CTR066201_-_WC_Excl..pdf
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- Attached to
- Master Agreement AZ|CTR066201
- Contract number
- CTR066201
- Issued by
- Arizona
About this file
This document is a Workers Compensation and Employers Liability Insurance Policy Endorsement issued by CopperPoint Indemnity Insurance Company for Northland Family Help Center. The endorsement is dated 02/01/2024 with Policy No. 1012347 and Endorsement No. 10. It specifically outlines a Partners, Officers and Others Exclusion, which modifies the standard workers compensation insurance policy to exclude coverage for certain individuals listed in the Schedule.
The endorsement stipulates that the policy does not cover bodily injury to persons listed in the Schedule (Jennifer McClelland, Kimberlie Geile-Gonzalez, Kathryn Mahady, and Noah W. Stalvey), and the premium basis does not include their remuneration. The insured organization will be required to reimburse the insurance company for any payments made due to bodily injury to these excluded individuals. The document is a standard form (WC 00 03 08) published by the National Council on Compensation Insurance, designed to modify standard workers compensation insurance coverage.
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Text version
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 08
(Ed. 1-00)
PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT
The policy does not cover bodily injury to any person described in the Schedule.
The premium basis for the policy does not include the remuneration of such persons.
You will reimburse us for any payment we must make because of bodily injury to such persons.
Schedule
Partners Officers Others
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.)
02/01/2024Endorsement Effective 1012347Policy No. 10Endorsement No.
Northland Family Help CenterInsured Premium $
CopperPoint Indemnity Insurance CompanyInsurance Company Countersigned by
This document may have been uploaded to the CopperPoint Portal.
WC 00 03 08
(Ed. 1-00)
© 1996–1999 National Council on Compensation Insurance, Inc.
McClelland, Jennifer
Geile-Gonzalez, Kimberlie
Mahady, Kathryn
Stalvey, Noah, W
File details come from the government source that posted it. Updated .