ACCEPTED ANY_ALL WC 07.31.24-07.31.25.pdf
PDF 276 KB Posted
- Attached to
- Master Agreement AZ|CTR077172
- Contract number
- CTR077172
- Issued by
- Arizona
About this file
This document is a Workers Compensation and Employers Liability Insurance Policy issued by Markel Insurance Company for Prime Collision LLC, a limited liability company located in Oro Valley, Arizona. The policy covers workers' compensation for automobile body repair and drivers, with the State of Arizona and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees named as a subrogant. The policy is effective from 07/31/2024 to 07/31/2025 and applies specifically to operations in Arizona.
The policy includes a total estimated annual premium of $1,800.00, with a minimum premium of $270.00 and a deposit premium of $20.40. The insurance covers Class Code 8393 for automobile body repair and drivers, with a payroll basis of $40,000.00. The policy provides employers liability insurance with limits of $1,000,000 for bodily injury by accident, bodily injury by disease (policy limit), and bodily injury by disease per employee. Additional charges include a terrorism charge and catastrophe charge, bringing the total estimated annual premium to $347.00 for the period of 05/29/2025 to 07/31/2025.
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Text version
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC890600B
(Ed. 7-01)
POLICY INFORMATION PAGE ENDORSEMENT
The following item(s) lnsured's Name (WC 89 06 01)
Policy Number (WC 89 06 02)
Effective Date (WC 89 06 03)
Expiration Date (WC 89 06 04) lnsured's Mailing Address (WC 89 06 05)
Experience Modification (WC 89 04 06)
Producer's Name (WC 89 06 07)
Change in Workplace of Insured (WC 89 06 08) lnsured's Legal Status (WC 89 06 10)
Item 3.A. States (WC 89 06 11 ) is changed as follows:
Action Type Previous Value
Add Waiver of N/A Subrogation
Total Estimated Annual Premium $1,800.00
Minimum Premium $270.00
All other terms and conditions of this policy remain unchanged.
Item 3.8. Limits (WC 89 06 12)
Item 3.C. States (WC 89 06 13)
X Item 3.D. Endorsement Numbers (WC 89 0614)
Item 4. Class, Rate, Other (WC 89 04 15)
Interim Adjustment of Premium (WC 89 04 16)
Carrier Servicing Office (WC 89 06 17)
Interstate/Intrastate Risk ID Number (WC 89 06 18)
Carrier Number (WC 89 06 19)
Issuing Agency/Producer Office Address (WC 89 06 25)
New Value
Type: Individual State: AZ Class Code: 8393 Payroll: 40000 Subrogant Name: State of Arizona and its departments, agencies, boards, commissions, universities, officers, officials, agents and employees Subrogant Address: 1655 W Jackson St MD 100P Subrogant City: Phoenix State: AZ Postal Code: 85007 Effective Date: 05/29/2025 Expiration Date: 07/31/2025
Premium Adjustment $100.00
Deposit Premium $20.40
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: 05/29/2025 Policy No. MWC0228911-01 Endorsement No.
Insured: Prime Collision LLC Premium $(See Attached)
Insurance Company: Markel Insurance Company Countersigned by ______________ _
WC890600B
(Ed. 7-01)
© 2001 National Council on Compensation Insurance, Inc. 1111■1111111111111
MWC0228911-01
Cindy Lewis WC Only
WC 00 0001 A
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Original Printing
Type: Stock
Markel Insurance Company 10275 West Higgins Road, Suite 750 Rosemont, IL 60018
1. The lnsured's Name and Mailing address:
Prime Collision LLC 1846 E Innovation Parle Dr Ste 100 Oro Valley, AZ 85755-1963 480-694-0392
Issued July 31, 2024
Other work place not shown above: See Attached Location Schedule
NCCI Carrier Code: 22616
Policy Number:
MWC0228911-01
Renewal of Policy:
Rewrite of Policy:
Fein # / Risk ID #:
1 991136755 , DBAName:
SIC CODE: 7538
Type of entity: Limited Liability Company
2. The policy period is from 07/31/2024 to 07/31/2025 [12.01 AM Standard Time] at the insured'& mailing address.
3. A. Workers Compensation Insurance: Part One of this policy applies to the Workers Compensation Law of the states listed here: ARIZONA
B. Employers liability Insurance: Part Two of this policy applies to work in each state listed in Item 3A.
The limits of our liability under Part Two are:
Bodily Injury by Accident : $1,000,000 each accident Bodily Injury by Disease : $1,000,000 policy limit Bodily Injury by Disease : $1,000,000 each employee
Standard
C. Other States Insurance: Part Three of this policy applies to the states, if any, listed here: AL, AK, AZ, AR, CA, CO, CT, DE, FL, GA, HI, IL, IN, IA, KS, KY, LA, ME, MD, MA, Ml, MN, MS, MO, NE, NV, NH, NJ, NM, NY, NC, OK, PA, RI, SC, SD, TN, TX, UT, VT, VA, WV and WI
D. California Endorsements and Schedules:
Other State Endorsements and Schedules:
MPIL 1007 01 20, MPIL 1083, WC000000C, WC000001A, WC000308, WC000313, WC000404, WC000406A, WC000414A, WC000419A, WC000421F,WC000422C,WC000424,WC000425, WC020401C,WC020601B,WC020603A, WC890600B, WC990322, WC990603, WC990621
4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All Information required is subject to verification and change by audit.
Minimum Premium: $270.00 Deposit Premium: $20.40 Total Estimated Annual Premium: $1,800.00
Pay plan: Payroll Reporting - 0% Producer: Automatic Data Processing Ins Agency Inc-Alpharetta 5800 Windward Parkway, MS B305 770-360-2000 Alpharetta, GA 30005
Servicing office: Marlcel Service, Inc. (888) 500-3344 13815 FNB Parkway, Ste 601 Omaha, NE 68154-5287
(See extension of information page for class code, rate and premium detail)
Countersigned By:
Date: 05/29/2025
THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AND ENDORSEMENTS, IF ANY ISSUED TO FORM A PART THEREOF, COMPLETES THE ABOVE NUMBERED POLICY.
WC 00 00 01 A Page 1 of 4
Highlight
Policy Number:MWC0228911-01 Issued to: Prime Collision LLC
EXTENSION OF INFORMATION PAGE
Worker's Compensation and
Employer's Liability Policy Schedule Of Premium Information
Effective Date: 07/31/2024 - 07/31/2025 Coverage Provided By: Markel Insurance Company Carrier Code: 22616 Period of Operation: 05/29/2025 - 07/31/2025 State of Operation: AZ
Code Classification
Premium Basis Total
Estimated Annual
Remuneration
Rate Per $100 of
Remuneration
AUTOMOBILE-BODY REPAIR &
DRIVERS
Manual Premium
Total Manual Premium
Waiver
Employers Liability
Subject Premium
Total Subject Premium
Modified Premium
Standard Premium
Terrorism Charge
Catastrophe (other than Certified Acts of Terrorism)
Estimated Annual Premium
Total Amount Due
WC 00 00 01 A
$34,520.55 0.690
5.000
1.100
0.010
0.010
Estimated Annual
Premium
$238.00
$238.00
$238.00
$100.00
$3.00
$341.00
$341.00
$341.00
$341.00
$3.00
$3.00
$347.00
$347.00
Page 2 of4
Policy Number:MWC0228911-01 Issued to: Prime Collision LLC
EXTENSION OF INFORMATION PAGE
Worker's Compensation and
Employer's Liability Policy Schedule Of Premium Information
Effective Date: 07/31/2024 - 07/31/2025 Coverage Provided By: Markel Insurance Company Carrier Code: 22616 Period of Operation: 07/31/2024 - 05/29/2025 State of Operation: AZ
Code Classification
Premium Basis Total
Estimated Annual
Remuneration
Rate Per $100 of
Remuneration
8393 AUTOMOBILE-BODY REPAIR &
DRIVERS
Manual Premium
$165,479.45 0.690
Total Manual Premium
Employers Liability
ELL Minimum
1.100
104.000
Policy Number:
Issued to:
Effective Date:
Subject Premium
Total Subject Premium
Modified Premium
Standard Premium
Expense Constant
Terrorism Charge
Catastrophe (other than Certified Acts of Terrorism)
Estimated Annual Premium
Total Amount Due
EXTENSION OF INFORMATION PAGE
Worker's Compensation and Employer's Liability Policy
LOCATION SCHEDULE
MWC0228911-01
Prime Collision LLC
07/31/2024 to 07/31/2025
Coverage Provided By: Markel Insurance Company
Carrier Code 22616
Other workplaces not shown above:
WC 00 00 01 A
0.010
0.010
Estimated Annual
Premium
$1,142.00
$1,142.00
$1,142.00
$13.00
$104.00
$1,259.00
$1,259.00
$1,259.00
$1,259.00
$160.00
$17.00
$17.00
$1,453.00
$1,453.00
Page 3 of4
Highlight
Location
1 1846 E Innovation Park Dr Ste 100 Oro Valley, AZ 85755-1963
WC 00 00 01 A
FEIN PHONE
991136755 480-694-0392
SIC
CODE
ENTITY
TYPE
Limited Liability
Company
Page 4 of4
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
WC 00 0313
{Ed. 4-84)
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.
Subrogant Information
State of Arizona and its departments, agencies, boards, commissions, universities, officers, officials, agents and employees 1655 W Jackson St MD 100P Phoenix, AZ. 85007
Class Code
Schedule
Description
AUTOMOBILE-BODY REPAIR &
DRIVERS
Payroll
$40,000.00
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: 05/29/2025 Policy No. MWC0228911-01 Endorsement No.
Insured: Prime Collision LLC Premium $(See Attached}
Insurance Company: Markel Insurance Company Countersigned by ______________ _
WC000313
Ed. 4-84
© 1983 National Council on Compensation Insurance. Page 1 of 1
File details come from the government source that posted it. Updated .