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HomeMy WebLinkAboutAGMT - Athens Administrators (for record keeping only)WORKERSCOMPENSATION SERVICE AGREEMENT This Agreement is entered into by and between City of Seal Beach ("Client") and Athens Administrators ("Administrator") this 1st day of January 2023. RECITALS WHEREAS Administrator provides claims administration services to California Clients subject to the California Workers' Compensation Laws; and WHEREAS Client desires to purchase Claims Administration Services from Administrator; NOW THEREFORE, it is agreed: This Agreement is between the Client and the Administrator to provide third party workers' compensation claim administration services for Client in the State of California, subject to the terms stated below: I. TERM. TERMINATION & FEES , 1.1 Term: The term of this agreement shall consist of an initial three (3) years and six (6) months commencing on January 1, 2023. Both parties will also have the option of including two (2),individual one (1) year amendments with pricing negotiated in good faith by both parties. Fees: When applicable, based on tl, a retention level of the Client, Client will pay the Managed Care Fees listed in Addendum A. 1.2 Termination: a. Either party may terminate this Agreement, with or without cause and without penalty, as defined below: s Without cause— Written notification by either party with 120 days notification. • With cause — Wriitteh notification by either party, outlining the reasons for the termination of the agreement with 90 days' notice. b. Upon termination of this Agreement for any reason, a final accounting agreeable to both parties will be made of fees payable to Administrator and a final accounting of any funds belonging to Client then in the possession of Administrator, and any balance due either party will be promptly paid over to the party entitled thereto. c., All claim files, records, reports and other material pertaining to the employee claims subject to this Agreement shall be the property of Client and shall be made available promptly to Client upon termination of this Agreement. 2022 Service Agreement 1 F1-9 ATHENS MIN1ISTRATfd� S d. Upon the effective date of any termination of this Agreement, all rights and obligations of the parties under this Agreement shall cease except with respect to rights and obligations, which have accrued or expressly survive termination. H. ADMINISTRATOR DUTIES AND SERVICES 2.1 Administrator agrees to meet on a regular basis with Client to: a. Develop procedures, forms, instructions, schedules and other materials related to claim management, including a procedure manual for Client's use, within thirty (30) days of the effective date of this Agreement and update such materials as needed. b. Provide claim reporting kits including, but not limited to, claim and accident report forms, required notices, and procedural instructions, for distribution by Client to Client's staff on or before the effective date of this Agreement, and as needed thereafter. c. Provide group education for Client's management personnel regarding claim management as requested. d. Assist Client's personnel in the development of directives, notices, and other program communication to employees as requested or needed based'on Administrators expertise and suggestion. e. Provide all forms and supplies necessary for the efficient operation of the Workers' Compensation insurance program, including customized benefit checks bearing Client's name and logo, and to prepare all legally required forms and documents including but not limited to, 1099 reports to the I.R.S. and any and all other documents and reports now or in the future required by the state or federal government or any other agency associated with Client's Workers' Compensation program. Work with Authority's Finance Department and bank to establish controls. g. Administrator agrees to attend two (2) in-person meetings per year. The Administrator's attendees will be mutually agreed to by the Administrator and the Client. 2.2 Administrator agrees to administer all claims as follows: a. Establish and maintain a claim file, with a diary date not to exceed thirty (30) days, on each active claim upon which indemnity benefits are being paid; A diary system not to exceed sixty (60) days on all other open, active Indemnity claims; and a supervisory review diary not to exceed one -hundred -twenty (120) days, or more often when needed. b. Manage timely receipt of all pertinent claim information from Client providers and other sources. c. Determine, on behalf of Client for each reported employee injury or illness, those benefits, if any that should be paid or rendered under the California Workers' Compensation Laws. Such 2022 Service Agreement determination shall include an estimate of future claim payment. Retain outside services with prior approval of Client, for the investigation and management of the claims. Outside services include but are not limited to: ■= AOE/COE Investigators ■, Activities Check/Sub-rosa Investigator; ■ Medical Case Management and Rehabilitation Nurses/Consultants *. Subrogation Investigators and Experts d. Exhibit in each Indemnity claim file good faith efforts to contact all injured workers by telephone within at least twenty-four hours of receipt of claim, and in no event any later than forty-eight hours of receipt of claim, excluding weekends and holidays. Establish phone contact with appropriate Client department for initial discussion of claims, as needed, within three (3) working days of receipt of claim. e. Initiate investigations, subject to approval by Client, to determine compensability of reported and actual claim status, Client shall have prior approval of the selection of any investigator used to investigate -Client's claims of industrial injury or illness. Take necessary statements and investigate facts of the case within thirty (30) days receipt of claim, when warranted. f. Prepare documentation of cases for litigation and continue to monitor legal counsel representing Client in legal action(s) and assist counsel as necessary in preparation of litigation. Client shall select and approve counsel prior to each referral. In addition, Administrator shall promptly provide Client with copies of all correspondence generated on those claim files which are litigated and shall immediately notify Client in writing and shall keep Client closely informed on those claims involving allegations of Serious and Willful Misconduct or alleged violation(s) of California Labor Code Section 132(a). At time of case referral to defense counsel administrator shall prepare a letter of direction to defense counsel outlining work to be done, by whom, and in what time frame. All assignments, instructions and communication with defense counsel must be documented in the claim file and computer note pads. Administrator shall manage defense counsel on an ongoing basis and obtain status reports from defense counsel every sixty (60) days. Administrator shall actively manage litigated files and not perform functions and shall not require defense counsel to perform activities which can be accomplished effectively by claims staff. Examples of required examiner activity on litigated files include by are not limited to: ■ Scheduling medical appointments Writing cover letters to doctors ■ Subpoenaing medical records ■ Answering applications = Filing and serving requisite documents Administrator shall obtain defense counsels' written evaluation within sixty (60) days of submission, including evaluation of liability, verdict potential, settlement value, and case strategy. 2022 Service Agreement MATHENS ADMINISTRATI7RS g. • Disburse payment on behalf of Client out of the bank trust account funded by Client, all "Allocated Loss Expenses", which is defined to include all costs incurred on behalf of Client specifically related to an individual claim, including but not limited to, attorneys, independent adjusters or investigators, expert witnesses, copying records or transcripts, court costs or Appeals Board fees or other costs deemed proper and necessary to represent Client. h, Examine on behalf of Client all reports of industrial injury or illness relating to Client's employees or former employees and reported to Administrator and to conduct investigations on such cases by Administrator's salaried employees as in Administrator's judgment is deemed necessary. Pay compensation, medical expense, "Allocated Loss Expense", and all other benefits as prescribed by law out of funds provided by Client. Payments made by Administrator without Client approval, where approval is required elsewhere in this Agreement, shall be the responsibility of the Administrator. j. Maintain a claim file on each reported claim which shall be available to Client at all times for inspection and to conduct, at a time and frequency to be determined by Client, claim file reviews with Client at either Client's or Administrator's offices. k. Index Bureau System. On the Client's behalf, Athens shall subscribe and report to the Index Bureau System related to each claim. The costs of such reports will be allocated to each individual claim file. 1. Create, reserve and enter required claim data into Administrator's computer system within five (5) working days of receipt of notice of claim from Client. Enter all payments, reserved revisions, and file closings into the information system within three (3) working days. m. Review Client's medical bills and other medical charges and treatment relating to Client's claims of industrial injury or illness, for causal relationship to all claims of injuries/illness, and reasonableness of treatment prior to payment. Solicit all medical bills, medical reports and records, and documentation of alleged wage loss prior to settlement negotiations. n. Make all disability payments and send all notices in a timely manner, abiding by all applicable provisions of the California Labor Code and California Workers' Compensation Laws, Rules and Regulations. o.. Make payments of bills within thirty (30) days of receipt and assure timely review and payment of all medical bills in accordance with statutory deadlines and requirements. p. Acknowledge to Client all claims reported to Administrator within three (3) working days of receipt of the notice of claim and to notify Client and injured workers within five (5) working days of the notice of claim to Client, whether the claim has been accepted, delayed for further investigation, or denied. q. Convert all Medical Only Claims to Indemnity Claims status when the paid amount reaches five thousand ($5,000) dollars or when the claim remains open in excess of one (1) year. 2022 Service Agreement r;. Recognize and where appropriate investigate all subrogation and/or contribution possibilities, preserving evidence and utilizing appropriate investigators and experts, as needed, after first obtaining Client's permission to engage such investigators/experts. As respects subrogation and contribution cases, any compromise settlements or lien reductions will be discussed with the Client. S. Administrator may receive compensation in connection with outsourced services, either by retaining a portion of expenses charged to the Account, or by receiving fees from preferred providers. The amount that Administrator receives will vary depending upon the preferred provider, and may be calculated based on percentage of savings, percentage of revenue to the provider or Administrators mark-up of provider fees. The amounts retained or received by Administrator in connection with outsourced services areJin addition to the basic fees, reimbursable expenses„ additional service fees, and the taxes paid to Athens by Company. t. MSA Allocations/SCHIP Reporting —Athens has contracted with third party Verisk for Medicare Set Aside allocations and State Children Health Insurance Program ("SCHIP") reporting efforts. Athens may exclusively ;utilize the services of Verisk for MSA allocations and SCHIP reporting requirements unless otherwise requested in writing by Client. 2.3 Administrator agrees to monitor relevancy of medical treatment by the following: a. Maintain continual contact with medical practitioners in order to monitor claimant treatment process and a timely return to work. Administrator shall make a good faith effort to establish contact with attending physician within twenty-four (24) hours of receipt of injury report and shall make contact with attending physician's office within forty-eight (48) hours of receipt of injury report and shall document such contact in the claim file. b. Review and discuss Vocational Rehabilitation Program(s) with Client prior to its initiation for an individual claimant. c. Monitor individual vocational rehabilitation programs to determine appropriateness and progress. 2.4 Administrator agrees to thefollowing record keeping and reporting requirements: a. Provide Client with monthly reports consisting of: (1) Daily check registers including all claim disbursements made on behalf of Client. (2) Computerized loss reports in an acceptable format as mutually agreed upon at the effective date of this: Agreement, showing descriptive data, details of each month's payments, total payments, reserves and total experience and incurred loss values for each claim. 2022 Service Agreement i 5 (3) Any and all other standard reports Administrator currently prepares, if desired by Client. Additional reports required by Client, which are not currently a standard offering by Administrator may be requested of Administrator per paragraph 2.7 above. b. Provide oral claims reports on demand, special specific -focus loss run reports within twenty- four (24) hours and larger or major computer analysis reports within seven (7) working days, excluding weekends and holidays. It is further agreed and understood that should Client require that Administrator prepare for Client special reports, which require additional programming costs there may be an additional charge for said reports. c. Maintain all records and statistical data on each employee claim of injury or illness, -including, but not limited to, a record of each denial, delay, litigated claim and loss, which records, and data shall be available upon request by Client. Client, at Client's discretion, may audit all records maintained by Administrator including, but not limited to, all payments made on behalf of Client. Such audit may incorporate random sampling or other audit procedures suitable to Client. d. Prepare and submit Federal Information Return (Form 1099) by statutory deadline for applicable payments made by Administrator on Client's behalf, during the term of this Agreement and as specified under Section 1.02. (e) of this Agreement. e. Prepare all other reports as necessary to remain in compliance with all Workers' Compensation Laws and other state and federal laws, rules and regulations. L Provide report to Accounting Department of Client of all payments when made and any other information necessaryfor Clientto adequatelyfund the banktrust account. All such payments shall be supported with check payment detail and monthly summary report showing all payees, payment amounts and dates of payment. g. Provide for Client the ability to be on-line with Administrator's computer system. This system will provide Client with all financial and statistical data relating to Client's workers' compensation claims, together with narrative topical "notepad" reports, on each individual claim. This system will also include electronic mail service between Administrator and Client; the ability to electronically transmit 5020's (Client's First Report of Industrial Injury/Illness); OSHA Log generation; and complete report generation capabilities. h. Special reports, new reports and data feeds can also be requested. They are subject to a cost per quote at a rate per project or per hour (per paragraph 2.7) once the scope has been agreed upon. III. CLIENT'S DUTIES 3.1 Client agrees to perform as follows: a. Within 5 business days, report to Administrator as they shall occur and become known to Client, the employee claims of occupational injury, disease, illness, or death. 2022 Service Agreement b. Within 5 business days, forward to Administrator all applications, notices of claims, notices of hearings or other Legal notices pertaining to claims against Client for occupational injury, disease, illness, or death, and all other correspondence or information received by Client which is or could be relevant to the efficient and proper handling of any reported claim of industrial injury, disease, illness, or death. C. Provide Administrator with all necessary data required for Administrator to perform under this Agreement and cooperate fully with Administrator in. the performance of this Agreement. d. Make available to Administrator funds for the payment of benefits or services to or for occupational injury, disease, illness, death, or vocational rehabilitation and medical treatment of employees of Client, or their dependents in the event of death, and "Allocated Loss Expense". Administrator shall administer said funds in accordance with the terms of this Agreement as Trustee of Client. IV. ELECTRONIC CLAIM FILES, STORAGE, AND TRANSFER OF FILES 4.1 Files Administrator shall record and maintain an electronic file of all industrial injuries reported. Files may be maintained electronically, in hard copy, or in other media, at Administrator's discretion. Such files shall be made available to Client or its designated representative for inspection upon request. 4.2 Storage Physical Documents If Client would like to transfer physical documents for active and closed claim files to Administrator, Client must choose one of the following options to do so: 1) Storage - Administrator will store the !physical documents at an offsite third -party storage facility with the direct costs passed-through,l with no markup, to Client to pay on a quarterly basis; 2) Scan and shred —Administrator will scan the physical documents received for Client's active claims files and shred them, at Administrator's expense; closed claim file boxes will be scanned and shredded by Administrator or third -parry vendors hired by Administrator, for a cost. to Client of $25 each box, to be paid to Administrator by Client with the first invoice after receipt of boxes. Client will instruct Administrator as to which option they choose, before sending the boxes to Administrator. If the boxes are received by Administrator without Client's instructions, Administrator will scan and shred the documents and bill Client as noted in choice #2 in this paragraph. Videos If Client would like to transfer video files for active and closed claim files, to Administrator, Client may transfer up to ITB (terabyte) of video that Administrator will store at Administrator's cost. For any additional space utilized: for video files, Administrator will bill .Client $1 per GB (gigabyte) on a monthly basis. 2022 Service Agreement 4.3 Transfer of Electronic Files Administrator will provide Client's files to Client, or an entity designated by Client, within 30 business days of the agreed upon transfer date of the files to the new Administrator. Client will reimburse Administrator all reasonable costs incurred in returning the files to the Client. The electronic files will be in the electronic form used by Administrator to provide the services to Client under this Agreement. Client may request that the files be provided in a different format or that the hard copies of the files be provided to it, provided that Client pays Administrator for all costs associated with such request. Notwithstanding the foregoing, Administrator will not be obligated to provide the files to Client, or an entity designated by Client, unless Client has paid Administrator for all amounts owed pursuant to the Agreement. Client agrees to comply, and to require any recipient of the files designated by it to comply, with all applicable laws and regulations relating to the storage, transmission, use and confidentiality of the files and to hold Administrator harmless in relation thereto, except for gross negligent acts of which the Administrator will be responsible. 4.4 Copies of Files Administrator may, at its discretion keep a copy of Client's files if it deems it necessary to comply with or defend itself in relation to any obligation or rights that it has under this Agreement, applicable laws or regulations. 4.5 Backup of Files Administrator currently hosts all data in our claims administration system in an Amazon Virtual Private Cloud (VPC). Communication between the Administrators end user's laptop, computer and our claims administration system in the VPC, is encrypted. The communications within the VPC are encrypted, the data at rest in the Database is encrypted and Administrator performs daily back- ups. We pay an independent company to conduct a vulnerability scan and penetration test annually and we engage an auding company to conduct a SOC 1, Type II audit annually. V. FINES, PENALTIES, AND STANDARDS 5.1 All services as described in this Agreement shall be performed in accordance with all applicable laws, rules and regulations of any and all governmental authorities and applicable.standards, and specifically performed in accordance with all applicable Workers' Compensation Laws of the State of California. 5.2 Administrator and Client acknowledge the obligations and penalties contained in the California Workers' Compensation Reform Act of 1989 that may be imposed on both Clients and claim administrators and agree to the following: a. Penalties for errors or omissions caused by Client's failure to actor timely report claims or issues to Administrator that create a delay in payment of benefits, incorrect payment of benefits, or administrative fine(s) or penalty(s) shall be the responsibility of Client. Penalties 2022 Service Agreement for errors or omissions caused by Administrator's performance of services under this contract that creates a delay in payment of benefits, incorrect payment of benefits,_ or administrative fine(s) or penalty(s) shall be the responsibility of Administrator. b. Administrator shall ,provide Client with a quarterly accounting of penalties paid by Administrator on behalf of Client including a description and detailed listing of each penalty payment and the specific claim file to which the penalty payment was charged. Penalties, which are computed, by Administrator, shall be paid out of Client's benefit account and Administrator shall then reimburse Client quarterly for those penalties, which are the responsibility of Administrator under the terms and conditions of this Agreement. c. Without limiting the provisions set forth in the above two paragraphs it is agreed that upon receipt by Administrator of a notice of claim from Client, upon which indemnity benefits shall be paid or notice given promptly to the employee in order to avoid late payment or notice of benefit penalties, Administrator shall have ten working days (excluding weekends and holidays) from the date of receipt of the claim from Client, to investigate and pay the temporary disability or send the required wage continuation notice, and that failure on the part of Administrator, to do so within this time frame shall be the financial responsibility of Administrator for any fine imposed for late notice or payment of benefits. Any fines or penalties for late payment or notice of benefits on claims, which are received from Client by Administrator on or, after the ninth day following the date Client knew or should have known about the clai m(s) shall be the responsibility of Client. d. Any controversy between the parties to this Agreement involving the construction or application of the terms, provisions, or conditions of this Agreement relating to the payment of penalties; or fines shall be submitted to arbitration upon the written request of one party, after service of that request upon the other party. e. Arbitration and controversies relating to the payment of penalties or fines under this Agreement shall comply with and be governed by the provisions of the California Arbitration Act, as set forth at sections 1280 et. seq. of the California Code of Civil Procedure. f. Failing informal efforts between the parties to this Agreement to resolve disputes regarding the payment of penalties or fines, each party shall appoint one person to hear and resolve the dispute. These arbitrators, one appointed by each party, shall be known for the purposes of this Agreement as "initial arbitrators". If the "initial arbitrators" are unable to agree on a resolution of the dispute they shall then choose a third independent and impartial arbitrator whose decision shall be final and conclusive on both parties. g. If a dispute or arbitration under this Agreement is pending at a time when payment of the disputed penalty(s) or fine(s) is either statutorily mandated or when failure to effect payment will result in an increase in the fine or penalty, or an additional fine or penalty, each party shall bear, liability for one-half of the penalty(s) or fine(s) in dispute until such time as the arbitration is concluded and liability for payment of the fine or penalty is finally determined. Once determined, the party adjudged to be liable for the penalty(s) or fine(s) 2022 Service Agreement ATHENS MIA ADMINI5 R!%MORS shall reimburse the non -liable party for any portion of the penalty(s) or fine(s) the non - liable party may have paid during the pendency of the arbitration. 5.3 Excess Coveran or Other Insurance Administrator, as a part of the regular claims administration process, shall comply with the reporting provisions, guidelines, and requirements imposed by the Client's Excess Workers' Compensation Insurance Carrier(s) and other carriers that may be involved in the administration of the Client's Workers' Compensation Program. However, Client as policyholder shall continue to be liable for all the duties; requirements, obligations, and penalties subject to section 6.1 and 6.2 of this agreement imposed by the Client's Carrier(s). VI. DEFINITION OF "MEDICAL ONLY" AND "INDEMNITY" CLAIM 6.1 The definition of an "Indemnity Claim" shall be: a. Any alleged work-related claim for which any of the following is claimed: (1) Temporary Disability (2) Permanent Disability (3) Vocational Rehabilitation (4) Life Pension (5) Death 6.2 The definition of a "Medical Only" claim shall be: Any alleged work-related injury or illness for which medical treatment is sought, the claimant is not hospitalized, temporary disability does not exceed the waiting period as defined by the Workers' Compensation Laws of California, and no other Indemnity benefits are claimed. VII. GENERAL PROVISIONS 7.1 Neither party shall assign this Agreement or any part hereof without the written consent of the other party. 7.2 Each party agrees to indemnify, defend, and hold harmless the other against all actions, claims or demands, and against all costs, expenses and attorneys' fees, arising directly or indirectly out of an actual or alleged injury to a person or to property as an actual or alleged result of an act or omission of the party or any of its shareholders, directors, officers, employees, or agents and each party's obligation to so indemnify, defend and hold harmless the other shall survive the expiration or earlier termination of this Agreement. 2022 Service Agreement 10 The provisions of the HIPPA Business Associate Agreement attached as an addendum to this contract imposes obligation on the parties in addition to the paragraph above. i 7.3 All notices or other communications under this Agreement shall be sent to the parties at the addresses set forth below: Client City of Seal Beach 2118th St, Seal Beach, CA 90740 Attn: Jill R. Ingram Administrator Athens Administrators P.O. Box 696 Concord, CA 94533 Attn: James Jenkins 7.4. In the event either party hereto shall institute formal legal action, the prevailing party shall be entitled to its reasonable attorneys' fees. i 7.5 This Agreement may be amended at any time by mutual agreement of the parties, but any such amendment must be in writing, dated, signed by the parties and attached hereto. i 7.6. Any failure of a party to insist upon strict compliance with any term, undertaking or condition of this Agreement shall not be deemed to be a waiver of such term, undertaking, or condition. To be effective, a waiver must be in writing, and signed by the parties hereto. 7.7 This Agreement shall be governed by California law and any action arising out of it shall be instituted and prosecuted only in the municipal or superior court of Contra Costa County, State of California. 7.8 This Agreement instrument constitutes the entire agreement between the parties. Any oral representations or modifications concerning this Agreement shall be of no force and effect. IN WITNESS WHEREOF: The Parties have hereto caused this Agreement to be executed by their duly authorized representatives as of the day and year stated. CITY OF SEAMEAC ,11 k.A •• r nature cit Manager Titie OV1512023 I Dated I 2022 Service Agreement 11 ATHENS ADMINIjS1jjRM0RS ATHENS ADMINISTRATORS James Jenkins (Feb 17,2023 14:27 PST) Signature James R. Jenkins Title Feb 17, 2023 Dated Addendum A — Prlcing Proposal Attached is final version of agreed upon pricing proposal 2022 Service Agreement 12 1) Athens Administrators will Invoice company for all basic fees on a monthly basis and such invoice shall be paid by company upon receipt of invoice. 2) Claims will be handled for the life of the contract with no additional per claim fees. If you should decide to non -renew with Athens Administrators, the existing open files can be handled in one of two ways. a) Athens Administrators could continue to handle open files at our prevailing rates per year per open file. b) Athens Administrators would return the files to the client at the clients expense 3) Account Administration includes the following: a) Detailed status reports b) Settlement authority set at $TBD i 4) Data Management includes the following: a) Monthly claim reporting by e-mail or website b) Carrier report package by e-mail or website 5 Custom Report Creation: Access to Athens' custom reports to be created there will be a i Legal fees Professional photographs Extraordinary cost for witness statements Medical records Experts' rehabilitation costs Fees for service of process Architects, Contractors and Engineers Police, fire, coroner, weather, or other such Property damage appraisals Sub rosa Investigations Official documents and transcripts Pre -and post judgment interest paid d) Banking Administration e) Scheduled meetings/claim reviews .te report library is standard and included in fees. In the event client requires of $125 per hour to create custom report. Managed care expenses Medical examinations Extraordinary travel made at client's request Court reports Accident reconstruction Collection cost payable to third parties Outside investigations Subrogation at 15% gross recovery Property damage appraisals Index bureau filings Chemist Claim intake fees ADDENDUM A Medical Fee Schedule Reduction (OMFS) $7.00 Per Bill (includes. Medical, Pharmacy and Supplies) Hospital In and Out Patient Fee Schedule Reductions $600.00 Per Bill PPO Network 23% of Savings Specialty Bill Negotiations 20% of Savings with a $3,000 Per Bill Maximum Charge Duplicate Bills No Charge Concurrent, Prospective and Retrospective Review $145 Flat Fee LIR appeals: Peer to Peer $300 Per Hour Authorization Only $40 Flat Rate Case Management I Nurse Case Management' $124 Per Hour Field Case Management' $130 Per Hour + Travel and Mileage Catastrophic Case Management' $145 Per Hour + Travel and Mileage ase Management Fees are subje'ct:W, 5096 annunal Increases on the anniversarydate,of the agre6ment , Peer Review Physician Peer Review $300 Flat Fee Records Review $250 Per Hour 11DD/TIONAL RFLATFr Pharmacy. Benefits Management (PBM) Included Pharmacy Drug Review $125 Per Hour Central Index Bureau & First and Subsequent Report of Incident Reporting $25 Per Claim Reporting Included Predictive Modeling Included MPN (Blue Cross) $5.75 Per Bill CMS Reporting, (Verisk) Included New Loss Text Messaging to Injured Workers Included Nurse Triage $170 Per Claim Updated Agreement Final Audit Report 2023-02-17 Created: 2023-02-17 By: Teryn Giaco letto "(tgiacoletto@athensadmin.com) i Status: Signed i Transaction ID: CBJCHBCAABAA2WFvxAOt7mVJNinwi irgrkAM "Updated Agreement" History Document created by Teryn Giacoletto (tgiacoletto@athensadmin.com) 2023-02-17 - 5:26:13 PM GMT- IP address: 76.126.238.58 P+ Document emailed to jjenkins@athensadmin.com for signature 2023-02-17 - 5:28:43 PM GMT Email viewed by jjenkins@athensadmin.com 2023-02-17 - 10:26:34 PM GMT- IP address: 198.240.121.44 d,D Signer jjenkins@athensadmin.com entered name at signing as James Jenkins 2023-02-17 - 10:27:34 PM GMT- IP address: 166.205.107.12 &q Document e -signed by James Jenkins (Jenkins@athensadmin.com) Signature Date: 2023-02-17 -10:27:36 PM GMT - Time Source: server- IP address: 166.205.107.12 Agreement completed. 2023-02-17 - 10:27:36 PM GMT Adobe Acrobat Sign j 1 ACOR,br CERTIFICATE OF LIABILITY INSURANCE 1 DATE(MM/DD/YYYY) 1 3/8/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL If SUBROGATION IS WAIVED, subject to the terms and this certificate does not confer rights to the certificate INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. conditions of the policy, certain policies may require an endorsement. A statement on holder in lieu of such endorsement(s). PRODUCER Edgewood Partners Insurance Center P.O Box 2110 Rancho Cordova CA 95670 SUBR WVD CONTACT Rebecca Foster PHONE FAX AIC No Ext : 916-576-1524 (,,JC.No): 916-583-7613 ADDRESS: Rebecca.Foster@_epicbrokers.com INSURERS AFFORDING COVERAGE NAIC# LIMITS I INSURER A: Travelers Property Casualty Co of Amer 25674 License#: OB29370 INSURED Athens Insurance Service, Inc. DBA Athens Administrators INSURER B: The Travelers Indemnity Company of CT 25682 INsuRERc: Federal Insurance Company 20281 INSURER D : P. O. Box 4029 CLAIMS -MADE � OCCUR Concord CA 94524 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 15465905na REVISION NUMBER - THIS IS TO CERTIFY THAT THE'POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE, TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD I POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MM/DDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY 63059Jj4M4320 1/1/2023 1/1/2024 EACH OCCURRENCE S1,000,000 CLAIMS -MADE � OCCUR I DAMAGE TO RENTED PREMISES Ea occurrence S300,000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY S1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 10,000,000 X POLICY ❑ jECT LOC PRODUCTS -COMP/OPAGG $2,000,000 $ OTHER: B AUTOMOBILE LIABILITY BABL572517 1/1/2023 1/1/2024 COMBINED SINGLE LIMIT $1,000,000 Ea accident BODILY INJURY (Per person) S X ANY AUTO ! 1AUTOS OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) S HIRED NON -OWNED ONLY AUTOS ONLY PROPERTY DAMAGE $ Per accident S A UMBRELIALIAB' X OCCUR EXOK045623 1/1/2023 1/1/2024 EACH OCCURRENCE $5,000,000 AGGREGATE $ 5,000,000 X EXCESS LIAB CLAIMS-MADEJjI DED RETENTION $ I S 1 A WORKERS COMPENSATIONUB9J160807 AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE 1/1/2023 1/1/2024 X PER OTH- STATUTE ER EJ_. EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? ❑ N /A E.L. DISEASE- EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE - POLICY LIMIT S 1,000,000 C Employee Theft 82376969 1/1/2023 1/1/2024 Per Loss $5,000,000 1 i Deductible $35,000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Re: All Contracts/Written Agreements between the Certificate Holder and the Insured. Additional Insured: sCalifornia Joint Powers Insurance Authority. When required by written contract, additional insured status with primary coverage applies to General Liability and Automobile Liability and waiver of subrogation applies to General Liability, Automobile Liability and Workers' Compensation, all per the attached endorsements. CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. California Joint Powers Insurance Authority 8081 Moody Street AUTHORIZED REPRESENTATIVE La Palma CA 90623 i ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Policy #630594M4320 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED (Excludes Products -Completed Operations) This endorsement modifies.insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PROVISIONS The following is added to SECTION II — WHO IS AN INSURED: Any person or organization that you agree in a written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only: a. With respect to liability for "bodily injurji' or "property damage" that occurs, or for "personal injury' caused by an offense that is committed, subsequent to the signing of that contract or agreement and while that part of the contract or agreement is in effect; and b. If, and only to the extent that, the injury or damage is caused by acts or omissions of you or your subcontractor in the performance of "your work' to which the written contract or agreement applies. Such person or organization does not qualify as an additional insured with respect to the independent acts or omissions of such person or organization. The insurance provided to such additional insured is subject to the following provisions: a. If the Limits of Insurance of this Coverage Part shown in the Declarations exceed the minimum limits required by the written contract or agreement, the insurance provided to the additional insured will be limited to such minimum required limits. For the purposes of determining whether this limitation applies, the minimum limits required by the written contract or agreement will be considered to include the minimum limits of any Umbrella or Excess liability coverage required for the additional insured by that written contract or agreement. This provision will not increase the limits of insurance described in Section III —Limits Of Insurance. architectural, engineering or surveying services, including: (a) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders or change orders, or the preparing, approving, or failing to prepare or approve, drawings and specifications; and (b) Supervisory, inspection, architectural or engineering activities. (2) Any "bodily injury' or "property damage" caused by "your worK' and included in the "products -completed operations hazard". c. The additional insured must comply with the following duties: (1) Give us written notice as soon as practicable of an "occurrence" or an offense which may result in a claim. To the extent possible, such notice should include: (a) How, when and where the "occurrence" or offense took place; (b) The names and addresses of any injured persons and witnesses; and (c) The nature and location of any injury or damage arising out of the "occurrence" or offense. (2) If a claim is made or "suit" is brought against the additional insured: (a) Immediately record the specifics of the claim or "suit" and the date received; and b. The insurance provided to such additional insured (b) Notify us as soon as practicable and see does not apply to: to it that we receive written notice of the 1 An "bodily injury", �. claim or "suit" as soon as practicable. () y y j N , property damage or "personal injury" arising out of the providing, (3) Immediately send us copies of all legal or failure to provide, any professional papers received in connection with the claim or "suit', cooperate with us in the CG D2 48 0419 © 2018 The Travelers Indemnity Company. All rights reserved. Page 1 of 2 COMMERCIAL GENERAL LIABILITY I investigation or settlement of the claim or defense against the "suit", and otherwise comply with all policy conditions. 1 (4) Tender the defense and indemnity of any claim or "suit" to any provider of other insurance which would cover such additional insured for a loss we cover. However, this condition does not affect whether the insurance provided to such additional insured is primary to other insurance available to such additional insured which covers that person or organization as a named insured as described in Paragraph 4., Other Insurance, of Section IV — Commercial General Liability Conditions. t Page 2 of 2 © 2018 The Travelers Indemnity Company. All rights reserved. CG D2 48 0419 Policy #630594M4320 COMMERCIAL GENERAL LIABILITY c. Method Of Sharing If all of the other insurance permits contribution by equal shares, we will follow this method also. Under this approach each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first. If any of the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer's share is based on the ratio of its applicable limit of insurance to the total applicable limits of insurance of all insurers. d. Primary And Non -Contributory Insurance If Required BY Written Contract If you specifically agree in a written contract or agreement that the insurance afforded to an insured under this Coverage Part must apply on a primary basis, or a primary and non- contributory basis, this insurance is primary to other insurance that is available tosuch insured which covers such insured as a named insured, and we will not share with that other insurance, provided that: (1) The "bodily injury' or "property damage" for which coverage is sought occurs; and (2) The "personal and advertising injury" for which coverage is sought is caused by an offense that is committed; subsequent to the signing of that contract or agreement by you. 5. Premium Audit a. We will compute all premiums for this Coverage Part in accordance with our rules and rates. b. Premium shown in this Coverage Part as advance premium is a deposit premium only. At the close of each audit period we will compute the earned premium for that period and send notice to the first Named Insured. The due date for audit and retrospective premiums is the date shown as the due date on the bill. If the sum of the advance and audit premiums paid for the policy period is greater than the earned premium, we will return the excess to the first Named Insured. a. The statements in the Declarations are accurate and complete; b. Those statements are based upon representations you made to us; and c. We have issued this policy in reliance upon your representations. The unintentional omission of, or unintentional error in, any information provided by you which we relied upon in issuing this policy will not prejudice your rights under this insurance. However, this provision does not affect our right to collect additional premium or to exercise our rights of cancellation or nonrenewal in accordance with applicable insurance laws or regulations. 7. Separation Of Insureds Except with respect to the Limits of Insurance, and any rights or duties specifically assigned in this Coverage Part to the first Named Insured, this insurance applies: a. As if each Named Insured were the only Named Insured; and b. Separately to each insured against whom claim is made or "suit" is brought. 8. Transfer Of Rights Of Recovery Against Others To Us If the insured has rights to recover all or part of any payment we have made under this Coverage Part, those rights are transferred to us. The insured must do nothing after loss to impair them. At our request, the insured will bring "suit" or transfer those rights to us and help us enforce them. 9. When We Do Not Renew If we decide riot to renew this Cave -age Part, we will mail or deliver to the first Named Insured shown in the Declarations written notice of the nonrenewal not less than 30 days before the expiration date. If notice is mailed, proof of mailing will be sufficient proof of notice. SECTION V— DEFINITIONS 1. "Advertisement" means a notice that is broadcast or published to the general public or specific market segments about your goods, products or services for the purpose of attracting customers or supporters. For the purposes of this definition: C. The first Named Insured must keep records of a. Notices that are published include material the information we need for premium placed on the Internet or on similar electronic computation, and send us copies at such times means of communication; and as we may request. b. Regarding websites, only that part of a website 6. Representations that is about your goods, products or services By accepting this policy, you agree: for the purposes of attracting customers or supporters is considered an advertisement. Page 16 of 21 © 2017 The Travelers Indemnity Company. All rights reserved. CG T1 00 0219 Includes copyrighted material of Insurance Services Office, Inc. with its permission. Policy #630594M4320 COMMERCIAL GENERAL LIABILITY the limits shown in the Declarations, whichever are less. D. BLANKET WAIVER OF SUBROGATION The following is added to Paragraph; 8., Transfer Of Rights Of Recovery Against Others To Us, of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: If the insured has agreed in a contract or agreement to waive that insured's right of recovery against any person or organization, we waive our right of recovery against such person or organization, but only for payments we make because of. a. "Bodily injury' or "property damage" that occurs; or b. "Personal and advertising injury" caused by an offense that is committed; subsequent to the execution of the contract or agreement. E. CONTRACTUAL LIABILITY — RAILROADS 1. The following replaces Paragraph c. of the definition of "insured contract" in the DEFINITIONS Section: c. Any easement or license agreement; 2. Paragraph f.(1) of the definition of "insured contrail" in the DEFINITIONS Section is deleted. F. DAMAGE TO PREMISES RENTED TO YOU The following replaces the definition of "premises damage" in the DEFINITIONS Section: "Premises damage" means "property damage" to: a. Any premises while rented to you or temporarily occupied by you with permission of the owner; or b. The contents of any premises while such premises is rented to you, if you rent such premises for a period of seven or fewer consecutive days. Page 2 of 2 ©2017 The Travelers Indemnity Company. All rights reserved. CG D5 52 02 19 Includes copyrightedmaterial of Insurance Services Office, Inc. with its permission. Policy #BA8L572517 CKeldiIJ,I408II1W,l1tto] THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY: BUSINESS AUTO EXTENSION ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GENERAL DESCRIPTION OF COVERAGE — This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to the Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement. The following listing is a general cover- age description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this en- dorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered. A. BROAD FORM NAMED INSURED B. BLANKET ADDITIONAL INSURED C. EMPLOYEE HIDED AUTO D. EMPLOYEES AS INSURED E. SUPPLEMENTARY PAYMENTS —INCREASED LIMITS F. HIRED AUTO — LIMITED WORLDWIDE COV- ERAGE — INDEMNITY BASIS G. WAIVER OF DEDUCTIBLE — GLASS PROVISIONS A. BROAD FORM NAMED INSURED The following is added to Paragraph A.1., Who Is An Insured, of SECTION II — COVERED AUTOS LIABILITY COVERAGE: Any organization you newly acquire or form dur- ing the policy period over which you maintain 50% or more ownership interest and that is not separately insured for Business Auto Coverage. Coverage under this provision is afforded only un- til the 180th day after you acquire or form the or- ganization or the end of the policy period, which- ever is earlier. B. BLANKET ADDITIONAL INSURED The following is added to Paragraph c. in A.1., Who Is An insured, of SECTION II — COVERED AUTOS LIABILITY COVERAGE: Any person or organization who is required under a written contract or agreement between you and that person or organization, that is signed and executed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period, to be named as an addi- tional insured is an "insured" for Covered Autos Liability Coverage, but only for damages to which H. HIRED AUTO PHYSICAL DAMAGE — LOSS OF USE — INCREASED LIMIT I. PHYSICAL DAMAGE — TRANSPORTATION EXPENSES — INCREASED LIMIT J. PERSONAL PROPERTY K. AIRBAGS L. NOTICE AND KNOWLEDGE OF ACCIDENT OR LOSS M. BLANKET WAIVER OF SUBROGATION N. UNINTENTIONAL ERRORS OR OMISSIONS this insurance applies and only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Section 11. C. EMPLOYEE HIRED AUTO 1. The following is added to Paragraph A.1., Who Is An Insured, of SECTION 11 — COV- ERED AUTOS LIABILITY COVERAGE: An "employee" of yours is an "insured" while operating an "auto" hired or rented under a contract or agreement in an "employee's" name, with your permission, while performing duties related to the conduct of your busi- ness. 2. The following replaces Paragraph b. in B.S., Other Insurance, of SECTION IV — BUSI- NESS AUTO CONDITIONS: b. For Hired Auto Physical Damage Cover- age, the following are deemed to be cov- ered "autos" you own: (1) Any covered "auto" you lease, hire, rent or borrow; and (2) Any covered "auto" hired or rented by your "employee" under a contract in an "employee's" name, with your CA T3 53 02 15 © 2015 The Travelers indemnity Company. All rights reserved. Page 1 of 4 Includes copyrighted material of Insurance Services Office, Inc. with Its permission. COMMERCIAL AUTO permission, while performing duties (a) With respect to any claim made or "suit' related to the conduct of your busi- brought outside the United States of ness. I America, the territories and possessions However, any "auto" that is leased, hired, of the United States of America, Puerto rented or borrowed withia driver is nota Rico and Canada: covered "auto". (1) You must arrange to defend the "in - D. EMPLOYEES AS INSURED sured" against, and investigate or set- tle any such claim or "suit" and keep The following is added to Paragr� ph A.1., Who Is us advised of all proceedings and ac - An Insured, of SECTION 11— COVERED AUTOS tions. LIABILITY COVERAGE: (it) Neither you nor any other involved Any "employee" of yours is an "insured" while us- Ing a covered auto you dont own, hire or borrow "insured" will make any settlement in your business or your personal, affairs. without our consent. (iii) We may, at our discretion, participate E. SUPPLEMENTARY PAYMENTS — INCREASED in defending the "insured" against, or LIMITS I in the settlement of, any claim or 1. The following replaces Paragraph A.2.a.(2), "suit". of SECTION 11— COVERED;AUTOS LIABIL- (iv) We will reimburse the "insured" for ITY COVERAGE: sums that the "insured" legally must (2) Up to $3,000 for cost of bail bonds (in- pay as damages because of "bodily cluding bonds for related traffic law viola- injury" or "property damage" to which tions) required because lof an "accident" this insurance applies, that the "in - we cover. We do not have to furnish sured" pays with our consent, but these bonds. only up to the limit described in Para - 2. The following replaces Paragraph A.2.a.(4), graph C.,, Limits Of Insurance, of of SECTION II — COVEREDI AUTOS LIABIL- SECTION II — COVERED AUTOS ITY COVERAGE: LIABILITY COVERAGE. (4) All reasonable expenses incurred by the (v) We will reimburse the "insured" for "insured" at our request; including actual the reasonable expenses incurred loss of earnings up to 1$500 a day be- with our consent for your investiga- cause of time off from work. tion of such claims and your defense I of the "insured" against any such F. HIRED AUTO — LIMITED WORLDWIDE COV- "suit", but only up to and included ERAGE — INDEMNITY BASIS jJ within the limit described in Para - The following replaces Subparagraph (5) in Para- graph C., Limits Of Insurance, of graph B.7., Policy Period, Coverage Territory, SECTION II — COVERED AUTOS of SECTION IV — BUSINESSI AUTO CONDI- LIABILITY COVERAGE, and not in TIONS: 1 addition to such limit. Our duty to (5) Anywhere in the world, except any country or make such payments ends when we jurisdiction while any trade sanction, em- have used up the applicable limit of bargo, or similar regulation imposed by the insurance in payments for damages, United States of America applies to and pro- settlements or defense expenses. hibits the transaction of business with or (b) This insurance is excess over any valid within such country or jurisdiction, for Cov- and collectible other insurance available ered Autos Liability Coverage for any covered to the "insured" whether primary, excess, "auto" that you lease, hire( rent or borrow contingent or on any other basis. without a driver for a period of 30 days or less (c) This insurance is not a substitute for re - and that is not an "auto" you lease, hire, rent quired or compulsory insurance in any or borrow from any of your "employees", country outside the United States, its ter - partners (if you are a partnership), members ritories and possessions, Puerto Rico and (if you are a limited liability company) or Canada. members of their households. Page 2 of 4 © 2015 The Travelers Indemnity Company. All rights reserved. CA T3 53 02 15 Includes copyrighted material of Insurance Services Office, Inc. with its permission. You agree to maintain all "required or compulsory insurance in any such coun- try up to the minimum limits required by local law. Your failure to comply with compulsory insurance requirements will not invalidate the coverage afforded by this policy, but we will only be liable to the same extent we would have been liable had you complied with the compulsory in- surance requirements. (d) It is understood that we are not an admit- ted or authorized insurer outside the United States of America, its territories and possessions, Puerto Rico and Can- ada. We assume no responsibility for the furnishing of certificates of insurance, or for compliance in any way with the laws of other countries relating to insurance. G. WAIVER OF DEDUCTIBLE — GLASS The "following is added to Paragraph D., Deducti- ble, of SECTION III — PHYSICAL DAMAGE COVERAGE: No deductible for a covered "auto" will apply to glass damage if the glass is repaired rather than replaced. H. HIRED AUTO .PHYSICAL DAMAGE — LOSS OF USE — INCREASED LIMIT The following replaces the last sentence of Para- graph AA.b., Loss Of Use Expenses, of SEC- TION III — PHYSICAL DAMAGE COVERAGE: However, the most we will pay for any expenses for loss of use is $65 per day, to a maximum of $750 for any one "accident". I. PHYSICAL DAMAGE — TRANSPORTATION EXPENSES —INCREASED LIMIT The following replaces the first sentence in Para- graph AA.a., Transportation Expenses, of SECTION 111 — PHYSICAL DAMAGE COVER- AGE: We will pay up to $50 per day to a maximum of $1,500 for temporary transportation expense in- curred' by you because of the total theft of a cov- ered "auto" of theprivate passenger type. J. PERSONAL PROPERTY The following is addedto Paragraph AA., Cover- age Extensions, of SECTION III — PHYSICAL DAMAGE COVERAGE: Personal Property We will pay up to $400 for "loss" to wearing ap- parel and other personal property which Is: (1) Owned by an "insured"; and COMMERCIAL AUTO (2) In or on your covered "auto". This coverage applies only in the event of a total theft of your covered "auto". No deductibles apply to this Personal Property coverage. K. AIRBAGS The following is added to Paragraph B.3., Exclu- sions, of SECTION III — PHYSICAL DAMAGE COVERAGE: Exclusion 3.a. does not apply to "loss" to one or more airbags in a covered "auto" you own that in- flate due to a cause other than a cause of "loss" set forth in Paragraphs A.1.b. and A.1.c., but only: a. If that "auto" is a covered "auto" for Compre- hensive Coverage under this policy; b. The airbags are not covered under any war- ranty; and c. The airbags were not intentionally inflated. We will pay up to a maximum of $1,000 for any one "loss". L. NOTICE AND KNOWLEDGE OPACCIDENT OR LOSS The following is added to Paragraph A.2.a., of SECTION IV— BUSINESS AUTO CONDITIONS: Your duty to give us or our authorized representa- tive prompt notice of the "accident" or "loss" ap- plies only when the "accident" or "loss" is known to: (a) You (if youare an individual); (b) A partner (if you are a partnership); (c) A member (if you are a limited liability com- pany); (d) An executive officer, director or insurance manager (if you are a corporation or other or- ganization); or (e) Any "employee" authorized by you to give no- tice of the "accident" or "loss". M. BLANKET WAIVER OF SUBROGATION The following replaces Paragraph A.5., Transfer Of Rights Of Recovery Against Others To Us, of SECTION IV — BUSINESS AUTO CONDI- TIONS: 5. Transfer Of Rights Of Recovery Against Others'To Us We waive any right of recovery we may have against any person or organization to the ex- tent required of you by a written contract signed and executed prior, to any "accident" or "loss", provided that the "accident" or "loss" arises out 'of operations contemplated by CA T3 53 02 15 0,2015 The Travelers Indemnity Company. All rights reserved. Page 3 of 4 Includes copyrighted material of Insurance Services Office, Inc. with its permission. COMMERCIAL AUTO such contract. The waiver applies only to the person or organization designated in such contract. N. UNINTENTIONAL ERRORS OR�OMISSIONS The following is added to Paragraph B.2., Con- cealment, Misrepresentation, I Or Fraud, of SECTION IV — BUSINESS AUTO CONDITIONS: Page 4 of 4 The unintentional omission of, or unintentional error in, any information given by you shall not prejudice your rights under this insurance. How- ever this provision does not affect our right to col- lect additional premium or exercise our right of cancellation or non -renewal. © 2015 The Travelers Indemnity Company. All rights reserved. Includes copyrighted material of Insurance Services Office, Inc. with its permission. { CA T3 53 0215 _ WORKERS COMPENSATION TRAVELERS AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD, CT 06183 ENDORSEMENT WC 99 03 76 ( A) — 001 POLICY NUMBER: U69J160807 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA (BLANKET WAIVER) We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. The additional premium for this endorsement shall be 1 .0 % of the California workers' compensation pre- mium. Schedule Person or Organization Job Description ANY PERSON OR ORGANIZATION FOR WHICH THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER. 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 01/01/2023 Policy No. U139J160807 Insured Athens Insurance Services, Inc. Insurance Company Travelers Property Casualty Countersigned by Company of America DATE OF ISSUE: ST ASSIGN: Endorsement No. Premium Page 1 of 1