukee 13935 Bishops Drive, Suite 200 Brookfield, WI 53005 (262)825-9203 Claims: 800-842-6172 WYOMING Denver, CO 6060 S. Willow Drive #300 Greenwood Village, CO 80111 Risk Control: (720) 200-8355 RiskMatugemadDivision /R'EVIEWED 6{�AP1P,ftO��VV�m BY. Rrsk Management Analyst TRAVELERS Report Claims Immediately by Calling* 1-800-238-6225 Speak directly with a claim professional 24 hours a day, 365 days a year *Unless Your Policy Requires Written Notice or Reporting WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY A Custom Insurance Policy Prepared for: THE FRIDA CINEMA 305 E 4TH ST STE 100 SANTA ANA CA 92701 Ride ManagementDWIon REVIE &APPROVED BY: F,w r,:o.a Z VjZVA t ® Risk Management Analyst TRAVELERS) ONE TOWER SQUARE HARTFORD CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: UB-OR3408OA-20-42-G REWRITING UB-BP528867-20-42-G INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA 1 NCCI CO CODE: 13579 INSURED: PRODUCER: THE FRIDA CINEMA METRO COAST INS SRVC LLC 305 E 4TH ST 25950 ACERO STE 345 STE 100 MISSION VIEJO, CA 92691 SANTA ANA, CA 92701 Insured is A CORPORATION Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 03-25-20 to 03-25-21 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: CA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 1,000,000 Each Accident Bodily Injury by Disease: $ 1,000,000 policy Limit Bodily Injury by Disease: $ 1,000,000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: AL AR AZ CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA ND ME MI MN MO MS MT NC WE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI WV D. This policy includes these endorsements and schedules: SEE LISTING OF - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY DATE OFISSUE: 05-11-20 JW OFFICE: BREA/LA/ORANGE CA 189 PRODUCER: METRO COAST INS SRVC LLC DPG66 ..� MakManage""d DMsim y,`g \� RtviE SAPPROVm BY: ® Rbk Management Maly t TRAVELERS ONE TOWER SQUARE HARTFORD CT 06183 CLASSIFICATION SCHEDULE: CLASSIFICATIONS SIC -CODE: 6512 CODE NO WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: UB-OR3408OA-20-42-G PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL REMUNERATION REMUNERATION PREMIUM SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S) NAICS: 531120 STANDARD TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 3759 PREMIUM DISCOUNT NONE 0900-04 EXPENSE CONSTANT 160 TERRORISM 40 TOTAL ESTIMATED PREMIUM 3959 TAXES AND SURCHARGES 134 DEPOSIT AMOUNT DUE 4093 Minimum Premium: $ 500 DATE OF ISSUE: 05-11-20 JW OFFICE: BREA/LA/ORANGE CA 189 PRODUCER: METRO COAST INS SRVC LLC DPG66 COUNTE Riele Managnnait Dnisian REVIEWED & APPROYm BY: �. ® R¢k klanagement Analyst 7RAVELERSJ'' ONE TOWER SQUARE HARTFORD CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE -SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: UB-OR3408OA-20-42-G INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA 072 003 INSURED'S NAME:THE FRIDA CINEMA PREMIUM BASIS ESTIMATED TOTAL ANNUAL CLASSIFICATION CODE REMUNERATION LOCATION 001 FEIN 270950151 ENTITY CD 001 00 THE FRIDA CINEMA 305 E 4TH ST STE 100 SANTA ANA , CA 92701 NAILS: 531120 THEATERS -MOTION PICTURE -ALL 9155 198884.00 EMPLOYEES DATE OF ISSUE:05-11-20 OW SCHEDULEN 13579-CA RATES ESTIMATED PER $100 OF ANNUAL REMUNERATION PREMIUM 1 .89 3759 Risk Manegnnent DMsimt ��/R'enEvrE� &{AP,P,IRIO�V/m BYE: FAFhGvi1 R. Y � Risk Management Analyst TRAVELERS, WORKERS COMPENSATION AND ONE TOWER SQUARE HARTFORD CT 06183 EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE -SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: UB-OR34080A-20-42-G CA MANUAL PREMIUM $ 3759 TOTAL PREMIUM SUBJECT TO EXPERIENCE MOD. $ 3759 EXPERIENCE MODIFICATION:NONE MODIFIED PREMIUM NONE TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 3759 EXPENSE CONSTANT(0900) 160 TERRORISM(9740) 40 TOTAL ESTIMATED PREMIUM 3959 1.704% WC ADMIN REVOLVING FUND ASSESSMENT 67 0.335% STATE FRAUD SURCHARGE 13 0.127% UNINSURED EMPLOYERS BENEFIT TRUST FUND ASST 5 0.482% SUBSEQUENT INJURY BENEFIT TRUST FUND ASST 19 0.391% OCCUPATIONAL SAFETY & HEALTH FUND ASSESSMENT 15 0.381% LABOR ENFORCEMENT & COMPLIANCE FUND ASSESSMENT 15 TOTAL PREMIUM 4093 DEPOSIT AMOUNT DUE 4093 DATE OF ISSUE: 05-11-20 JW SCHEDULE N WdeManagementDMs(an ' REVIEWED&{ PPR�O/VVMBY. F'L4WSN.E R. V' �. '-® Risk Management Analyst �- se TRAVELERS, WORKERS COMPENSATION ONE TOWER SQUARE AND HARTFORD CT 06183 EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 00 00 01 (A) POLICY NUMBER: UB-OR3408OA-20-42-G LISTING OF ENDORSEMENTS EXTENSION OF INFO PAGE We agree that the following listed endorsements form a part of this policy on its effective date. WC 00 00 01 A - 001 WC 00 00 01 A - 001 WC 00 00 01 A - 001 WC 00 00 01 A - 001 WC 00 04 22 B - 001 WC 04 03 01 B - 001 WC 99 03 99 00 - 001 WC 99 03 F3 00 - 001 WC 00 04 21 D - 001 WC 99 04 10 00 - 001 WC 04 03 17 B - 001 WC 04 03 45 A - 001 WC 04 03 60 B - 001 WC 04 04 21 00 - 001 WC 04 04 22 00 - 001 WC 04 06 01 A - 001 INFORMATION PAGE INFORMATION PAGE 2 EXTENSION OF INFORMATION PAGE - SCHEDULE ENDORSEMENT LISTING TERRORISM RISK INS FROG REAUTH ACT ENDT POLICY AMENDATORY ENDORSEMENT-CALIFORNIA CA WORKERS' COMP NOTICE OF NON -RENEWAL CA LIMITS OF LIABILITY ENDT CATASTROPHE (O/T CERT. ACTS OF TERR)ENDT PREMIUM ADJ. FROM EFFECTIVE DATE ENDT. EMPLOYEE INSD BY GENERL EMPLYER EXCLUDED COMPREHENSIVE PERSONAL LIAB POL EXCL EMPLOYERS' LIAR COV AMENDATORY ENDT-CA OPTIONAL PREMIUM INCREASE ENDORSEMENT - CALIFORNIA CALIFORNIA SHORT -RATE CANCELATION ENDT CA CANCELATION ENDT DATE OF ISSUE: 05-11-20 STASSIGN: Page of RlAMknsgmentDMsion RwEWm 6pAPPROVED BY: ®' Rnk Management Analyst WC000000(C) (Ed. 1-15) The Travelers Insurance Companies (Each a Stock Insurance Company) Hartford, Connecticut WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject PART ONE to all terms of this policy, we agree with you as WORKERS COMPENSATION INSURANCE follows: GENERAL SECTION A. The Policy This policy includes at its effective date the In- formation Page and all endorsements and sched- ules listed there. It is a contract of insurance be- tween you (the employer named in Item 1 of the Information Page) and us (the insurer named on the Information Page). The only agreements re- lating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy. B. Who is Insured You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an employer of the partnership's employees. C. Workers Compensation Law Workers Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect dur- ing the policy period. It does not include any fed- eral workers or workmen's compensation law, any federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D. State State means any state of the United States of America, and the District of Columbia. E. Locations This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it cov- ers all other workplaces in Item 3.A. states unless you have other insurance or are self -insured for such workplaces. A. How This Insurance Applies This workers compensation insurance applies to bodily injury by accident or bodily injury by dis- ease. Bodily injury includes resulting death. 1. Bodily injury by accident must occur during the policy period. 2. Bodily injury by disease must be caused or aggravated by the conditions of your em- ployment. The employee's last day of last exposure to the conditions causing or aggra- vating such bodily injury by disease must occur during the policy period. B. We Will Pay We will pay promptly when due the benefits re- quired of you by the workers compensation law. C. We Will Defend We have the right and duty to defend at our ex- pense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to investigate and settle these claims, proceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. D. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend: 1. reasonable expenses incurred at our request, but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this in- surance; and 5. expenses we incur. © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. Rule Management Division v' REv1EWm&APPRovm By: m�m�aarra�q-"a i. Risk Management Analyst E. Other Insurance We will not pay more than our share of benefits and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self- insurance is exhausted, the shares of all remain- ing insurance will be equal until the loss is paid. F. Payments You Must Make You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required be- cause: 1. of your serious and willful misconduct; 2. you knowingly employ an employee in viola- tion of law; 3. you fail to comply with a health or safety law or regulation; or 4. you discharge, coerce or otherwise discrimi- nate against any employee in violation of the workers compensation law. If we make any payments in excess of the bene- fits regularly provided by the workers compensa- tion law on your behalf, you will reimburse us promptly. G. Recovery From Others We have your rights, and the rights of persons entitled to the benefits of this insurance, to re- cover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H. Statutory Provisions These statements apply where they are required by law. 1. As between an injured worker and us, we have notice of the injury when you have no- tice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our duties under this insurance after an injury oc- curs. 3. We are directly and primarily liable to any person entitled to the benefits payable by this insurance. Those persons may enforce our duties; so may an agency authorized by law. Enforcement may be against us or against you and us. WC000000(C) (Ed. 1-15) 4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this pol- icy that are not in conflict with that law. S. This insurance conforms to the parts of the workers compensation law that apply to: a. benefits payable by this insurance; b. special taxes, payments into security or other special funds, and assessments payable by us under that law. 6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. Nothing in these paragraphs relieves you of your duties under this policy. PART TWO EMPLOYERS LIABILITY INSURANCE A. How This Insurance Applies This employers liability insurance applies to bod- ily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or inci- dental to your work in a state or territory listed in Item 3.A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your em- ployment. The employee's last day of last exposure to the conditions causing or aggra- vating such bodily injury by disease must occur during the policy period. 5. If you are sued, the original suit and any re- lated legal actions for damages for bodily in- jury by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. B. We Will Pay We will pay all sums that you legally must pay as damages because of bodily injury to your em- ployees, provided the bodily injury is covered by this Employers Liability Insurance. © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. �/�j�������,, ' liiek Management Division RE\nt D APPRCUMBY: F,,wu Z Mm4,2 R¢k kianagement Matyet The damages we will pay, where recovery is per- mitted by law, include damages: 1. For which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against such third party as a result of injury to your employee; 2. For care and loss of services; and 3. For consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee; provided that these damages are the direct consequence of bodily injury that arises out of and in the course of the injured employee's employment by you; and 4. Because of bodily injury to your employee that arises out of and in the course of em- ployment, claimed against you in a capacity other than as employer. C. Exclusions This insurance does not cover: WC000000(C) (Ed. 1-15) employee, or any personnel practices, poli- cies, acts or omissions; 8. Bodily injury to any person in work subject to the Longshore and Harbor Workers' Com- pensation Act (33 U.S.C. Sections 901 et seq.), the Nonappropriated Fund Instrumen- talities Act (5 U.S.C. Sections 8171 et seq.), the Outer Continental Shelf Lands Act (43 U.S.C. Sections 1331 et seq.), the Defense Base Act (42 U.S.C. Sections 1651-1654), the Federal Mine Safety and Health Act (30 U.S.C. Sections 801 et seq. and 901-944), any other federal workers or workmen's com- pensation law or other federal occupational disease law, or any amendments to these laws; 9. 1. Liability assumed under a contract. This ex- clusion does not apply to a warranty that your work will be done in a workmanlike manner; 10. 2. Punitive or exemplary damages because of bodily injury to an employee employed in vio- lation of law; 3. Bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your execu- tive officers; 4. Any obligation imposed by a workers com- pensation, occupational disease, unemploy- ment compensation, or disability benefits law, or any similar law; S. Bodily injury intentionally caused or aggra- vated by you; 6. Bodily injury occurring outside the United States of America, its territories or posses- sions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 7. Damages arising out of coercion, criticism, demotion, evaluation, reassignment, disci- pline, defamation, harassment, humiliation, discrimination against or termination of any Bodily injury to any person in work subject to the Federal Employers' Liability Act (45 U.S.C. Sections 51 et seq.), any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws; Bodily injury to a master or member of the crew of any vessel, and does not cover puni- tive damages related to your duty or obliga- tion to provide transportation, wages, mainte- nance, and cure under any applicable mari- time law; 11. Fines or penalties imposed for violation of federal or state law; and 12. Damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 U.S.C. Sections 1801 et seq.) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws. D. We Will Defend We have the right and duty to defend, at our ex- pense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceedings and suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. wokn+� ,q: nenenm,�n •g Rt EWED&APPRaVID13r q` Risk Management Analyst E. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding, or suit we defend: 1. Reasonable expenses incurred at our re- quest, but not loss of earnings; 2. Premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance; 3. Litigation costs taxed against you; 4. Interest on a judgment as required by law until we offer the amount due under this in- surance; and 5. Expenses we incur. F. Other Insurance We will not pay more than our share of damages and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insur- ance and self-insurance will be equal until the loss is paid. G. Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.13. of the In- formation Page. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for 'bodily injury by accident — each accident' is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for "bodily injury by disease — policy limit" is the most we will pay for all damages covered by this insurance and arising out of bodily injury by disease, regardless of the number of em- ployees who sustain bodily injury by disease. The limit shown for "bodily injury by disease — each employee" is the most we will pay for all damages because of bodily injury by disease to any one employee. WC000000(C) (Ed. 1-15) Bodily injury by disease does not include dis- ease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liabil- ity under this insurance. H. Recovery From Others We have your rights to recover our payment from anyone liable for an injury covered by this insur- ance. You will do everything necessary to protect those rights for us and to help us enforce them. 1. Actions Against Us There will be no right of action against us under this insurance unless: 1. You have complied with all the terms of this policy; and 2. The amount you owe has been determined with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a defendant in an action against you to determine your liability. The bankruptcy or insol- vency of you or your estate will not relieve us of our obligations under this Part. PART THREE OTHER STATES INSURANCE A. How This Insurance Applies 1. This other states insurance applies only if one or more states are shown in Item 3.C. of the Information Page. 2. If you begin work in any one of those states after the effective date of this policy and are not insured or are not self -insured for such work, all provisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page. 3. We will reimburse you for the benefits re- quired by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have work on the effective date of this policy in any state not listed in Item 3.A. of the Information Page, coverage will not be af- forded for that state unless we are notified within thirty days. © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. RIA Mansgm entDividm ,y Rim & APPRMM By F .: 2. V:Usnut n Risk Management Analyst B. Notice Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. PART FOUR YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be cov- ered by this policy. Your other duties are listed here. 1. Provide for immediate medical and other ser- vices required by the workers compensation law. 2. Give us or our agent the names and ad- dresses of the injured persons and of wit- nesses, and other information we may need. 3. Promptly give us all notices, demands and legal papers related to the injury, claim, pro- ceeding or suit. 4. Cooperate with us and assist us, as we may request, in the investigation, settlement or defense of any claim, proceeding or suit. 5. Do nothing after an injury occurs that would interfere with our right to recover from others. 6. Do not voluntarily make payments, assume obligations or incur expenses, except at your own cost. PART FIVE PREMIUM A. Our Manuals All premium for this policy will be determined by our manuals of rules, rates, rating plans and clas- sifications. We may change our manuals and ap- ply the changes to this policy if authorized by law or a governmental agency regulating this insur- ance. B. Classifications Item 4 of the Information Page shows the rate and premium basis for certain business or work classifications. These classifications were as- signed based on an estimate of the exposures you would have during the policy period. If your actual exposures are not properly described by those classifications, we will assign proper classi- fications, rates and premium basis by endorse- ment to this policy. WC000000(C) (Ed. 1-15) C. Remuneration Premium for each work classification is deter- mined by multiplying a rate times a premium ba- sis. Remuneration is the most common premium basis. This premium basis includes payroll and all other remuneration paid or payable during the policy period for the services of: 1. all your officers and employees engaged in work covered by this policy; and 2. all other persons engaged in work that could make us liable under Part One (Workers Compensation Insurance) of this policy. If you do not have payroll records for these persons, the contract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the employers of these persons lawfully secured their workers com- pensation obligations. D. Premium Payments You will pay all premium when due. You will pay the premium even if part or all of a workers com- pensation law is not valid. E. Final Premium The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, pre- mium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classi- fications covered by this policy. If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise: 1. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. 2. If you cancel, final premium will be more than pro rata; it will be based on the time this pol- icy was in force, and increased by our short - rate cancelation table and procedure. Final premium will not be less than the minimum premium. © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. RbAManagementDivision Revi w & APPROVED BY. Risk Management Analyst F. Records You will keep records of information needed to compute premium. You will provide us with cop- ies of those records when we ask for them. G. Audit You will let us examine and audit all your records that relate to this policy. These records include ledgers, journals, registers, vouchers, contracts, tax reports, payroll and disbursement records, and programs for storing and retrieving data. We may conduct the audits during regular business hours during the policy period and within three years after the policy period ends. Information developed by audit will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provi- sion. PART SIX CONDITIONS A. Inspection We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurability of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any per- son to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or stan- dards. Insurance rate service organizations have the same rights we have under this provision. WC000000(C) (Ed. 1-15) B. Long Term Policy If the policy period is longer than one year and sixteen days, all provisions of this policy will ap- ply as though a new policy were issued on each annual anniversary that this policy is in force. C. Transfer of Your Rights and Duties Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days after your death, we will cover your legal repre- sentative as insured. D. Cancelation 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation is to take effect. 2. We may cancel this policy. We must mail or deliver to you not less than ten days advance written notice stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancelation notice. 4. Any of these provisions that conflict with a law that controls the cancelation of the insur- ance in this policy is changed by this state- ment to comply with the law. E. Sole Representative The insured first named in Item 1 of the Informa- tion Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancelation. IN WITTNESS WHEREOF, the company has caused this policy to be signed by its President and Secre- tary at Hartford, Connecticut and countersigned on the Information page by a duly authorized agent of the company. Secretary © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved, President Risk Mnnegemmt Division REVIEWED S APPROVED BY. �'. ® Risk Management Analyst TRAVELERS, WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 00 04 22 ( B) POLICY NUMBER: UB-OR34080A-20-42-G TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extend- ed by the Terrorism Risk Insurance Program Reauthorization Act of 2015. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, defini- tions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act .If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amend- ments thereto, including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2015. "Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property or infrastructure. c. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss" means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2015, and ending on December 31, 2020, an amount equal to 20% of our direct earned premiums, during the immediately preceding calendar year. Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a calendar year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. Policyholder Disclosure Notice 1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses exceed: a. $100,000,000, with respect to such Insured Losses occurring in calendar year 2015, the United States Gov- ernment would pay 85% of our Insured Losses that exceed our Insurer Deductible DATE OF ISSUE: 05-11-20 ST ASSIGN: © Copyright 2015 National Council on Compensation Insurance, Inc. All Rights Reserved. s. Wi °. `' Risk MaruganadDisuert " Ren D 6 APPROVEDBr g, Rnk Management Analyst TRAVELERS, WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 00 04 22 ( B) POLICYNUMBER: UB-OR340BOA-20-42-c b. $120,000.000, with respect to such Insured Losses occurring in calendar year 2016, the United States Gov- ernment would pay 84% of our Insured Losses that exceed our Insurer Deductible. c. $140,000,000, with respect to such Insured Losses occurring in calendar year 2017, the United States Gov- ernment would pay 83% of our Insured Losses that exceed our Insurer Deductible. d. $160,000,000, with respect to such Insured Losses occurring in calendar year 2018, the United States Gov- ernment would pay 82% of our Insured Losses that exceed our Insurer Deductible. e. $180,000,000, with respect to such Insured Losses occurring in calendar year 2019, the United States Gov- ernment would pay 81 % of our Insured Losses that exceed our Insurer Deductible. f. $200,000,000, with respect to such Insured Losses occurring in calendar year 2020, the United States Gov- ernment would pay 80% of our Insured Losses that exceed our Insurer Deductible. 2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100.000,000,000. 3. The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate Premium This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Premium $ Insurance Company Countersigned by s� RAMa ;';;itDMs[. DATE OF ISSUE: 05-11-20 ST ASSIGN: % REVIEWED&APPROVEDBY © Copyright 2015 National Council on Compensation Insurance, Inc. All Rights Reserved. 99; `AW Rtsk Management Analyst or TRAVELERS/� WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 04 03 01 ( B) POLICYNUMBER: uH-OR3408OA-20-42-G POLICY AMENDATORY ENDORSEMENT - CALIFORNIA It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: 1. Minors Illegally Employed — Not Insured. This policy does not cover liability for additional compensation imposed on you under Section 4557, Division IV, Labor Code of the State of California, by reason of injury to an employee under sixteen years of age and illegally employed at the time of injury. 2. Punitive or Exemplary Damages — Uninsurable. This policy does not cover punitive or exemplary dam- ages where insurance of liability therefor is prohibited by law or contrary to public policy. 3. Increase in Indemnity Payment — Reimbursement. You are obligated to reimburse us for the amount of increase in indemnity payments made pursuant to Subdivision (d) of Section 4650 of the California Labor Code, if the late indemnity payment which gives rise to the increase in the amount of payment is due less than seven (7) days after we receive the completed claim form from you. You are obligated to reimburse us for any increase in indemnity payments not covered under this policy and will reimburse us for any increase in indemnity payment not covered under the policy when the aggregate total amount of the reimbursement payments paid in a policy year exceeds one hundred dollars ($100). If we notify you in writing, within 30 days of the payment, that you are obligated to reimburse us, we will bill you for the amount of increase in indemnity payment and collect it no later than the final audit. You will have 60 days, following notice of the obligation to reimburse, to appeal the decision of the insurer to the Depart- ment of Insurance. 4. Application of Policy. Part One, "Workers Compensation Insurance", A, "How This Insurance Applies", is amended to read as follows: This workers compensation insurance applies to bodily injury by accident or disease, including death result- ing therefrom. Bodily injury by accident must occur during the policy period. Bodily injury by disease must be caused or aggravated by the conditions of your employment. Your employee's exposure to those conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. Rate Changes. The premium and rates with respect to the insurance provided by this policy by reason of the designation of California in Item 3 of the Information Page are subject to change if ordered by the Insurance Commissioner of the State of California pursuant to Section 11737 of the California Insurance Code. 6. Long Term Policy. If this policy is written for a period longer than one year, all the provisions of this policy shall apply separately to each consecutive twelve-month period or, if the first or last consecutive period is less than twelve months, to such period of less than twelve months, in the same manner as if a separate pol- icy had been written for each consecutive period. 7. Statutory Provision. Your employee has a first lien upon any amount which becomes owing to you by us on account of this policy, and in the case of your legal incapacity or inability to receive the money and pay it to the claimant, we will pay it directly to the claimant. 8. Part Five, "Premium", E, "Final Premium", is amended to read as follows: The premium shown on the Information Page, schedules, and endorsements is an estimate. The final pre- mium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund zx Rialk gernentDivieian DATE OF ISSUE: 05-11-20 ST ASSIGN: RE\neurEo&APPRwmer: © 2011 Workers' Compensation Insurance Rating Bureau of California. All rights reserved. Fvw.a.e ♦;, Vw"AI Ruk Management Anayu TRAVELERSAM WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 04 03 01 ( B) POLICYNUMBER: UH-OR3408OA-20-42-G the balance to you. The final premium will not be less than the highest minimum premium for the classifica- tions covered by this policy. If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise: a. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. b. If you cancel, final premium may be more than pro rata; it will be based on the time this policy was in force, and may be increased by our short -rate cancelation table and procedure. Final premium will not be less than the pro rata share of the minimum premium. It is further agreed that this policy, including all endorsements forming a part thereof, constitutes the entire contract of insurance. No condition, provision, agreement, or understanding not set forth in this policy or such endorsements shall affect such contract or any rights, duties, or privileges arising therefrom. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Insured DATE OF ISSUE: 05-11-20 Policy No. Insurance Company ST ASSIGN: Countersigned by © 2011 Workers' Compensation Insurance Rating Bureau of California. All rights reserved. Endorsement No. ss R16MmugmeydDivision ((R''nnI D&APPROVED BY: MAd Rkk Management Analyst TRAVELERS ONE TOWER SQUARE HARTFORD CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 99 03 99 (00) POLICY NUMBER: U13-OR34080A-20-42-G CALIFORNIA WORKERS' COMPENSATION NOTICE OF NON -RENEWAL Section 11664 of the California Insurance Code which becomes operative November 30, 1994 requires us in most instances to provide you with a notice of non -renewal. Except as specified in paragraphs 1 through 6 below, if we elect to non -renew your policy, we are required to deliver or mail to you a written notice stating the reason or reasons for the non -renewal of the policy. The notice is required to be sent to you no earlier than 120 days before the end of the policy period and no later than 30 days before the end of the policy period. If we fail to provide you the required notice, we are required to continue the coverage under the policy with no change in the premium rate until 60 days after we provide you with the required notice. We are not required to provide you with a notice of non -renewal in any of the following situations: 1. Your policy was transferred or renewed without a change in its terms or conditions or the rate on which the premium is based to another insurer or other insurers who are members of the same insurance group as us. 2. The policy was extended for 90 days or less and the required notice was given prior to the extension. 3. You obtained replacement coverage or agreed, in writing, within 60 days of the termination of the policy, to obtain that coverage. 4. The policy is for a period of no more than 60 days and you were notified at the time of issuance that it may not be renewed. 5. You requested a change in the terms or conditions or risks covered by the policy within 60 days prior to the end of the policy period. 6. We made a written offer to you at least 30 days, but not more than 120 days, prior to the end of the policy period to renew the policy at a changed premium rate. DATE OF ISSUE: 05-11-20 STASSIGN: el RiekM�agnurtfDtxaiun RREviEvrEo &pAPFR vim Sr} t\o� f�M1�GN.t ram, V�t.IFA(K �k Risk Management Matyst TRAVELERSJ'� ONE TOWER SQUARE HARTFORD CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY ENDORSEMENT WC 99 03 F3 (00) POLICY NUMBER: Ua—OR34080A-20-42—G CALIFORNIA LIMITS OF LIABILITY ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. The limits of our liability under Part Two of the policy are: Bodily Injury by Accident $1,000,000 or the amount shown in Item 3.13. of the Information Page, whichever is greater, each accident Bodily Injury by Disease $1,000,000 or the amount shown in Item 3.6. of the Information Page, whichever is greater, policy limit Bodily Injury by Disease $1,000,000 or the amount shown in Item 3.B. of the Information Page, whichever is greater, each employee This change applies to the insurance this policy provides for California operations only. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Premium $ Insurance Company Countersigned by DATE OF ISSUE: 05-11-20 ST ASSIGN: 2 Risk MeagemadDMsm eRt Ewm & pAPPROVm aY r'�YNMQ I\. VauNiKC ; Risk Management Maly t w �F TRAVELERS,A, WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 00 04 21 ( D) POLICY NUMBER: UB-OR3408OA-20-42-c CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT This endorsement is notification that your insurance carrier is charging premium to cover the losses that may occur in the event of a Catastrophe (other than Certified Acts of Terrorism) as that term is defined below. Your policy provides coverage for workers compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism). This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 B), attached to this policy. For purposes of this endorsement, the following definitions apply: • Catastrophe (other than Certified Acts of Terrorism): Any single event, resulting from an Earthquake, Noncertified Act of Terrorism, or Catastrophic Industrial Accident, which results in aggregate workers compensation losses in excess of $50 million. • Earthquake: The shaking and vibration at the surface of the earth resulting from underground movement along a fault plane or from volcanic activity. • Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary of Treasury pursuant to the Terrorism Risk Insurance Act of 2002 (as amended) but that meets all of the following criteria: a. It is an act that is violent or dangerous to human life, property, or infrastructure; b. The act results in damage within the United States, or outside of the United States in the case of the premises of United States missions or air carriers or vessels as those terms are defined in the Terrorism Risk Insur- ance Act of 2002 (as amended); and c. It is an act that has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Govern- ment by coercion. • Catastrophic Industrial Accident: A chemical release, large explosion, or small blast that is localized in nature and affects workers in a small perimeter the size of a building. The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism) is shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate Premium This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Insured Insurance Company DATE OF ISSUE: 05-11-20 Policy No. ST ASSIGN: Countersigned by © Copyright 2015 National Council on Compensation Insurance, Inc. All Rights Reserved. Endorsement No. Premium $ Risk Mmaganadtllvlswl ti p rrRenEWm&pM,P,ftlI �,o)'vm� B�re of o'+ r�IAM1Y.N�[ R. Vj4wd ®' RisWanagement Analyst TRAVELERS Jw WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 99 04 10 (00) POLICY NUMBER: UE-OR3408OA-20-42-c PREMIUM ADJUSTMENT FROM EFFECTIVE DATE ENDORSEMENT It is agreed that the premium for the policy is subject to an experience modification not available at the time of policy issuance. Such experience modification, when determined, will be stated in an endorsement issued to form a part of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Premium $ Insurance Company Countersigned by DATE OF ISSUE: 05-11-20 ST ASSIGN: „��...., RieleMn„gm,ot onasiun ., REVIEWED&APPROVEDBY: ®� F"hHU.Ft z Va'u �� ® R¢k Nlanagemen[Anayrt lk TRAVELERS]- ONE TOWER SQUARE HARTFORD CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 04 03 17 ( B) POLICY NUMBER: US-OR3408OA-20-42-G ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Employee Insured by General Employer Excluded The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: NO LIABILITY FOR Any liability you may have as the special employer of an employee who is not on EMPLOYEE INSURED BY your payroll at the time of injury, based upon your representation that: (1) you have GENERAL EMPLOYER entered into a valid and enforceable agreement pursuant to Labor Code Section 3602(d) with the employee's general employer under which the general employer agrees to secure the payment of compensation for such employee and (2) the general employer has obtained workers' compensation coverage for the employee. This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer actually obtains coverage for the excluded liability and (2) such coverage remains in effect for the term of this policy. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements or limitations in this endorsement. It is further agreed that "remuneration" when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). DATE OF ISSUE: 05-11-20 ST ASSIGN: y . IUek Managemetti D islm RWn D & APPRov® Br. Risk Management Analyst TRAVELERSJfths ONE TOWER SQUARE HARTFORD CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 04 03 17 ( B) POLICY NUMBER: UB-OR34080A-20-42-G This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Insured Insurance Company Policy No. DATE OF ISSUE: 05-11-20 ST ASSIGN: Countersigned by Endorsement No. Premium $ Rink Management DMsian ^ Rene &APPRwmBY: ® Risk Management Analyst TRAVELERS, WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 04 03 45 (A) POLICY NUMBER: UB-OR34080A-20-42-G ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Comprehensive Personal Liability Policy Exclusion The insurance under this policy is limited as follows: It is AGREED that, any thing in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: THIS POLICY DOES Any liability you may have for any injury to any employee(s) who is covered for workers' NOT INSURE ANY compensation benefits on a policy also affording comprehensive personal liability insurance EMPLOYEE(S) which has been issued to this insured. COVERED BY A COMPREHENSIVE PERSONAL LIABILITY POLICY Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements, or limitations of this endorsement It is further agreed that "remuneration" when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Premium $ Insurance Company Countersigned by Risk MmagnnentDMsian DATE OF ISSUE: 05-11-20 ST ASSIGN: W REmEWED&APPROVED BY. ZMZ Risk Nlanagemenl Analyst WORKERS, COMPENSATION —TRAVELERS pp r _rp ___ _ -AND- _. TI[A�E SQUARE EMPLOYERS LIABILITY POLICY ONE TOWER SQUARE WC 04 03 60 B HARTFORD CT 06163 ENDORSEMENT ( ) POLICY NUMBER: UB-OR3408OA-20-42-G EMPLOYERS' LIABILITY COVERAGE AMENDATORY ENDORSEMENT CALIFORNIA The insurance afforded by Part Two (Employers' Liability Insurance) by reason of designation of California in item 3 of the information page is subject to the following provisions: A. "How This Insurance Applies," is amended to read as follows: A. Flow This Insurance Applies This employers' liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury means a physical injury, including resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or incidental to your work in California. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The em- ployee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. C. The "Exclusions" section is modified as follows (all other exclusions in the "Exclusions" section remain as is): 1. Exclusion 1 is amended to read as follows: 1. liability assumed under a contract. 2. Exclusion 2 is deleted. 3. Exclusion 7 is amended to read as follows: 7, damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, termination of employ- ment, or any personnel practices, policies, acts or omissions. 4. The following exclusions are added: 1. bodily injury to any member of the flying crew of any aircraft. 2. bodily injury to an employee when you are deprived of statutory or common law defenses or are subject to penalty because of your failure to secure your obligations under the workers' compensation law(s) appli- cable to you or otherwise fail to comply with that law. 3. liability arising from California Labor Code Section 2810.3 which relates to labor contracting. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Premium Insurance Company Countersigned by Rick Managnnent Diwlon DATE OF ISSUE: 05-11-20 ST ASSIGN: 8 „ ,3 Ry.. �EMEWED&APPRovmB © 2014 Workers' Compensation Insurance Rating Bureau of California. All Rights Reserved. 1'44*ie,; d Z ` Risk Management Analyst TRAVELERS Jam' ONE TOWER SQUARE HARTFORD CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 04 04 21 (00) POLICYNUMBER: Ua-OR34080A-20-42-G OPTIONAL PREMIUM INCREASE ENDORSEMENT—CALIFORNIA You must provide us, or our authorized representative, access to records necessary to perform a payroll verifica- tion audit. If you fail to provide access within 90 days after expiration of the policy, you are liable to pay a total premium equal to 3 times our current estimate of the annual premium for your policy. In addition, if you fail to provide access after our third request within a 90 day or longer period, you are also liable for our costs in at- tempting to perform the audit unless you provide a compelling business reason for your failure. We will contact you to schedule appointments during normal business hours. We will notify you of your failure to provide access by mailing a certified, return -receipt document stating the increased premium and the total amount of our costs incurred in our attempt(s) to perform an audit. In addition to any other obligations under this contract, 30 days after you receive the notification, you will be obligated to pay the total premium and costs referenced above. If, thereafter, you provide access to your records within three years after the policy expires, or within another mutually agreed upon time, and we succeed in performing the audit to our satisfaction, we will revise your total premium and the costs due to reflect the results of the audit. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Insurance Company Countersigned By DATE OF ISSUE: 05-11-20 ST ASSIGN: Rick Managzment D[vislon REIAEVBED&@APPROVm Sr. Risk Management Analyst TRAVELERSJ�' ONE TOWER SQUARE HARTFORD CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY WC 04 04 22 (00) POLICYNUMBER: UB-OR34080A-20-42-G CALIFORNIA SHORT -RATE CANCELATION ENDORSEMENT It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: If you cancel the policy and a disclosure was provided in accordance with Section 481(c) of the California Insurance Code, final premium will be based on the time this policy was in force and increased by the short -rate cancelation table below: Short Rate Cancelation Table Days In Policy Period Short Rate Percentages Factors to Apply to Earned Premium for Period Policy in Effect Days In Policy Period Short Rate Percentages Factors to Apply to Earned Premium for Period Policy In Effect Days In Policy Period Short Rate Percentages Factors to Apply to Earned Premium for Period Policy In Effect 1 5% 18.2482 46 23% 1,8250 91 35% 1_,4038 2 6 10.9489 47 23 1.7861 92 36 1.4283 3 7 8.5158 48 24 1.8250 93 36 1.4129 4 7 6.3869 49 24 1.7877 94 36 1.3979 5 8 5.8394 50 24 1.7520 95 37 1A216 6 8 4.8662 51 24 1.7176 96 37 1.4068 7 9 4.6924 52 25 1.7548 97 37 1.3923 8 9 4.1058 53 25 1.7216 98 37 1,3781 9 10 4.0552 54 25 1,6899 99 38 1.4010 10 10 3.6496 55 26 1.7255 100 38 1.3870 11 11 3.6496 56 26 1.6947 101 38 1.3733 12 11 3.3455 57 26 1.6650 102 38 1.3598 13 12 3.3689 58 26 1.6362 103 39 1.3820 14 12 3.1283 59 27 1.6704 104 39 1.3688 15 13 3.1630 60 27 1.6425 105 39 1.3557 16 13 2.9653 61 27 1.6156 106 40 1.3774 17 14 3.0056 62 27 1.5895 107 40 1.3645 18 14 2.8386 63 28 1.6222 108 40 1.3519 19 15 2.8818 64 28 1.5969 109 40 1.3395 20 15 2.7377 65 28 1.5723 110 41 1.3605 21 16 2.7812 66 29 1.6038 111 41 1.3482 22 16 2.6547 67 29 1.5799 112 41 1.3362 23 17 2.6980 68 29 1.5566 113 41 1.3243 24 17 2.5856 69 29 1.5341 114 42 1.3447 25 17 2.4821 70 30 1.5643 115 42 1.3330 26 18 2,5270 71 30 1.5423 116 42 1.3215 27 18 2.4334 72 30 1.5208 117 43 1.3414 28 18 2.3465 73 30 1.5000 118 43 1.3301 29 18 2.2656 74 31 1.5291 119 43 1.3189 30 19 2.3117 75 31 1.5087 120 43 1.3079 31 19 2.2371 76 31 1.4888 121 44 1.3273 32 19 2.1672 77 32 1.5169 122 44 1.3164 33 20 2.2121 78 32 1.4974 123 44 1.3057 34 20 2.1471 79 32 1.4785 124 44 1.2951 35 20 2.0857 80 32 1.4600 125 45 1.3140 36 20 2.0278 81 33 1.4870 126 45 1.3036 37 21 2.0716 82 33 1.4689 127 45 1.2933 38 21 2.0171 83 33 1.4512 128 46 1.3117 39 21 1.9654 84 34 1,4774 129 46 1.3016 40 21 1.9162 85 34 1.4600 130 46 1.2916 41 22 1.9585 86 34 1,4430 131 46 1.2817 42 22 1.9119 87 34 1.4264 132 47 1.2996 43 22 1.8674 88 35 1.4517 133 47 1.2899 44 23 1.9079 89 35 1.4354 134 47 1.2802 45 23 1.8655 90 35 1.4194 135 47 1.2708 © 2011 Workers' Compensation Insurance Rating Bureau of California. All rights reserved DATE OF ISSUE: 05-11-20 ST ASSIGN: ,, �` r Riele ManagetnentDhtielan �rRitviEwED&pAP,P`Rov®Br. ; I ahkf vNe h. Y�idv14F,Q Risk Mana9exten[Analyst ' -- -- - A01k - TRAVELERSJ' ONE TOWER SQUARE HARTFORD CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 04 04 22 (00) POLICY NUMBER: UH-OR3408OA-20-42-0 Days In Policy Period Short Rate Percentages Factors to Apply to Earned Premium for Period PolicyIn Effect Days In Policy Period Short Rate Percentages Factors to Apply to Earned Premium for Period PolicyIn Effect Days In Policy Period Short Rate Percentages Factors to Apply to E arned Premium for Period Policy In Effect 136 48% 1.2882 181 60% 1.2099 226 70% 1.1305 137 48 1.2788 182 60 1.2033 227 70 1.1255 138 48 1.2696 183 61 1.2167 228 70 1.1206 139 49 1.2867 184 61 1.2101 229 71 1.1317 140 49 1.2775 185 61 1.2035 230 71 1-.1267 141 49 1.2684 186 61 1.1970 231 71 1.1219 142 49 1.2595 187 61 1.1906 232 71 1.1170 143 50 1.2762 188 62 1.2037 233 72 1.1279 144 50 1.2674 - 189 62 1.1974 234 72 1.1231 145 50 1.2586 190 62 1.1910 235 72 1.1183 146 50 1.2500 191 62 1.1848 236 72 1.1136 147 51 1.2663 192 63 1.1977 237 72 1.1089 148 51 1.2578 193 63 1.1914 238 73 1.1195 149 51 1.2493 194 63 1.1853 239 73 1.1149 150 52 1.2653 195 63 1.1792 240 73 1.1102 151 52 1.2569 196 63 1.1732 241 73 1.1056 152 52 1.2487 197 64 1.1858 242 74 1.1161 153 52 1.2405 198 64 1.1798 243 74 1.1115 154 53 1.2562 199 64 1.1739 244 74 1.1070 155 53 1.2481 200 64 1.1680 245 74 1.1025 166 53 1.2401 201 65 1.1804 246 74 1.0980 157 54 1.2554 202 65 1.1745 247 75 1.1083 158 54 1.2475 203 65 1.1687 248 75 1.1038 159 54 1.2396 204 65 1.1630 249 75 1.0994 160 54 1.2319 205 65 1.1573 250 75 1.0950 161 55 1.2469 206 66 1.1694 251 76 1.1052 162 55 1.2392 207 66 1.1638 252 76 1.1008 163 55 1.2316 208 66 1.1582 253 76 1.0964 164 55 1.2241 209 66 1.1526 254 76 1.0921 165 56 1.2388 210 67 1.1645 255 76 1.0878 166 56 1.2313 211 67 1.1590 256 77 1.0979 167 56 1.2240 212 67 1.1535 257 77 1.0936 168 57 1.2384 213 67 1.1481 258 77 1.0893 169 57 1.2311 214 67 1.1428 259 77 1.0651 170 57 1.2238 215 68 1.1544 260 77 1.0810 171 57 1.2167 216 68 1.1491 261 78 1.0908 172 58 1.2308 217 68 1.1438 262 78 1.0866 173 58 1.2237 218 68 1.1385 263 78 1.0825 174 58 1.2167 219 69 1.1500 264 78 1.0784 175 58 1.2097 220 69 1.1448 265 79 1.0881 176 59 1.2236 221 69 1.1396 266 79 1.0840 177 59 1.2167 222 69 1.1345 267 79 1.0800 178 59 1.2098 223 69 1.1294 268 79 1.0759 179 60 1.2235 224 70 1A406 269 79 1.0719 180 60 1.2167 225 70 1.1356 270 80 1.0815 © 2011 Workers' Compensation Insurance Rating Bureau of California. All rights reserved DATE OF ISSUE: 05-11-20 ST ASSIGN: ��++ Rtek Managenent Dhdaian pRENEWED&DA.P'PIRO�V}EDBY. t 18�1� �: ii f M4fYM�Q R,. N+,KRAfR.G �- hisk Management Analyst TRAVELERSJ� ONE TOWER SQUARE HARTFORD CT 06183 - WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 04 04 22 (00) POLICY NUMBER: UE-OR340BOA-20-42-G Days In Policy Period Short Rate Percentages Factors to Apply to Earned Premium for Period Policy In Effect Days In Policy Period Short Rate Percentages Factors to Apply to Earned Premium for Period Policy In Effect Days In Policy Period Short Rate Percentages Factors to Apply to Earned Premium for Period Policy in Effect 271 80 % 1.0775 316 90 % 1.0396 361 100% 1.0111 272 80 1.0735 317 90 1.0363 362 100 1.0083 273 80 1.0696 318 90 1.0330 363 100 1.0055 274 81 1.0790 319 90 1.0298 364 100 1.0027 275 81 1.0751 320 91 1.0380 365 100 1.0000 276 81 1.0712 321 91 1.0347 277 81 1.0673 322 91 1.0315 278 81 1.0635 323 91 1.0283 279 82 1.0728 324 92 1.0364 280 82 1.0689 325 92 1.0332 281 82 1.0651 326 92 1.0301 282 82 1.0614 327 92 1.0269 283 83 1.0705 328 92 1.0238 284 83 1.0667 329 93 1.0318 285 83 1.0630 330 93 1.0286 286 83 1.0593 331 93 1.0255 287 83 1.0556 332 93 1.0224 288 84 1.0646 333 94 1.0303 289 84 1.0609 334 94 1.0272 290 84 1.0572 336 94 1.0242 291 84 1.0536 336 94 1.0211 292 85 1.0625 337 94 1.0181 293 85 1.0589 338 95 1.0259 294 85 1.0553 339 95 1.0229 295 85 1.0517 340 95 1.0198 296 85 1.0481 341 95 1.0169 297 86 1.0569 342 95 1.0139 298 86 1.0534 343 96 1.0216 299 86 1.0498 344 96 1.0186 300 86 1.0463 345 96 1.0156 301 86 1.0429 346 96 1.0127 302 87 1.0515 347 97 1.0203 303 87 1.0480 348 97 1.0174 304 87 1.0446 349 97 1.0145 305 87 1.0411 350 97 1.0116 306 88 1.0497 351 97 1.0087 307 88 1.0462 352 98 1.0162 308 88 1.0429 353 98 1.0133 309 88 1.0395 354 98 1.0105 310 88 1.0361 355 98 1.0076 311 89 1.0445 356 99 1.0150 312 89 1.0412 357 99 1.0122 313 89 1.0379 358 99 1.0094 314 89 1.0346 359 99 1.0065 315 90 1.0429 360 99 1.0038 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Premium $ Insurance Company Countersigned by © 2011 Workers' Compensation Insurance Rating Bureau of California. All rights reserved DATE OF ISSUE: 05-11-20 STASSIGN: ry� Risk Management Dlvislan REVIEWED&APPROVEDfi r R¢k Management Analyst TRAVELERS WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 04 06 01 (A) POLICY NUMBER: UB-OR34080A-20-42-c CALIFORNIA CANCELATION ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the information page. The cancelation condition in Part Six (Conditions) of the policy is replaced by these conditions: CANCELATION 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation is to take effect. 2. We may cancel this policy for one or more of the following reasons a. Non-payment of premium; b. Failure to report payroll; c. Failure to permit us to audit payroll as required by the terms of this policy or of a previous policy issued by us; d. Failure to pay any additional premium resulting from an audit of payroll required by the terms of this policy or any previous policy issued by us; e. Material misrepresentation made by you or your agent; f. Failure to cooperate with us in the investigation of a claim; g. Failure to comply with Federal or State safety orders; h. Failure to comply with written recommendations of our designated loss control representatives; i. The occurrence of a material change in the ownership of your business; j. The occurrence of any change in your business or operations that materially increases the hazard for frequency or severity of loss; k. The occurrence of any change in your business or operation that requires additional or different classification for premium calculation; I. The occurrence of any change in your business or operation which contemplates an activity excluded by our reinsurance treaties. 3. If we cancel your policy for any of the reasons listed in (a) through (f), we will give you 10 days advance written notice, stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. If we cancel your policy for any of the reasons listed in Items (g) through (1), we will give you 30 days advance written notice; however, we agree that in the event of cancelation and reinsuance of a policy effective upon a material change in ownership or operations, notice will not be provided. 4. The policy period will end on the day and hour stated in the cancelation notice. DATE OF ISSUE: 05-11-20 STASSIGN: RiekManagelttentDiWsion .� ♦ /REVIEWED& pAPPR�O/V10 Sr SI>�' f•AIrHG�.i.2 F,. VM,tR/4F1� ,W Risk Management Analyst TRAVELERSJft, Travelers Medical Provider Network (MPN) Plan — CALIFORNIA Necessary Action for MPN Participation Dear Policyholder: As your workers compensation insurer, Travelers is pleased to include your Company in our California Medical Provider Network (MPN) plan. Travelers has an extensive MPN with physicians who understand workers compensa- tion and are experienced in providing expert care for injured workers. Our program ensures that every covered employee that suffers a work -related injury or illness has access to prompt medical care and an improved likelihood of a safe return to work as soon as medically appropriate. MPN utilization can reduce overall workers compensation claim payouts by providing greater control over medical fees and obtaining more favorable medical treatment outcomes. Your role is crucial to the success of the MPN program. Together, we can better manage your Workers Compensation claims within the MPN. The MPN is a standard product in all Travelers workers compensation policies, and all policyholders are expected to participate. This information is being provided to you to help you understand the requirements for proper MPN participation. The State Division of Workers' Compensation (DWC) regulates how an employee is notified of an employer's MPN participation. Section § 9767.12 of Title 8, California Code of Regulations specifies what notices are to be provided to employees, as well as when and how they are to be provided. Information about the Travelers MPN and notice requirements is available to policyholders on www.travelers.com. Please type this web address into your browser to access the information: www.travelers.com/CAMPN A "Frequently Asked Questions" page is also available through the above web address. Look for the link called FAQ — MPN. If you have additional, general questions regarding the MPN and do not have a contact in the Claim Department, you can contact the Travelers MPN Team by calling (800) 287-9682 or sending an email to CAMPN@travelers.com. Please listen for the prompts for Employers or Employer Representatives. In addition to reviewing the information on our web page, we also recommend that you: • Make sure your management staff has instructions on how to access the MPN Medical Provider directory via www.travelers.com/CAMPN. • Select an occupational medicine clinic, urgent care clinic, or, an acute care hospital from the MPN to serve as your designated initial injury treatment facility for each plant/location. Contact this facility and inform them that you are participating in the Travelers Medical Provider Network Plan. Update the State Posting Notices to in- clude the name, address, and phone number of the facility. • Review your procedures for handling work -related injuries, your modified duty policy, and your safety commit- tee operation with your management staff. We believe the MPN program will provide better overall workers compensation outcomes for you as an employer. Sincerely, Travelers W04NIB15 Z� R®kMu,agemmfDKisian RE\ne & APPROvID B, R¢k Management AnApt IMPORTANT NOTICE - COPYRIGHT NO COVERAGE IS PROVIDED BY THIS NOTICE. THIS NOTICE DOES NOT AMEND ANY PROVISION OF YOUR POLICY. YOU SHOULD REVIEW YOUR ENTIRE POLICY CAREFULLY FOR COMPLETE INFORMATION ON THE COVERAGES PROVIDED AND TO DETERMINE YOUR RIGHTHS AND DUTIES UNDER YOUR POLICY. PLEASE CONTACT YOUR AGENT OR BROKER IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR ITS CONTENTS. IF THERE IS ANY CONFLICT BETWEEN YOUR POLICY AND THIS NOTICE, THE PROVISIONS OF YOUR POLICY PREVAIL. The National Council on Compensation Insurance and certain state workers compensation bureaus require a copyright notice on policy forms that contain their copyrighted material. This Important Notice addresses this copyright notice requirement for any policy form included in this policy that does not separately contain a copyright notice. For all policy forms other than the workers compensation bureau forms of the states identified below: Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission. © 1983-2020 National Council on Compensation Insurance, Inc. All Rights Reserved For the workers compensation bureau policy forms of the following states: DELAWARE: © 2020 Delaware Compensation Rating Bureau MICHIGAN: Includes copyright material of the National Council on Compensation Insurance, Inc. and the Michigan Workers' Compensation Placement Facility, used with their permission. MINNESOTA: © 1992-2020 Minnesota Workers' Compensation Insurers Association, Inc. All Rights Reserved. NEW JERSEY: ©Compensation Rating and Inspection Bureau NEW YORK: © 1987-2020 New York Compensation Insurance Rating Board PENNSYLVANIA: © 2020 Pennsylvania Compensation Rating Bureau WUNN1 B18 © 2020 The Travelers Indemnity Company. All rights reserved. anR1ekMmugmentDivision ' ` W: VRisk Management Analyst IMPORTANT NOTICE - NEW, UNCOLLECTED OR UNCONTEMPLATED SURCHARGES NO COVERAGE IS PROVIDED BY THIS NOTICE. THIS NOTICE DOES NOT AMEND ANY PROVISION OF YOUR POLICY. YOU SHOULD REVIEW YOUR ENTIRE POLICY CAREFULLY FOR COMPLETE INFORMATION ON THE COVERAGES PROVIDED AND TO DETERMINE YOUR RIGHTS AND DUTIES UNDER YOUR POLICY. PLEASE CONTACT YOUR AGENT OR BROKER IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR ITS CONTENTS. IF THERE IS ANY CONFLICT BETWEEN YOUR POLICY AND THIS NOTICE, THE PROVISIONS OF YOUR POLICY PREVAIL. The insurer is responsible for the collection of any surcharge related to the policy premium in accordance with state laws or regulations. While surcharges are commonly known at the time of policy issuance, there are instances when a state amends existing, or institutes new, surcharge rates after policy issuance. The insured is responsible to reimburse the insurer when billed for the amount of any surcharge. WUND1C17 © 2016 The Travelers Indemnity Company. All rights reserved. �w. Riak MarogementDhislsn REVIEWED & APPROVED BY. �i 4 f�bM(�Me R• YEAS �' Risk Management Analyst STATE OF CALIFORNIA IMPORTANT LOSS CONTROL INFORMATION California Labor Code § 6354.5 (b)(3) requires workers' compensation insurance carriers to provide their California policyholders with occupational safety and health loss control consultation services at no additional charge. See the enclosed Safety Services notice for a list of services available and for the phone number and address of the Travelers Risk Control office nearest you. Notice To Policy Recipient: If you are not the person directly responsible for the loss control activities of your company in California, please direct these safety services notices to the person directly responsible for loss control activities. W04N1C14 � � RIekM¢nagemeniDfvision Remo & APPRovm By. F44*'O; .a P. V1t!Mmn Risk Mxu�a9em nt Analyst IMPORTANT NOTICE TO CALIFORNIA EMPLOYERS NO COVERAGE IS PROVIDED BY THIS NOTICE. THIS NOTICE DOES NOT AMEND ANY PROVISION OF YOUR POLICY. YOU SHOULD REVIEW YOUR ENTIRE POLICY CAREFULLY FOR COMPLETE INFORMATION ON THE COVERAGES PROVIDED AND TO DETERMINE YOUR RIGHTS AND DUTIES UNDER YOUR POLICY. PLEASE CONTACT YOUR AGENT OR BROKER IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR ITS CONTENTS. IF THERE IS ANY CONFLICT BETWEEN YOUR POLICY AND THIS NOTICE, THE PROVISIONS OF YOUR POLICY PREVAIL. California Labor Code Section 3550 requires you to post and keep posted in each of your California workplaces, in a conspicuous location frequented by employees, a notice that states the name of your current workers compensation insurance carrier and who is responsible for claims adjustment. The notice must be posted in English and Spanish if you have Spanish-speaking employees. Failure to keep the notice posted as required constitutes a misdemeanor. For your convenience, we have enclosed copies of notice DWC 7, Notice to Employees — Injuries Caused by Work, for each of your California locations. W04N1J15 © 2015 The Travelers Indemnity Company. All rights reserved. ^� w�k��rot�lon g�3 REVIEWED&APPROVED BY, �aa.r�uma F. V;ffcne�C Risk Management Malyst POLICYHOLDER NOTICE SHORT RATE CANCELATION CALIFORNIA INSURANCE CODE SECTION 481 CA Insurance Code Section 481 requires that where an insurance policy includes a provision to refund premium on anything other than a pro rata basis, including the assessment of cancellation fees, the insurer must disclose that fact to the policyholder in writing prior to, or concurrent with, the proposal or quote prior to each renewal. The disclosure must include the actual or maximum fees or penalties to be applied. The WCIRB also created a Short Rate Cancelation Endorsement which complements the disclosure requirement. This requirement applies to in- surance policies issued or renewed on or after January 1, 2012. In order to respond to this insurance code requirement we have created this Policyholder Notice to disclose our use of short rate calculations as described in the California Short Rate Cancelation Endorsement included in the policy. W04N2H12 -.1 MAMmuganmtotwe1m . REVIEWED&APPROVF7]BY: ---� Risk Management Analyst P_N_04 99 02 B (Ed. 5-02) POLICYHOLDER NOTICE CALIFORNIA WORKERS' COMPENSATION INSURANCE RATING LAWS Pursuant to Section 11752.8 of the California Insurance Code, we are providing you with an explanation of the California workers' compensation rating laws. 1. We establish our own rates for workers' compensation. Our rates, rating plans, and related information are filed with the insurance commissioner and are open for public inspection. 2. The insurance commissioner can disapprove our rates, rating plans, or classifications only if he or she has determined after public hearing that our rates might jeopardize our ability to pay claims or might create a mo- nopoly in the market. A monopoly is defined by law as a market where one insurer writes 20% or more of that part of the California workers' compensation insurance that is not written by the State Compensation Insur- ance Fund. If the insurance commissioner disapproves our rates, rating plans, or classifications, he or she may order an increase in the rates applicable to outstanding policies. 3. Rating organizations may develop pure premium rates that are subject to the insurance commissioner's ap- proval. A pure premium rate reflects the anticipated cost and expenses of claims per $100 of payroll for a given classification. Pure premium rates are advisory only, as we are not required to use the pure premium rates developed by any rating organization in establishing our own rates. 4. We must adhere to a single, uniform experience rating plan. If you are eligible for experience rating under the plan, we will be required to adjust your premium to reflect your claim history. A better claim history generally results in a lower experience rating modification; more claims, or more expensive claims, generally result in a higher experience rating modification. The uniform experience rating plan, which is developed by the insur- ance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. S. A standard classification system, developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. The standard classification system is a method of recognizing and separating policyholders into industry or occupational groups according to their similarities and/or differences. We can adopt and apply the standard classification system or develop and ap- ply our own classification system, provided we can report the payroll, expenses, and other costs of claims in a way that is consistent with the uniform statistical plan or the standard classification system. 6. Our rates and classifications may not violate the Unruh Civil Rights Act or be unfairly discriminatory. 7. We will provide an appeal process for you to appeal the way we rate your insurance policy. The process re- quires us to respond to your written appeal within 30 days. If you are not satisfied with the result of your ap- peal, you may appeal our decision to the insurance commissioner. CALIFORNIA WORKERS' COMPENSATION INSURANCE NOTICE OF NONRENEWAL Section 11664 of the California Insurance Code requires us, in most instances, to provide you with a notice of nonrenewal. Except as specified in paragraphs 1 through 6 below, if we elect to nonrenew your policy, we are required to deliver or mail to you a written notice stating the reason or reasons for the nonrenewal of the policy. The notice is required to be sent to you no earlier than 120 days before the end of the policy period and no later than 30 days before the end of the policy period. If we fail to provide you the required notice, we are required to continue the coverage under the policy with no change in the premium rate until 60 days after we provide you with the required notice. We are not required to provide you with a notice of nonrenewal in any of the following situations: 1. Your policy was transferred or renewed without a change in its terms or conditions or the rate on which the premium is based to another insurer or other insurers who are members of the same insurance group as us. 2. The policy was extended for 90 days or less and the required notice was given prior to the extension. ©2002 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. W04NBA02 of 1 %skManeytmwtDi s[m REVIEWED&AppR vm By: FIA4Ynf.2 ✓;, lftEPRaaak Risk Management Analyst PN 04 99 02 B (Ed. 5-02) 3. You obtained replacement coverage or agreed, in writing, within 60 days of the termination of the policy, to obtain that coverage. 4. The policy is for a period of no more than 60 days and you were notified at the time of issuance that it may not be renewed. 5. You requested a change in the terms or conditions or risks covered by the policy within 60 days prior to the end of the policy period. 6. We made a written offer to you to renew the policy at a premium rate increase of less than 25 percent. (A) If the premium rate in your governing classification is to be increased 25 percent or greater and we intend to renew the policy, we shall provide a written notice of a renewal offer not less than 30 days prior to the policy renewal date. The governing classification shall be determined by the rules and regulations estab- lished in accordance with California Insurance Code Section 11750.3(c). (B) For purposes of this Notice, "premium rate" means the cost of insurance per unit of exposure prior to the application of individual risk variations based on loss or expense considerations such as scheduled rating and experience rating. This notice does not change the policy to which it is attached. ©2002 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. W04NBA02 "gc RlekManagemrntD[ s1m i, RMAe D&l6narmvm BY. si ' f4�crY -44 . �nntFi rt(sk rdanagemenl Analys[ PN 04 99 01 G POLICYHOLDER NOTICE YOUR RIGHT TO RATING AND DIVIDEND INFORMATION I. Information Available to You A. Information Available from Us —Travelers Property Casualty Company of America (1) General questions regarding your policy should be directed to: TRAVELERS P.O. Box 6512 21688 Gateway Center Drive Diamond Bar, CA 91765 Telephone: 1.909.612-3609 Fax:1-909.612.3629 Website: www.travelers.com (2) Dividend Calculation. If this is a participating policy (a policy on which a dividend may be paid), upon payment or non-payment of a dividend, we shall provide a written explanation to you that sets forth the basis of the dividend calculation. The explanation will be in clear, understandable language and will express the dividend as a dollar amount and as a percentage of the earned premium for the policy year on which the dividend is calculated. (3) Claims Information. Pursuant to Sections 3761 and 3762 of the California Labor Code, you are entitled to receive information in our claim files that affects your premium. Copies of documents will be supplied at your expense during reasonable business hours. For claims covered under this policy, we will estimate the ultimate cost of unsettled claims for statistical purposes eighteen months after the policy becomes effective and will report those estimates to the Workers' Compensation Insurance Rating Bureau of California (WCIRB) no later than twenty months after the policy becomes effective. The cost of any settled claims will also be reported at that time. At twelve-month intervals thereafter, we will update and report to the WCIRB the estimated cost of any unsettled claims and the actual final cost of any claims settled in the interim. The amounts we report will be used by the WCIRB to compute your experience modification if you are eligible for experience rating. B. Information Available from the Workers' Compensation Insurance Rating Bureau of California (1) The WCIRB is a licensed rating organization and the California Insurance Commissioner's designated statistical agent. As such, the WCIRB is responsible for administering the California Workers' Compensation Uniform Statistical Reporting Plan-1995 (USRP) and the California Workers' Compensation Experience Rating Plan-1995 (ERP). WCIRB contact information is: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Customer Service; 888.229.2472 (phone); 415.778.7272 (fax); customerservice@wcirb.com (email). The regulations contained in the USRP and the ERP are available for public viewing through the WCIRB's website at wcirb.com. (2) Policyholder Information. Pursuant to California Insurance Code (CIC) Section 11752.6, upon written request, you are entitled to information relating to loss experience, claims, classification assignments, and policy contracts as well as rating plans, rating systems, manual rules, or other information impacting your premium that is maintained in the records of the WCIRB. Complaints and Requests for Action requesting policyholder information should be forwarded to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Custodian of Records. The Custodian of Records can be reached at 415.777.0777 (phone) and 415.778.7272 (fax). (3) Experience Rating Form. Each experience rated risk may receive a single copy of its current Experience Rating Form/Worksheet free of charge by completing a Policyholder Experience Rating Worksheet Request Form on the WCIRB's website at wcirb.com/ratesheet. The Experience Rating Form/Worksheet will include a Loss -Free Rating, which is the experience modification that would have PN049901G W04NBC19 WakMmugemadDlW 1m RED EWED & APPRovm BY. (����lVl';j3 fnaro�ta.e 2, V�if�naaC Risk Management Analyst PN049901G been calculated if $0 (zero) actual losses were incurred during the experience period. This hypothetical rating calculation is provided for informational purposes only. II. Dispute Process You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1. A. Our Dispute Resolution Process. If you are aggrieved by our decision adopting a change in a classification assignment that results in increased premium, or by the application of our rating system to your workers' compensation insurance, you may dispute these matters with us. If you are dissatisfied with the outcome of the initial dispute with us, you may send us a written Complaint and Request for Action as outlined below. You may send us a written Complaint and Request for Action requesting that we reconsider a change in a classification assignment that results in an increased premium and/or requesting that we review the manner in which our rating system has been applied in connection with the insurance afforded or offered you. Written Complaints and Requests for Action should be forwarded to: TRAVELERS TRAVELERS 1109 White Rock Road P.O. Box 6512 Rancho Cordova, CA 95670-6001 21688 Gateway Center Drive Diamond Bar, CA 91765 Phone:1-800-328-2189 Phone:1-909-612-3609 Fax:1-909-612-3629 Website: www.Travelers.com Website: www.Travelers.com After you send your Complaint and Request for Action, we have 30 days to send you a written notice indicating whether or not your written request will be reviewed. If we agree to review your request, we must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If we decline to review your request, if you are dissatisfied with the decision upon review, or if we fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below. B. Disputing the Actions of the WCIRB. If you have been aggrieved by any decision, action, or omission to act of the WCIRB, you may request, in writing, that the WCIRB reconsider its decision, action, or omission to act. You may also request, in writing, that the WCIRB review the manner in which its rating system has been applied in connection with the insurance afforded or offered you. For requests related to classification disputes, the reporting of experience, or coverage issues, your initial request for review must be received by the WCIRB within 12 months after the expiration date of the policy to which the request for review pertains, except if the request involves the application of the Revision of Losses rule. For requests related to your experience modification, your initial request for review must be received by the WCIRB within 6 months after the issuance, or 12 months after the expiration date, of the experience modification to which the request for review pertains, whichever is later, except if the request for review involves the application of the Revision of Losses rule. If the request involves the Revision of Losses rule, the time to state your appeal may be longer. (See Section VI, Rule 147 of the ERP). You may commence the review process by sending the WCIRB a written Inquiry. Written Inquiries should be sent to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Customer Service. Customer Service can be reached at 888.229.2472 (phone), 415.778.7272 (fax) and customerservice@wcirb.com (email). If you are dissatisfied with the WCIRB's decision upon an Inquiry, or if the WCIRB fails to respond within 90 days after receipt of the Inquiry, you may pursue the subject of the Inquiry by sending the WCIRB a written Complaint and Request for Action. After you send your Complaint and Request for Action, the WCIRB has 30 days to send you written notice indicating whether or not your written request will be reviewed. If the WCIRB agrees to review your request, it must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If the WCIRB declines to review your request, if you are dissatisfied with the decision upon review, or if the WCIRB fails to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below. Written Complaints and Requests for Action should be forwarded to: WCIRB, 1221 PN 04 99 01 G W04NBC19 Risk ManagementDt s[m BEvrwrt:o & Rrreovm BY. I u� 3 t cHCH e R li[llraasE RBk Management Analyst PN049901G Broadway, Suite 900, Oakland, CA 94612, Attn: Complaints and Reconsideration. The WCIRB's contact information is 888.229.2472 (phone), 415.371.5204 (fax) and customerserviceftwcirb.com (email). C. California Department of Insurance — Appeals to the Insuanrce Commissioner. After you follow the appropriate dispute resolution process described above, if (1) we or the WCIRB decline to review your request, (2) you are dissatisfied with the decision upon review, or (3) we or the WCIRB fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner pursuant to CIC Sections 11737, 11752.6, 11753.1 and Title 10, California Code of Regulations, Section 2509.40 et seq. You must file your appeal within 30 days after we or the WCIRB send you the notice rejecting review of your Complaint and Request for Action or the decision upon your Complaint and Request for Action. If no written decision regarding your Complaint and Request for Action is sent, your appeal must be filed within 120 days after you sent your Complaint and Request for Action to us or to the WCIRB. The filing address for all appeals to the Insurance Commissioner is: Administrative Hearing Bureau California Department of Insurance 45 Fremont Street, 22nd Floor San Francisco, CA 94105 415,538.4102 You have the right to a hearing before the Insurance Commissioner, and our action, or the action of the WCIRB, may be affirmed, modified, or reversed. III Resources Available to You in Obtaining Information and Pursuing Disputes A. Policyholder Ombudsman. Pursuant to California Insurance Code Section 11752.6, a policyholder ombudsman is available at the WCIRB to assist you in obtaining and evaluating the rating, policy, and claims information referenced in I.A. and I.B., above. The ombudsman may advise you on any dispute with us, the WCIRB, or on an appeal to the Insurance Commissioner pursuant to Section 11737 of the Insurance Code. The address of the policyholder ombudsman is WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Policyholder Ombudsman. The policyholder ombudsman can be reached at 415.778.7159 (phone), 415.371,5288 (fax) and ombudsman(o)wcirb.com (email). B. California Department of Insurance — Information and Assistance. Information and assistance on policy questions can be obtained from the Department of Insurance Consumer HOTLINE, 800.927.HELP (4357) or www.insurance.ca.gov. For questions and correspondence regarding appeals to the Administrative Hearing Bureau, see the contact information in paragraph II.C. This notice does not change the policy to which it is attached. PN049901G W04NBC19 N n"x a RiA�[hi8118f�1111L•NtDivlalan REvtEwED 6 APPRovm Br. l t' F4A4•e% FP, Gt" Risk Management Analyst POLICYHOLDER NOTICE CALIFORNIA INSURANCE GUARANTEE ASSOCIATION (CIGA) SURCHARGE Companies writing property and casualty insurance business in California are required to participate in the California Insurance Guarantee Association. If a company becomes insolvent, the California Insurance Guarantee Association settles unpaid claims and assesses each insurance company for its fair share. California law requires all companies to surcharge policies to recover these assessments. If your policy is surcharged, "CA Surcharge" or "CA Surcharge (CIGA) Surcharge)' with an amount will be displayed on your premium notice. This notice does not change the policy to which it is attached. PN 04 99 04 (00) et °RmkManagxm�mEDktiaian �s REVIEWED&APPRWm BY. ` RukManageinent Analyst _TRAVELERS.JW' Your Workers' Compensation Benefits CALIFORNIA This form should be given to all newly hired employees in the State of California. Its content applies to industrial injuries on or after January 1, 2013. Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony. You may be entitled to workers' compensation benefits if you are injured or become ill because of your job, or are a victim of a workplace crime. Workers' compensation covers most work -related physical or mental injuries and illnesses. An injury or illness can be caused by one event (such as hurting your back in a fall) or by repeated exposures to a harmful condition (such as hurting your wrist from doing the same motion over and over). Workers' compensation benefits include: Medical Care: Doctor visits, hospital services, physical therapy, lab tests, x-rays, and medicines that are reasonably necessary to treat your injury. You should never see a bill. Physical therapy, occupational therapy and chiropractic visits may be limited to 24 each. Temporary Disability Benefits: Payments if you lose wages while recovering. For most injuries, temporary disability benefits are limited to 104 weeks within 5 years from your date of injury. Filing a timely Employment Development Department claim may result in additional state disability benefits when TTD benefits are terminated, delayed or denied. Permanent Disability Benefits: Payments if your injury causes a permanent disability. Once your injury stabilizes, your treating physician may find permanent disability, depending upon your level of recovery. The amount of permanent disability found by your doctor will be rated by your claims administrator according to your age and occupation in order to determine the percentage and corresponding dollar amount of permanent disability due. These amounts are set by state law. You have the right to obtain a state disability rating or appeal a rating. Supplemental Job Displacement Vouchers: If your injury causes you to miss time from work and results in permanent disability, you may receive a supplemental job displacement voucher if your employer has not offered modified, alternative or regular employment within 60 days of receipt of the doctor's medical report indicating you have made a maximum medical recovery. The voucher is for reimbursement of education -related costs and is capped at $6,000.00, If you receive a voucher as a result of your injury, you have two years from the date you are furnished the voucher or five years from your date of injury (whichever occurs later), to request reimbursement for qualifying expenditures. Death Benefits: Paid to dependents of a worker who dies from a work -related injury or illness. Burial expenses are also provided, with the maximum amount allowed dependent upon the date of injury. Return to Work Program: If you experience a permanent earnings loss as a result of your injury and your permanent disability benefits are determined to be disproportionately low, you may qualify for additional monies from the Department of Industrial Relation's Return to Work Fund. Contact the Department of Industrial Relations at: to learn more benefit. Temporary disability, permanent disability, and death benefits are all payable at a rate based on 2/3 of your average weekly wage, and subject to state minimum and maximum amounts in effect on your date of injury. These benefits are paid every two weeks while you are eligible. Voluntary, off duty, recreational, social or atheltic activities may not be covered under workers' compensation. W04NE116 travelers.com The Travelers Indemnity Company and its property casualty affiliates. One Tower Square, Hartford, CT 06183 © 2016 The Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are regi; Travelers Indemnity Company in the U.S. and other countries. CE-10277 Rev. 10-2015 RiakMRmpnmdDMsI nt rREVIEWED &ppAPrPr'R'O//VIyED BY. '�-^" Rlsk Management Analyst If you get hurt: Get Medical Care. If you need first aid, contact your employer. If you need emergency care, call for help immediately. Report Your Injury. Report the injury immediately to your supervisor. Don't delay. There are time limits. If you wait too long, you may lose your right to benefits. Your employer is required to provide you a claim form within one working day after learning about your injury, and must also authorize treatment within one working day after you have returned a signed and completed copy of the form. The statute of limitations for filing a workers' compensation claim is one year from the date of injury or, if resulting from repeated exposures, one year from when you realized or should have realized that your job caused the injury. See Your Treating Physician. Your primary treating physician is the doctor with overall responsibility for treating your injury or illness. He or she is charged with maintaining the continuity of your care, as well as initiating referrals to specialists. If your employer has an approved Medical Provider Network (MPN), they may be able to limit your choices of treating physicians retain medical control, and require you to treat with an MPN physician from the onset. (An MPN is a selected network of healthcare providers who provide treatment to workers injured on the job. See your employer for more information on your MPN.) Otherwise, your employer has the right to select the physician who will treat you for the first 30 days. If your employer does not have an approved MPN and you wish to change doctors in the first 30 days after reporting your claim, your claims administrator must select a new physician within five days of your request. If you have provided your employer with the name of your personal physician before your injury and have group health insurance at the time of injury, you may see your personal physician for treatment even if your employer has an approved MPN. Your personal physician must be a general practitioner or a board -certified or board -eligible internist, pediatrician, obstetrician- gynecologist, family practitioner, or multi -specialty medical group of doctors of medicine or osteopathy, and must have treated you and maintained your medical history and records before your work injury and must also agree to treat you for a work -related injury or illness. If your employer does not have an approved MPN and you gave your employer the name of your personal chiropractor or acupuncturist in writing before you were injured, you may switch to the chiropractor or acupuncturist upon request. If you still need medical care after 30 days, you may be able to switch to a doctor of your own choice. For your convenience, optional forms to predesignate your personal physician or multi -specialty medical group of doctors of medicine or osteopathy are attached to this document. Also attached, are forms to predesignate your personal acupuncturist or chiropractor if your employer does not have a medical provider network in place. By law, chiropractors are not allowed to be the treating physician after 24 visits. Discrimination: It is illegal for your employer to punish or fire you for having a work injury or illness, for filing a claim, or testifying in another person's workers' compensation case. If your employer has been found to discriminate, you may be entitled to job reinstatement with back pay, increased compensation, and costs and expenses. You may also have additional rights under the Americans with Disabilities Act (ADA) or the Fair Employment and Housing Act (FEHA). For additional information, contact FEHA at (800) 884-1684 or the Equal Employment Opportunity Commission (EEOC) at (800) 669-3362. You can get free information from a state Division of Workers' Compensation Information & Assistance Officer. Hear recorded information and a list of local offices by calling toll -free (800) 736.7401 or learn more online at: http://www.dir.ca.gov. If medical care is not being provided by your employer you have several options. First, contact your claims administrator to find out the status of your claim. If you have given your employer a completed and signed claim form but your claim has been delayed for investigation, your employer is still required to authorize treatment, up to $10,000.00, during the delay. If the claim has not been accepted yet and your medical costs have exceeded the statutory $10,000.00 cap, you can go to your group health plan for care, find a doctor, clinic or hospital that will bill the claims administrator directly, or use public health services. You have the right to disagree with decisions affecting your claim. If you have a disagreement, contact your claims administrator first to see if you can resolve it. W04NEI16 travelers.com The Travelers Indemnity Company and its property casualty affiliates. One Tower Square, Hartford, CT 06183 © 2016 The Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are regi: Travelers Indemnity Company in the U.S. and other countries. CE-10277 Rev. 10-2015 a� xsq� Itlek Mcnegement Dlvielon 'Y 9% REVIEWED&APPROVED BY: 83 F�r.u,e.e P., U:,FFanaak ®" Risk Management Analyst Your Workers' Compensation Insurance Company is Travelers Property Casualty Company of America. You can also look up your insurance carrier at the WCIRB online lookup: https://www.caworkcompcoverage.com You can obtain free information from an Information and Assistance Officer of the state Division of Workers' Compensation, or you can hear recorded information and a list of local offices by calling (800) 736-7401. A list of Information and Assistance offices can be found at the end of this pamphlet to help you locate the I&A office nearest you. You may also go to the DWC web site at: http://www.dir.ca.gov for further information. You can consult with an attorney. Most attorneys offer one free consultation. If you decide to hire an attorney, his or her fee may be taken out of some of your benefits. For names of workers' compensation attorneys, call the State Bar of California at (415) 538-2120 or go to their web site at: http://www.californiaspecialist.org. You may get a list of attorneys from your local information and assistance officer or look in your yellow pages. W04NEI16 travelers.com The Travelers Indemnity Company and its property casualty affiliates. One Tower Square, Hartford, CT 06183 © 2016 The Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are regi: Travelers Indemnity Company in the U.S. and other countries. CE-10277 Rev. 10-2015 v RiekMmt�xmenEDMsfon i:% eRl 6�}APPRcivm Sr. , Risk Managenren[ Analyst " PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness by your personal medical doctor (M.D.) or doctor of osteopathic medicine (D.O.) or medical group if: • on the date of your work injury, you have health care coverage for injuries or illnesses that are not work related; • the doctor is your regular physician, who shall be either a physician who has limited his or her practice of medicine to general practice or who is a board -certified or board -eligible internist, pediatrician, obstetrician -gynecologist, family practitioner, and has previously directed your medical treatment, and retains your medical records; • your "personal physician" may be a medical group if it is a single corporation or partnership composed of licensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical group providing comprehensive medical services predominantly for nonoccupational illnesses and injuries; • prior to the injury your doctor agrees to treat you for work injuries or illnesses; • prior to the injury you provided your employer the following in writing: (1) notice that you want your personal doctor to treat you for a work -related injury or illness, and (2) your personal doctor's name and business address. You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work- related injury or illness and the above requirements are met. NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee: Complete this section. If I have a work -related injury or illness, I choose to (Name of Doctor, M.D., D.O., or medical group) (Street address, city, state, zip code) (Telephone number) Employee Name (please Employee's of employer) Name of Insurance Company, Plan, or Fund providing health coverage for nonoccupational injuries or illnesses: Employee's Signatu Physician: I agree to this Predesignation. Date: Signature: Date: (Physician or designated employee of the physician or medical group) The physician is not required to sign this form, however, if the physician or designated employee of the physician or medical group does not sign, other documentation of the physician's agreement to be predesignated will be required pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3). Title 8, California Code of Regulations, section 9783 (Optional DWC Form 9783 Effective date July 1, 2014) Predesignation of Personal Physician; Reporting Duties of the Primary Treating Physician Regulations 8 C.C.R. section 9780, et seq. (Approved 02/12/2014) W04NEI16 travelers.com The Travelers Indemnity Company and its property casualty affiliates. One Tower Square, Hartford, CT 06183 © 2016 "rhe Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are rep Travelers Indemnity Company in the U.S. and other countries. CE-10277 Rev. 10-2015 �y Rlek Management 1%filan REVIEWED&APPROVED BY: i pp 'I ee p gill Lm '� Risk Management Arnlyst NOTICE OF PERSONAL CHIROPRACTOR OR PERSONAL ACUPUNCTURIST If your employer or your employer's insurer does not have a Medical Provider Network, you may be able to change your treating physician to your personal chiropractor or acupuncturist following a work -related injury or illness. In order to be eligible to make this change, you must give your employer the name and business address of a personal chiropractor or acupuncturist in writing prior to the injury or illness. Your claims administrator generally has the right to select your treating physician within the first 30 days after your employer knows of your injury or illness. After your claims administrator has initiated your treatment with another doctor during this period, you may then, upon request, have your treatment transferred to your personal chiropractor or acupuncturist. NOTE: If your date of injury is January 1, 2004, or later, a chiropractor cannot be your treating physician after you have received 24 chiropractic visits unless your employer has authorized additional visits in writing. The term "chiropractic visit" means any chiropractic office visit, regardless of whether the services performed involve chiropractic manipulation or are limited to evaluation and management. Once you have received 24 chiropractic visits, if you still require medical treatment, you will have to select a new physician who is not a chiropractor. This prohibition shall not apply to visits for postsurgical physical medicine visits prescribed by the surgeon, or physician designated by the surgeon, under the postsurgical component of the Division of Workers' Compensation's Medical Treatment Utilization Schedule. You may use this form to notify your employer of your personal chiropractor or acupuncturist. Your Chiropractor or Acupuncturist's Information: (name of chiropractor or acupuncturist) (street address, city, state, zip code) (Telephone number) Employee Name (please print): Employee's Address: Employee's Title 8, California Code of Regulations, section 9783.1 (Optional DWC Form 9783.1 Effective date July 1, 2014) Predesignation of Personal Physician; Reporting Duties of the Primary Treating Physician Regulations 8 C.C.R. section 9780, et seq. (Approved 02/12/2014) W04NE116 travefers.com w..rFt RfdrManalfuntmtDivis[mt The Travelers IndemnityCompany and its property casual affiliates. One Tower Square, Hartford, CT 06183 Remois<APPRWmBr: P Y P P Y casualty q © 2016 The Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are regi Travelers Indemnity Company in the U.S. and other countries. CE-10277 Rev. 10-2015 Risk Management Anatyst Contact the information & assistance unit • By phone at 1-800-736-7401: For recorded information that helps injured workers, employers and others understand • California's workers' compensation system, and their rights and responsibilities under the law. • By attending a workshop for injured workers • By calling or going in person to a local Information & Assistance Unit office: Anaheim Oxnard San Francisco 1065 N. PacifiCenter Drive 1901 N. Rice Ave., Ste. 200 455 Golden Gate Avenue, 2nd floor Anaheim, CA 92806 Oxnard, CA 93030 San Francisco, CA 94102-7014 (714)414-1801 (805)485-3528 (415)703-5020 Bakersfield Pomona San Jose 1800 30th Street, Suite 100 732 Corporate Center Drive 100 Paseo de San Antonio Bakersfield, CA 93301-1929 Pomona, CA 91768-2653 Room 241 (661) 395-2514 (909) 623-8568 San Jose, CA 95113-1402 (408) 277-1292 Eureka Redding San Luis Obisoo 100 W' Street, Room 202 2115 Civic Center Drive, Room 15 4740 Allene Way, Suite 100 Eureka, CA 95501-0481 Redding, CA 96001-2796 San Luis Obispo, CA 93401 (707) 441-5723 (530) 225-2047 (805) 596-4159 Fresno Riverside Santa Ana 2550 Mariposa Mall, Room 2035 3737 Main Street, Room 300 605 W Santa Ana Blvd Fresno, CA 93721-2219 Riverside, CA 92501-3337 Bldg 28, Room 451 (559) 445-5355 (951) 782-4347 Santa Ana, CA 92701 (714)558-4597 Long Beach Sacramento Santa Barbara*Satellite office 300 Oceangate Street, Suite 200 160 Promenade Circle, Suite 300 130 East Ortega Street Long Beach, CA 90802-4304 Sacramento, CA 95834 Santa Barbara, CA 93101-1631 (562)590-5240 (916)928-3158 (805) 884 1032 Los Angeles Salinas Santa Rosa 320 W. 4th Street, 9th floor 1880 North Main Street, Suite 100 50 "D" Street, Room 420 Los Angeles, CA 90013-2329 Salinas, CA 93906-2037 Santa Rosa, CA 95404-4771 (213) 576-7389 (831) 443-3058 (707) 576-2452 Marina del Rev San Bernardino Stockton 4720 Lincoln Blvd, 2nd floor 464 W. Fourth Street, Suite 239 31 East Channel Street, Room 344 Marina del Rey, CA 90292-6902 San Bernardino, CA 92401-1411 Stockton, CA 95202-2314 (310) 482-3820 (909) 383-4522 (209) 948-7980 Oakland San Diego Van Nuys 1515 Clay Street, 6th floor 7575 Metropolitan Drive, Suite 202 6150 Van Nuys Blvd., Room 105 Oakland, CA 94612 San Diego, CA 92102-4424 Van Nuys, CA 91401-3370 (510) 622-2861 (619) 767-2082 (818) 901-5367 W04NE116 travelers.com The Travelers Indemnity Company and its property casualty affliates. One Tower Square, Hartford, CT 06183 © 2016 The Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are regl[ Travelers Indemnity Company in the U.S. and other countries. CE-10277 Rev. 10-2015 ,„ RiekManagtmtwttlliviefon I REVIEWED6 APPROVED 6Y.' Rnk Management Analyst TRAVELERS J�' Sus beneficios de compensation laboral CALIFORNIA Este formulario debe entregarse a todos los emp/eados recien contratados en el estado de California. Su contenido se aplica a los accidentes de trabajo ocurridos a partir del 1 de enero de 2013. Cualquier persona que haga o propicie que se haga cualquier declaraci6n sustancial a sabiendas falsa o fraudulenta con el prop6sito de obtener o denegar beneficios o pages de compensation laboral es culpable de un delito. Usted puede tener derecho a beneficios de compensaci6n laboral si resulta lesionado o se enferma a causa de su trabajo, o si es victima de un delito en el lugar de trabajo. La compensaci6n laboral cubre la mayoria de las lesiones y enfermedades fisicas o mentales relacionadas con el trabajo. Una lesi6n o enfermedad puede ser causada per un acontecimiento (como lastimarse la espalda en una calda) o per exposiciones repetidas a una circunstancia perjudicial (come lastimarse la mufieca per hater el mismo movimiento una y otra vez). Los beneficios de compensaci6n laboral incluyen: Atenci6n medica: consultas m6dicas, servicios hospitalarios, fisioterapia, anAlisis de laboratorio, radiografias y medicamentos que Sean razonablemente necesarios para tratar su lesi6n. No debe recibir nunca una factura. Es posible que las visitas para fisioterapia, terapia ocupacional y al quiropractico tengan un limite de 24 vistas para cada tipo. Beneficios per incapacidad temporal: Pages si usted deja de recibir su salario mientras se recupera. Para la mayoria de las lesiones ocurridas despu6s del 18 de abril de 2004, los beneficios per incapacidad temporal se limitan a 104 semanas dentro del lapse de 5 anos a partir de la fecha de la lesi6n. Presentar de forma oportuna una reclamaci6n en el Departamento de Desarrollo Laboral (Employment Development Departmeno puede conducir a la obtenci6n de beneficios estatales adicionales per incapacidad cuando se terminan los beneficios per incapacidad total temporal (TTD, per sus siglas en ingles), o cuando estos se demoran o los deniegan. Beneficios por incapacidad permanente: Pages si su lesi6n causa una incapacidad permanente. Una vez que su lesi6n se estabilice, es posible que el medico que to trata determine que usted tiene una incapacidad permanente, dependiendo de su grade de recuperaci6n. La cantidad de incapacidad permanente que su medico determine sera clasificada per su administrador de reclamaciones segtin su edad y ocupaci6n con el fin de determinar el porcentaje y la cantidad correspondiente en d6lares que se le debe a usted a causa de la incapacidad permanente. La ley estatal establece dichas cantidades. Usted tiene derecho a obtener una clasificaci6n estatal de incapacidad o a apelar la clasificaci6n. Vales suplementarios par destitucibn laboral: Si su lesi6n conlleva a que usted falte a su trabajo y le causa una incapacidad permanente, usted puede recibir un vale suplementario per destitucibn laboral si su empleador no le ofrece un empleo modificado, alternative o regular dentro de 60 dias de haber recibido el informe medico que indique que usted logr6 una recuperaci6n m6dica maxima. El vale es para reembolsar los costos educativos y tiene un limite de $6,000.00. Si usted recibe un vale come consecuencia de su lesi6n, tiene dos Silos desde la fecha en que le proporcionen el vale o cinco anos desde la fecha de su lesi6n (lo que ocurra Gltimo), para solicitar el reembolso de los gastos que califiquen. Beneficios por muerte: Se pagan a los dependientes de un trabajador que muere a causa de una lesi6n o enfermedad laboral. Tambien se cubren los gastos del entierro; la cantidad maxima permitca depende de la fecha de la lesi6n. Los beneficios per incapacidad temporal, incapacidad permanente y muerte se pagan a una tasa basada en 2/3 de su salario semanal promedio, y estan sujetos a las cantidades minimas y maximas vigentes en el estado en la fecha de su lesi6n. Estos beneficios se pagan cada dos semanas mientras usted sea elegible. Programa para reintegrarse al trabajo: Si usted sufre la p6rdida permanente de sus ingresos come resultado de su lesi6n y se determina que sus beneficios per incapacidad permanente son desproporcionadamente bajos, es posible que usted califique para recibir dinero adicional del Fondo para la reintegraci6n al trabaio del Departamento de W04NF116 travelers.com The Travelers Indemnity Company y sus filiales de seguros generales/patrimoniales. One Tower Square, Hartford, © 2016 The Travelers Indemnity Company. Toros los derechos reservados. Travelers y at logotipo con Is sombrill marcas registradas de The Travelers Indemnity Company an los EE. UU. y otros pa ses. CE- 10277 Rev. 10-2015 Pagina 1 of 6 "—An Rkk ManagemrttDlW bn �. ReAevao & APPRo6vvm By.. �Aotsv.+ro•F �, Vet Risk Management Analyst J3elaciones_.Laborales (Department of Industrial Relations). Comuniquese con el-Departamento de Relaciones Laborales en: www.dir.ca.gov/ para conocer m6s acerca de este beneficio adicional. Es posible que las actividades como voluntario, en sus horas libres, recreacionales, sociales o atleticas no esten cubiertas bajo la compensaci6n laboral. Si se lastima: Obtenga atenci6n medica. Si necesita primeros auxilios, comuniquese con su empleador. Si necesita atenci6n urgente, pida ayuda de inmediato. Informe sobre su lesion. Informe de inmediato a su supervisor sobre su lesi6n. No demore en hacerlo; existen limites de tiempo. Si espera demasiado, puede perder los derechos que tiene a recibir beneficios. Su empleador tiene que proporcionarle un formulario de reclamaci6n a m6s tardar un dia laborable despu6s de que est6 enterado de su lesion, y tambi6n debe autorizar el tratamiento a m6s tardar un dia laborable despu6s de que usted le entregue una copia del formulario Ileno y firmado. El plazo de prescripcl6n para presentar una reclamaci6n de compensation laboral es de un afio a partir de la fecha de la lesi6n o, si esta se debe a exposiciones repetidas, un afio a partir del momento en que usted se dio cuenta o debi6 darse cuenta de que su trabajo caus6 la lesion. Vea a su medico tratante. Su medico tratante primario es el m6dico con la responsabilidad global de tratar su lesi6n o enfermedad. 1�I o ella est6n a cargo de mantener la continuidad de su atenci6n, asi como de remitirlo a los especialistas. Si su empleador tiene una Red de Proveedores Medicos (MPN, por sus siglas en ingles) aprobada, es posible que ellos puedan limitar sus opciones de medicos tratantes, que retengan el control medico, y que le exijan que se atienda con un medico de la MPN desde el principio. (Una MPN es una red escogida de proveedores de atenci6n medica que proveen tratamiento a los empleador que se lesionan en el trabajo. Consulte con su empleador para obtener m6s informacion sobre su MPN). De to contrario, su empleador tiene el derecho de escoger el medico que to tratar6 a usted por Jos primeros 30 dias. Si su empleador no tiene una MPN aprobada y usted desea cambiar de medico en los primeros 30 dias despu6s de presentar su reclamaci6n, su administrador de reclamaciones debe escoger un medico nuevo en un lapso de cinco dias despu6s de que usted to solicite. Si usted le proporcion6 a su empleador el nombre de su medico personal antes de sufrir la lesi6n y tiene seguro medico de grupo al momento de la lesi6n, usted puede tratarse con su medico personal incluso si su empleador tiene una MPN aprobada. Su medico personal debe ser un medico general o un medico internista, pediatra, ginecobstetra o medico de familia con certificado de especialidad o que haya completado su especialidad, o un grupo medico con multiples especialidades con doctores o licenciados en medicina, y debe haberlo tratado y tener sus antecedentes medicos y su historia clinica antes de su lesi6n laboral y tambien debe estar de acuerdo en tratarlo par una lesion o enfermedad laboral. Si su empleador no tiene una MPN aprobada y usted le dio a su empleador por escrito el nombre de su quiropr6ctico o acupunturista personal antes de sufrir la lesi6n, usted puede cambiarse al quiropr6ctico o acupunturista cuando to solicite. Si todavia necesita recibir atenci6n medica luego de 30 dias, quiz6s pueda cambiarse a un medico de su propia election. Para mayor comodidad, se adjuntan a este documento formularios opcionales para predesignar a su medico personal o a un grupo medico con multiples especialidades con doctores o licenciados en medicina. Tambien se adjuntan formularios para predesignar a su acupunturista o quiropr6ctico personal si su empleador no cuenta con una red de proveedores medicos. Por ley, no se permite que Jos quiropr6cticos Sean el medico tratante luego de 24 visitas. Discriminaci6n: Es ilegal que su empleador to castigue o to despida por sufrir una lesion o enfermedad laboral, por presentar una reclamaci6n, o por testificar en el caso de compensaci6n laboral de otra persona. Si se determina que su empleador ha cometido discriminaci6n, usted puede tener derecho a que se le reincorpore a su puesto de trabajo con pagos retroactivos, una mayor compensaci6n, y costos y gastos. Es posible que usted tenga otros derechos bajo la Ley de Protection para Personas Discapacitadas (ADA, por sus siglas en ingles) o la Ley de Igualdad en el Empleo y la Vivienda (FEHA, por sus siglas en ingles). Para obtener m6s informacion, comuniquese con FEHA al (800) 884-1684 o con la Comisi6n de Igualdad de Oportunidades Laborales (EEOC, por sus siglas en ingles) al (800) 669-3362. Puede obtener information gratuita de un funcionario de information y ayuda de la Divisl6n de Compensation Laboral de su estado. Puede escuchar information grabada y una lista de las oficinas locales Ilamando sin costo al (800) 736-7401 o averiguar m6s en Iinea en: http://www.dir.ca.gov. W04NFI16 travelers.com The Travelers Indemnity Company y sus filiales de seguros generales/patrimoniales. One Tower Square, Hartford, © 2016 The Travelers Indemnity Company. Todos los derechos reservados. Travelers y el logolipo con Is sombrlll marcas registradas de The Travelers Indemnity Company an los EE. UU. y otros pa ses. CE- 10277 Rev. 10-2016 Pagina 2 of 6 lUek Ma�gemimfDitrieion REVIEWED&ryrA�PPRD� MBY. Risk Management Analyst Si su empleador no le proporciona atenci6n medica, usted tiene varias opciones. Primero, comuniquese con su administrador de reclamaciones para averiguar el estado de su reclamaci6n. Si le entreg6 a su empleador un formulario de reclamaci6n Ileno y firmado pero su reclamaci6n est6 retrasada par la investigaci6n, su empleador tiene que autorizar el tratamiento, hasta un mfiximo de $10,000.00, durante el retraso. Si todavia no se ha aceptado la reclamaci6n y sus costos medicos sobrepasan el Iimite reglamentario de $10,000.00, usted puede acudir a su plan medico de grupo para recibir atenci6n, buscar un medico, una clinical o un hospital que le facture directamente al administrador de reclamaciones, o utilizar los servicios p6blicos de atenci6n m6dica. Usted tiene derecho a estar en desacuerdo con las decisiones que afectan su reclamaci6n. Si este en desacuerdo, comuniquese primero con su administrador de reclamaciones para ver si to pueden resolver. Su compafila de seguros de compensaci6n laboral es Travelers Property Casualty Company of America. Tambien puede buscar su compafila de seguros en el directorio en linea de WCIRB: https://www.caworkcornpcoverage.com/ Puede obtener informaci6n gratuita de un funcionario de Informaci6n y Ayuda de la Divisi6n de Compensaci6n Laboral de su estado, o puede escuchar informaci6n grabada y una lista de las oficinas locales Ilamando al (800) 736-7401. Al final de este folieto, encontrare una lista de las oficinas de Informaci6n y Ayuda. Esto to ayudar6 a localizar la oficina mes cerca de usted. Para mas informaci6n, tambi@n puede visitar el sitio web del DWC en: http://v4ww.dir.ca.clov. Puede consultar con un abogado. La mayoria de los abogados ofrecen una consulta gratuita. Si decide contratar un abogado, es posible que los honorarios se saquen de algunos de sus beneficios. Para obtener los nombres de los abogados especializados en compensaci6n laboral, Ilame al Colegio de Abogados del estado de California al (415) 538-2120 o visite su sitio web en: http://www.californiaspecialist.org. El funcionario local de informaci6n y ayuda puede proporcionarle una lista de IDS abogados o usted puede buscarlos en las paginas amarillas. W04NFI16 travelers.com The Travelers Indemnity Company y sus fliales de seguros generales/patrimoniales. One Tower Square, Hartford, © 2016 The Travelers Indemnity Company. Todos los derechos reservados. Travelers y el Iogotipo con Is sombrill+ marcas registradas de The Travelers Indemnity Company an los EE. UU. y otros pa ses. CE- 10277 Rev. 10-2015 Pagina 3 of 6 RW1skMawVg tDlvrslon ti REVIEWED&APPROVED By' Q i44avlma R, mud �-- Risk M,nagelT rt Analyst Designacion Previa De Medico Particular En caso de que usted sufra una lesi6n o enfermedad relacionada con su empleo, usted puede recibir tratamiento m6dico por esa lesi6n o enfermedad de su m6dico particular (M.D.), m6dico oste6pata (D.C.) o grupo medico si: • en la fecha de su lesi6n de trabajo, usted tiene cobertura de salud par lesiones o enfermedades que no est6n relacionado con el trabajo • el medico es su m6dico familiar o de cabecera, que sera un medico que ha limitado su pr6ctica m6dica a medicina general o que es un internista certificado o elegible para certificaci6n, pediatra, gineco-obstreta, o m6dico de medicina familiar y que previamente ha estado a cargo de su tratamiento medico y tiene su expediente medico • su "medico particular" puede ser un grupo medico si es una corporaci6n o sociedad o asociaci6n compuesta de doctores certificados en medicina u osteopatia, que opera un integrado grupo medico multidisciplinario que predominantemente proporciona amplios servicios medicos para lesiones y enfermedades no relacionadas con el trabajo. • antes de la lesi6n su medico esta de acuerdo a proporcionarle tratamiento m6dico para su lesi6n o enfermedad de trabajo • antes de la lesi6n usted le proporcion6 a su empleador por escrito to siguiente: (1) notificaci6n de que quiere que su medico particular le brinde tratamiento para una lesi6n o enfermedad de trabajo y (2) el nombre y direcci6n comercial de su m6dico particular. Puede utilizar este formulario pars notificarle a su empleador que desea que su m6dico particular o medico oste6pata to atienda para una lesi6n o enfermedad de trabajo y que IDS requisitos mencionados arriba han sido cumplidos. NOTICIA DE DESIGNA06N PREVIA DE MEDICO PARTICULAR Empleado: Llene esta secci6n. A: (nombre del empleador) Si tengo una lesi6n o enfermedad de trabajo, yo elijo ser atendido por: (nombre del m6dico) (M.D., D.O., o grupo m6dico) (direcci6n, ciudad, estado, c6digo postal) de telefono) Nombre del Empleado (en letras de molde, por favor): Domicilio del Empleado: Nombre de la Companla de Seguros, Plan o Fondo de proporcionar cobertura de salud para lesiones o enfermedades no ocupacionales: Firma del Empleado: Fecha: Medico: Estoy de acuerdo con esta Designaci6n Previa: Firma: Fecha: (Medico o Empleado designado por el Medico o Grupo Medico) El m6dico no esta o bligado a firmer este formul ario, sin embargo, at el m6dico o empl eado designado por el m6dico o grupo m6dico no firma, ser6 n ecesario presenter documentacidn sabre at consentimiento del m6dico de ser designado previamente de acuerdo al C6digo de Reglamentos de California, T( tulo 8, seccidn 9780.1 (a) (3). TI tulo 8, C6digo de Regulaciones de California, secci6n 9783 Opcional Formulario DW C 9783, Fecha de vigencia 1 de Julio 2014 Designacidn Previa del M6dico Personal;Obligaciones de Informaci6n de Is prima ria El tratamiento m6dico Reglamentos 8 CCR Seccidn 9780, at seq. (Aprobado 12102/2014) W04NFI16 travelers.com The Travelers Indemnity Company y sus filiales de seguros genemles/patrimoniales. One Tower Square, Hartford, © 2016 The Travelers Indemnity Company. Todos los derechos reservados. Travelers y el logotipo con Is sombrill marcas registradas de The Travelers Indemnity Company en Ins EE. UU. y otros pa ses. CE- 10277 Rev. 10-2015 Pagina 4 of 6 " Rink MmnagemenEDMaicm rrR��EVIEWED&{�AP`P`IRIOppVgED BY. 8 E"4ENr5vkl �, Y:.GCA44(�e, . Risk Management Analyst AVISO DE QUIROPRACTICO PERSONAL O A CUPUNTURISTA PERSONAL mp SI su eea a or o compania de seguros de su empleador no tiene una Red de Proveedores Medicos establecida, posiblemente puede cambiar su medico que to esta atendiendo a su quiropr6ctico o acupunturista personal despu6s de una lesion o enfermedad de trabajo. Para hacer este cambio, usted debe darle por escrito a su empleador el nombre y la direcci6n comercial de un quiropr6ctico o acupunturista personal antes de la lesi6n o enfermedad. Generalmente, su administrador de reclamos tiene el derecho de elegir al medico que le proporcionara el tratamiento dentro de los primeros 30 dias despu6s de que su empleador sepa de su lesion o enfermedad. Despues de que su administrador de reclamos ha iniciado su tratamiento con otro medico durante este tiempo, puede entonces usted, bajo petici6n, transferir su tratamiento a su quiropr6ctico o acupunturista personal. NOTA: Si la fecha de la lesion es el 1 de enero de 2004 o posterior, un quiropractico no puede ser su m6dico tratante despu6s de haber recibido 24 visitas al quiropr6ctico a menos que su empleador ha autorizado visitas adicionales por escrito. El t6rmino "visita quiropractica", cualquier visita a la oficina de la quiropractica, independientemente de si los servicios prestados implican la manipulaci6n quiropr6ctica o se limitan a la evaluacion y gesti6n. Una vez que haya recibido 24 visitas al quiropr6ctico, si aun necesita tratamiento medico, usted tendra que elegir un nuevo medico que no es un quiropractica. Esta prohibicion no se aplicara a las visitas para las visitas de medicina flsica posquirurgicos prescritos por el cirujano o un medico designado por el cirujano, en el marco del componente posquirurgica de la Division de Tratamiento Medico programa de utilizaci6n de Compensaci6n para Trabajadores. Puede utilizar este formulario para notificarle a su empleador de su quiropractica o acupunturista personal. Informaci6n sobre su Quiropractico o Acupunturista: (nombre del quiropractico o acupunturis ta) (direcci6n, ciudad, estado, c6digo postal) (n(imero de telefono) Nombre del Empleado (en letras de molde, por favor): Domicilio del Empleado: Firma del Empleado: _Fecha: Ti tulo 8, C6digo de Regulaciones de California, secci6n 9783.1 (Opcional Formulario DW C 9783.1, Fecha de vigence 1 de Julio 2014) Designaci6n Previa del Medico Personal;Obligaciones de Informaci6n del M6dico Primario - Regulaciones 8 C.C.R. Secci6n 9780,et seq. (Aprobado 12102/2014) W04NF116 travelers.com The Travelers Indemnity Company y sus filiales de seguros generales/patrimoniales. One Tower Square, Hartford, © 2016 The Travelers Indemnity Company. Todos los derechos reservados. Travelers y el logotipo con la sombrill marcas registradas de The Travelers Indemnity Company an los EE. UU. y otros pa ses. CE- 10277 Rev. 10-2015 Pagina 5 of 6 „ RiskMwugesimtDivislon 3��,+ REVIEWED&APPROVED BY. LAR Risk Management Analyst - Comuniquese coma unidad de inform ion y ayuda -- Por telefono al 1-800-736-7401: Para obtener informaci6n grabada que ayuda a los trabajadores lesionados, los empleadores y otras personas a entender el sistema de compensaci6n laboral de California, y sus derechos y responsabilidades conforme a la ley. • Asistiendo a un taller Para trabajadores lesionados • Llamando o yendo en persona a una oficina local de la Unidad de informaci6n y ayuda: Anahel Oxnard San Francisco 1065 N. PacifiCenter Drive 1901 N. Rice Ave., Ste. 200 455 Golden Gate Avenue, 2nd floor Anaheim, CA 92806 Oxnard, CA 93036 San Francisco, CA 94102-7014 (714)414-1801 (805)485-3528 (415)703-5020 Bakersfield Pomona San Jose 1800 30th Street, Suite 100 732 Corporate Center Drive 100 Paseo de San Antonio Bakersfield, CA 93301-1929 Pomona, CA 91768-2653 Room 241 (661)395-2514 (909)623-8568 San Jose, CA 95113-1402 (408) 277-1292 Eureka Reddina San Luis Obispo 100 "H" Street, Room 202 25o Hemsted-Drive, 2nd Floor, Ste. B 4740 Allene Way, Suite 100 Eureka, CA 95501-0481 Redding, CA 96002 San Luis Obispo, CA 93401 (707) 441-5723 (530) 225-2047 (805) 596-4159 Fresno Riverside Santa Ana 2550 Mariposa Mall, Suite 4078 3737 Main Street, Room 300 605 W Santa Ana Blvd Bldg 28, Fresno, CA 93721-2219 Riverside, CA 92501-3337 Room 451 (559) 445-5355 (951) 782-4347 Santa Ana, CA 92701 (714) 558-4597 Long Beach Sacramento Santa Barbara Satellite Office 300 Oceangate Street, Suite 200 160 Promenade Circle, Suite 300 130 E. Ortega Street Long Beach, CA 90802-4304 Sacramento, CA 95834 Santa Barbara, CA 93101-1631 (562) 590-5240 (916) 928-3158 (805) 884-1032 Los Angeles Salinas Santa Rosa 320 W. 4th Street, 9th floor 1880 North Main Street, Suite 100 50 "D" Street, Room 420 Los Angeles, CA 90013-2329 Salinas, CA 93906-2037 Santa Rosa, CA 95404-4771 (213)576-7389 (831)443-3058 (707)576-2452 Marina del Rev San Bernardino Stockton 4720 Lincoln Blvd, 2nd &3rd floors 464 W. Fourth Street, Suite 239 31 East Channel Street, Room 344 Marina del Rey, CA 90292-6902 San Bernardino, CA 92401-1411 Stockton, CA 95202-2314 (310)482-3858 (909)383-4522 (209)948-7980 Oakland San Dieao Van Nuys 1515 Clay Street, 6th floor 7575 Metropolitan Drive, Suite 202 6150 Van Nuys Blvd., Room 105 Oakland, CA 94612 San Diego, CA 92108 Van Nuys, CA 91401-3370 (510)622-2861 (619)767-2082 (818)901-5367 W04NF116 travelers.com The Travelers Indemnity Company y sus filiales de seguros generales/patrimoniales. One Tower Square, Hartford, © 2016 The Travelers Indemnity Company. Todos los derechos reservados. Travelers y el logotipo con la sombrilli marcas registradas de The Travelers Indemnity Company an los EE. UU. y otros pa sea. CE- 10277 Rev. 10-2015 Pagina 6 of 6 AWN' Riskangge MmedDWIElon REVIEWED &APPROVED BY. al ' o''' Risk Management Anatysl ' IMPORTANT Policy Audit Information Dear Policyholder: This policy is issued with an estimated premium based upon information provided through your Producer. This premium is subject to adjustment at the end of the policy period. At that time, you may receive a request for information in the mail or a premium auditor may contact you to review the necessary records. The information developed is needed to determine the final earned premium for this policy. Record Maintenance In order to facilitate audit service, it is necessary to maintain proper records and have them available at the proper time. Based on the nature of your business, some of the following data will be necessary to complete the audit: 1. General Ledger, Financial Statements 2. Payroll Records, Time Books, State Unemployment Returns, FICA Returns, Individual Earnings Records -Monthly totals separated by type of work and overtime. 3. Cash Receipts, Sales Journal 4. Cash Disbursements Journal - Including subcontractors. casual labor and material costs. 5. Certificates of Insurance IMPORTANT COVERAGE NOTE: If you utilize subcontractors whose legal status is that of sole proprietor/partner, we may charge premium for these persons as provided under Part 5 of the policy contract even though certificates of insurance may exist. Please contact your producer if you have any questions regarding your Workers' Compensation coverage needs. Work in Other States Please advise your Producer if employees are hired for work in states other than those listed in Item 3. of your policy. This will enable your producer to consider your need for coverage in accordance with state laws. We appreciate the opportunity to serve you. If you have any questions about the enclosed policy or any insurance matters please contact your producer or your Company representative. WUNN7F00 RAMmsgemmtD1M1m 3"Y y REVIEWED&APPtR(a/v�mRY: 8 '7 ��FNGvI�t M1, MufF/i� Risk Management Analyst IMPORTANT NOTICE - PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2015 NO COVERAGE IS PROVIDED BY THIS NOTICE. THIS NOTICE DOES NOT AMEND ANY PROVISION OF YOUR POLICY. YOU SHOULD REVIEW YOUR ENTIRE POLICY CAREFULLY FOR COMPLETE INFORMATION ON THE COVERAGES PROVIDED AND TO DETERMINE YOUR RIGHTS AND DUTIES UNDER YOUR POLICY. PLEASE CONTACT YOUR AGENT OR BROKER IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR ITS CONTENTS. IF THERE IS ANY CONFLICT BETWEEN YOUR POLICY AND THIS NOTICE, THE PROVISIONS OF YOUR POLICY PREVAIL. The Terrorism Risk Insurance Act of 2002 (TRIA), as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2015 (TRIPRA 2015), provides for a program under which the Federal Government will share in insured losses caused by certain acts of terrorism. Unless the United States Congress takes action to extend it, TRIA will expire on December 31, 2020. Your policy provides coverage for workers compensation losses caused by acts of terrorism, subject to the policy's terms, definitions, exclusions and conditions. This coverage includes workers compensation benefit obligations dictated by state law, except in Pennsylvania, where injuries or deaths resulting from certain war - related activities are excluded from workers compensation coverage. The premium charge for the coverage that your policy provides for terrorism losses is shown on the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement that is included in your policy. In the event of TRIA's expiration, this premium amount may continue or change for new, renewal, and in -force policies in effect on or after December 31, 2020, subject to regulatory review in accordance with applicable state law. No action regarding this notice is required on your part at this time. If you have any questions about this notice, please contact your Travelers representative. WUNNBA20 © 2018 The Travelers Indemnity Company. All rights reserved. �r�nn Rule Manage ED[vIs[= 4 °-,n REVIEWED&�}APPRO{vm8y: 01 '"1f1 Risk Management Analyst TRAVELERS ALASKA NOTICE TO INSURED Dear Policyholder: This is to notify you that your Workers' Compensation and Employers Liability policy does not provide Other States Coverage for the State of Alaska. If you have operations or start up an operation in Alaska, and it is not listed in Item 3A of the Information Page, you or your agent must notify us and request that this state be covered under your policy. With receipt of your request for coverage, we will extend the policy to include this state. Your Agent can provide you with necessary information and will assist you in obtaining coverage for this state. WUNN9C01 w MskManmg, tDhUlm REVIt D & APPROVED BY. '" Risk Management Analyst TRAVELERSJ* PRIVACY NOTICE PRIVACY POLICY Thank you for selecting THE TRAVELERS INSURANCE COMPANIES as your workers compensation insurer. At THE TRAVELERS INSURANCE COMPANIES a subsidiary of Travelers, we recognize that privacy is important to you. That is why we are committed to protecting your privacy through the adoption of the following privacy principles: Collection Of Information We collect, retain, and use information about you, or about participants, beneficiaries or claimants under your workers compensation coverage, only where we believe that it will help or is necessary to provide you products and services or otherwise conduct our business. We collect nonpublic personal financial information about you, or about participants, beneficiaries or claimants under your workers compensation coverage, from the following sources: • information we receive from you or through your agent or broker on applications or other forms; • information we receive from or about you in the process of adjusting claims; • information about your other transactions, including risk control and other consulting services, with us, our affiliates or other third parties; • information about your coverages and loss activity with other carriers; and • information we receive from a consumer reporting agency. Such information includes identifying information such as policyholder, participant, beneficiary or claimant name, address, and social security number; financial information such as income, payment history, or credit history; and, under certain circumstances, health information such as information about an illness, disability, or injury. It could also include information on claims with other insurance companies and us and the condition and mainte- nance of your property. Disclosure Of Information We usually do not disclose nonpublic personal information about you, or about participants, beneficiaries or claimants under your workers compensation coverage, without your consent. However, in some circumstances we may disclose information to others without your prior authorization. The most common disclosures are to the following persons: • our affiliated property and casualty insurance companies; • state insurance departments, for their regulation of our business; • other government authorities; • our agents and brokers as necessary to conduct our business; • organizations that perform underwriting and claims investigations; • another insurance company to which you have applied for a policy or submitted a claim; • insurance support agencies, law enforcement agencies and our reinsurers; and • any other third party, as permitted or required by law. Most importantly, THE TRAVELERS INSURANCE COMPANIES does not and will not disclose or sell nonpublic personal information about you, or about participants, beneficiaries or claimants under your workers compensation coverage, to anyone for marketing purposes. WUNNAB09 . as R®kManagcrnmtlHviafen ;k � REVIEWED&IApmavvm By: SI -1 F4402 R, V e ` Risk Mana9eirrent Anatyst Confidentiality And Security We restrict access to nonpublic personal information about you, or about participants, beneficiaries or claimants under your workers compensation coverage, to those who need it to serve your insurance needs and to maintain and improve customer service. We maintain physical, electronic, and procedural safeguards that comply with federal and state laws and regulations to guard your nonpublic personal information. Disclosure and Protection of Former Customers' Information We may disclose all the personal information we have collected, as described above. However, even if you no longer have a customer relationship with us, we will continue to follow our privacy policies and practices to protect your information. Changes In Privacy Policy We may choose to modify our policy regarding the treatment of personal information at any time. Before we do so, we will notify you and provide an updated privacy notice. WUNNAB09 P nFo MakMamgmtmtD[Welm REVIEWED&APPROVED BY. t F44"4,e R. Vcddt"ead Risk Management Analyst IMPORTANT NOTICE - INDEPENDENT AGENT AND BROKER COMPENSATION NO COVERAGE IS PROVIDED BY THIS NOTICE. THIS NOTICE DOES NOT AMEND ANY PROVISION OF YOUR POLICY. YOU SHOULD REVIEW YOUR ENTIRE POLICY CAREFULLY FOR COMPLETE INFORMATION ON THE COVERAGES PROVIDED AND TO DETERMINE YOUR RIGHTS AND DUTIES UNDER YOUR POLICY. PLEASE CONTACT YOUR AGENT OR BROKER IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR ITS CONTENTS. IF THERE IS ANY CONFLICT BETWEEN YOUR POLICY AND THIS NOTICE, THE PROVISIONS OF YOUR POLICY PREVAIL. For information about how Travelers compensates independent agents and brokers, please visit www.travelers.com, call our toll -free telephone number 1-866-904-8348, or request a written copy from Marketing at One Tower Square, 2GSA, Hartford, CT 06183. WUNNDD08 RN T4 54 0108 RiskManugt tDiv IM RREVIEWED&@APPROVED RY. Risk Management Analyst ATTENTION The enclosed Posting Notices must be displayed in a prominent location in the workplace. It is your responsibility to distribute the applicable Posting Notice(s) to each of your locations and to notify each location that it must post these notices, and keep them posted, in a conspicuous location frequented by your employees. Posting Notices for the states of Missouri, New Mexico and Texas (Spanish Version) are provided on two separate forms, which must be connected to create one large notice to be posted. Please contact us at wcppn@travelers.com for assistance in completing the healthcare provider information on Posting Notices for Georgia, Pennsylvania, Tennessee and Virginia. While carriers are required to provide Posting Notices in AZ, AR, CA, DC, FL, ID, KS, KY, MO, and NY, Travelers is providing Posting Notices to you for all states* covered under your policy as a courtesy. All such Posting Notices remain subject to state regulation and are subject to change at any time. For states in which Travelers is providing you with Posting Notices as a courtesy, Travelers assumes no obligation to provide you with revised notice(s) if a state changes its Posting Notice during the current policy term. If you need additional copies of any Posting Notice, please contact your agent. * Excluding: DE, GU, IA, NE, ND, OH, PR, SD, VI, WA, WI and WY. The following states do not require posting notices: DE, GU, IA, NE, SD, and WI. The state of OR will provide the posting notice directly. The following are monopolistic states — there are no posting notices for employers' liability: ND, OH, PR, VI, WA and WY. WUNNNN19 M&APPRovD Dm8y. . g i Fusv. R, V&AUd Risk Marn9emenl Mayst THE FRIDA CINEMA ISSUE TO: STATE OF CALIFORNIA- DEPARTMENT OF INDUSTRIAL RELATIONS" Division of Workers' -Compensation - - Notice to Employees - Injuries Caused By Work You may be entitled to workers' compensation benefits if you are injured or become ill because of your job. Workers' compensation covers most work -related physical or mental injuries and illnesses. An Injury or illness can be caused by one event (such as hurting your back in a fall) or by repeated exposures (such as hurting your wrist from doing the same motion over and over). Benefits. Workers' compensation benefits include: • Medical Care: Doctor visits, hospital services, physical therapy, lab tests, x-rays, medicines, medical equipment and travel costs that are reasonably necessary to treat your injury. You should never see a bill. There are limits on chiropractic, physical therapy and occupational therapy visits. • Temporary Disability (TD) Benefits: Payments if you lose wages while recovering. For most injuries, TD benefits may not be paid for more than 104 weeks within five years from the date of injury. • Permanent Disability (PD) Benefits: Payments if you do not recover completely and your injury causes a permanent loss of physical or mental function that a doctor can measure. • Supplemental Job Displacement Benefit: A nontransferable voucher, if you are injured on or after 1/112004, your injury causes permanent disability, and your employer does not offer you regular, modified, or alternative work. • Death Benefits: Paid to your dependents if you die from a work -related injury or illness. Naming Your Own Physician Before Injury or Illness (Predesignation). You may be able to choose the doctor who will treat you for a job injury or illness. If eligible, you must tell your employer, in writing, the name and address of your personal physician or medical group before you are injured. You must obtain their agreement to treat you for your work injury. For instructions, see the written information about workers' compensation that your employer is required to give to new employees. If You Get Hurt: 1. 'Get Medical Care. If you need emergency care, call 911 for help immediately from the hospital, ambulance, fire department or police department. If you need first aid, contact your employer. 2. Report Your Injury. Report the injury immediately to your supervisor or to an employer representative. Don't delay. There are time limits. If you wait too long, you may lose your right to benefits. Your employer is required to provide you with a claim form within one working day after learning about your injury. W !thin one working day after you file a claim form, your employer or claims administrator must authorize the provision of all treatment, up to ten thousand dollars, consistent with the applicable treatment guidelines, for your alleged injury until the claim is accepted or rejected. 3. See Your Primary Treating Physician (PTP). This is the doctor with overall responsibility for treating your injury or illness. • If you predesignated your personal physician or a medical group, you may see your personal physician or the medical group after you are injured. ° If your employer is using a medical provider network (MPN) or a health care organization (HCO), in most cases you will be treated within the MPN or HCO unless you predesignated a personal physician or medical group. An MPN is a group of physicians and health care providers who provide treatment to workers injured on the job. You should receive information from your employer if you are covered by an HCO or a MPN. Contact your employer for more information. • If your employer is not using an MPN or HCO, in most cases the claims administrator can choose the doctor who first treats you when you are injured, unless you predesignated a personal physician or medical group. 4. Medical Provider Networks. Your employer may be using an MPN, which is a group of health care providers designated to provide treatment to workers injured on the job. If you have predesignated a personal physician or medical group prior to your work injury, then you may go there to receive treatment from your predesignated doctor. If you are treating with a non-MPN doctor for an existing injury, you may be required to change to a doctor within the MPN. For more information, see the MPN contact information below: MPN website: WWW.MYWCINFO.COM MPN Effective Date: 03-25-20 MPN Identification number 2493 If you need help locating an MPN physician, call your MPN access assistant at: (800) 287-9682 If you have questions about the MPN or want to file a complaint against the MPN, call the MPN Contact Person at (800) 287.9682 Discrimination. It is illegal for your employer to punish or fire you for having a work injury or illness, for filing a claim, or testifying in another person's workers' compensation case. If proven, you may receive lost wages, job reinstatement, increased benefits, and costs and expenses up to limits set by the state. Questions? Learn more about workers' compensation by reading the information that your employer is required to give you at time of hire. If you have questions, see your employer or the claims administrator (who handles workers' compensation claims for your employer): TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA Claims Administrator THE TRAVELERS INSURANCE COMPANIES Phone (800) 238-6225 W orkers' compensation insurer (Enter "self -insured" if appropriate) You can also get free information from a State Division of W orkers' Compensation Information (DWC) & Assistance Officer. The nearest Information & Assistance Officer can be found at location: or by calling toll -free (800) 736.7401. Learn more information about workers' compensation online: www.dwc.ca.gov and access a useful booklet "Workers' Compensation in California: A Guidebook for Injured W orkers." False claims and false denials. Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments be fined and imprisoned. a.„ Risk Ma EDlvisim Your employer may not be liable for the payment of workers' compensation benefits for any injury that adREvIEwm&APPRal BY: participation in any off -duty, recreational, social, or athletic activity that is not part of your work-relk it DWC 7 (111/2016) Risk Management Analyst W04P2K16 ISSUE TO: THE FRIDA CINEMA ESTADO DE CALIFORNIA— DEPARTAMENTO DE RELACIONES INDUSTRIALES= Division de Compensacion de Trabajadores -- - - Aviso a los ores — Lesiones Causadas por el Trabajo 0 Es posible qua usted tenga derecho a beneficios de compensaci6n de trabajadores st usted se Iesiona o se enferma a causa de su trabajo. La compensaci6n de trabajadores cubre Is mayora de las lesiones y enfermedades flsicas o mentales relacionadas con el trabajo. Una Iesi6n o enfermedad puede ser causada por un evento (come por ejemplo lastimarse to espalda an una ca do) o per acciones repetidas (come por ejemplo lastimarse la muneca per hacer el mismo movimiento una y otra vez). Beneficios. Los beneficios de compensaci6n de trabajadores incluyen: • Atenci6n M6dtca: Consultas m6dlcas, servictos de hospital, terapia fisica, analisis de laboratorio, radtograflas, medicinas, equipo medico y castes de viajar qua son razonablemente necesarias pars tratar su lesion. Usted nunca debera ver un cobro. Hay Ilmites para visitas quiropr6cticas, de terapia fisica y de terapia ocupacional. • Beneficios por Incapacidad Temporal (TD): Pages si usted pierce sueldo mantras se recupera. Para la mayors de las lesiones, beneficios de TD no se pagar6n por mas de 104 semanas dentro de cinco anos despu6s de Is fecha de la lesion. • Beneficios por Incapacidad Permanente (PD): Pages si usted no se recupere completamente y si su lesion Is causa una p6rdida permanente de su func16n fisica o mental qua un medico puede medir. • Beneficfo Suplementario por Desplazamiento de Trabajo: Un vale no-transferible si su Iesi6n surge on o despu6s del 111/04, y su Iesi6n Is ocasiona una incapacidad permanente, y su empleador no le ofrece a usted un trabajo regular, modificado, o alternative. • Beneficios por Muerte: Pagodas a sus dependientes si usted muere a cause de una lesion o enfermedad relacionada con el trabajo. Designaci6n de su Propto M6dico Antes de una Lesi6n o Enfermedad (Designaci6n previa). Es posible quo usted pueda elegir at m6dico quo le atender6 an una lesion o enfermedad relacionada con of trabajo. Si elegible, usted debe informarle al empleador, por escrito, at nombre y Is direction de su m6dico personal o grupo m6dico, antes de qua usted se Iesiona. Usted debe de ponerse de acuerdo con su m6dtco para qua atienda la Iesi6n causada per el trabajo. Para instructions, vea la informacion escrita sabre Is compensaci6n de trabajadores qua se Is exige a su empleador carte a los empleador nuevos. Si Usted se Lastima: 1. Obtenga Atenci6n Medica. Si usted necesita atenct6n de emergencia, flame of 911 pare ayuda inmediata de un hospital, una ambulancla, of departamento de bomberos o departamento de policia. Si usted necesita primeros auxiltos, comuniquese con an empleador. 2. Reports su Lesi6n. Reports la Iesi6n inmediatamente a su supervisor(a) o a un representante del empleador. No se demore. Hay Ilmites de. tompo. Si usted espera demasiado, as posible qua usted pterda su derecho a beneficios. Su empleador esta obligado a proporctonarle un formulario de reclamo dentro de un die laboral despu6s de saber de an Iesi6n. Dentro de un dfa despu6s de qua usted presents un formulario de reclamo, el empleador o administrador de reclamos debe autorizar todo tratamiento m6dico, hasta diez mil d6lares, de acuerdo con las pautas de tratamiento aplicables a su presunta Iasi n, haste quo el reclamo sea aceptado o rechazado. 3. Consults al Medico quo Is esta Atendtendo (PTP). Este as el m6dico con to responsabilidad total de tratar su Iesi6n o enfermedad. • Si usted design6 previamente a su medico personal o grupo medico, usted puede consulter a su medico personal o grupo medico despu6s de lesionarse. • Si su empleador esta utilizando una Red de Proveedores M6dlces (MPN) o una Organizacibn de Cull Medico (HCO), an Is mayoria de Ica cases usted sera tratado dentro de to MPN o to HCO a manes que usted design6 previamente un m6dico personal o grupo medico. Una MPN es un grupo de m6dicos y proveedores de atencibn medicaque proporcionan tratamiento a trabajadores lesionados en el trabajo. Usted debe recibir informact n de su empleador si est cubterto por una HCO o una MPN. Hable con su empleador para m6s informacion. • Si su empleador no esta utilizando una MPN o HCO, en Is mayoria de los cases el administrador de reclamos puede escoger at medico qua to atiende primate, cuando usted as Iesiona, a menos quo usted design6 previamente a un m6dtco personal o grupo medico. 4. Red de Proveedores Medicos (MPN): Es posible qua su empleador use una MPN, to cual as un grupo de proveedores de asistencia medica designados Para dar tratamiento a los trabajadores lesionados an el trabajo. Si usted he hecho una designactbn previa de un medico personal antes de lesionarse on el trabajo, entonces usted puede recibir tratamiento de su medico previamente designado. Si usted esta recibiendo tratamiento de parte de un m6dico qua no pertenece a la MPN para una lesion existente, puede querime qua usted se cambia a un medico dentro de to MPN. Para mas informacion, vea la siguiente informacion de contacto de la MPN: Pagtna web de la MPN: WWW.MYWCINFO.COM Fecha de vigencia de to MPN: 03 -25-20 Numero de identificaci6n de la MPN: 2493 Si usted necesita ayuda an localizar un medico de una MPN, Ilame a su asistente de acceso de Is MPN al: (B00) 287-9682 _ Si uste d tie ne pre gunta s sobm to MPN o qutere presenter una queja on contra de to MPN, Ilame a Is Persona de Contacto de la MPN at Discriminaci6n. Es legal qua su empleador Is castigue o despida por sufrir una lesion o enferm edad en at trabajo, par presentar un reclamo a por testificar an el caso de compensaci6n de trabajadores de otra persona. De ser probado, usted puede recibir pages por p6rdida de sueldos, reposici6n del trabajo, aumento de beneficios y gastos hasta los If mites establectdos por el estado. t,Preguntas? Aprenda mas sabre Is compensaci6n de trabajadores leyendo la informacil qua se requiere qua su empleador le de cuando as contratado. Si usted bane preguntas, vea a su empleador o al administrador de reclamos (qua se encarga de los reclamos de compensaci6n de trabajadores de su empleador): Administrador de TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA Reclamos THE TRAVELERS INSURANCE COMPANIES Telefono (800) 238-6225 Asegurador del Segura de Compensaci6n de trabajador (Anote "autoasegurado" si as aproptado) Usted tambien puede obtener informacion gratuita de un Official de Informacl6n y Asistencia de to Divisi6n Estatal de Compensaci6n de Trabajadores. El Oficial de Informacion y Asistencia mas cercano se localize an: o Ilamando al numero gratuito (800) 736.7401. Usted puede obtener mas informacion sabre la compensacion del trabajador on el Internet en: www.dwc.ca.gov y acceder a una gufa util "Compensaci6n del Trabajador de California Una Gufa para Trabajadores Lesionados." Los reclamos falsos y rechazos falsos del reclamo. Cualquier persona qua haga o quo ocasione qua s representacitin material intenctonalmente falsa o fraudulenta, con el fin de obtener o negar beneficios trabajadores, as culpable de un delito grave y puede ser multado y encarcelado. RlskManage LDfviston - ,+ rREMEwED&ryAP'PROVmBr. 8I,', t e{ rM1£ kM�0�4 M1, yuf�vLQ� — Risk M.inagenenl Analyst Es posible qua su empleador no sea responsable por el page de beneficios de compensaci6n de trabajadores par su participaci6n voluntaria en cualquire actividad fuera del trabajo, recreative, social, o atletica quo no sea pa DWC 7 (1/12016) W04P3K16 1,00AN CROW CXECUTIVL QlNeoToR 323-420-7411 thafrldaglnom1401XMall AO , 1pt'1 3D19��DU �. 4,n' treat Santa Ana, CA 02701 xwnma„nw.,�w,,,emu�s,n w,. September 3, 2oIS City of Santa Ana To Whom It May Conoern, My name Is Logan Crow, and f am the Founder and Executive Director of The Iwrlde Cinema, Orange County's only non-profit, Indepondent art house oinema, located in Downtown Santa Ana, In reference to our upcoming programming which will be funded In pert by the city of Santa Ana's InveatIng In the Arts Grant, ploase be advised that Thai Frids Cinema will not be using a vehicle for our project, All activities related to the artlat grant will take place Inside our place of business. Thank you, and plehtse don't hesitate to get in touch should you have any additfnnal questions or needs. Most sincerely, pan w ExeouttveC1treator The) Frida Cinema TI'i Pii R'[iltliLCINIMA-01110 f vie w D 4k APPtdoVEI) By RIST < ANA(i01f:MT DIVISION Q 2010 2a :litit , SILL NISA , R1VlY1G.NTMWPIV.kkNJ1=AyFM�MMIMW.tlMM0.WMMNX4XikNM MMM,MNNNMYY%ARb A OD1(C)(�j, nog•pgwpraPlk ark hnuxe Giryorna dediCakad to enrlChing, aonneatrnm and adunating Coamnunklx8 through the art Of Cinema, TeX ICE 27-0900101 00's yuamound film foatival, 's'z. RteieManagementD(vielon ' REOErEO 6 APPROVED BY. Risk Management Analyst