CTR062834_-_WC_WOS__1_.pdf
PDF 230 KB Posted
- Attached to
- Master Agreement AZ|CTR062834
- Contract number
- CTR062834
- Issued by
- Arizona
About this file
This document is a Workers' Compensation Insurance Policy Endorsement for Verde Valley Homeless Coalition, issued by AmGUARD Insurance Company through Crest Insurance Group LLC. The policy covers the State of Arizona and the Department of Economic Security, with the policy period running from August 26, 2024 to August 26, 2025. The insurance is specifically for a social services organization operating a homeless shelter in Arizona.
The policy includes two key endorsements: an added code 0_040 and a Waiver of Subrogation. The organization's annual payroll is $162,000, with a new estimated annual premium of $2,198 and a premium change of $250. The waiver specifically covers the State of Arizona and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees. The endorsement includes an Audit Noncompliance Charge provision, which allows the insurance company to apply a charge if the insured does not allow examination of records or provide requested audit information, with a potential maximum charge of two times the estimated annual premium.
View the file
Other files
Show all 39
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
Important Information
Agency
CREST INSURANCE GROUP LLC
5285 E. Williams Circle Suite 4500 Tucson, AZ 85711
VERDE VALLEY HOMELESS COALITION
PO Box 2893 Cottonwood, AZ 86326-2585
Changes to Your Workers' Compensation Policy
Policy Number R2WC573143 with AmGUARD Insurance Company
Policy Period From August 26, 2024 to August 26, 2025, 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 08/26/2024
State: AZ; Code: 8864 SOCIAL SERVICES ORGANIZATION; Payroll: $162,000
The Agent - Added Waiver of Subrogation effective 08/26/2024
Name: The State of Arizona & Dept of Economic Security; Job Description: Operating a homeless shelter
New AZ Estimated Annual Premium 2,198
Premium change: 250.00$
R2WC573143
VERDE VALLEY HOMELESS COALITION $250
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
Job Description: Operating a homeless shelter
Waiver Premium: 250.00
Class State Payroll Subject to Waiver
8864 AZ 162,000
R2WC573143
Person/Organization:
mhastings Typewritten text The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents,and employees 1789 W. Jefferson St.
Phoenix, AZ 85007
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.: R2WC573143Endorsement Effective: 08/26/2024
(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
2,198
Two TimesEstimated 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.: R2WC573143Endorsement Effective: 08/26/2024
(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
File details come from the government source that posted it. Updated .