1.15.23 WC AOS WOS Blanket.pdf
PDF 10 KB Posted
- Attached to
- Master Agreement AZ|CTR055987
- Contract number
- CTR055987
- Issued by
- Arizona
About this file
This document is a Waiver of Our Right to Recover from Others Endorsement issued by LM Insurance Corporation for Weston Solutions Inc., with policy number WA5-63D-477160-012. The endorsement outlines state-specific premium charges for waiving subrogation rights in workers' compensation insurance, with variations across multiple states including Alabama, Arizona, Arkansas, Connecticut, Florida, Georgia, Hawaii, Louisiana, Massachusetts, New York, Tennessee, and Virginia. The document specifically notes that the waiver is not applicable in Kentucky, Missouri, New Hampshire, and New Jersey.
The endorsement details premium calculation methods for different states, ranging from 1% to 5% of total manual premium, with minimum premiums typically set at $100 or $250 per policy. For most states in the list, the premium charge is 2% of the total manual premium, subject to a minimum premium of $100 or $250. Specific variations exist, such as Hawaii's flat $250 premium and Virginia's 5% rate. The document includes a provision allowing waivers of subrogation where required by written contract prior to loss and permitted by law, with special considerations for certain state-specific scenarios, including a note about construction classifications in Missouri.
View the file
Other files
Show all 21
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Not applicable in Kentucky, Missouri, New Hampshire and New Jersey
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.)
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
Schedule
Any person or organization for which the employer has agreed by written contract, executed prior to loss, may execute a waiver of subrogation. However, for purposes of work performed by the employer in Missouri, this waiver of subrogation does not apply to any construction group of classifications as designated by the waiver of right to recover from others (subrogation) rule in our manual.
The waiver does not apply to any right to recover payments which the Minnesota Workers Compensation Reinsurance Association may have or pursue under M.S. 79.36.
Where required by contract or written agreement prior to loss and allowed by law.
In the states of Alabama, Arizona, Arkansas, Colorado, Delaware, Dist. Of Col, Guam, Georgia, Idaho, Illinois, Indiana, Kansas, Maine, Michigan, Minnesota, Mississippi, Montana, Nevada, New Mexico, North Carolina, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Vermont, West Virginia, the premium charge is 2% of the total manual premium, subject to a minimum premium of $100 per policy.
In the states ofConnecticut, Florida, Iowa, Maryland, Nebraska, Oregon, the premium charge is 1% of the total manual premium, subject to a minimum premium of $250 per policy.
In the state of Hawaii, the premium charge is $250 and determined as follows: The premium charge for this endorsement is 1% of the total manual premium, subject to a minimum premium of $250 per policy.
In the state of Louisiana, the premium charge is 2% of the total standard premium, subject to a minimum premium of $250 per policy.
In the state of Massachusetts, the premium charge is 1% of the total manual premium.
WC 00 03 13
Ed. 04/01/1984
© 1983 National Council on Compensation Insurance. Page of 1 2
In the states of New York, Tennessee, the premium charge is 2% of the total manual premium, subject to a minimum premium of $250 per policy.
In the state of Virginia, the premiumcharge is 5% of the total manual premium, subject to a minimum premium of $250 per policy.
Issued by
For attachment to Policy No. Effective Date Premium $
Issued to Endorsement No.Weston Solutions Inc.
LM Insurance Corporation 27243
WA5-63D-477160-012
WC 00 03 13
Ed. 04/01/1984
© 1983 National Council on Compensation Insurance. Page of 2 2
File details come from the government source that posted it. Updated .