-004-ENDT-07-23-2021_R2WC216559_-_Email__R2WC216559__.pdf
PDF 188 KB Posted
- Attached to
- Master Agreement AZ|CTR055535
- Contract number
- CTR055535
- Issued by
- Arizona
About this file
This document is a Workers' Compensation Insurance Policy Endorsement from AmGUARD Insurance Company for Milemarkers Therapy, Inc., located in Lake Havasu City, Arizona. The policy is managed through S Wolf and Associates in Chicago, Illinois, and is specifically tied to the State of Arizona Department of Economic Security's Developmental Disabilities (DDD) Programs. The policy period runs from February 20, 2021, to February 20, 2022.
The endorsement includes two key modifications: adding a classification code 8832 for Physician & Clerical workers with an annual payroll of $100,000, and implementing a Waiver of Subrogation for the State of Arizona Department of Economic Security. The new estimated annual premium is $13,074, with a premium change of $412.00. The waiver specifically covers programs for developmental and physical disabilities, with a waiver premium of $250.00. The document also includes an Audit Noncompliance Charge Endorsement, which outlines potential penalties if the insured does not allow proper examination of records related to the policy.
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Text version
Important Information
Agency
S WOLF AND ASSOCIATES
2338 W MORSE AVE APT 1C
Chicago, IL 60645
MILEMARKERS THERAPY, INC.
1515 Lake Havasu Ave N Ste 100 Lake Havasu City, AZ 86404
Changes to Your Workers' Compensation Policy
Policy Number R2WC216559 with AmGUARD Insurance Company
Policy Period From February 20, 2021 to February 20, 2022, 12:01 AM, standard time at the insured's mailing address.
Party Requesting the Change and Type of Endorsement
The Agent - Added 0_040 effective 02/20/2021
State: AZ; Code: 8832 PHYSICIAN & CLERICAL; Payroll: $100,000
The Agent - Added Waiver of Subrogation effective 02/20/2021
Name: State of AZ Department of Economic Security, DDD; Job Description: Programs for developmental and physical disabilities
New AZ Estimated Annual Premium 13,074
Premium change: 412.00$
R2WC216559
MILEMARKERS THERAPY, INC. $412
See Above
AmGUARD Insurance Company
Thank You Again for Choosing Berkshire Hathaway GUARD Insurance Companies!
Call Customer Service at 800-673-2465 with any questions.
Endorsement
Specific Waiver
Person/Organization: State of AZ Department of Economic Security, DDD
Job Description: Programs for developmental and physical disabilities
Waiver Premium: 250.00
Class State Payroll Subject to Waiver
8832 AZ 100,000
R2WC216559
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 24
(Ed. 1-17)
AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT
Part Five-Premium, Section G. (Audit) of the Workers Compensation and Employers Liability Insurance Policy is revised by adding the following:
If you do not allow us to examine and audit all of your records that relate to this policy, and/or do not provide audit information as requested, we may apply an Audit Noncompliance Charge. The method for determining the Audit Noncompliance Charge by state, where applicable, is shown in the Schedule below.
If you allow us to examine and audit all of your records after we have applied an Audit Noncompliance Charge, we will revise your premium in accordance with our manuals and Part 5-Premium, E. (Final Premium) of this policy.
Failure to cooperate with this policy provision may result in the cancellation of your insurance coverage, as specified under the policy.
Note:
For coverage under state-approved workers compensation assigned risk plans, failure to cooperate with this policy provision may affect your eligibility for coverage.
© Copyright 2016 National Council on Compensation Insurance, Inc. All Rights Reserved.
(Ed. 1-17)
Countersigned by ____________________________________WC 00 04 24
Insurance Company: AmGUARD Insurance Company
Insured:
Endorsement No.: Policy No.: R2WC216559Endorsement Effective: 02/20/2021
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
Premium
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 24
(Ed. 1-17)
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICYWC 00 04 24
(Ed. 1-17)
Schedule
State(s) Basis of Audit Noncompliance Charge
Maximum Audit Noncompliance Charge Multiplier
AZ
13,074
Estimated Annual Premium
Of $
PAAMGU20
© Copyright 2016 National Council on Compensation Insurance, Inc. All Rights Reserved.
(Ed. 1-17)
Countersigned by ____________________________________WC 00 04 24
Insurance Company: AmGUARD Insurance Company
Insured:
Endorsement No.: Policy No.: R2WC216559Endorsement Effective: 02/20/2021
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
Premium
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