2024-2025 Policy.pdf

www.saif.com

Pol_PC1_REN

400 High Street SE Salem, OR 97312 P: 800.285.8525 F: 503.373.8020

July 12, 2024

CLATSOP COUNTY

800 EXCHANGE ST STE 410

ASTORIA, OR 97103-4641

SAIF policy: 4700

Thank you for again choosing SAIF as your workers’ comp carrier. Enclosed you’ll find your workers' compensation policy, effective July 01, 2024.

Included with this letter is a policy information page that shows your estimated payroll, premium modifiers, and premium amount. All previous policy endorsements continue to apply unless they have been cancelled or amended.

We've also provided some key information below. You'll find everything else you need to know about your policy, workplace safety, filing and managing a claim, and more on saif.com in our "Employer Guide." You can request printed information on topics that interest you and your workers by calling us at 800.285.8525, or by emailing uwpayroll@saif.com.

Payroll reporting | At the end of each Annual reporting period, we'll send you a form to report the actual payroll for your covered workers for that period. For your convenience, you can also report your payroll and make your payments online. Visit the Employer Guide on saif.com for more details.

For more on payroll reporting, visit these pages on saif.com:

· Learn how to complete your payroll report: saif.com/instructions

· View details on the requirements for reporting your payroll by class: saif.com/class

· See an explanation of who is covered (also called “subject workers") and who is not:

saif.com/whomiscovered

· Learn when to report a worker in multiple classifications: saif.com/vtr

Your premium | Payment options based on your estimated premium of $250,208.11 are listed below.

Installment payment plan Due date Amount

08/25/2024 $250,208.11

Please notify us of any changes in your business.

Premium audits | We want you to pay only what you're required to pay. Premium auditors verify your payroll and classification. Learn more about the premium audit process at saif.com/premiumaudit.

Nondisabling claim reimbursement | This program could help you reduce or eliminate costs that are considered when determining your future experience rating modification factors. Learn more about the program and billing options at saif.com/ndr.

Clatsop County July 12, 2024

4700 Clatsop County

Workplace safety and health | Safety professionals will assist you in analyzing your operations, hazards, injury records, and management controls.

In addition, they will help you:

· Improve workplace safety culture

· Learn how to conduct onsite health and safety surveys

· Assess your safety and health programs

· Learn to identify and evaluate safety training requirements, best practices, and available resources

· Understand your responsibilities and the rules which pertain to your workplace under the

Oregon Safe Employment Act (OSEA) and the Oregon Occupational Safety and Health Divisions (OR-OSHA). OSEA and OR-OSHA require employers to provide a safe and healthful workplace and to do everything reasonably necessary to protect the life, health, and safety of their employees. Learn more at www.orosha.org or 800.922.2689.

You also can find workplace safety information on saif.com/safetyandhealth. To request safety and health services contact our safety team at 877.242.5211.

Your policy information page includes any changes that may have been made to your policy. Please review it and let us know if any information needs to be updated. Remember to notify us of any changes to your business, including ownership, operations, and address.

Here at SAIF, our goals are to provide you exceptional service at an affordable price, and to help you make your workplace as safe as possible. We appreciate the confidence you have placed in us in the past and look forward to working with you during the coming policy year.

Do you have any questions, or need help? Please contact Alycia Johnson at 541.687.4799. You can also contact SAIF at the phone number or email address below.

Sincerely, /s/ Kory Pratt Underwriter P: 503.373.8254 F: 503.584.8254

KORPRA@SAIF.COM

c: Alycia Johnson

Carrier no: 20001

Information Page Policy no: 4700

Employer identification no: 93-6002287 NCCI Risk ID no: 360126218

Pol_PC1_P401

400 High Street SE Salem, OR 97312 P: 800.285.8525 F: 503.373.8020

Item 1. The Insured: Entity Type:

Clatsop County Political Subdivision: County

Mailing address:

CLATSOP COUNTY

800 EXCHANGE ST STE 410

ASTORIA, OR 97103-4641

Agent:

ALYCIA JOHNSON

ASSUREDPARTNERS OF OREGON LLC

3125 CHAD DR STE 120

EUGENE, OR 97408-7440

Other workplaces not shown above:

Clatsop County 749 Commercial St Astoria, OR 97103-4544

Clatsop County 355 7th St Astoria, OR 97103-4533

Clatsop County 1315 SE 19th St Warrenton, OR 97146-7405

Clatsop County 1190 SE 19th St Warrenton, OR 97146-9584

Clatsop County Wickiup Mountain Astoria, OR 97103

Clatsop County Green Mtn Rd Astoria, OR 97103

Clatsop County 1100 Olney Ave Astoria, OR 97103-5533

Clatsop County Cullaby Lake Park Warrenton, OR 97146

Clatsop County 857 Commercial St Astoria, OR 97103-4514

Clatsop County 800/820 Exchange Astoria, OR 97103

Clatsop County 92937 Walluski Loop Astoria, OR 97103-8521

Clatsop County 92435 Svensen Market Rd

SAIF policy: 4700

Astoria, OR 97103

Clatsop County 79532 Highway 202 Seaside, OR 97138

Item 2. The policy period is from 07/01/2024, 12:01 A.M. to 07/01/2025, 12:01 A.M. at the insured’s mailing address.

Item 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: OREGON.

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 $2,000,000 each accident Bodily Injury by Disease $2,000,000 each employee Bodily Injury by Disease $2,000,000 policy limit

C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:

NONE

D. This policy includes these endorsements and schedules:

WC360601E Oregon Cancellation Endorsement WC360402 Oregon Contracting Classification Premium Adjustment Endorsement WC990401C Premium Payment Rating Plan Endorsement WC890406 Policy Information Page Endorsement WC000414A 90-Day Reporting Requirement-Notification of Change in Ownership Endorsement WC000310 Sole Proprietors, Partners, Officers and Others Coverage Endorsement WC000310 Sole Proprietors, Partners, Officers and Others Coverage Endorsement WC000310 Sole Proprietors, Partners, Officers and Others Coverage Endorsement WC000424 Audit Noncompliance Charge Endorsement WC990616 Confidentiality Endorsement WC360304 Oregon Amendatory Endorsement WC000106A Longshore And Harbor Workers' Compensation Act Coverage Endorsement WC000421F Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement WC000422C Terrorism Risk Insurance Program Reauthorization Act Disclosure endorsement.

WC000406A Premium Discount Endorsement WC000419A Part Five - Premium Amendatory Endorsement WC360406 Premium Due Date Endorsement WC000201B Maritime Coverage Endorsement WC990203 Voluntary Compensation Maritime Coverage Endorsement

Item 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. The experience rating modification factor and other rating plan factors, if any, may change on your rating effective date of 7/1/2025. All information required below is subject to verification and change by audit.

Rating period: 07/01/2024 to 07/01/2025 Location 1: Clatsop County

Classification description Class Subject payroll Rate Premium

County Search And Rescue- Volunteer

7720 $3,000.00 2.38 $71.40

Total manual premium $3,000.00 $71.40

Location 4: Clatsop County

Classification description Class Subject payroll Rate Premium

Fish Hatchery & Dr 0113 $376,127.00 2.74 $10,305.88 Carpentry-NOC 5403 $0.00 4.6 $0.00 Street/Rd Const-Fnl Grad/Pve/Rep/Dr

5506 $2,058,800.00 3.86 $79,469.68

Vol Search/Resc Diver-State Act Exp 6876 $1,000.00 2.27 $22.70 Vessels-NOC-State Act 7024 $40,000.00 2.72 $1,088.00 Drivers/Chauffrs/Messengrs & Helpr 7380 $0.00 3.65 $0.00 Aviation-Patrol/Photo/Sur-Fly Crew 7422 $0.00 1.08 $0.00 Police Officers & Dr 7720 $8,427,745.00 2.38 $200,580.33 USLH:Police Officers & Dr 7720 $0.00 4.36 $0.00 Inmates 7720 $183,397.00 2.38 $4,364.85 Vol Physician/Medical Staff 7720 $0.00 2.38 $0.00 City/County-Veh/Equip Repr Shop-Dr 8380 $225,521.00 1.68 $3,788.75 Vol Dpty Sheriff @ 4500/Qtr Ea 8411 $18,000.00 1.09 $196.20 Field Representatives 8742 $0.00 0.16 $0.00 Vol Commissioners 8742 $1,500.00 0.16 $2.40 Office Clerical 8810 $4,805,226.00 0.07 $3,363.66 Vol Library Prof Emp & Cler 8810 $0.00 0.07 $0.00 Attorney & Cler/Messenger/Dr 8820 $1,988,798.00 0.07 $1,392.16 Dog Pounds-Incl Dog Catcher/Dr 8831 $342,808.00 0.85 $2,913.87 Vol Care/Feed Animals-Dr 8831 $62,700.00 0.85 $532.95 Physician & Clerical 8832 $2,504,788.00 0.28 $7,013.41 Buildings-Operation By Owner Or Lessee & Drivers

9015 $341,241.00 2.23 $7,609.67

County Fairs/Dr 9016 $197,137.00 1.86 $3,666.75 Vol Fairgrounds Worker-Dr 9016 $0.00 1.86 $0.00 Park NOC-All Employees & Dr 9102 $158,236.00 2.53 $4,003.37 Municipal/Twn/Cnty/State Emp-NOC 9410 $3,026,089.00 1.11 $33,589.59 Vol Disaster Asst Emrgncy Ops Wrkr 9410 $0.00 1.11 $0.00

Total manual premium $24,759,113.00 $363,904.22

Description Basis Factor Premium EL Increased Limits premium (Admiralty) $1,088.00 1.88 $957.44 EL Increased Limits premium (Part II) $363,975.62 1.007 $2,547.83

Total subject premium $367,480.89

Description Basis Factor Premium Experience Rating $367,480.89 0.76 -$88,195.41

Total modified premium $279,285.48

Description Basis Factor Premium Pre-pay credit $279,285.48 0.97 -$8,378.56

Total standard premium $270,906.92

Description Basis Factor Premium Oregon Total Premium $270,906.92 Premium Discount $270,906.92 0.172 -$46,588.25 USLH Expense Constant $100.00 1.0 $100.00 Terrorism Premium $24,762,113.00 0.005 $1,238.11 Catastrophe Premium $24,762,113.00 0.01 $2,476.21 DCBS Assessment $225,256.34 1.098 $22,075.12

Total premium and assessment $250,208.11

Policy Minimum Premium: $500

Part Two Coverage Increased Limits Minimum Premium: $140

Maritime Coverage Minimum Premium: $175

Your policy premium is based on your current estimated premium and may be prorated for policies in effect for less than a full year or adjusted based on actual payroll by classification.

Terrorism Premium is in addition to Policy Minimum Premium.

Catastrophe Premium is in addition to Policy Minimum Premium.

DCBS Premium Assessment excludes Part Two Coverage.

Payroll Reporting Frequency: Annual

Policyholder Option to Reimburse SAIF Corporation for Medical Expenses (Nondisabling Claims Reimbursement Program): This policyholder has chosen to enroll in the Nondisabling Claims Reimbursement program with Quarterly claim evaluation.

This information page is part of your policy.

Countersigned on July 12, 2024 at Salem, Oregon

Chip Terhune President and Chief Executive Officer

WC000001A

Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission.

Copyright 2013 National Council on Compensation Insurance, Inc. All rights reserved. Pol_PC1_BPVOLA

STANDARD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY PARTICIPATING

GENERAL SECTION

In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows:

A. The Policy This policy includes at its effective date the Information Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Information Page) and us (the insurer named on the Information Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy.

B. Who Is Insured You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an employer of the partnership’s employees.

C. Workers Compensation Law Workers Compensation Law means the workers or workmen’s compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect during the policy period. It does not include any federal workers or workmen’s compensation law, any federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits.

D. State State means any state of the United States of America, and the District of Columbia.

E. Locations This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A. states unless you have other insurance or are self-insured for such workplaces.

PART ONE - WORKERS COMPENSATION INSURANCE

A. How This Insurance Applies This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death.

1. Bodily injury by accident must occur during the policy period.

2. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee’s last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period.

B. We Will Pay We will pay promptly when due the benefits required of you by the workers compensation law.

C. We Will Defend We have the right and duty to defend at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to investigate and settle these claims, proceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance.

D. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend:

1. reasonable expenses incurred at our request, but not loss of earnings;

2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance;

3. litigation costs taxed against you;

4. interest on a judgment as required by law until we offer the amount due under this insurance; and

5. expenses we incur.

E. Other Insurance We will not pay more than our share of benefits and costs covered by this insurance and other insurance or self-insurance.

Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid.

F. Payments You Must Make You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required because:

1. of your serious and willful misconduct;

2. you knowingly employ an employee in violation of law;

3. you fail to comply with a health or safety law or regulation; or

4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law.

If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly.

SAIF Policy: 4700

Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission.

Copyright 2013 National Council on Compensation Insurance, Inc. All rights reserved.

G. Recovery From Others We have your rights, and the rights of persons entitled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them.

H. Statutory Provisions These statements apply where they are required by law.

1. As between an injured worker and us, we have notice of the injury when you have notice.

2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our duties under this insurance after an injury occurs.

3. We are directly and primarily liable to any person entitled to the benefits payable by this insurance. Those persons may enforce our duties; so may an agency authorized by law. Enforcement may be against us or against you and us.

4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law.

5. This insurance conforms to the parts of the workers compensation law that apply to:

a. benefits payable by this insurance;

b. special taxes, payments into security or other special funds, and assessments payable by us under that law.

6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law.

Nothing in these paragraphs relieves you of your duties under this policy.

PART TWO - EMPLOYERS LIABILITY INSURANCE

A. How This Insurance Applies This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death.

1. The bodily injury must arise out of and in the course of the injured employee’s employment by you.

2. The employment must be necessary or incidental to your work in a state or territory listed in Item 3.A. of the Information

Page.

3. Bodily injury by accident must occur during the policy period.

4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee’s last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period.

5. If you are sued, the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada.

B. We Will Pay We will pay all sums that you legally must pay as damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay, where recovery is permitted by law, include damages:

1. For which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against such third party as a result of injury to your employee;

2. For care and loss of services; and

3. For consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee; provided that these damages are the direct consequence of bodily injury that arises out of and in the course of the injured employee’s employment by you; and

4. Because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer.

C. Exclusions This insurance does not cover:

1. Liability assumed under a contract. This exclusion does not apply to a warranty that your work will be done in a workmanlike manner;

2. Punitive or exemplary damages because of bodily injury to an employee employed in violation of law;

3. Bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers;

4. Any obligation imposed by a workers compensation, occupational disease, unemployment compensation, or disability benefits law, or any similar law;

5. Bodily injury intentionally caused or aggravated by you;

6. Bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries;

7. Damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, or any personnel practices, policies, acts or omissions;

8. Bodily injury to any person in work subject to the Longshore and Harbor Workers’ Compensation Act (33 U.S.C. Sections 901 et seq.), the Nonappropriated Fund Instrumentalities Act (5 U.S.C. Sections 8171 et seq.), the Outer Continental Shelf Lands Act (43 U.S.C. Sections 1331 et seq.), the Defense Base Act (42 U.S.C. Sections 1651-1654), the Federal Mine Safety and Health Act (30 U.S.C. Sections 801 et seq. and 901-944), any other federal workers or workmen’s compensation law or other federal occupational disease law, or any amendments to these laws;

9. Bodily injury to any person in work subject to the Federal Employers’ Liability Act (45 U.S.C. Sections 51 et seq.), any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws;

Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission.

Copyright 2013 National Council on Compensation Insurance, Inc. All rights reserved.

10. Bodily injury to a master or member of the crew of any vessel, and does not cover punitive damages related to your duty or obligation to provide transportation, wages, maintenance, and cure under any applicable maritime law;

11. Fines or penalties imposed for violation of federal or state law; and

12. Damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 U.S.C. Sections 1801 et seq.)

and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws.

D. We Will Defend We have the right and duty to defend, at our expense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceedings and suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance.

E. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend:

1. Reasonable expenses incurred at our request, but not loss of earnings;

2. Premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance;

3. Litigation costs taxed against you;

4. Interest on a judgment as required by law until we offer the amount due under this insurance; and

5. Expenses we incur.

F. Other Insurance We will not pay more than our share of damages and costs covered by this insurance and other insurance or self-insurance.

Subject to any limits of liability that apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance and self-insurance will be equal until the loss is paid.

G. Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.B. of the Information Page. They apply as explained below.

1. Bodily Injury by Accident. The limit shown for “bodily injury by accident-each accident” is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident.

2. Bodily Injury by Disease. The limit shown for “bodily injury by disease-policy limit” is the most we will pay for all damages covered by this insurance and arising out of bodily injury by disease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for “bodily injury by disease-each employee” is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include disease that results directly from a bodily injury by accident.

3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance.

H. Recovery From Others We have your rights to recover our payment from anyone liable for an injury covered by this insurance. You will do everything necessary to protect those rights for us and to help us enforce them.

I. Actions Against Us There will be no right of action against us under this insurance unless:

1. You have complied with all the terms of this policy; and

2. The amount you owe has been determined with our consent or by actual trial and final judgment.

This insurance does not give anyone the right to add us as a defendant in an action against you to determine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obligations under this Part.

PART THREE - OTHER STATES INSURANCE

A. How This Insurance Applies

1. This other states insurance applies only if one or more states are shown in Item 3.C. of the Information Page.

2. If you begin work in any one of those states after the effective date of this policy and are not insured or are not self-insured for such work, all provisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page.

3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them.

4. If you have work on the effective date of this policy in any state not listed in Item 3.A. of the Information Page, coverage will not be afforded for that state unless we are notified within thirty days.

B. Notice Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page.

PART FOUR - YOUR DUTIES IF INJURY OCCURS

Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here.

1. Provide for immediate medical and other services required by the workers compensation law.

Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission.

Copyright 2013 National Council on Compensation Insurance, Inc. All rights reserved.

2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need.

3. Promptly give us all notices, demands and legal papers related to the injury, claim, proceeding or suit.

4. Cooperate with us and assist us, as we may request, in the investigation, settlement or defense of any claim, proceeding or suit.

5. Do nothing after an injury occurs that would interfere with our right to recover from others.

6. Do not voluntarily make payments, assume obligations or incur expenses, except at your own cost.

PART FIVE - PREMIUM

A. Our Manuals All premium for this policy will be determined by our manuals of rules, rates, rating plans and classifications. We may change our manuals and apply the changes to this policy if authorized by law or a governmental agency regulating this insurance.

B. Classifications Item 4 of the Information Page shows the rate and premium basis for certain business or work classifications. These classifications were assigned based on an estimate of the exposures you would have during the policy period. If your actual exposures are not properly described by those classifications, we will assign proper classifications, rates and premium basis by endorsement to this policy.

C. Remuneration Premium for each work classification is determined by multiplying a rate times a premium basis. Remuneration is the most common premium basis.

This premium basis includes payroll and all other remuneration paid or payable during the policy period for the services of:

1. all your officers and employees engaged in work covered by this policy; and

2. all other persons engaged in work that could make us liable under Part One (Workers Compensation Insurance) of this policy. If you do not have payroll records for these persons, the contract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the employers of these persons lawfully secured their workers compensation obligations.

D. Premium Payments 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.

E. Final Premium The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is cancelled, final premium will be determined in the following way unless our manuals provide otherwise:

1. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium.

2. If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short-rate cancellation table and procedure. Final premium will not be less than the minimum premium.

F. Records You will keep records of information needed to compute premium. You will provide us with copies of those records when we ask for them.

G. Audit You will let us examine and audit all your records that relate to this policy. These records include ledgers, journals, registers, vouchers, contracts, tax reports, payroll and disbursement records, and programs for storing and retrieving data. We may conduct the audits during regular business hours during the policy period and within three years after the policy period ends.

Information developed by audit will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provision.

PART SIX - CONDITIONS

A. Inspection We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurability of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organizations have the same rights we have under this provision.

B. Long Term Policy If the policy period is longer than one year and sixteen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force.

Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission.

Copyright 2013 National Council on Compensation Insurance, Inc. All rights reserved.

C. Transfer of Your Rights and Duties Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days after your death, we will cover your legal representative as insured.

D. Cancellation

1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect.

2. We may cancel this policy. We must mail or deliver to you not less than ten days advance written notice stating when the cancellation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice.

3. The policy period will end on the day and hour stated in the cancellation notice.

4. Any of these provisions that conflicts with a law that controls the cancellation of the insurance in this policy is changed by this statement to comply with the law.

E. Sole Representative The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancellation.

F. Participation Provision The insured shall be entitled to participate in the distribution of dividends to the extent and under the conditions prescribed by the Board of Directors of the company if the Board in its sole discretion declares a dividend in accordance with law after expiration of the policy period to which the dividend is applicable.

To comply with the Oregon law regarding dividends, the following statement expresses the intent of the Oregon Insurance Code: “It is unlawful in Oregon for an insurer to promise to pay policyholder dividends for any unexpired portion of the policy term or to misrepresent the conditions for dividend payment. Dividends will be due and payable only for a policy period that has expired, and only if declared by and under conditions prescribed by the Board of Directors of the Insurer.”

In witness whereof, SAIF Corporation has caused this policy to be signed by its President at Salem, Oregon, but this policy shall not be binding unless completed by the attachment hereto of an Information Page.

Chip Terhune

Pol_PC1_LS241L

NOTICE TO EMPLOYEES U.S. Department of Labor

Longshore and Harbor Workers' Compensation Act Employment Standards Administration Office of Workers' Compensation Programs

Employer Clatsop County This employer is insured to provide compensation benefits (including medical and hospital care) to its employees, or monetary benefits eligible survivors, in case of work-connected injury, occupational illness or death, in accordance with the provisions of the above law and rules of the Office of Workers' Compensation Programs

WHAT

TO DO

WHEN

INJURED

AT WORK

NOTIFY YOUR EMPLOYER IMMEDIATELY. If possible, complete Form LS-201, Notice of Injury, available from your employer. You should give notice of injury to the following person(s):

MEDICAL TREATMENT. Request authority (Form LS-1) from your employer for treatment by the physician you choose. You may not select a physician that is not authorized by the Office of Workers' Compensation Programs to provide medical care under the Act. Your employer has a list of physicians who are not authorized. In an emergency or if unable to contact your employer, go to the nearest hospital or physician, but be sure to let your employer know as soon as possible.

DISABILITY. If you are disabled more than 3 days, contact your employer or the insurance company indicated below for payment or compensation, payable 14 days after your employer has knowledge of injury.

IMPORTANT! The law requires you to give written notice of injury (Form LS-201) to your employer and to the Office of Workers' Compensation Programs within 30 days.

Additional time may be allowed for certain hearing loss and occupational disease claims. The address of the Office of Workers' Compensation Programs District Office for this area is:

300 5th Avenue, Suite 1050L Seattle, WA 98104-2429

Insurance Carrier for This Employer For Further Assistance and Information:

Name SAIF Corporation

On request, the Office of Workers' Compensation Programs will explain benefits and proceedings under the above Act. In addition, the Office of Workers' Compensation Programs will inform employees receiving compensation about medical and vocational rehabilitation services, and will assist in obtaining such services.

Address 400 High Street SE Salem, OR 97312-1000

Telephone 503.373.8000

Policy Number Expiration Date of Policy 4700 07/01/2025 Oregon

Authorized Signature for the Employer Date Signed This Notice must be posted and maintained in a conspicuous place in and about the place of business

(33 U.S.C. 934)

IMPORTANT NOTICE

Section 31 (a)(1) of the Longshore Act, 33 U.S.C. 931(a)(1), provides as follows: Any claimant or representative of a claimant who knowingly and willfully makes a false statement or representation for the purpose of obtaining a benefit or payment under this act shall be guilty of a felony, and on conviction thereof shall be punished by a fine not to exceed $10,000, by imprisonment not to exceed five years, or by both.

Pol_PC1_CLADD

400 High Street SE Salem, OR 97312 P: 800.285.8525 F: 503.373.8020

SAIF policy: 4700

Classification Addendum

Verifiable time records

Oregon Administrative Rules require you to report wages under the highest rated classification applicable to any part of the worker’s duties if you choose not to keep verifiable time records.

In most instances, if you have more than one classification on your insurance policy and your workers shift duties between those classifications, you can use verifiable time records to separate the payroll of the workers and report it in more than one classification on the payroll report.

Verifiable payroll records must be supported by original entries from other records, including, but not limited to, time cards, calendars, planners, or daily logs prepared by the employee or the employee’s direct supervisor or manager. Estimated percentages or ratios will not be accepted. For more information on how to keep verifiable time records, visit saif.com and choose: Employers Guide > Payments and payroll reporting > Report your payroll > Verifiable time records.

The following classifications will become effective on your policy July 01, 2024:

0113 01 Fish Hatchery & Dr

Class 0113 applies to your employees involved in direct labor, supervision and driving who are engaged in the operation of your fish hatchery or in the raising of oysters, and are not engaged in any activities on a dock when your hatchery or other land based operations are located next to the dock.

This class applies to the use of all acreage or facilities devoted to the raising of both large and small fish and oysters. The operations are usually carried on outside, in and around ponds and pools which can vary considerably in depth. Class 0113 includes the construction of dams and ditches for additional pools. While this class does include the repair or maintenance of your pools, building, equipment and vehicles, it does not apply to new construction of buildings, fences, or other structures, other than dams or ditches. Class 0113 does not apply to aerial stocking of lakes; loading or unloading of vessels; or to maintenance or repair work performed on docks or equipment located on the docks.

Employees who are involved in the loading or unloading of vessels; the maintenance of the dock or equipment located on the dock; spend all of their time on the dock; or work both on the dock and also work in your hatchery or other land based operations, when your hatchery or land based operation is located next to the dock are subject to the United States Longshoremen and Harbor Workers? Act (USL&HWA) and are not covered unless your policy is endorsed for USL&HWA Coverage.

5403 27 Carpentry-NOC

5403 Carpentry-NOC; Carpentry-Commercial or Dwellings Over 3 Stories; Siding Installation All Types Commercial or Dwellings Over 3 Stories; Silo Erection-Wood; Scaffold Erection: All Types.Class 5403 applies when all of the carpentry work in connection with the construction of residential dwellings exceeding three stories in height or commercial buildings and structures is performed by employees of the same carpentry contractor or general contractor responsible for the entire new construction project. This includes the construction of exterior, load bearing walls, using wood or metal studs, sill, rough framework, rough floors, interior wood or light-gauge steel studs or steel joists, rafters, roof deck, all types of roofing materials, sidewall sheathing, siding, insulation, doors, wallboard installation including patching or finishing operations such as spray texturing, lathing, windows, jalousie or jalousie screen, sky lights, stairs, fencing, and decking. (Light-gauge steel framing is generally a

Classification addendum thickness of 12 to 25 gauge.) Separately rate the installation of cabinet work, interior trim, and wood flooring to class 5437.The construction of mixed-use buildings, with no restriction in height, is also assigned to class 5403. These are defined as a combination of residential, commercial, industrial, or office use. The construction of residential dwellings not exceeding three stories in height to be separately rated as class 5645. Housing facilities such as dormitories and assisted living facilities are considered commercial structures. A story is defined as fifteen (15) feet in height measured from the lowest point above ground level to the highest point above ground level. Carpentry repair and/or remodeling of commercial buildings and structures as well as dwellings exceeding three stories in height is also assigned to class 5403 if the work involves some framing or structural carpentry renovation. Class 5403 would then apply to all carpentry operations in connection with the repair or renovation project. Class 5403 does not apply when performing a single operation such as repairing or replacing a roof or wallboard. These singular repair operations and others are to be separately rated along with 5437 carpentry work.Class 5403 also applies to the construction of exterior, load bearing walls, using metal studs. Additionally, 5403 operations include, but are not limited to, the construction of wooden bridges and decks; the setup of wood silos, tanks, gazebos, pergolas, and trellises; the setup of wood or plastic playground equipment; repair or removal in wooden buildings and dwellings;

wood oil rig or derrick erecting or dismantling; and the wrecking or salvage of non-marine wooden buildings or structures, including those designed for dwelling occupancy.Class 5403 also applies to the repair and maintenance of your equipment used for this work when performed at the job site. If you maintain a permanent yard for the purpose of storage or maintaining your vehicles, equipment, buildings, or structures, class 8227 - Contractors - Permanent Yards would apply to that operation.

Carpentry work that involves the making of or setting up or taking down of forms in connection with concrete construction is assigned to the proper concrete construction code. This rule is applicable even when the forming contractor is a specialist not directly involved with actual concrete mixing or pouring. Specialty contractors installing doors, windows or interior light-gauge metal studs are separately classed 5102-Doors and Window Installation-All Types-Residential and Commercial.

5506 11 Street/Rd Const-Fnl Grad/Pve/Rep/Dr

Class 5506 applies to your employees involved in direct labor, supervision, driving, and flagging who are engaged in street or road construction involving the paving or surfacing of new streets or roads or the repaving, resurfacing, or scraping of existing streets or roads. New construction includes all work beginning with the construction of the concrete or crushed stone base on an established grade and carries on through the paving or surfacing of the street or road, regardless of the types of surface, and finishing operations, i.e., trimming of road shoulders, erecting guardrails or fences, painting safety lines or center stripes (whether performed by specialist contractors or the prime), and installing curbs or gutters when part of the paving contract. Repaving includes the scraping or cleaning of the existing surface and the application of the resurfacing material as well as the scraping of existing dirt or gravel roads including regraveling operations. Airport construction involving the paving of runways or warming aprons is also included within this class as are asphalt works set up at a particular job site.

Oil distributors who deliver and spread oil in conjunction with the spreading of sand or gravel are also classed as 5506 as are specialist contractors engaged in asphalt laying on top of already constructed highways and the spraying of roads with liquid asphalt. Contractors engaged in asphalt surfacing;

application of the initial adhesive bonding material; the surface spreading and rolling of the crushed aggregate in connection with the installation of artificial turf for baseball and football stadiums; and the operation of asphalt works, including grinding, pulverizing, or mixing asphalt that is operated by a road paving contractor at a temporary location are properly assigned to class 5506. Class 5506 also applies to the repair and maintenance of your equipment and vehicles used for this work only if performed at the job site. If you maintain a permanent yard for the purpose of storage or maintaining your vehicles, equipment, buildings, or structures, class 8227 - Contractors - Permanent Yards would apply to that operation. If you are a municipality, Class 8380 - City/County-Vehicle/Equipment Repair, applies in place of Class 8227. Painting of lines or stripes on parking lots by hand or machine is separately classed as 5474 - Painting, when done by contractors that did not engage in the paving of the parking lot. Specialty contractors involved in the installation of curbs or gutters on streets or roads is separately classed as 5221. Class 5506 does not apply to operations involving the widening or changing of the subsurface roadbed, clearing of right-of-way, earth or rock excavation, filling or grading, tunneling, bridge or culvert building, or quarrying or stone crushing. Permanent asphalt

Classification addendum works to be separately classed as 1463 - Asphalt Works.

6876 AG Vol Search/Resc Diver-State Act Exp 9410 AM Vol Disaster Asst Emy Ops Wkr 9016 AE Vol Fairgrounds Worker-Dr 8810 AD Vol Library Prof Emp & Cler 8411 BW Vol Dpty Sheriff @ 4500/Qtr Ea 8831 AC Vol Care/Feed Animals-Dr 7720 EX Vol Physician/Medical Staff 8742 BQ Vol Commissioners 7024 03 Vessels-NOC-State Act

Class 7024M applies to the master and crew members of a vessel, weighing 15 tons or greater, who perform admiralty operations not described by another admiralty classification and who are subject to the Jones Act. Types of employment subject to 7024M include pilots who board ships and guide them in and out of ports, crew members of a barge used to cut weeds or vegetation from bottom rooted plants in navigable waterways, and crews that conduct trial runs of newly constructed boats or submarines. Class 7024M also applies to the operation of vessels that supply water, gasoline or oil from a main storage point to other storage points and to the master or crew members when they repair your vessel, regardless of whether or not the repair work is performed on water or land.

7380 07 Drivers/Chauffrs/Messengrs & Helpr

7380 - Drivers, Chauffeurs, Messengers, and Their Helpers NOC-Commercial. This classification is assigned to employees who perform work on or in connection with a vehicle. Class 7380 includes garage employees and employees using bicycles as part of their duties. Duties include, but not limited to, delivering good owned by the employer.

Class 7380 includes the transportation of your employees and the pick-up and delivery of your own merchandise, products, and supplies, including loading, unloading when performed by your drivers and their helpers and the incidental set-up of your merchandise or products.

Class 7380 may not be used if driving operations are contemplated within another classification for your operations.

7422 02 Aviation-Patrol/Photo/Sur-Fly Crew

7422 - Aviation - NOC- Other Than Helicopters - Flying Crew; Aviation - Flight Testing - Flying Crew;

Aviation - Patrol, Photography, Mapping, or Survey Work - Flying Crew; Aviation - Sales or Service Agency or Student Instruction - Flying Crew. Applies to flight testing operations of aircraft other than helicopters. All helicopter operations are assigned to Class 7425 - Aviation - Helicopters - Flying Crew. For prototype or experimental aircraft, assign exposure to the one aviation classification that best describes that nature of the aircraft being testing. Separately rate all other employees and drivers.Class 7422 applies to your employees involved in direct labor and supervision who are members of the flying crew of aircraft engaged in student pilot instruction, aerial advertising (including skywriting, and sign towing), the operation of lighter-than-air craft (balloons); aerial patrol and photography, mapping or survey work, and flight testing of aircraft you manufacture. Members of a flying crew may include the pilot, co-pilot, flight engineers, radio operators, navigators, and camera operators or observers. Wages paid to the flight crew for the time they are "on call" and not actually in flight are to be reported under class 7422. In addition, air ambulance operations conducted with fixed-wing aircraft are classified to Class 7422. Medical personnel, employed by the air ambulance, who accompany patients in-flight are considered to be members of the crew and are classified to Class 7422.Ground support personnel such as those performing maintenance or servicing of the aircraft

Classification addendum shall be assigned to Class 7403 - Aviation - All Other Employees and Drivers. Class 8868 - School applies to only classroom instruction of students wishing to learn to fly aircraft. Photography laboratory work to be separately rated as Class 4361 - Photographer-All Employees and Clerical, including on ground photography laboratory work when performed by your pilots and flight crew.

7720 EV Inmates

This classification applies to your unpaid workers required to be covered by worker¿s compensation per Oregon Statute. These workers are subject to the hourly assumed wage available by the Oregon Bureau of Labor and Industries (BOLI) in effect on January 1 of the calendar year in which your policy is effective.