ONE TOWER SQUARE

HARTFORD CT 06183

POLICY NUMBER: UB-2S772386-23-42-G

NEW YORK SECURITY FUND SURCHARGE

Dear Policyholder:
"Companies writing workers compensation insurance business in New York are required
to participate in the New York Workers' Compensation Security Fund. If a company becomes
insolvent, the security fund settles unpaid claims and assesses each insurance company for its
fair share.
New York law requires all companies to surcharge policies to recover these assessments.
If your policy is surcharged "NY surcharge", an amount will be displayed on your premium
notice."

DATE OF ISSUE: 03-22-23

W31N2E04
 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 Industrial Hygiene/Health Services – Travelers has
the writing companies owned or managed by The an AIHA accredited lab to analyze air samples taken by
Travelers Companies, Inc. We appreciate your our IH Specialists, or by you, through our Pump Loan
business and welcome the opportunity to be of service. program to help you identify potential exposures to
An important part of that service concerns safety and occupational illnesses.
accident prevention. Travelers Risk Control has an Safety Literature and Digital Media – Our Risk
extensive staff of safety and loss prevention Control customer website has hundreds of resources
professionals assisting customers across the country including checklists, sample programs, self-
and around the world. We have one of the largest Risk assessments, instructional videos and other safety and
Control departments in the industry, and our scale health related tools.
allows us to apply the right resource at the right time to
Safety Training – We offer face-to-face classroom
meet customer needs.
courses, as well as distance learning and online
We have a wide range of industry-specific experience, training programs on a variety of safety and risk
which includes manufacturing, construction, wholesale management topics in order to provide flexibility for
and retail businesses, service organizations, your safety training needs.
technology-related business, the oil and gas industry,
the public sector and others. Return-To-Work Coordination – We have consultants
Following are some examples of available safety who specialize in post injury management that can
services: assist you with developing or enhancing a return-to-
work program, along with other aspects of our Corridor
Accident Prevention – Our staff can help you identify of Care® post injury process.
present and potential hazards within your operations,
premises and equipment, and recommend solutions for
reducing or eliminating these hazards.
Analysis of Accident Causes – Our REACT accident Please note: For ALL loss control assistance
investigation program can assist you in determining requests, please contact your local office directly,
root causes of accidents and help you prevent which is listed on one of the following pages.
recurrences.
Safety Consultations – Our consultants can assist
you with solutions in specialized areas such as
ergonomics, industrial hygiene and fleet safety.
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 helping protect your business. Travelers Risk Control has the experience,
resources and capabilities to provide a range of safety services Onsite, Online
and On-Demand. As our customer, you have access to hundreds of safety The loss of a key employee
resources that cover an array of safety and risk management topics to help you due to an injury can seriously
control hazards and reduce risks of injury or illness. You can access these impact your business. We can
resources by logging in at www.travelers.com. Not registered? Select "Log In" help you to understand the
and then "Register Now" to register for MyTravelers for Business. types of accidents that may
Examples of what you will find include: occur in your business and
the steps you can take to help
• Safety checklists, sample programs and self-assessments. prevent them.
• Safety training offerings including classroom, and online.
• Additional safety products and services
These resources can help you improve your workplace safety practices.
Contact Us
For more information, please visit travelers.com/riskcontrol or contact your local Travelers office.

WUNT3A21 © 2020 The Travelers Indemnity Company. All rights reserved. Page 1 of 4
 Please call these numbers
FOR SAFETY SERVICES ONLY
For all other inquiries please contact your agent, underwriter or claim representative
ALABAMA CALIFORNIA ILLINOIS
Birmingham Walnut Creek Naperville
3000 Riverchase Galleria 401 Lennon Lane, Suite 100 215 Shuman Boulevard
Ste. 600 Walnut Creek, CA 94598 P.O. Box 3208
Birmingham, AL 35244 Risk Control: 1-800-973-9215 Naperville, IL 60566
Risk Control: 1-800-973-9215 Claims: (800) 842-7354 Risk Control: 1-800-973-9215
Claims: 1-800-238-6214 Claims: 800-842-6172
ALASKA COLORADO INDIANA
Portland, OR Denver Indianapolis
4000 SW Kruse Place, Suite 100 6060 S. Willow Dr. #300 Suite 300
Lake Oswego, OR 97035 Greenwood Village, CO 80111 280 East 96th Street
Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215 Indianapolis, IN 46240
Claims: 720-200-8100 Risk Control: 1-800-973-9215
Claims: 800-238-6210
ARIZONA CONNECTICUT IOWA
Phoenix Hartford Des Moines
2401 W Peoria Ave., Suite 130 300 Windsor Street 7101 Vista Dr.
Phoenix, AZ 85029 Hartford, CT 06120 West Des Moines, IA 50266-9313
Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215
Claims: 1 (877) 828-4110 Claims: 800-255-5072
ARKANSAS DELAWARE KANSAS
Kansas City, KS Philadelphia, PA Kansas City
7465 West 132nd, Suite 400 10 Sentry Parkway, Suite 300 7465 West 132nd, Suite 400
Overland Park, KS 66213 Blue Bell, PA 19422 Overland Park, KS 66213
Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215
Claims: 1-800-368-3562
CALIFORNIA DISTRICT OF COLUMBIA KENTUCKY
Diamond Bar Washington, DC Louisville
21688 Gateway Center Drive 14200 Park Meadow Dr. Suite 150
P.O. Box 6512 Chantilly, VA 20151 303 N Hurstbourne Pkwy
Diamond Bar, CA 91765-8512 Risk Control: 1-800-973-9215 Louisville, KY 40222
Risk Control: 1-800-973-9215 Claims: 1-800-368-3562 Risk Control: 1-800-973-9215
Claims: (909) 612-3000 Claims: 800-238-6210
CALIFORNIA FLORIDA LOUISIANA
Glendale Orlando New Orleans
655 N. Central Avenue, Suite 1600 2420 Lakemont Dr 3838 N. Causeway, Suite 2700
Glendale, CA 91203 Orlando, FL 32814 Metairie, LA 70002
Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215 P.O. Box 61479
Claims: (909) 612-3000 Claims: 407-388-2400 New Orleans, LA 70161-1479
Risk Control: 1-800-973-9215
Claims: 800-842-2556
CALIFORNIA GEORGIA MAINE
Irvine Atlanta Portland, ME
3333 Michelson Dr. City Blvd. W 1000 Windward Concourse 207 Larrabee Road, Suite 3
Suite 1000 Alpharetta, GA 30005 Westbrook, ME 04092
Irvine, CA 92612 Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215
Risk Control: 1-800-973-9215 Claims: 800-238-6214
CALIFORNIA HAWAII MARYLAND
Los Angeles Irvine, CA Blue Bell, PA
888 South Figueroa St., Ste. 500 3333 Michelson Drive City Blvd. W 10 Sentry Parkway, Suite 300
Los Angeles, CA 90017 Suite 1000 Blue Bell, PA 19422
Risk Control: 1-800-973-9215 Irvine, CA 92612 Risk Control: 1-800-973-9215
Claims: (909) 612-3000 Risk Control: 1-800-973-9215 Claims: 1-800-368-3562
CALIFORNIA IDAHO MASSACHUSETTS
Sacramento Sacramento, CA Boston
11070 White Rock Road, Suite 130 11070 White Rock Rd, Suite 130 100 Summer Street, Suite 201A
Rancho Cordova, CA 95670 Rancho Cordova, CA 95670 Boston, MA 02110
Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215
Claims: (800) 727-3995 Claim: (800) 727-3995 Claims: 800-832-7839
CALIFORNIA ILLINOIS MASSACHUSETTS
San Diego Chicago Hudson
9325 Sky Park Court, Suite 220 161 N Clark St. 1 Cabot Road
San Diego, CA 92123 Suite 900 Suite 250
Risk Control: 1-800-973-9215 Chicago, IL 60601 Hudson, MA 01749
Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215
Claims: 800-842-6172 Claims: 800-832-7839

WUNT3A21 © 2020 The Travelers Indemnity Company. All rights reserved. Page 2 of 4
 Please call these numbers
FOR SAFETY SERVICES ONLY
For all other inquiries please contact your agent, underwriter or claim representative
MASSACHUSETTS NEVADA NEW YORK
Braintree Las Vegas Syracuse
350 Granite Street 7450 Arroyo Crossing Pkwy 440 South Warren Street
Suite 1201 Suite 200 P.O. Box 4963
Braintree, MA 02184 Las Vegas, NV 89113 Syracuse, NY 13221-4963
Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215
Claims: 800-832-7839 Claims: 702-479-4200 Claims: 800-842-2475
MICHIGAN NEW HAMPSHIRE NORTH CAROLINA
Grand Rapids Portland, ME Charlotte
625 Kenmoor Ave 207 Larrabee Road, Suite 3 11440 Carmel Commons Blvd.
Suite 213 Westbrook, ME 04092 Suite 400
Grand Rapids, MI 49546 Risk Control: 1-800-973-9215 Charlotte, NC 28226
Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215
Claims: 800-238-6210 Claims: (704) 544-3500
MICHIGAN NEW JERSEY NORTH CAROLINA
Troy Morristown Raleigh
1441 W. Long Lake Rd., Ste. 300 445 South Street 4504 Emperor Blvd.
Troy, MI 48098 Morristown, NJ 07960 Durham, NC 27703
Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215
Claims: 800-238-6210 Claims: 1-800-842-2475 Claims: (704) 544-3500
MINNESOTA NEW JERSEY NORTH DAKOTA
St. Paul Marlton St. Paul, MN
385 Washington St., MC 104P Lake Center Exec Park Building 30 385 Washington St., MC 104P
St. Paul, MN 55102 Suite 110 St. Paul, MN 55102
Risk Control: 1-800-973-9215 Marlton, NJ 08053 Risk Control: 1-800-973-9215
Claims: 800-842-3073 Risk Control: 1-800-973-9215 Claims: 800-842-3073
Claims: 800-842-2475
MISSISSIPPI NEW MEXICO OHIO
Jackson Phoenix Cincinnati
1080 River Oaks Dr 2401 W Peoria Ave., Suite 130 Baldwin Center, Suite 500
Ste B-200 Phoenix, AZ 85029 625 Eden Park Drive
Flowood, MS 39232 Risk Control: 1-800-973-9215 Cincinnati, OH 45202
Risk Control: 1-800-973-9215 Claims: 602-861-8600 Risk Control: 1-800-973-9215
Claims: 1-800-342-4064 Claims: 800-238-6210
MISSOURI NEW YORK OHIO
St. Louis Albany Cleveland
940 West Port Plaza, Suite 270 900 Watervliet-Shaker Road 6150 Oak Tree Blvd., Suite 400
St. Louis, MO 63146 Albany, NY 12205 Independence, OH 44131
Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215
Claims: 800-842-9621 Claims: 800-842-2475 Claims: 800-238-6210
Kansas City NEW YORK OKLAHOMA
7465 W 132nd, Suite 400 Buffalo Tulsa
Overland Park, KS 66213 60 Lakefront Blvd. 9820 East 41st St., Suite 401
Risk Control: 1-800-973-9215 P.O. Box 242 P.O Box 3510
Claims: 800-255-5072 Buffalo, NY 14240-0242 Tulsa, OK 74101
Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215
Claims: 800-842-2475
Missouri Workers' NEW YORK OREGON
Compensation Plan (MWCP) Melville Portland
4801 Main Street, Suite 350 3 Huntington Quadrangle 4000 SW Kruse Way Place,
Kansas City, MO 64112 Melville, NY 11747 Building 1, Suite 255
Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215 Lake Oswego, OR 97035
Claims: 800-842-2475 Risk Control: 1-800-973-9215
Claims: 800-698-6883
MONTANA NEW YORK PENNSYLVANIA
Sacramento, CA New York Philadelphia
11070 White Rock Rd, Suite 130 485 Lexington Ave. 10 Sentry Parkway, Suite 300
Rancho Cordova, CA 95670 New York, NY 10017-2630 Blue Bell, PA 19422
Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215
Claims: (800) 727-3995 Claims: 1-800-842-2475 Claims: 800-832-0606
NEBRASKA NEW YORK PENNSYLVANIA
Omaha Rochester Pittsburgh
11516 Miracle Hills Dr., St. 400 75 Town Centre Drive 112 Washington Place, Suite 910
Omaha, NE 68154 P.O. Box 23235 Pittsburgh, PA 15219
Risk Control: 1-800-973-9215 Rochester, NY 14692-3235 Risk Control: 1-800-973-9215
Claims: 800-255-5072 Risk Control: 1-800-973-9215 Claims: (412) 338-3000
Claims: 1-800-842-2475

WUNT3A21 © 2020 The Travelers Indemnity Company. All rights reserved. Page 3 of 4
 Please call these numbers
FOR SAFETY SERVICES ONLY
For all other inquiries please contact your agent, underwriter or claim representative
PENNSYLVANIA VERMONT
Reading Hartford, CT
1105 Berkshire Blvd. 300 Windsor Street
P.O. Box 13426 Hartford, CT 06120
Wyomissing, PA 19610 Risk Control: 1-800-973-9215
Risk Control: 1-800-973-9215 Claims: (800) 422-3340
Claims: 800-832-0606
RHODE ISLAND VIRGINIA
Braintree Richmond
350 Granite Street 9954 Mayland Drive, Suite 6100
Suite 1201 Richmond, VA 23233
Braintree, MA 02184 Risk Control: 1-800-973-9215
Risk Control: 1-800-973-9215 Claims: (804) 330-6000
Claims: 800-832-7839
SOUTH CAROLINA Washington, DC
Charlotte 14200 Park Meadow Dr.
11440 Carmel Commons Blvd. Chantilly, VA 20151
P.O. Box 473500 Risk Control: 1-800-973-9215
Charlotte, NC 28247-3500 Claims: 800-368-3562
Risk Control: 1-800-973-9215
Claims: 704-544-3500
SOUTH DAKOTA WASHINGTON
St. Paul, MN Seattle
385 Washington St. 1501 4th Avenue, Suite 400
St. Paul, MN 55102 Seattle, WA 98101
Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215
Claims: 800-842-3073
TENNESSEE WEST VIRGINIA
Franklin Charleston, WV
6640 Carothers Pkwy, Suite 300 119 Virginia St. W.
Franklin, TN 37067 Charleston, WV 25302
Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215
Claims: (615) 660-6000 Claims: (443) 353-1000
TEXAS WISCONSIN
Dallas Milwaukee
1301 E Collins Blvd., Suite 300 13935 Bishops Drive, Suite 200
Richardson, TX 75081 Brookfield, WI 53005
Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215
Claims: 214-570-6000 Claims: 800-842-6172
TEXAS WYOMING
Houston Denver, CO
4650 Westway Park Blvd., Suite 350 6060 S. Willow Drive #300
Houston, TX 77041 Greenwood Village, CO 80111
Risk Control: 1-800-973-9215 Risk Control: 1-800-973-9215
Claims: 800-235-3610
UTAH
Denver, CO
6060 S. Willow Drive#300
Greenwood Village , CO 80111
Risk Control: 1-800-973-9215
Claims: 800-453-3025

WUNT3A21 © 2020 The Travelers Indemnity Company. All rights reserved. Page 4 of 4
 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:

LARES, LLC
28 BELLEFAIR RD
RYE BROOK NY 10573
 WORKERS COMPENSATION
ONE TOWER SQUARE AND
HARTFORD CT 06183
EMPLOYERS LIABILITY POLICY

TYPE V INFORMATION PAGE WC 00 00 01 ( A)

POLICY NUMBER: UB-2S772386-23-42-G

RENEWAL OF (UB-2S772386-22-42-G)

INSURER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT

A Stock Company
NCCI CO CODE: 12637
1.
INSURED: PRODUCER:
LARES, LLC THE CODY GROUP INC
28 BELLEFAIR RD 150 W 28TH ST STE 301
RYE BROOK, NY 10573 NEW YORK, NY 10001

Insured is A LIMITED LIABILITY COMPANY

Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 04-26-23 to 04-26-24 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:
NY

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 CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI
MN MO MS MT NC NE NH NJ NM NV OK OR PA RI SC SD TN TX UT VA VT WI
WV

D. This policy includes these endorsements and schedules:

SEE LISTING OF ENDORSEMENTS - 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 OF ISSUE: 03-22-23 SD

OFFICE: NEW YORK - METRO 140
PRODUCER: THE CODY GROUP INC DGF59
 WORKERS COMPENSATION
ONE TOWER SQUARE AND
HARTFORD CT 06183 EMPLOYERS LIABILITY POLICY

TYPE V INFORMATION PAGE WC 00 00 01 ( A)

POLICY NUMBER: UB-2S772386-23-42-G

CLASSIFICATION SCHEDULE:
PREMIUM BASIS
ESTIMATED RATES ESTIMATED
TOTAL ANNUAL PER $100 OF ANNUAL
CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION PREMIUM

SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S)

SIC-CODE: 8742 NAICS: 541611

STANDARD
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 181
PREMIUM DISCOUNT NONE
0900-31 EXPENSE CONSTANT 200
TERRORISM 56
CAT (OTHER THAN CERT ACTS OF TERRORISM) 9
TOTAL ESTIMATED PREMIUM 446
TAXES AND SURCHARGES 24
DEPOSIT AMOUNT DUE 470

Minimum Premium: $ 213

DATE OF ISSUE: 03-22-23 SD

OFFICE: NEW YORK - METRO 140
PRODUCER: THE CODY GROUP INC DGF59 COUNTERSIGNED-AGENT
 WORKERS COMPENSATION
AND
ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY
HARTFORD CT 06183

EXTENSION OF INFO PAGE-SCHEDULE WC 00 00 01 ( A)

POLICY NUMBER: UB-2S772386-23-42-G

INSURER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT

INSURED'S NAME: LARES, LLC 12637-NY

RATE BUREAU ID: 001660581

EXP. MOD. EFFECTIVE DATE: 04-26-23
PREMIUM BASIS
ESTIMATED RATES ESTIMATED
TOTAL ANNUAL PER $100 OF ANNUAL
CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM
LOCATION 001
FEIN 830858163 ENTITY CD 001 00

LARES, LLC

28 BELLEFAIR RD
RYE BROOK , NY 10573
NAICS: 541611

CLERICAL OFFICE EMPLOYEES NOC 8810 156000.00 0.12 187

NY MANUAL PREMIUM $ 187

---------------------------------------------------------------------------------------
TOTAL PREMIUM SUBJECT TO EXPERIENCE MOD. $ 187
EXPERIENCE MODIFICATION:0.97 MODIFIED PREMIUM 181
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 181
EXPENSE CONSTANT(0900) 200
TERRORISM(9740) 56
CAT(OTHER THAN CERT ACTS OF TERRORISM)(9741) 9
TOTAL ESTIMATED PREMIUM 446
9.80% NY STATE ASSESSMENT 24
TOTAL PREMIUM 470
DEPOSIT AMOUNT DUE 470

DATE OF ISSUE: 03-22-23 SD SCHEDULE NO: 1 OF 1

 WORKERS COMPENSATION
AND
ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY
HARTFORD CT 06183
ENDORSEMENT WC 00 00 01 (A )

POLICY NUMBER: UB-2S772386-23-42-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 INFORMATION PAGE

WC 00 00 01 A - 001 INFORMATION PAGE 2
WC 00 00 01 A - 001 EXTENSION OF INFORMATION PAGE - SCHEDULE
WC 00 00 01 A - 001 ENDORSEMENT LISTING
WC 00 04 14 A - 001 NOTIFICATION OF CHG IN OWNR ENDT
WC 00 04 22 C - 001 TERRORISM RISK INS PROG REAUTH ACT ENDT
WC 00 04 25 00 - 001 EXPER RATING MOD FACTOR REVISION ENDT
WC 00 04 21 E - 001 CATASTROPHE (O/T CERT ACTS OF TERR) ENDT
WC 00 04 19 00 - 001 PREMIUM DUE DATE ENDORSEMENT
WC 31 03 08 00 - 001 NEW YORK LIMIT OF LIABILITY ENDORSEMENT
WC 31 03 19 L - 001 NY CONST CLASS PREM ADJUST PROG
WC 31 04 05 A - 001 NY SAFE PTNT HNDLG ACT PRGM ENDT FLAT CR
WC 31 06 18 A - 001 NEW YORK NOTICE OF RIGHT TO APPEAL

DATE OF ISSUE: 03-22-23 ST ASSIGN: Page 1 of 1

 WC 00 00 00 ( C)
(Rev 5-20)

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:
A. How This Insurance Applies
GENERAL SECTION This workers compensation insurance applies to
A. The Policy bodily injury by accident or bodily injury by
disease. Bodily injury includes resulting death.
This policy includes at its effective date the
Information Page and all endorsements and 1. Bodily injury by accident must occur during
schedules listed there. It is a contract of the policy period.
insurance between you (the employer named in 2. Bodily injury by disease must be caused or
Item 1 of the Information Page) and us (the aggravated by the conditions of your
insurer named on the Information Page). The only employment. The employee's last day of last
agreements relating to this insurance are stated exposure to the conditions causing or
in this policy. The terms of this policy may not be aggravating such bodily injury by disease
changed or waived except by endorsement must occur during the policy period.
issued by us to be part of this policy.
B. We Will Pay
B. Who is Insured
We will pay promptly when due the benefits
You are insured if you are an employer named in required of you by the workers compensation law.
Item 1 of the Information Page. If that employer is
a partnership, and if you are one of its partners, C. We Will Defend
you are insured, but only in your capacity as an We have the right and duty to defend at our
employer of the partnership's employees. expense any claim, proceeding or suit against
you for benefits payable by this insurance. We
C. Workers Compensation Law
have the right to investigate and settle these
Workers Compensation Law means the workers claims, proceedings or suits.
or workmen's compensation law and occupational We have no duty to defend a claim, proceeding or
disease law of each state or territory named in
suit that is not covered by this insurance.
Item 3.A. of the Information Page. It includes any
amendments to that law which are in effect during D. We Will Also Pay
the policy period. It does not include any federal We will also pay these costs, in addition to other
workers or workmen's compensation law, any amounts payable under this insurance, as part of
federal occupational disease law or the provisions any claim, proceeding or suit we defend:
of any law that provide nonoccupational disability
benefits. 1. reasonable expenses incurred at our request,
but not loss of earnings;
D. State
2. premiums for bonds to release attachments
State means any state of the United States of
and for appeal bonds in bond amounts up to
America, and the District of Columbia.
the amount payable under this insurance.
E. Locations
3. litigation costs taxed against you;
This policy covers all of your workplaces listed in
Items 1 or 4 of the Information Page; and it 4. interest on a judgment as required by law
covers all other workplaces in Item 3.A. states until we offer the amount due under this
unless you have other insurance or are self- insurance; and
insured for such workplaces.
5. expenses we incur.

© Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. Page 1 of 6
 WC 00 00 00 ( C)
(Rev 5-20)

E. Other Insurance Enforcement may be against us or against

We will not pay more than our share of benefits you and us.
and costs covered by this insurance and other 4. Jurisdiction over you is jurisdiction over us for
insurance or self-insurance. Subject to any limits purposes of the workers compensation law.
of liability that may apply, all shares will be equal We are bound by decisions against you under
until the loss is paid. If any insurance or self- that law, subject to the provisions of this
insurance is exhausted, the shares of all policy that are not in conflict with that law.
remaining insurance will be equal until the loss is 5. This insurance conforms to the parts of the
paid. workers compensation law that apply to:
F. Payments You Must Make a. benefits payable by this insurance;
You are responsible for any payments in excess b. special taxes, payments into security or
of the benefits regularly provided by the workers other special funds, and assessments
compensation law including those required payable by us under that law.
because:
6. Terms of this insurance that conflict with the
1. of your serious and willful misconduct; workers compensation law are changed by
2. you knowingly employ an employee in this statement to conform to that law.
violation of law; Nothing in these paragraphs relieves you of your
3. you fail to comply with a health or safety law duties under this policy.
or regulation; or
PART TWO
4. you discharge, coerce or otherwise EMPLOYERS LIABILITY INSURANCE
discriminate against any employee in violation
of the workers compensation law. A. How This Insurance Applies
If we make any payments in excess of the This employers liability insurance applies to bodily
benefits regularly provided by the workers injury by accident or bodily injury by disease.
compensation law on your behalf, you will Bodily injury includes resulting death.
reimburse us promptly.
G. Recovery From Others 1. The bodily injury must arise out of and in the
course of the injured employee's employment
We have your rights, and the rights of persons
by you.
entitled to the benefits of this insurance, to
recover our payments from anyone liable for the 2. The employment must be necessary or
injury. You will do everything necessary to protect incidental to your work in a state or territory
those rights for us and to help us enforce them. listed in Item 3.A. of the Information Page.
H. Statutory Provisions
3. Bodily injury by accident must occur during
These statements apply where they are required the policy period.
by law.
4. Bodily injury by disease must be caused or
1. As between an injured worker and us, we
aggravated by the conditions of your
have notice of the injury when you have
employment. The employee's last day of last
notice.
exposure to the conditions causing or
2. Your default or the bankruptcy or insolvency aggravating such bodily injury by disease
of you or your estate will not relieve us of our must occur during the policy period.
duties under this insurance after an injury
occurs. 5. If you are sued, the original suit and any
related legal actions for damages for bodily
3. We are directly and primarily liable to any
injury by accident or by disease must be
person entitled to the benefits payable by this
brought in the United States of America, its
insurance. Those persons may enforce our
territories or possessions, or Canada.
duties; so may an agency authorized by law.

© Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. Page 2 of 6
 WC 00 00 00 ( C)
(Rev 5-20)

B. We Will Pay Canada who is temporarily outside these

We will pay all sums that you legally must pay as countries;
damages because of bodily injury to your 7. Damages arising out of coercion, criticism,
employees, provided the bodily injury is covered demotion, evaluation, reassignment,
by this Employers Liability Insurance. discipline, defamation, harassment,
The damages we will pay, where recovery is humiliation, discrimination against or
permitted by law, include damages: termination of any employee, or any
personnel practices, policies, acts or
1. For which you are liable to a third party by omissions;
reason of a claim or suit against you by that
third party to recover the damages claimed 8. Bodily injury to any person in work subject to
against such third party as a result of injury to the Longshore and Harbor Workers'
your employee; Compensation Act (33 U.S.C Sections 901 et
seq.), the Nonappropriated Fund
2. For care and loss of services; and Instrumentalities Act (5 U.S.C Sections 8171
3. For consequential bodily injury to a spouse, et seq.), the Outer Continental Shelf Lands
child, parent, brother or sister of the injured Act (43 U.S.C Sections 1331 et seq.), the
employee; provided that these damages are Defense Base Act (42 U.S.C Sections 1651–
the direct consequence of bodily injury that 1654), the Federal Mine Safety and Health
arises out of and in the course of the injured Act (30 U.S.C Sections 801 et seq. and 901–
employee's employment by you; and 944), any other federal workers or workmen's
compensation law or other federal
4. Because of bodily injury to your employee
occupational disease law, or any
that arises out of and in the course of
amendments to these laws;
employment, claimed against you in a
capacity other than as employer. 9. Bodily injury to any person in work subject to
the Federal Employers' Liability Act (45 U.S.C
C. Exclusions
Sections 51 et seq.), any other federal laws
This insurance does not cover: obligating an employer to pay damages to an
1. Liability assumed under a contract. This employee due to bodily injury arising out of or
exclusion does not apply to a warranty that in the course of employment, or any
your work will be done in a workmanlike amendments to those laws;
manner; 10. Bodily injury to a master or member of the
2. Punitive or exemplary damages because of crew of any vessel, and does not cover
bodily injury to an employee employed in punitive damages related to your duty or
violation of law; obligation to provide transportation, wages,
maintenance, and cure under any applicable
3. Bodily injury to an employee while employed
maritime law;
in violation of law with your actual knowledge
or the actual knowledge of any of your 11. Fines or penalties imposed for violation of
executive officers; federal or state law; and
4. Any obligation imposed by a workers 12. Damages payable under the Migrant and
compensation, occupational disease, Seasonal Agricultural Worker Protection Act
unemployment compensation, or disability (29 U.S.C Sections 1801 et seq.) and under
benefits law, or any similar law; any other federal law awarding damages for
violation of those laws or regulations issued
5. Bodily injury intentionally caused or
thereunder, and any amendments to those
aggravated by you;
laws.
6. Bodily injury occurring outside the United
States of America, its territories or D. We Will Defend
possessions, and Canada. This exclusion We have the right and duty to defend, at our
does not apply to bodily injury to a citizen or expense, any claim, proceeding or suit against
resident of the United States of America or you for damages payable by this insurance. We

© Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. Page 3 of 6
 WC 00 00 00 ( C)
(Rev 5-20)

have the right to investigate and settle these employees who sustain bodily injury by
claims, proceedings and suits. disease. The limit shown for "bodily injury by
We have no duty to defend a claim, proceeding or disease – each employee" is the most we will
suit that is not covered by this insurance. We pay for all damages because of bodily injury
have no duty to defend or continue defending by disease to any one employee.
after we have paid our applicable limit of liability Bodily injury by disease does not include
under this insurance. disease that results directly from a bodily
injury by accident.
E. We Will Also Pay
We will also pay these costs, in addition to other 3. We will not pay any claims for damages after
amounts payable under this insurance, as part of we have paid the applicable limit of our
any claim, proceeding or suit we defend: liability under this insurance.
1. Reasonable expenses incurred at our H. Recovery From Others
request, but not loss of earnings; We have your rights to recover our payment from
anyone liable for an injury covered by this
2. Premiums for bonds to release attachments
insurance. You will do everything necessary to
and for appeal bonds in bond amounts up to
protect those rights for us and to help us enforce
the limit of our liability under this insurance;
them.
3. Litigation costs taxed against you;
I. Actions Against Us
4. Interest on a judgment as required by law There will be no right of action against us under
until we offer the amount due under this this insurance unless:
insurance; and
1. You have complied with all the terms of this
5. Expenses we incur. policy; and
F. Other Insurance 2. The amount you owe has been determined
We will not pay more than our share of damages with our consent or by actual trial and final
and costs covered by this insurance and other judgment.
insurance or self-insurance. Subject to any limits This insurance does not give anyone the right to
of liability that apply, all shares will be equal until add us as a defendant in an action against you to
the loss is paid. If any insurance or self-insurance determine your liability. The bankruptcy or
is exhausted, the shares of all remaining insolvency of you or your estate will not relieve us
insurance and self-insurance will be equal until of our obligations under this Part.
the loss is paid.
G. Limits of Liability PART THREE
OTHER STATES INSURANCE
Our liability to pay for damages is limited. Our
limits of liability are shown in Item 3.B. of the A. How This Insurance Applies
Information Page. They apply as explained below: 1. This other states insurance applies only if one
1. Bodily Injury by Accident. The limit shown for or more states are shown in Item 3.C. of the
"bodily injury by accident – each accident" is Information Page.
the most we will pay for all damages covered
by this insurance because of bodily injury to 2. If you begin work in any one of those states
one or more employees in any one accident. after the effective date of this policy and are
not insured or are not self-insured for such
A disease is not bodily injury by accident work, all provisions of the policy will apply as
unless it results directly from bodily injury by though that state were listed in Item 3.A. of
accident. the Information Page.
2. Bodily Injury by Disease. The limit shown for
"bodily injury by disease – policy limit" is the 3. We will reimburse you for the benefits
most we will pay for all damages covered by required by the workers compensation law of
this insurance and arising out of bodily injury that state if we are not permitted to pay the
by disease, regardless of the number of benefits directly to persons entitled to them.

© Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. Page 4 of 6
 WC 00 00 00 ( C)
(Rev 5-20)

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

© Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. Page 5 of 6
 WC 00 00 00 ( C)
(Rev 5-20)

2. If you cancel, final premium will be more than comply with laws, regulations, codes or
pro rata; it will be based on the time this standards. Insurance rate service organizations
policy was in force, and increased by our have the same rights we have under this
short-rate cancelation table and procedure. provision.
Final premium will not be less than the
B. Long Term Policy
minimum premium.
If the policy period is longer than one year and
F. Records sixteen days, all provisions of this policy will apply
You will keep records of information needed to as though a new policy were issued on each
compute premium. You will provide us with copies annual anniversary that this policy is in force.
of those records when we ask for them. C. Transfer of Your Rights and Duties
G. Audit Your rights or duties under this policy may not be
transferred without our written consent.
You will let us examine and audit all your records
that relate to this policy. These records include If you die and we receive notice within thirty days
ledgers, journals, registers, vouchers, contracts, after your death, we will cover your legal
tax reports, payroll and disbursement records, representative as insured.
and programs for storing and retrieving data. We D. Cancelation
may conduct the audits during regular business
hours during the policy period and within three 1. You may cancel this policy. You must mail or
years after the policy period ends. Information deliver advance written notice to us stating
developed by audit will be used to determine final when the cancelation is to take effect.
premium. Insurance rate service organizations 2. We may cancel this policy. We must mail or
have the same rights we have under this deliver to you not less than ten days advance
provision. written notice stating when the cancelation is
to take effect. Mailing that notice to you at
PART SIX your mailing address shown in Item 1 of the
CONDITIONS Information Page will be sufficient to prove
A. Inspection notice.
We have the right, but are not obliged to inspect 3. The policy period will end on the day and
your workplaces at any time. Our inspections are hour stated in the cancelation notice.
not safety inspections. They relate only to the 4. Any of these provisions that conflict with a law
insurability of the workplaces and the premiums that controls the cancelation of the insurance
to be charged. We may give you reports on the in this policy is changed by this statement to
conditions we find. We may also recommend comply with the law.
changes. While they may help reduce losses, we E. Sole Representative
do not undertake to perform the duty of any
person to provide for the health or safety of your The insured first named in Item 1 of the
employees or the public. We do not warrant that Information Page will act on behalf of all insureds
your workplaces are safe or healthful or that they to change this policy, receive return premium, and
give or receive notice of cancelation.

IN WITNESS WHEREOF, the company has caused this policy to be signed by its President and Secretary
at Hartford, Connecticut and countersigned on the Information page by a duly authorized agent of the
company.

Secretary President

© Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. Page 6 of 6
 WORKERS COMPENSATION
AND
ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY
HARTFORD CT 06183
ENDORSEMENT WC 00 04 14 ( A)

POLICY NUMBER: UB-2S772386-23-42-G

90-DAY REPORTING REQUIREMENT—NOTIFICATION OF CHANGE IN

OWNERSHIP ENDORSEMENT

You must report any change in ownership to us in writing within 90 days of the date of the change. Change in
ownership includes sales, purchases, other transfers, mergers, consolidations, dissolutions, formations of a new
entity, and other changes provided for in the applicable experience rating plan. Experience rating is mandatory for all
eligible insureds. The experience rating modification factor, if any, applicable to this policy, may change if there is a
change in your ownership or in that of one or more of the entities eligible to be combined with you for experience rating
purposes.
Failure to report any change in ownership, regardless of whether the change is reported within 90 days of such
change, may result in revision of the experience rating modification factor used to determine your premium.
This reporting requirement applies regardless of whether an experience rating modification is currently applicable to
this 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. EndorsementNo.

Insured Premium

Insurance Company Countersigned by

DATE OF ISSUE: 03-22-23 ST ASSIGN: Page 1 of 1

© Copyright 2017 National Council on Compensation Insurance, Inc. All Rights Reserved.
 WORKERS COMPENSATION
ONE TOWER SQUARE AND
HARTFORD CT 06183 EMPLOYERS LIABILITY POLICY

ENDORSEMENT WC 00 04 22 ( C)

POLICY NUMBER: UB-2S772386-23-42-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
extended by the Terrorism Risk Insurance Program Reauthorization Act of 2019. 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,
definitions, 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
amendments thereto, including any amendments resulting from the Terrorism Risk Insurance Program
Reauthorization Act of 2019
"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, 2021, and ending on December 31, 2027 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.

Form WC 00 04 22 ( C)
DATE OF ISSUE: 03-22-23 ST ASSIGN: Page 1 of 2
© 2020 National Council on Compensation Insurance, Inc. All rights reserved.
 WORKERS COMPENSATION
ONE TOWER SQUARE AND
HARTFORD CT 06183 EMPLOYERS LIABILITY POLICY

ENDORSEMENT WC 00 04 22 ( C)

POLICY NUMBER: UB-2S772386-23-42-G

Policyholder Disclosure Notice

1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry
Insured Losses occurring in any calendar year exceed $200,000,000, the United States Government 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

For all other states please refer to the other Federal Terrorism Risk Insurance Act Disclosure
Endorsements attached to your 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

Form WC 00 04 22 ( C)
DATE OF ISSUE: 03-22-23 ST ASSIGN: Page 2 of 2
© 2020 National Council on Compensation Insurance, Inc. All rights reserved.
 WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
ONE TOWER SQUARE
HARTFORD CT 06183
ENDORSEMENT WC 00 04 25 (00)

POLICY NUMBER: UB-2S772386-23-42-G

EXPERIENCE RATING MODIFICATION FACTOR REVISION ENDORSEMENT

This endorsement is added to Part Five—Premium of the policy.

The premium for the policy is adjusted by an experience rating modification factor. The factor shown on the
Information Page may be revised and applied to the policy in accordance with our manuals and endorsements. We will
issue an endorsement to show the revised factor, if different from the factor shown, when it is calculated.

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: 03-22-23 ST ASSIGN: Page 1 of 1

© Copyright 2016 National Council on Compensation Insurance, Inc. All Rights Reserved.
ONE TOWER SQUARE WORKERS COMPENSATION
HARTFORD CT 06183 AND
EMPLOYERS LIABILITY POLICY

ENDORSEMENT WC 00 04 21 ( E)

POLICY NUMBER: UB-2S772386-23-42-G

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 C), 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 the
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 Insurance 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 Government 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 Policy No. Endorsement No.
Insured Premium $
Insurance Company Countersigned by
Form WC 00 04 21 ( E)
DATE OF ISSUE: 03-22-23 ST ASSIGN: Page 1 of 1
© 2020 National Council on Compensation Insurance, Inc. All Rights Reserved.
 WORKERS COMPENSATION
ONE TOWER SQUARE AND
HARTFORD CT 06183 EMPLOYERS LIABILITY POLICY
ENDORSEMENT WC 00 04 19 (00)

POLICY NUMBER: UB-2S772386-23-42-G

PREMIUM DUE DATE ENDORSEMENT

This endorsement is used to amend:

Section D. of Part Five of the policy is replaced by this provision.
PART FIVE
PREMIUM

D. Premium is amended to read:

You will pay all premium when due. You will pay the premium even if part or all of a workers compensation
law is not valid. The due date for audit and retrospective premiums is the date of the billing.

DATE OF ISSUE: 03-22-23 ST ASSIGN: Page 1 of 1

 WORKERS COMPENSATION
AND
ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY
HARTFORD CT 06183
ENDORSEMENT WC 31 03 08 (00)

POLICY NUMBER: UB-2S772386-23-42-G

NEW YORK LIMIT OF LIABILITY ENDORSEMENT

This endorsement applies only to the insurance provided by Part Two (Employers Liability Insurance) because
New York is shown in Item 3.A of the Information Page.
We may not limit our liability to pay damages for which we become legally liable to pay because of bodily injury
to your employees if the bodily injury arises out of and in the course of employment that is subject to and is
compensable under the Workers Compensation Law of New York.

DATE OF ISSUE: 03-22-23 ST ASSIGN:

 WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
ONE TOWER SQUARE
HARTFORD CT 06183
ENDORSEMENT WC 31 03 19 ( L)

POLICY NUMBER: UB-2S772386-23-42-G

NEW YORK CONSTRUCTION CLASSIFICATION PREMIUM ADJUSTMENT

PROGRAM EXPLANATORY ENDORSEMENT

The New York Construction Classification Premium Adjustment Program (NYCCPAP) allows premium credits for
some employers in the construction industry. These credits exist to recognize the difference in wage rates
between employers within the same construction industries in New York.

Credits are earned for average wages in excess of $23.24 per hour for each eligible class. If your policy shows
one of the following classification codes, and you are experience rated, you are eligible to apply for an NYCCPAP
credit:

0042 5057 5193 5429 5491 5606 6003 6229 6400 9527
3365 5059 5213 5443 5506 5610 6005 6233 6701 9534
3724 5069 5221 5445 5507 5645 6017 6235 7536 9539
3726 5102 5222 5462 5508 5648 6018 6251 7538 9545
3737 5160 5223 5473 5536 5651 6045 6252 7601 9549
5000 5183 5348 5474 5538 5701 6204 6306 7855 9553
5022 5184 5402 5479 5545 5703 6216 6319 8227
5037 5188 5403 5480 5547 5709 6217 6325 9526
5040 5190 5428

If you have any eligible classes on your policy, you should have been notified by your insurance carrier or the
New York Compensation Insurance Rating Board approximately four months prior to the inception date of this
policy. If you believe you may be eligible for a credit and have not received an application, you should
immediately contact your agent, insurance carrier, or the New York compensation Insurance Rating Board.

The basis for determining the credit is the limited payroll of each employee for the number of hours worked
(excluding overtime premium pay) for each construction classification (other than employees engaged in the
construction of one or two-family residential housing). For policies with effective dates between January 1 and
March 31, the payroll submitted is for the third quarter, as reported to taxing authorities, for the second calendar
year preceding the policy effective date. For policies with effective dates between April 1 and December 31, the
payroll submitted is for the third quarter, as reported to taxing authorities, for the calendar year preceding the
policy effective date. Total payroll (and not limited payroll) is to be reported for employees engaged in the
construction of one or two-family residential housing.

Credits are calculated by the New York Compensation Insurance Rating Board. Completed applications can be
submitted to: Attention: Audit Division, New York Compensation Insurance Rating Board, 733 Third Avenue, New
York, New York 10017, email: cpap@nycirb.org or via entry on the CPAP online application on the Rating Board's
website http://www.nycirb.org/cpap.

The application for credit on a renewal policy must be received by the Rating Board three (3) months prior to the
policy renewal effective date. The Rating Board will accept and process an application if it is received between the

DATE OF ISSUE: 03-22-23 ST ASSIGN: Page 1 of 2

©2011 New York Compensation Insurance Rating Board
 WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
ONE TOWER SQUARE
HARTFORD CT 06183
ENDORSEMENT WC 31 03 19 ( L)

POLICY NUMBER: UB-2S772386-23-42-G

renewal policy effective and expiration date, however, it must be accompanied with an explanation from the
employer stating the reason for the delay.

Under no circumstances will an original application be accepted for any policy if it is received after the expiration
date of the policy to which the credit would have applied, nor will a revised application be accepted if it is received
later than one (1) year from the expiration date of the policy to which the credit would have applied.

The New York Workers' Compensation and Employers' Liability Manual, and not this endorsement, govern the
implementation and use of the NYCCPAP.

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: 03-22-23 ST ASSIGN: Page 2 of 2

©2011 New York Compensation Insurance Rating Board
ONE TOWER SQUARE WORKERS COMPENSATION
HARTFORD CT 06183 AND
EMPLOYERS LIABILITY POLICY

ENDORSEMENT WC 31 04 05 ( A)

POLICY NUMBER: UB-2S772386-23-42-G

NEW YORK SAFE PATIENT HANDLING ACT PROGRAM EXPLANATORY

ENDORSEMENT (FLAT CREDIT)

The New York Safe Patient Handling Act Program (NYSPHAP) allows a premium credit for New York employers in the
healthcare industry. This credit exists to recognize compliance with Section 2997-k(2) of the New York State Public
Health Law.

The Information Page of this policy will show a credit of 2.5% if you are eligible for this credit. You are eligible for a
NYSPHAP credit if you are in compliance with the requirements of New York State Public Health Law Section 2997-
k(2) and your policy contains classification codes subject to the NYSPHAP, which may include, but are not limited to
the following:

8829 "Nursing Home-All Employees"

8833 "Hospital-Professional Employees"
8865 "Alcohol or Drug Rehabilitation Facility – All Employees & Clerical"
8866 "Assisted Living Facility – All Employees & Clerical"
9040 "Hospital-All Other Employees"
Contact your broker, agent, or insurance carrier if you believe you are eligible for a NYSPHAP credit.

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: 03-22-23 ST ASSIGN: Page 1 of 1

© 2016 New York Compensation Insurance Rating Board
 WORKERS COMPENSATION
AND
ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY
HARTFORD CT 06183
ENDORSEMENT WC 31 06 18 ( A)

POLICY NUMBER: UB-2S772386-23-42-G

NEW YORK WORKERS' COMPENSATION POLICYHOLDER NOTICE OF

RIGHT TO APPEAL

Policyholder Disputes
Policyholders are entitled to inquire, challenge and dispute issues relating to classification, ownership, premium
auditing and/or other New York Compensation Insurance Rating Board ("Rating Board") rulings or decisions pertaining
to this policy. Please refer to the New York Workers' Compensation Policyholder Notice of Right to Appeal process
noted below.

Inquiries may also be directed to the New York State Department of Financial Services (DFS) at:
http://www.dfs.ny.gov/about/contactus.htm#consumer
or by calling the Consumer Hotline at 800-342-3736 (Monday through Friday, 8:30 AM to 4:30 PM).

New York Workers' Compensation Policyholder Notice of Right to Appeal Process

An insured, or its representative, (hereafter referred to as "insured") may appeal the application of a rule or procedure
contained in the New York Workers' Compensation & Employers' Liability Manual. Rules or procedures are defined as
those determinations, either by a carrier or the Rating Board, which define the variables which make up, the policy
conditions. Examples include: classification codes, ownership information, premium audits, and any other
determination which may affect the policy.

To be considered for a review, a written request explaining the reason(s) for the appeal must be submitted to the
Rating Board. Upon receipt of the request for review, the following actions will be taken:

1. The Rating Board will review the request and respond to the parties within sixty (60) days, either granting the
parties or their authorized representatives their request or sustaining the Rating Board's original ruling.

2. If not satisfied with the outcome of 1. above, the parties may then request, in writing, a conference with members
of the Rating Board staff. The request must state the nature of the complaint and supply any supporting
documents. The appropriate Department Vice President or his or her designated representative will preside at the
conference.

3. If the dispute is not resolved by the conference, the parties may then appeal to the Underwriting Committee of the
Rating Board for a hearing to consider the staff ruling. This appeal must be in writing and must specify the
reasons for the appeal and the nature of the complaint.

Following the Committee's receipt of the appeal request, the parties will be notified about the time and place for the
hearing. The appeal will be heard at the next Underwriting Committee meeting for which appropriate time can be
devoted to the matter.

After the hearing, the parties will be advised, in writing, of the Underwriting Committee decision on the complaint.

DATE OF ISSUE: 03-22-23 ST ASSIGN: Page 1 of 2

© 2015 New York Compensation Insurance Rating Board
 WORKERS COMPENSATION
AND
ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY
HARTFORD CT 06183
ENDORSEMENT WC 31 06 18 ( A)

POLICY NUMBER: UB-2S772386-23-42-G

4. If the Underwriting Committee ruling is not satisfactory to either party, then the aggrieved party may request a
hearing at the New York State Department of Financial Services to consider the disputed decision.

5. The decision of the New York State Department of Financial Services may be appealed to a court of law, by the
parties involved or the Rating Board.

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: 03-22-23 ST ASSIGN: Page 2 of 2

© 2015 New York Compensation Insurance Rating Board
 WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
ONE TOWER SQUARE
HARTFORD CT 06183

POLICY NUMBER: UB-2S772386-23-42-G

NOTICE OF ELECTION TO ACCEPT AN INSURANCE DEDUCTIBLE

FOR NEW YORK WORKERS' COMPENSATION INDEMNITY AND MEDICAL BENEFITS

This medical and indemnity deductible program is being offered to policyholders with an estimated annual
premium at inception of twelve thousand dollars or more. Under this deductible program we pay all amounts in
their entirety applicable to each compensable claim under Part One of the policy.
We then obtain reimbursement from you, the policyholder, subject to the limits of the deductible amount for each
occurrence. You are liable to us for the deductible amount in regard to benefits paid for compensable claims, and
failure by you to reimburse any deductible amounts to us shall be treated in the same manner as nonpayment of
premium.
The deductibles paid by you during any one year period of insurance shall not exceed the estimated annual
premium at inception for such policy of insurance. A policy written under this deductible program shall have
attached the New York Benefits Deductible Endorsement WC 31 03 15 (A) to the policy. One of the following
deductible amounts, per occurrence, is available for selection by you to activate this program.
To prevent putting you in an uninsured position, your policy has been issued at full rates with no deductible
applied.
If you wish to have this deductible option apply to your policy, fill in the information requested at the bottom of
this form. Retain your copy for your records and send the agent and company copies to your agent within sixty
(60) days from the effective date of your policy. An endorsement will then be attached to your policy to reflect the
change.
If you decide that you do not want the deductible to apply, you may disregard this form. Your policy will continue
in force as issued.
For a complete explanation of how this program operates or the savings available, please contact your agent.

DEDUCTIBLE TABLE
DEDUCTIBLE
PER OCCURRENCE:
$ 100 $1,000
$ 200 $1,500
$ 300 $2,000
$ 400 $2,500
$ 500 $5,000

DATE OF ISSUE: 03-22-23

W31N3C06 Page 1 of 2
YES, I WANT A DEDUCTIBLE OF $ APPLIED TO MEDICAL AND INDEMNITY BENEFITS
UNDER THE NEW YORK WORKERS COMPENSATION LAW. I understand that the company shall pay the
deductible amount and seek reimbursement from the employer shown below.
I understand that in accordance with New York law, I have the option of modifying the above deductible program
choice at the time of renewal of my Workers' Compensation policy with the insurance company named below .

Date: Employer:

Name:

Title:

Signature:

Insurance Company:

W31N3C06 Page 2 of 2
 New York Notice to Employers
The Construction Employment Payroll Limitation Law, enacted under Senate Bill S7744 and Assembly Bill
A11294, provides a more equitable distribution of premium between high wage paying and low wage paying
employers in the construction industry. One or more classification codes applicable to your policy may be subject
to the Payroll Limitation Law. See list of eligible classifications below. The Law does not, however, apply to
employments engaged in the construction of one or two family residential housing.
Your overall premium may increase or decrease depending on geographic territories and/or payroll limitations.
The actual weekly payroll of each employee performing the employments subject to an eligible classification code
is subject to the following limitations:
• a maximum of $1,401.17 for the weekly wage upon which the maximum weekly benefit is based for
policies with effective dates on or after July 1, 2019.
• a maximum of $1,450.17 for the weekly wage upon which the maximum weekly benefit is based for
policies with effective dates on or after July 1, 2020.
• a maximum of $1,594.57 for the weekly wage upon which the maximum weekly benefit is based for
policies with effective dates on or after July 1, 2021.
• a maximum of $1,688.19 for the weekly wage upon which the maximum weekly benefit is based for
policies with effective dates on or after July 1, 2022.

The construction employment geographic territories are:

Territory 1 – Counties of the Bronx, Kings, New York, Queens and Richmond
Territory 2 – Counties of Duchess, Nassau, Orange, Putnam, Rockland, Suffolk and Westchester
Territory 3 – All other counties within the State
Please note that since your operations may be subject to the law, an employer with an eligible
classification code is required to maintain true and accurate weekly records for each employee that
shows:
1. Each employee's total weekly wages and hours worked;
2. The type of work performed;
3. The geographic territory in which the work was performed; and
4. Whether or not the work was performed on commercial structures or on one/two family residential
housing.
Eligible classification codes are those currently contained in the New York Construction Classification Premium
Adjustment Program (PAP), with the exception of code 5645, which applies to the construction of one or two
family residential dwellings. The specific listing of eligible classification codes is as follows:
0042 5057 5193 5428 5480 5547 6003 6229 6325 9526
3365 5059 5213 5429 5491 5606 6005 6233 6400 9527
3724 5069 5221 5443 5506 5610 6017 6235 6701 9534
3726 5102 5222 5445 5507 5648 6018 6251 7536 9539
3737 5160 5223 5462 5508 5651 6045 6252 7538 9545
5000 5183 5348 5473 5536 5701 6204 6260 7601 9549
5022 5184 5402 5474 5538 5703 6216 6306 7855 9553
5037 5188 5403 5479 5545 5709 6217 6319 8227
5040 5190

The definition of the term "construction" as used in the Payroll Limitation Law includes new construction, as well
as the remodeling, repair and maintenance work on existing structures.
If you have any questions regarding this law, please contact your agent, broker or insurance carrier underwriter.

W31M5G22 Page 1 of 1
 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 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 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.
© 1983-2023 National Council on Compensation Insurance, Inc. All Rights Reserved

For the workers compensation bureau policy forms of the following states:

DELAWARE:
© 2023 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- 2023 Minnesota Workers' Compensation Insurers Association, Inc. All Rights Reserved.

NEW JERSEY:
© Compensation Rating and Inspection Bureau

NEW YORK:
© 1987- 2023 New York Compensation Insurance Rating Board

NORTH CAROLINA:
© 2008- 2023 North Carolina Rate Bureau. Includes copyright material of the National Council on
Compensation Insurance, Inc. used with its permission.

PENNSYLVANIA:
© 2023 Pennsylvania Compensation Rating Bureau

WUNN1B23 © 2023 The Travelers Indemnity Company. All rights reserved. Page 1 of 1
 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. Page 1 of 1
 IMPORTANT NOTICE TO NEW YORK POLICYHOLDERS

If you have New York employees meeting either of the following conditions, you must take action to obtain a
specific posting notice:
1. If you own or operate an automotive or horse drawn vehicle, and have no minimum staff of regular
employees who are required to report for work at your established place or business; or
2. If you engage in the business of moving household goods or furniture.
If you meet either of these conditions, New York statute requires you to post and maintain notice C-105.1 in every
vehicle owned or operated by you. New York may fine you $250 for each violation.
Please contact your agent and request the number of copies of this notice that you need. A sample copy of the
notice is included.

PN T4 91 01 06 Page 1 of 2
W31M5D06
 State of New York
WORKERS' COMPENSATION BOARD
PRESCRIBED COPY
SAMPLE COPY Form C-105.1
Notice to be Posted by Employer Under NY WCL Section 51
for Automotive or Horse-Drawn Vehicles
Color: White
Size: 6" X 4"
Stock: Index or Ledger

STATE OF NEW YORK

WORKERS' COMPENSATION BOARD
The undersigned employer hereby gives notice that he/she has conformed to the provisions of
the Workers' Compensation Law and the rules of the Workers' Compensation Board of the
State of New York, and that he/she has secured the payment of compensation to his/her
employees, and the dependents of employees, engaged in employments enumerated in or
brought within the provisions of said law. Such compensation has been secured for such
employees in accordance with Section 50 of the Workers' Compensation Law, by insuring
with:
Name, address and telephone number of licensed insurance carrier, authorized group
self-insurer or main office of authorized self-insurer:

Policy No........................................Policy in Force from ...........................to ..........................

(For Insurance Carriers Only)
................................................................... By .....................................................................
Legal Name of Insured (Employer) Signature of Employer

Failure by an employer to post this notice in an automotive or horse-drawn vehicle as required by NY WCL
Section 51, or in every veh icle used to move household goods or services, may result in a $250 penalty for
each violation.

THE WORKERS' COMPENSATION BOARD EMPLOYS AND

C-105.1 (9-05) SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION

Section 51 of the NYS Workers' Compensation Law

Every employer who has complied with section fifty of this article shall post and maintain in a
conspicuous place or places in and about his place or places of business typewritten or
printed notices in form prescribed by the chairman, stating the fact that he has complied with
all the rules and regulations of the chairman and the board and that he has secured the
payment of compensation to his employees and their dependents in accordance with the
provisions of this chapter, but failure to post such notice as herein provided shall not in any
way affect the exclusiveness of the remedy provided for by section eleven of this chapter.
Every employer who owns or operates automotive or horse-drawn vehicles and has no
minimum staff of regular employees required to report for work at an established place of
business maintained by such employer and every employer who is engaged in the business of
moving household goods or furniture shall post such notices in each and every vehicle owned
or operated by him. Failure to post or maintain such notice in any of said vehicles shall
constitute presumptive evidence that such employer has failed to secure the payment of
compensation. The chairman may require any employer to furnish a written statement at any
time showing the stock corporation, mutual corporation or reciprocal insurer in which such
employer is insured or the manner in which such employer has complied with any provision of
this chapter. Failure for a period of ten days to furnish such written statement shall constitute
presumptive evidence that such employer has neglected or failed in respect of any of the
matters so required. Any employer who fails to comply with the provisions of this section shall
be required to pay to the board a fine of up to two hundred fifty dollars for each violation, in
addition to any other penalties imposed by law to be deposited into the uninsured employers'
fund.
C-105.1 Reverse (9-05)

Page 2 of 2 PN T4 91 01 06
W31M5D06
 State of New York
Determination of Classification Change from 10/1/2021 to 10/1/2022 Rates

LCMs for policy

effective dates LCMs for policy
between effective dates
Company 10/01/2021 - of 11/01/2021
Company Name Abbreviation 10/31/2021 and later
The Charter Oak Fire Insurance Company COF 1.025 1.025
The Travelers Indemnity Company of America TIA 1.140 1.140
The Travelers Indemnity Company of Connecticut TCT 1.207 1.207
The Travelers Indemnity Company IND 1.274 1.274
Travelers Casualty and Surety Company ACR 1.341 1.341
Travelers Property Casualty Company of America TIL 1.341 1.081
Travelers Casualty Insurance Company of America ACJ 1.408 1.408
The Phoenix Insurance Company PHX 1.475 1.475

Notes: "If you were insured with a different carrier last year, compare the current loss costs and multiplier to those used by
your prior carrier."

To obtain the classification percentage change, multiply the loss cost classification percentage change in the attached
pages by the change in LCM based on the writing company LCM and policy effective date found in the above table.
Divide your Proposed Company LCM by your Prior Company LCM. (Small differences may exist due to rounding).

The pages below compare the loss costs revision from 10/01/2021 to 10/01/2022. On 11/01/2021 there was an LCM
change as shown in the table above. The following examples illustrate how to determine the impact.
Example 1 (No change in LCM):
This example assumes a proposed effective date of 11/1/2022 (effective date of previous policy term was 11/1/2021).
Prior Company: TIL
Proposed Company: TIL
Class Code: 2594
Take the change in decimal form for class 2594 from the attached pages (loss cost comparison) which is 0.917
(-0.083+1.000). Then multiply by the company LCM change (Proposed Company LCM / Prior Company LCM).
( 0.917 ) x (1.081 / 1.081) = 0.917 (-8.3%)

which indicates a 8.3% decrease from the November 2021 rate. If the result of the multiplication was greater than
1.000, then the result is an increase. If the result of the multiplication is less than 1.000; this implies a decrease.

Example 2 (Change in LCM):

This example assumes a proposed effective date of 10/1/2022 (effective date of previous policy term was 10/1/2021).
Prior Company: TIL
Proposed Company: IND
Class Code: 2594
Take the change in decimal form for class 2594 from the attached pages (loss cost comparison) which is 0.917
(-0.083+1.000). Then multiply by the company LCM change (Proposed Company LCM / Prior Company LCM).
( 0.917 ) x (1.274 / 1.341) = 0.871 (-12.9%)
which indicates a 12.9% decrease from the October 2021 rate. If the result of the multiplication was greater than
1.000, then the result is an increase. If the result of the multiplication is less than 1.000; this implies a decrease.

W31M6J22 Page 1 of 10
 NEW YORK WORKERS' COMPENSATION

November 1, 2021 LOSS COST MULTIPLIER CHANGE

EXPLANATORY MEMORANDUM

Effective November 1, 2021, the company loss cost multiplier was revised for Travelers Casualty Insurance
Company of America. The LCMs are multiplied by the appropriate classification loss costs to determine the final
rate. The reason for the change in LCM is to create a newly deviated company.

W31M6J22 Page 2 of 10
 NEW YORK WORKERS' COMPENSATION

OCTOBER 1, 2022 LOSS COST REVISION

EXPLANATORY MEMORANDUM

An overall loss cost decrease of 8.7%, which includes a decrease of 8.9% in the average manual
loss cost level and no change in the loss cost provision for terrorism, natural disasters and catastrophic
industrial accidents, has been approved by the New York State Department of Financial Services to
become effective on October 1, 2022.

The following is a description of the various components of the approved change:

Loss Experience – The latest two policy years of experience produced a decrease of 3.8% in the
overall loss cost level.

Legislative Changes – This revision includes an estimate of the cost impact of the latest
increases in the maximum weekly benefits that were set forth in the 2007 workers’ compensation
reform legislation. This component contributed an increase of 0.8% to the overall change.

Loss Adjustment Expenses – A review of the latest data available resulted in an increase of
0.3% in the Loss Adjustment Expense provision.

Future Trends – The latest analysis of New York claim severity and claim frequency indicates a
continuing decrease in claim frequency, an upward trend in indemnity claim costs and a mild upward
trend in medical claim costs. Combined with a projected wage trend, the final selected net trend factor
is -6.3%.

Catastrophe Provision – This revision contains no changes in the loss cost provisions for
terrorism and for natural disasters and catastrophic industrial accidents.

Classification Loss Costs – Although the average manual loss cost level is decreasing by 8.9%,
individual classification loss cost changes are based on the most recently available loss experience for
each classification. Both increases and decreases from the current loss costs have been actuarially
calculated for each class. This process ensures that each classification loss cost reflects the
appropriate level relative to the experience of the other classifications.

W31M6J22 Page 3 of 10
 Workers' Compensation - New York
Loss Cost Comparison - October 1, 2021 to October 1, 2022

Class Class
Code Oct. 2022 Oct. 2021 % Change Code Oct. 2022 Oct. 2021 % Change
0005 1.47 1.72 -14.5% 2089 5.33 5.85 -8.9%
0006 1.96 2.32 -15.5% 2095 4.80 5.54 -13.4%
0007 1.42 1.56 -9.0% 2101 6.49 6.77 -4.1%
0031 1.54 1.88 -18.1% 2105 3.85 4.69 -17.9%
0034 3.39 3.59 -5.6% 2111 1.78 2.04 -12.7%

0035 2.06 2.47 -16.6% 2112 5.53 6.68 -17.2%

0042 4.19 4.56 -8.1% 2114 7.21 7.17 0.6%
0050 2.07 2.63 -21.3% 2121 4.25 4.79 -11.3%
0106 5.24 5.76 -9.0% 2143 2.81 3.10 -9.4%
0251 11.74 13.18 -10.9% 2150 7.06 8.07 -12.5%

0771 8.02 8.11 -1.1% 2157 10.16 11.37 -10.6%

0908 150.82 163.50 -7.8% 2172 3.81 3.81 0.0%
0909 206.16 211.06 -2.3% 2288 4.85 6.02 -19.4%
0912 1151.30 993.22 15.9% 2302 2.43 2.70 -10.0%
0913 514.93 510.09 0.9% 2362 1.81 1.92 -5.7%

0917 3.32 3.86 -14.0% 2380 4.80 5.71 -15.9%

1170 2.66 2.85 -6.7% 2387 3.64 3.81 -4.5%
1320 3.77 4.02 -6.2% 2388 2.40 2.80 -14.3%
1430 2.17 2.64 -17.8% 2402 1.80 2.07 -13.0%
1438 9.33 8.82 5.8% 2413 3.02 3.41 -11.4%

1439 3.33 4.06 -18.0% 2416 2.82 2.76 2.2%

1452 7.84 7.50 4.5% 2417 2.14 2.50 -14.4%
1463 4.60 5.38 -14.5% 2501 0.83 0.93 -10.8%
1470 7.56 8.49 -11.0% 2503 0.82 0.97 -15.5%
1624 2.96 3.58 -17.3% 2534 2.54 3.40 -25.3%

1701 3.90 4.07 -4.2% 2553 1.78 2.08 -14.4%

1710 5.36 5.86 -8.5% 2570 3.43 4.27 -19.7%
1741 7.80 7.58 2.9% 2571 2.92 3.23 -9.6%
1747 11.75 14.90 -21.1% 2576 3.14 3.22 -2.5%
1748 7.03 7.37 -4.6% 2578 2.07 2.69 -23.0%

1809 9.23 9.30 -0.8% 2590 2.21 2.42 -8.7%

1810 5.66 6.09 -7.1% 2591 4.42 4.95 -10.7%
1860 4.75 6.28 -24.4% 2593 4.70 5.00 -6.0%
1924 3.09 4.14 -25.4% 2594 5.41 5.90 -8.3%
1925 5.74 6.51 -11.8% 2600 6.06 6.62 -8.5%

2001 3.06 3.74 -18.2% 2623 2.74 3.26 -16.0%

2002 4.40 4.23 4.0% 2640 11.66 12.36 -5.7%
2003 4.78 5.31 -10.0% 2660 1.91 2.27 -15.9%
2014 4.21 3.77 11.7% 2670 4.16 3.84 8.3%
2021 3.53 3.47 1.7% 2683 4.25 4.61 -7.8%

2039 7.00 7.51 -6.8% 2688 1.30 1.39 -6.5%

2041 2.91 3.43 -15.2% 2689 0.67 0.80 -16.3%
2065 2.48 2.51 -1.2% 2702 8.80 9.50 -7.4%
2070 4.97 5.59 -11.1% 2710 3.46 4.47 -22.6%
2081 6.55 8.01 -18.2% 2714 5.31 5.97 -11.1%

W31M6J22 Page 4 of 10
 Workers' Compensation - New York
Loss Cost Comparison - October 1, 2021 to October 1, 2022

Class Class
Code Oct. 2022 Oct. 2021 % Change Code Oct. 2022 Oct. 2021 % Change
2731 3.29 4.05 -18.8% 3200 2.76 3.02 -8.6%
2737 5.25 5.65 -7.1% 3220 2.25 2.54 -11.4%
2759 7.06 8.79 -19.7% 3227 26.32 28.44 -7.5%
2790 1.05 1.22 -13.9% 3241 5.15 5.60 -8.0%
2802 4.10 5.23 -21.6% 3257 2.50 2.76 -9.4%

2817 3.23 3.52 -8.2% 3270 1.51 1.90 -20.5%

2835 2.00 2.13 -6.1% 3307 2.19 2.51 -12.7%
2841 4.00 4.41 -9.3% 3315 13.46 12.02 12.0%
2881 2.90 3.30 -12.1% 3336 1.96 2.48 -21.0%
2883 2.46 2.95 -16.6% 3365 6.56 7.31 -10.3%

2913 5.96 6.83 -12.7% 3372 2.81 2.68 4.9%

2916 2.98 3.19 -6.6% 3381 1.48 1.62 -8.6%
2923 3.19 3.07 3.9% 3383 0.43 0.49 -12.2%
3004 3.75 4.17 -10.1% 3384 0.22 0.25 -12.0%
3018 7.40 8.46 -12.5% 3385 0.75 0.86 -12.8%

3022 5.29 6.12 -13.6% 3400 9.30 11.17 -16.7%

3027 1.80 2.12 -15.1% 3507 3.46 3.53 -2.0%
3028 6.02 7.54 -20.2% 3515 2.89 3.17 -8.8%
3030 8.01 8.73 -8.2% 3548 1.91 1.86 2.7%
3040 8.25 8.15 1.2% 3559 4.07 4.24 -4.0%

3041 4.38 4.43 -1.1% 3561 2.65 2.84 -6.7%

3042 3.96 4.64 -14.7% 3574 0.95 1.03 -7.8%
3060 6.84 8.26 -17.2% 3581 1.45 1.53 -5.2%
3064 3.99 4.00 -0.2% 3612 2.56 2.69 -4.8%
3066 3.41 3.58 -4.7% 3620 3.84 4.35 -11.7%

3067 2.90 3.11 -6.8% 3629 1.48 1.71 -13.5%

3076 2.78 3.22 -13.7% 3632 2.60 3.02 -13.9%
3081 3.76 4.03 -6.7% 3634 1.51 1.80 -16.1%
3085 6.07 7.02 -13.5% 3635 1.43 1.81 -21.0%
3110 6.12 7.90 -22.5% 3638 2.02 2.41 -16.2%

3111 3.06 3.66 -16.4% 3642 0.91 1.12 -18.8%

3113 1.87 2.00 -6.5% 3643 2.42 2.78 -12.9%
3114 1.86 2.31 -19.5% 3647 4.14 4.87 -15.0%
3118 2.03 2.12 -4.2% 3648 2.08 2.26 -8.0%
3122 5.20 5.23 -0.6% 3681 1.05 1.10 -4.5%

3126 9.10 12.67 -28.2% 3685 1.33 1.41 -5.7%

3129 3.48 4.17 -16.5% 3686 1.41 1.57 -10.2%
3132 1.64 1.78 -7.9% 3724 3.88 4.42 -12.2%
3145 2.09 2.22 -5.9% 3726 3.52 4.86 -27.6%
3146 1.43 1.59 -10.1% 3737 4.17 4.64 -10.1%

3169 3.81 4.18 -8.9% 3807 3.68 4.26 -13.6%

3179 1.94 2.23 -13.0% 3808 3.70 3.95 -6.3%
3188 2.58 3.00 -14.0% 3821 6.01 6.67 -9.9%
3190 2.74 2.83 -3.2% 3823 3.57 3.97 -10.1%
3191 2.03 2.59 -21.6% 3824 4.20 4.05 3.7%

W31M6J22 Page 5 of 10
 Workers' Compensation - New York
Loss Cost Comparison - October 1, 2021 to October 1, 2022

Class Class
Code Oct. 2022 Oct. 2021 % Change Code Oct. 2022 Oct. 2021 % Change
3826 1.36 1.47 -7.5% 4432 1.78 1.96 -9.2%
3827 3.37 3.92 -14.0% 4452 2.46 2.81 -12.5%
3830 1.29 1.70 -24.1% 4459 3.53 3.71 -4.9%
3832 2.01 2.26 -11.1% 4470 3.81 4.32 -11.8%
3865 2.39 2.63 -9.1% 4475 2.12 2.29 -7.4%

3881 2.76 3.56 -22.5% 4476 1.91 1.95 -2.1%

4000 4.35 4.96 -12.3% 4493 3.49 3.88 -10.1%
4024 6.51 6.49 0.3% 4511 0.59 0.70 -15.7%
4034 6.98 8.38 -16.7% 4557 0.99 1.18 -16.1%
4038 2.26 2.52 -10.3% 4558 3.25 3.90 -16.7%

4053 2.65 3.26 -18.7% 4568 1.91 2.23 -14.3%

4061 2.44 3.09 -21.0% 4583 6.65 6.95 -4.3%
4062 6.75 7.08 -4.7% 4597 1.44 1.80 -20.0%
4101 2.34 2.60 -10.0% 4611 1.84 2.04 -9.8%
4111 2.06 2.17 -5.1% 4628 1.82 2.06 -11.7%

4112 1.01 1.22 -17.2% 4635 6.00 6.24 -3.8%

4114 2.11 2.61 -19.2% 4653 3.70 3.39 9.1%
4130 4.25 5.18 -18.0% 4665 9.32 10.25 -9.1%
4131 4.29 4.64 -7.5% 4692 0.88 1.07 -17.8%
4133 2.92 3.21 -9.0% 4693 2.03 2.15 -5.6%

4150 1.26 1.55 -18.7% 4710 1.62 2.00 -19.0%

4207 0.75 0.89 -15.7% 4712 1.95 1.97 -1.0%
4239 2.67 2.68 -0.4% 4720 2.19 2.62 -16.4%
4240 3.23 3.79 -14.8% 4751 1.75 2.04 -14.2%
4243 2.97 3.31 -10.3% 4771 2.07 2.49 -16.9%

4244 2.88 2.85 1.1% 4825 0.70 0.79 -11.4%

4250 2.51 2.72 -7.7% 4828 2.38 2.50 -4.8%
4251 1.86 2.08 -10.6% 4829 2.06 2.26 -8.8%
4263 3.22 3.55 -9.3% 4902 2.08 2.62 -20.6%
4273 3.17 3.47 -8.6% 4923 0.99 1.21 -18.2%

4279 3.48 4.30 -19.1% 5000 9.49 12.19 -22.1%

4282 0.27 0.32 -15.6% 5022 16.56 18.14 -8.7%
4298 1.66 1.93 -14.0% 5037 29.28 29.64 -1.2%
4299 2.09 2.26 -7.5% 5040 18.57 21.38 -13.1%
4304 10.48 11.52 -9.0% 5057 9.17 10.42 -12.0%

4307 2.58 2.90 -11.0% 5059 22.09 32.87 -32.8%

4312 2.82 2.98 -5.4% 5069 25.02 31.55 -20.7%
4351 2.15 2.09 2.9% 5102 11.74 13.44 -12.6%
4352 0.55 0.56 -1.8% 5160 4.32 5.13 -15.8%
4360 0.31 0.33 -6.1% 5183 5.98 6.58 -9.1%

4361 0.48 0.52 -7.7% 5184 6.46 6.71 -3.7%

4362 0.33 0.39 -15.4% 5188 4.85 5.71 -15.1%
4410 4.60 5.16 -10.9% 5190 4.39 4.83 -9.1%
4420 10.47 11.90 -12.0% 5191 1.20 1.28 -6.3%
4431 3.48 4.02 -13.4% 5192 4.92 5.07 -3.0%

W31M6J22 Page 6 of 10
 Workers' Compensation - New York
Loss Cost Comparison - October 1, 2021 to October 1, 2022

Class Class
Code Oct. 2022 Oct. 2021 % Change Code Oct. 2022 Oct. 2021 % Change
5193 6.46 6.90 -6.4% 6251 14.66 16.31 -10.1%
5213 18.94 20.55 -7.8% 6252 2.16 2.44 -11.5%
5221 10.17 11.32 -10.2% 6306 7.27 9.35 -22.2%
5222 10.53 12.11 -13.0% 6319 3.85 4.13 -6.8%
5223 5.66 6.24 -9.3% 6325 5.94 7.37 -19.4%

5348 7.82 8.34 -6.2% 6400 5.88 5.62 4.6%

5402 4.40 5.67 -22.4% 6504 3.79 4.15 -8.7%
5403 13.30 13.72 -3.1% 6701 14.06 15.48 -9.2%
5428 7.21 7.07 2.0% 6801 27.08 28.55 -5.1%
5429 6.46 7.01 -7.8% 6811 3.97 4.29 -7.5%

5443 8.67 9.60 -9.7% 6824 10.12 10.81 -6.4%

5445 9.09 9.20 -1.2% 6826 3.23 3.90 -17.2%
5462 6.54 7.37 -11.3% 6834 2.68 3.01 -11.0%
5473 28.24 28.17 0.2% 6836 2.83 3.17 -10.7%
5474 9.61 9.74 -1.3% 6843 9.16 10.28 -10.9%

5479 4.99 6.10 -18.2% 6854 2.45 2.59 -5.4%

5480 10.52 11.04 -4.7% 6872 9.99 12.77 -21.8%
5491 1.71 2.04 -16.2% 6874 38.18 46.02 -17.0%
5506 12.83 13.00 -1.3% 6875 83.26 92.33 -9.8%
5507 6.76 7.71 -12.3% 6882 9.27 8.02 15.6%

5508 3.24 3.96 -18.2% 6884 37.31 40.20 -7.2%

5536 5.17 6.02 -14.1% 6885 53.49 57.96 -7.7%
5538 7.20 7.35 -2.0% 7016 11.16 10.37 7.6%
5545 14.93 18.11 -17.6% 7024 12.40 11.52 7.6%
5547 8.70 8.97 -3.0% 7038 2.80 3.02 -7.3%

5606 3.46 3.34 3.6% 7046 2.29 2.53 -9.5%

5610 8.82 9.15 -3.6% 7047 21.90 20.16 8.6%
5645 7.13 8.46 -15.7% 7050 5.49 5.88 -6.6%
5648 11.97 12.89 -7.1% 7090 3.11 3.36 -7.4%
5651 7.27 7.80 -6.8% 7098 2.55 2.81 -9.3%

5701 13.23 13.72 -3.6% 7099 4.50 4.92 -8.5%

5703 11.23 13.61 -17.5% 7133 4.00 4.53 -11.7%
5709 22.30 24.37 -8.5% 7197 7.11 7.35 -3.3%
5951 0.53 0.64 -17.2% 7201 2.42 2.74 -11.7%
6003 9.31 10.46 -11.0% 7207 3.36 3.65 -7.9%

6005 4.42 4.05 9.1% 7219 9.63 10.04 -4.1%

6017 3.82 3.72 2.7% 7231 8.20 8.84 -7.2%
6018 7.53 8.61 -12.5% 7309 3.70 3.98 -7.0%
6045 4.09 4.41 -7.3% 7313 2.17 2.44 -11.1%
6204 6.80 7.91 -14.0% 7317 22.47 25.13 -10.6%

6216 7.47 8.61 -13.2% 7327 24.08 26.88 -10.4%

6217 5.32 5.92 -10.1% 7333 5.11 5.58 -8.4%
6229 3.51 3.73 -5.9% 7335 5.67 6.20 -8.5%
6233 3.46 4.39 -21.2% 7337 10.02 10.86 -7.7%
6235 6.06 6.56 -7.6% 7364 0.46 0.69 -33.3%

W31M6J22 Page 7 of 10
 Workers' Compensation - New York
Loss Cost Comparison - October 1, 2021 to October 1, 2022

Class Class
Code Oct. 2022 Oct. 2021 % Change Code Oct. 2022 Oct. 2021 % Change
7366 4.49 5.55 -19.1% 8021 5.08 5.62 -9.6%
7367 5.75 6.50 -11.5% 8025 0.83 0.91 -8.8%
7368 5.68 6.17 -7.9% 8031 1.82 1.96 -7.1%
7370 (c) (c) -11.3% 8032 0.92 0.99 -7.1%
7377 5.07 5.81 -12.7% 8033 3.08 3.41 -9.7%

7380 7.84 8.38 -6.4% 8034 4.15 4.53 -8.4%

7390 12.46 15.65 -20.4% 8039 1.85 1.93 -4.1%
7394 3.14 3.41 -7.9% 8043 0.95 1.04 -8.7%
7395 3.48 3.79 -8.2% 8044 3.07 3.43 -10.5%
7398 6.15 6.63 -7.2% 8046 2.33 2.69 -13.4%

7403 5.73 5.81 -1.4% 8047 1.24 1.28 -3.1%

7405 1.26 1.30 -3.1% 8048 3.73 4.62 -19.3%
7421 0.52 0.59 -11.9% 8068 0.13 0.16 -18.8%
7422 1.21 1.61 -24.8% 8069 0.30 0.40 -25.0%
7431 0.51 0.54 -5.6% 8072 0.61 0.71 -14.1%

7445 0.23 0.27 -14.8% 8090 0.63 0.66 -4.5%

7453 0.22 0.26 -15.4% 8102 4.21 4.53 -7.1%
7502 2.26 2.15 5.1% 8103 3.28 3.52 -6.8%
7515 2.00 2.10 -4.8% 8105 1.74 2.00 -13.0%
7520 5.14 5.71 -10.0% 8106 5.57 6.27 -11.2%

7536 7.91 6.75 17.2% 8107 2.71 3.07 -11.7%

7538 3.66 4.15 -11.8% 8111 3.80 3.99 -4.8%
7539 1.18 1.37 -13.9% 8116 1.43 1.37 4.4%
7542 3.10 3.51 -11.7% 8199 3.61 3.63 -0.6%
7580 2.85 3.80 -25.0% 8209 4.79 5.82 -17.7%

7590 7.98 7.99 -0.1% 8215 3.29 4.28 -23.1%

7600 6.30 7.86 -19.8% 8227 9.64 11.06 -12.8%
7601 3.81 4.23 -9.9% 8232 4.81 5.29 -9.1%
7610 0.20 0.20 0.0% 8235 4.40 5.23 -15.9%
7710 4.10 3.56 15.2% 8263 5.20 6.21 -16.3%

7711 (e) (e) -2.0% 8264 5.42 5.99 -9.5%

7716 (e) (e) -2.0% 8265 5.98 7.42 -19.4%
7720 3.32 3.43 -3.2% 8280 11.54 13.68 -15.6%
7723 1.39 1.52 -8.6% 8288 3.79 4.27 -11.2%
7855 6.05 5.16 17.2% 8291 5.53 5.77 -4.2%

7998 1.71 1.62 5.6% 8292 4.45 4.69 -5.1%

7999 1.84 1.96 -6.1% 8293 8.04 8.92 -9.9%
8001 1.93 2.16 -10.6% 8350 8.44 9.60 -12.1%
8006 1.43 1.54 -7.1% 8353 5.19 5.44 -4.6%
8008 0.87 0.97 -10.3% 8381 1.41 1.66 -15.1%

8012 1.66 1.72 -3.5% 8382 1.32 1.50 -12.0%

8013 0.24 0.28 -14.3% 8385 11.26 10.81 4.2%
8016 0.61 0.67 -9.0% 8391 2.58 2.83 -8.8%
8017 1.14 1.31 -13.0% 8392 2.29 2.49 -8.0%
8018 3.26 3.36 -3.0% 8394 4.69 4.86 -3.5%

W31M6J22 Page 8 of 10
 Workers' Compensation - New York
Loss Cost Comparison - October 1, 2021 to October 1, 2022

Class Class
Code Oct. 2022 Oct. 2021 % Change Code Oct. 2022 Oct. 2021 % Change
8500 5.25 6.23 -15.7% 9030 4.46 4.51 -1.1%
8601 0.37 0.42 -11.9% 9040 3.99 4.41 -9.5%
8709 22.71 25.53 -11.0% 9044 2.83 3.19 -11.3%
8719 1.65 1.89 -12.7% 9048 2.13 2.38 -10.5%
8720 1.66 1.83 -9.3% 9051 2.13 2.63 -19.0%

8723 0.10 0.12 -16.7% 9052 3.03 3.14 -3.5%

8726 1.75 2.02 -13.4% 9055 0.82 1.08 -24.1%
8731 1.84 2.15 -14.4% 9058 4.35 4.84 -10.1%
8742 0.24 0.27 -11.1% 9059 8.10 8.56 -5.4%
8745 4.45 5.60 -20.5% 9060 1.23 1.35 -8.9%

8747 0.17 0.18 -5.6% 9061 1.62 1.82 -11.0%

8748 0.78 0.99 -21.2% 9063 0.87 0.94 -7.4%
8751 3.22 3.53 -8.8% 9065 0.91 0.97 -6.2%
8755 0.71 0.74 -4.1% 9071 1.42 1.65 -13.9%
8800 1.74 1.84 -5.4% 9072 1.48 1.78 -16.9%

8802 0.85 0.99 -14.1% 9074 0.97 1.02 -4.9%

8803 0.04 0.04 0.0% 9088 7.10 7.51 -5.5%
8809 0.14 0.17 -17.6% 9089 0.30 0.34 -11.8%
8810 0.10 0.12 -16.7% 9093 0.92 1.18 -22.0%
8820 0.10 0.11 -9.1% 9101 2.41 2.78 -13.3%

8829 3.06 3.18 -3.8% 9102 2.49 2.92 -14.7%

8831 1.10 1.10 0.0% 9149 0.88 0.98 -10.2%
8832 0.37 0.37 0.0% 9157 4.11 4.26 -3.5%
8833 1.11 1.14 -2.6% 9158 1.89 1.89 0.0%
8838 0.50 0.59 -15.3% 9159 1.17 1.20 -2.5%

8840 0.42 0.45 -6.7% 9160 1.34 1.50 -10.7%

8854 3.42 3.94 -13.2% 9178 3.36 3.90 -13.8%
8855 0.10 0.12 -16.7% 9179 6.04 6.26 -3.5%
8857 2.09 2.51 -16.7% 9180 2.58 2.71 -4.8%
8864 2.81 3.09 -9.1% 9182 1.85 1.62 14.2%

8865 2.65 2.81 -5.7% 9186 4.00 4.49 -10.9%

8866 2.20 2.26 -2.7% 9220 6.27 6.77 -7.4%
8868 0.37 0.41 -9.8% 9402 4.35 5.00 -13.0%
8869 0.70 0.81 -13.6% 9403 9.23 10.40 -11.3%
8871 0.11 0.12 -8.3% 9410 6.54 7.19 -9.0%

8901 0.17 0.15 13.3% 9501 1.89 1.90 -0.5%

9014 4.05 4.21 -3.8% 9505 2.98 3.51 -15.1%
9015 1.69 1.80 -6.1% 9519 3.32 3.35 -0.9%
9016 3.38 3.48 -2.9% 9521 3.15 3.34 -5.7%
9019 2.14 2.89 -26.0% 9522 1.56 1.63 -4.3%

9025 14.49 14.53 -0.3% 9526 9.21 11.12 -17.2%

9026 3.66 4.06 -9.9% 9527 25.84 30.13 -14.2%
9027 14.35 12.31 16.6% 9534 10.14 10.13 0.1%
9028 2.76 3.03 -8.9% 9539 8.36 8.80 -5.0%
9029 3.71 4.60 -19.3% 9545 10.82 13.88 -22.0%

W31M6J22 Page 9 of 10
 Workers' Compensation - New York
Loss Cost Comparison - October 1, 2021 to October 1, 2022

Class Class
Code Oct. 2022 Oct. 2021 % Change Code Oct. 2022 Oct. 2021 % Change
9549 2.89 3.16 -8.5%
9552 9.83 11.34 -13.3%
9553 3.91 4.69 -16.6%
9585 0.67 0.79 -15.2%
9586 0.55 0.62 -11.3%

9600 2.37 2.04 16.2%

9610 0.90 0.88 2.3%
9620 1.38 1.35 2.2%

Legend:

(c) - Refer to Miscellaneous Values in the manual for loss costs.

(e) - Refer to Volunteer Firefighters schedule for loss costs. Loss cost change is the same for all population groups
in this class.

W31M6J22 Page 10 of 10
 IMPORTANT NOTICE – PAYOR COMPLIANCE PROGRAM – NEW YORK

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.

In April 2015, the New York State Workers' Compensation Board issued Subject No. 046-760 to all employers,
employees, insurance carriers providing benefits under the Workers' Compensation Law, attorneys and licensed
representatives appearing before the Board regarding the Board's Payor Compliance Program. The subject number
states that all payors (including carriers, third-party administrators [TPAs], self-insureds, self-insured trusts/groups
and governmental subdivisions) will receive a quarterly report, starting in January 2016, of their performance in each of
the following areas:

• Timeliness of the First Report of Injury Filing;

• Timeliness and Reporting of Initial Payment of Compensation;
• Timeliness of Notice of Controversy Filing; and
• Percentage of Claims Controverted.
Your timely reporting of claims is CRITICAL to ensuring compliance with this program. As mandated by
WCL 110(2) and NYCRR 300.22, you, as an employer, must report any injury meeting either of the following
criteria:

• Injury which has caused, or will cause, a loss of time from regular duties of one day beyond the work shift in
which the accident occurred.

• More than ordinary first aid treatment, defined as a single treatment and subsequent observation of minor
cuts, scratches, burns, splinters and the like, which do not ordinarily require medical care.

YOU MUST IMMEDIATELY REPORT ALL INJURIES THAT MEET EITHER OF THESE TESTS TO TRAVELERS
OR YOUR TRAVELERS AUTHORIZED THIRD - PARTY CLAIMS ADMINISTRATOR.

For more information please visit the Workers' Compensation Board's website, www.wcb.ny.gov, to obtain detailed
educational materials, including webinars and other training regarding the Payor Compliance Program.

W31N1C16 © 2015 The Travelers Indemnity Company. All rights reserved. Page 1 of 1
 IMPORTANT NOTICE – SAFE PATIENT HANDLING PROGRAM
AFFIDAVIT – NEW YORK

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 New York Safe Patient Handling Act Program allows a 2.5% premium credit for New York health care facilities
that comply with the requirements of New York State Public Health Law Section 2997-k(2). If you are an employer that
wishes to apply for this premium credit, please complete and sign the attached affidavit W31N4J17 and mail it to your
Travelers representative. We will require an updated affidavit at each subsequent renewal. If we do not receive the
executed affidavit within thirty (30) days of the policy's inception date no credit will be allowed for that policy period.

W31N4J17 © 2017 The Travelers Indemnity Company. All rights reserved. Page 1 of 3
 NEW YORK SAFE PATIENT HANDLING ACT
AFFIDAVIT OF COMPLIANCE

AFFIDAVIT OF: (name of health care facility)

STATE OF: New York
COUNTY OF:

I [NAME OF AFFIANT], being duly sworn, hereby

attest to the following:

1. I am over the age of 18, and I reside in the State of ;

2. I have personal knowledge of the facts stated herein, and, if called upon as a witness, will testify completely
thereto;
3. I suffer no legal disabilities;
4. On or before POLICY EFFECTIVE DATE],
[NAME OF HEALTH CARE FACILITY] (the "Facility")
established a safe patient handling program;
5. The Facility has implemented a safe patient handling program;
6. The Facility conducts patient handling hazard assessments;
7. The Facility has developed a process to identify the appropriate use of the safe patient handling policy;
8. The Facility provides initial and on-going yearly training and education on safe patient handling for all
employees involved in patient handling or movement;
9. The Facility has established procedures to ensure that retraining for any employee found deficient is provided
as needed;
10. The Facility has set up and utilizes a process for incident investigation and post-investigation review, which
may include a plan of correction and implementation of controls;
11. The Facility conducts annual performance evaluations of the program to determine its effectiveness;
12. The Facility considers the feasibility of incorporating patient handling equipment or the physical space and
construction design needed to incorporate that equipment at a later date when developing architectural plans
for constructing or remodeling a health care facility;
13. The Facility has developed a process by which an employee may refuse to perform or be involved in patient
handling or movement that the employee reasonably believes in good faith will expose a patient or the
employee to an unacceptable risk of injury.

I declare that the information stated herein is true, correct, and complete, to the best of my knowledge, information
and belief.

Executed this day of , 20 .

Signature

W31N4J17 © 2017 The Travelers Indemnity Company. All rights reserved. Page 2 of 3
Printed name

Title

NOTARY ACKNOWLEDGEMENT

STATE OF , COUNTY OF ,

Notary Public

My commission expires

W31N4J17 © 2017 The Travelers Indemnity Company. All rights reserved. Page 3 of 3
 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
 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
 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 Page 1 of 2
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 Page 2 of 2
 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 Page 1 of 1
PN T4 54 01 08
 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, CO, 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.

WUNNNH22 Page 1 of 1
 STATE OF NEW YORK - WORKERS' COMPENSATION BOARD
ESTADO DE NUEVA YORK - JUNTA DE COMPENSACION OBRERA
NOTICE OF COMPLIANCE AVISO DE CUMPLIMIENT O
TO EMPLOYEES A EMPLEADOS
IMPORTANT INFORMATION FOR EMPLOYEES WHO ARE INJURED INFORMACION IMPORTANTE PARA EMPLEADOS QUE SEAN
OR SUFFER AN OCCUPATIONAL DISEASE WHILE WORKING. LESIONADOS O SUFRAN UNA ENFERMEDAD OCUPACIONAL
MIENTRAS TRABAJAN.
1. By posting this notice and information concerning your rights as an 1. Su patrono está cumpliendo la Ley de Compensación Obrera cuando
injured worker, your employer is in compliance with the Workers' despliega este comunicado concerniente a sus derechos como
Compensation Law. trabajador lesionado.
2. If you do not notify your employer within 30 days of the date of your 2. Si usted no notifica a su patrono dentro del término de 30 dias de
injury your claim may be disallowed, so do so immediately. haber sufrido su lesión su reclamación podría ser desestimada, por
3. You are entitled to obtain any necessary medical treatment and eso notifique inmediatamente.
should do so immediately. 3. Usted tiene derecho a recibir cualquier tratamiento médico necesario
4. You may choose any doctor, podiatrist, chiropractor or psychologist relacionado con su lesión y debe gestionarlo inmediatamente.
referred by a medical doctor that accepts NY State Workers' 4. Para el tratamiento de cualquier lesión o enfermedad relacionada con
Compensation patients and is Board authorized. However, if your el trabajo, usted puede escoger cualquier médico, podiatra,
employer is involved in a certified preferred provider organization quiropractico ó psicologo (si es referido por un médico autorizado)
(PPO) you must first be treated by a provider chosen by your que esté autorizado y acepte pacientes de la Junta de Compensación
employer and your employer must give you a written statement of Obrera. Sin embargo, si su patrono está autorizado a participar en una
your rights concerning further medical care. organización certificada de proveedores preferidos (PPO), usted
5. You should tell your doctor to file copies of medical reports deberá obten er tratamiento inicial para cualquier lesión o enfermedad
concerning your claim with the Workers' Compensation Board and relacionada con el trabajo de la correspondiente entidad. Patronos que
with your employer's insurance company, which is indicated at the participen en cualquiera de estos programas establecidos por ley
bottom of this form. estan obligados a proveer a sus empleados notificación escrita
explicando sus derechos y obligaciones bajo el programa a que esté
6. You may be entitled to lost time benefits if your work-related injury acogido.
keeps you from work for more than seven days, compels you to work
at lower wages or results in permanent disability to any part of your 5. Usted deberá requerir de su Médico que radique copias de los
body. You may be entitled to rehabilitation services if you need help informes médicos de su caso en la Junta de Compensación Obrera y
returning to work. en la compañia de seguros de su patrono, que se indica al final de
esta forma.
7. You should not pay any medical providers directly. They should send
their bills to your employer's insurance carrier. If there is a dispute, 6. Usted tiene derecho a compensación si su lesión relacionada con el
the provider must wait until the Board makes a decision before it trabajo le impide trabajar por más de si ete dìas, le obliga a trabajar a
attempts to collect payment from you. If you do not pursue your sueldo más bajo ó resulta en incapacidad permanente de cualquier
claim or the Board rules that your injury is not work-related, you may parte de su cuerpo. Usted puede tener derecho a servicios de
be responsible for the payment of the bills. rehabilitación si necesita ayuda para regresar al trabajo.

8. You are entitled to be represented by an attorney or licensed 7. No pague a ningun proveedor médico directamente por tratamiento de
representative, but it is not required. If you do hire a representative su lesión o enfermedad relacionada con el trabajo. Ellos deben enviar
do not pay him/her directly. Any fee will be set by the Board and will sus facturas al asegurador de su patrono. Si el caso es cuestionado,
be deducted from your award. el proveedor deberá esperar hasta que la Junta decida el caso, antes
de iniciar gestión de cobro alguna contra usted. Si usted no tramita su
9. If you have difficulty in obtaining a claim form or need help in filling it caso ó la Junta falla que su lesión o enfermedad no está relacionada
out, or if you have any other questions or problems about a job- con el trabajo, usted podr a ser responsable del pago de las facturas.
related injury, contact any office of the Workers' Compensation
Board. 8. No es obligatorio el estar representado en ninguno de los
procedimientos de la Junta, pero es un derecho que usted tiene, el
estar representado por abogado ó por representante licenciado si
usted así lo desea. Si es representado, no pague alabogado ó al
alabogado ó al representante licenciado. Cuando la Junta decida su
NYS Workers' Compensation Board caso, los honorarios seran determinados por la Junta y descontados
Centralized Mailing de sus beneficios.
PO Box 5205 9. Si tiene dificultad en conseguir un formulario de reclamación o
Binghamton, NY 13902-5205 necesita ayuda para llenarlo ó tiene dudas sobre cualquier
situación relacionada con una lesión o enfermedad
Customer Service Line: 877-632-4996 comuniquese con la oficina mas cercana de la Junta.

CHAIR/PRESIDENTE
Workers' Compensation Board
Workers' Compensation benefits, when due, will be paid by (Los beneficios de Compensación obrera, cuando debidos, seran pagados por):
Name, address and telephone number of licensed insurance carrier, authorized group self-
insurer or main office of authorized self-insurer Name of employer (Nombre del patrono)
LARES, LLC __________________________
THE TRAVELERS INSURANCE COMPANIES THIS NOTICE MUST BE POSTED
ONE TOWER SQUARE CONSPICUOUSLY IN AND ABOUT THE
EMPLOYER'S PLACE OR PLACES OF
HARTFORD, CT 06183 BUSINESS.
(800) 238-6225
Failure by an employer to post this
For Insurance Carriers ONLY: Policy No 2S772386 notice in and about the employer's place
or places of business may result in
Policy in Force from 04-26-23 to 04-26-24 a $250 penalty for each violation.
Workers' Compensation Board
www.wcb.ny.gov
C-105 (9-17) Prescribed of by Chairman
State New York

W31P1I17