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Home My WebLink About106130 MYERS INC - INSURANCE CERTIFICATECERTIFICATE OF LIABILITY INSURANCE 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 ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- LOC JECT OTHER: PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON-OWNED AUTOS BODILY INJURY (Per accident) $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS-MADE EACH OCCURRENCE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? Y (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A Y WC 1021025-03 7/1/2019 7/1/2020 WC 00 00 01 A U WC-D-314-A (07-94) Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY --- -INFORMATION PAGE Servicing Office: Insurance for this coverage part provided by: 1. Policy Number Renewal of Number Named Insured and Mailing Address Producer and Mailing Address Producer Code Other workplaces not shown above: See Schedule of Locations FEIN: NCCI Company No. New Renewal Rewrite of Prior Policy No. This information page, with policy provisions and endorsements, if any, completes this policy. Insured is: 2. Policy Period: From: to at 12:01 A. M. Standard Time at insured’s mailing address. Insured’s Identification number(s): See Schedule Locations 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers’ Compensation Law of the states listed here: B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident: each accident Bodily Injury by Disease: policy limit Bodily Injury by Disease: each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required on the following Classification Schedule is subject to verification and change by audit. See Classification Schedule TOTAL ESTIMATED STANDARD PREMIUM $ PREMIUM DISCOUNT $ EXPENSE CONSTANT $ If indicated below, adjustment of premium shall be made: PREMIUM FOR ENDORSEMENT $ TAXES AND SURCHARGES $ TOTAL ESTIMATED ANNUAL PREMIUM $ MINIMUM PREMIUM $ DEPOSIT PREMIUM $ Annually Semi-Annually Quarterly Monthly This is a Three Year Fixed Rate Policy Agent or Producer Countersigned by Resident Licensed Agent Date WC 1021025-03 WC 1021025-02 07-01-2019 07-01-2020 ZURICH AMERICAN INSURANCE COMPANY WC 1021025-02 CORPORATION 20953-000 X OMAHA 13810 FNB PARKWAY PO BOX 542003 OMAHA, NE 68154 S.D. MYERS, LLC. 180 SOUTH AVE. TALLMADGE OH 44278 SCHEDULE OF FORMS AND ENDORSEMENTS Policy Number: Form Number & Edition Date Form Name U-WC-320-A (07-94) WC 1021025-03 WORKERS COMPENSATION FORMS AND ENDORSEMENTS U-WC-3068-B CA 04-18 CA NOTICE - WAIVER OF WC COVERAGE U-GU-1223-B CA 09-16 REVISED DEFINITION OF SPOUSE ENDORSEMENT WC 99 06 43 01-13 BLANKET NOTIFICATION TO OTH CANC/NONREN U-WC-D-314-A 07-94 WORKERS COMPENSATION INFORMATION PAGE U-WC-320-A 07-94 SCHEDULE OF FORMS AND ENDORSEMENTS WC 99 00 02 10-99 SCHEDULE OF INSUREDS AND LOCATIONS U-WC-315-A 07-94 CLASSIFICATION SCHEDULE WC 00 00 00 C 01-15 INSURANCE POLICY WC 00 03 02 04-84 DESIGNATED WORKPLACES EXCLUSION ENDT WC 00 03 08 04-84 PARTNERS, OFFICERS AND OTHERS EXCL ENDT WC 00 03 13 04-84 WAIVER OF RIGHTS TO RECOVER FROM OTHERS WC 00 04 04 04-84 PENDING RATE CHANGE ENDORSEMENT WC 00 04 06 08-84 PREMIUM DISCOUNT ENDORSEMENT WC 00 04 06 A 07-95 PREMIUM DISCOUNT ENDT WC 00 04 14 A 01-19 90DAY REPORT-NOTIF CHANGE IN OWNERSHIP WC 00 04 19 01-01 PREMIUM DUE DATE ENDORSEMENT WC 00 04 21 D 01-15 CATASTROPHE (OTHER THAN CERT ACTS) ENDT WC 00 04 22 B 01-15 TERRORISM RISK PGM REAUTH ACT DISCL ENDT WC 00 04 24 01-17 AUDIT NONCOMPLIANCE CHARGE ENDT WC 00 04 25 05-17 EXPERIENCE RATING MODIFICATION FCTR REV WC 99 06 48 A CA 06-14 CALIFORNIA CANCELATION ENDORSEMENT WC 02 06 01 A 09-15 AZ CANCELLATION AND NONRENEWAL ENDT WC 03 06 01 B 03-18 AR AMENDATORY ENDT WC 04 03 01 D 02-18 CA POLICY AMENDATORY ENDORSEMENT WC 04 03 60 B 01-15 CA EMPLOYERS’ LIAB COV AMENDATORY ENDT WC 04 04 21 01-08 CA OPTIONAL PREMIUM INCREASE ENDORSEMENT WC 04 04 22 01-12 CA SHORT-RATE CANCELATION ENDORSEMENT WC 04 06 01 A 12-93 CA CANCELATION ENDORSEMENT WC 05 04 02 11-90 CO CLASSIFICATION ENDORSEMENT WC 09 03 03 08-05 FL EMPLOYERS LIAB COV. ENDT WC 09 04 03 B 01-15 FL TERRORISM RISK INS PROGRAM REAUTH ACT WC 09 04 07 07-13 FL NON-COOPERATION W/ PREMIUM AUDIT ENDT WC 09 06 06 10-98 FL EMPLOYMENT AND WAGE INFO. REL. ENDT. WC 10 06 01 C 07-18 GA CANCELLATION NONRENEWAL & CHANGE ENDT WC 17 03 03 12-00 LA DUTY TO DEFEND ENDORSEMENT WC 17 06 01 J 08-18 LA AMENDATORY ENDT WC 17 06 02 A 02-96 LA COST CONTAINMENT ACT WC 21 03 04 04-84 MI LAW ENDORSEMENT WC 21 04 02 B 01-15 MI TERRORISM RISK INS PROGRAM REAUTH ACT WC 24 03 02 01-14 MO NOTIF OF ADDL MESOTHELIOMA BEN ENDT WC 24 04 06 D 08-16 MO EMPLOYER PAID MEDICAL ENDORSEMENT WC 24 06 01 B 01-96 MO CANCELATION AND NONRENEWAL ENDT WC 24 06 02 B 07-06 MO PROPERTY & CASUALTY GUARANTY ASSOC WC 24 06 04 B 01-17 MO AMENDATORY ENDORSEMENT WC 26 04 03 05-17 NE EXP RATING MODIFICATION REVISION ENDT WC 26 06 01 C 07-96 NE CANCELATION & NONRENEWAL WC 27 06 01 C 10-08 NV CANCELLATION AND NONRENEWAL ENDT WC 31 03 08 04-84 NY LIMIT OF LIABILITY WC 31 03 19 I 01-18 NY CONST CLASS PREM ADJ ENDT WC 31 04 05 10-17 NY SAFE PATIENT HANDLING ACT PRGM ENDT WC 31 06 18 03-15 NY POLICY NOTICE OF RIGHT TO APPEAL WC 32 03 01 D 07-18 NC AMENDED COVERAGE ENDT WC 36 03 06 01-02 OR LIMITS OF LIABILITY ENDORSEMENT WC 36 04 06 10-01 OR PREMIUM DUE DATE ENDT WC 99 06 43 Page 1 of 1 (Ed. 01-13) Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission. 2012 Copyright National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 43 BLANKET NOTIFICATION TO OTHERS OF CANCELLATION OR NONRENEWAL ENDORSEMENT This endorsement adds the following to Part Six of the policy. PART SIX CONDITIONS Blanket Notification to Others of Cancellation or Nonrenewal 1. If we cancel or non-renew this policy by written notice to you, we will mail or deliver notification that such policy has been cancelled or non-renewed to each person or organization shown in a list provided to us by you if you are required by written contract or written agreement to provide such notification. However, such notification will not be mailed or delivered if a conditional notice of renewal has been sent to you. Such list: a. Must be provided to us prior to cancellation or non-renewal; b. Must contain the names and addresses of only the persons or organizations requiring notification that such policy has been cancelled or non-renewed; and c. Must be in an electronic format that is acceptable to us. 2. Our notification as described in Paragraph 1. above will be based on the most recent list in our records as of the date the notice of cancellation or non-renewal is mailed or delivered to you. We will mail or deliver such notification to each person or organization shown in the list: a. Within seven days of the effective date of the notice of cancellation, if we cancel for non-payment of premium; or b. At least 30 days prior to the effective date of: (1) Cancellation, if cancelled for any reason other than nonpayment of premium; or (2) Non-renewal, but not including conditional notice of renewal. 3. Our mailing or delivery of notification described in Paragraphs 1. and 2. above is intended as a courtesy only. Our failure to provide such mailing or delivery will not: a. Extend the policy cancellation or non-renewal date; b. Negate the cancellation or non-renewal; or c. Provide any additional insurance that would not have been provided in the absence of this endorsement. 4. We are not responsible for the accuracy, integrity, timeliness and validity of information contained in the list provided to us as described in Paragraphs 1. and 2. above. All other terms and conditions of this policy remain unchanged. 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 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION FOR WHOM YOU ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT TO OBTAIN THIS WAIVER OF RIGHTS FROM US. WC 36 06 01 E 01-08 OREGON CANCELLATION ENDORSEMENT WC 36 06 04 01-17 OREGON AMENDATORY ENDORSEMENT WC 37 04 01 01-17 PA AUDIT NONCOMPLIANCE CHARGE ENDT WC 37 04 05 08-96 PA MERIT RATING PLAN ENDORSEMENT WC 37 06 01 04-84 SPECIAL PA ENDT-INSPECTION OF MANUALS Page 1 See next page UNITED STATES INSURANCE SERVICES 856 ELKRIDGE LANDING RD LINTHICUM MD 21090-2903 1,000,000 1,000,000 1,000,000 515.00 20,410.00 20,410.00 10863 81-4225502 -950.00 250.00 301.00 19,841.00 X ALABAMA, ARKANSAS, ARIZONA, CALIFORNIA, COLORADO, FLORIDA, GEORGIA, IOWA, ALL STATES EXCEPT ND, OH, WA, WY AND THOSE STATES LISTED IN 3 A. IDAHO, INDIANA, LOUISIANA, MICHIGAN, MISSOURI, NORTH CAROLINA, NEBRASKA, NEVADA, NEW YORK, OREGON, PENNSYLVANIA, SOUTH CAROLINA, TENNESSEE, TEXAS, VIRGINIA, WEST VIRGINIA PER STATUTE OTH- ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION ACORD 25 (2014/01) 2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. DATE (MM/DD/YYYY) 05/29/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS 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 UNITED STATES INSURANCE SERVICES, INC. 856 ELDRIDGE LANDING RD. LINTHICUM, MD 21090-2903 CONTACT JULIE PHILLIPS NAME: PHONE 614-728-0535 (A/C, No, Ext): FAX 1-800-671-2351 (A/C, No): E-MAIL BWCOTHERSTATESCOVERAGE@BWC.STATE.OH.US ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : ZURICH AMERICAN INSURANCE COMPANY 16535 INSURED SD MYERS, LLC SD MYERS, INC GOOD PLACE HOLDING CO ON NOW DIGITAL, LLC 180 SOUTH AVE TALLMADGE, OH 44278 INSURER B : INSURER C : INSURER D : INSURER E : City of Fort Collins PO Box 580 Fort Collins, CO 80522 283 Waiver of subrogation applies for workers’ compensation and employer’s liability as required by written contract. Waiver of subrogation applies in favor of City of Fort Collins with respect to workers’ compensation policy, as required by written contract.