MWM WORKERS COMP.pdf

Wesco Insurance Company

Authorization Agreement for Direct Payments

I (we) hereby authorize AmTrust North America, Inc. to initiate monthly deductions from my (our) account, identified below, for payment of premium on the insurance policy issued to me (us) by AmTrust North America, Inc.. I (we) authorize the financial institution named to accept and post entries to my (our) account.

I (we) understand that this authorization allows AmTrust North America, Inc. to adjust the monthly deductions to reflect any premium changes with the exception of the final premium audit. Any additional premiums resulting from the final premium audit will be invoiced directly to me (us).

I (we) understand that any refunds due on the policy listed below will be refunded by check and not through electronic transfer.

I (we) understand that if renewal policies are issued, that this authorization will extend to that policy term unless I (we) provide written notice to AmTrust North America, Inc. of a request to terminate this authorization.

I (we) understand that if payment is dishonored by the bank designated below from the account specified this agreement may be considered cancelled and the dishonored payment and all remaining payments may be required to be made by check or other negotiable instrument to ensure the continuance of my (our) coverage. All payments must be paid as invoiced.

Insurance Company Name: Wesco Insurance Company

Master Account Number: 30959677 *If requesting the direct debit payment plan for the master account above, all policies assigned to that master account must be on direct debit.

Bank Information

Banking information must be received for payments to begin to withdraw automatically. If banking information Is Not received timely, the policies listed below could be cancelled for non-payment.

Policy Number Name on Account Type of Account Bank Name Bank Routing # Bank Account #

This authorization will remain in effect until I (we) provide written notice to AmTrust North America, Inc. of its termination in such time and in such manner as to afford AmTrust North America, Inc. a reasonable opportunity to act on it.

Signature of Insured / Policy Holder Date

Insured Email Address (for email notification of funds transfer)

Please allow five (5) business days for processing of this authorization.

To ensure accuracy, please attach a sample check or deposit slip marked ‘VOID’.

Please fax or mail this form to:

Secure Accounting Fax Only:216 - 520 - 3178

E-mail – AmtrustAR@amtrustgroup.com

Mail to –

800 Superior Avenue East, 21st Floor Cleveland, OH 44114

Attn: Accounts Receivable

Direct Debit

Frequently Asked Questions

What is direct debit?

Direct debit is an automatic payment option for insureds that prefer not to write a check each month to make their insurance payments. Each month your monthly installment will be automatically withdrawn from the bank account you have designated.

How do I add direct debit to my policy?

Complete the Direct Debit Authorization Form with all of the information requested and attach a copy of a VOIDED check.

For fastest service, please return the form to our secure accounting fax number, 216-520-3178 or e-mail the form to AmtrustAR@amtrustgroup.com.

If you do not have a Direct Debit Authorization Form or require a replacement, please contact our Customer Service Department at 877-528-7878 to obtain the form.

When will the installment payments be withdrawn from my account?

The first payment will be directly debited as an electronic funds transfer on the effective date of the policy or the date that the policy is issued, whichever is later. All subsequent payments will be processed as an electronic funds transfer on the 10th day of each month. If this date falls on a date that is not a business day, the applicable date will be the following business day.

Will I continue to receive an invoice?

On the first of each month a reminder letter will be mailed in place of an invoice listing the amount of the direct debit for that month and the scheduled date of debit. This is not an invoice requesting payment.

What if my bank information changes?

Contact our Customer Service Department at 877-528-7878 to request a Direct Debit Authorization Form. You can make any necessary changes and resubmit the form to our secure accounting fax number 216-520-3178 or e-mail the form to AmtrustAR@amtrustgroup.com.

Please allow five (5) business days for processing of any changes.

What if there are endorsements on my policy changing the policy cost?

If your premium changes you will receive, from your agent, copies of any endorsements that are processed on your policy. These endorsements will show the change in the premium and the change in the installment schedule.

The new installment amount will be listed on the reminder letter that you will receive and that amount will be debited from your account.

Direct Debit Frequently Asked Questions

What if the funds are not available in my bank account on the due date?

If the first attempt for payment fails due to insufficient funds, our bank will make another attempt the next business day. If the second attempt for electronic funds transfer payment fails due to insufficient funds we will notify you by mail. You will receive an invoice and payment will be required to be made by check or credit card on or before the due date shown to avoid cancellation of your coverage.

How do I terminate the direct debit option?

If you would like to terminate the direct debit option you must provide the insurance carrier written notification.

You can contact our Customer Service Department at 877-528-7878 and request a Direct Debit Termination Form that must be completed and returned to us.

For fastest service, please return the form to our secure accounting fax number, 216-520-3178 or e-mail the form to AmtrustAR@amtrustgroup.com.

Please allow five (5) business days for processing of the termination form from the date it is received. It is possible that due to the timing of the receipt of the Termination form that the next scheduled direct debit payment will be processed as originally scheduled. If you request termination between the 1st and the 9th calendar day of the month please contact our Customer Service Department to confirm whether the Termination form has been processed. To avoid potential fee charges by your bank, if the Termination form has not been processed by the 9th calendar day, please make sure that there are sufficient funds in the designated bank account for the amount of the scheduled payment as per the reminder notice you received.

WESCO INSURANCE COMPANY

874 Walker Rd, Suite C Dover, DE 19904

WORKERS' COMPENSATION

and

EMPLOYERS’ LIABILITY INSURANCE POLICY

In Witness Whereof, we have caused this policy to be executed and attested, and, if required by state law, this policy shall not be valid unless countersigned by our authorized representative.

Stephen Ungar, Secretary Christopher H. Foy, President

To obtain information, please contact your agent or Wesco Insurance Company at 877- 528-7878. You may also write Wesco Insurance Company Consumer Relations at:

800 Superior Avenue East, 21st Floor Cleveland, OH 44114

WC 99 00 00 A

24/7 Toll Free Claim Reporting for All States

Information Required for All Claims Reported

(888)239-3909 WorkersCompClaimReport@AmTrustgroup.com www.amtrustfinancial.com

© 2023, AmTrust Financial Services, Inc.

877.528.7878 I www.amtrustfinancial.com

This material is for informational purposes only and is not legal or business advice. Neither AmTrust Financial Services, Inc. nor any of its subsidiaries or affiliates represents or warrants that the information contained herein is appropriate or suitable for any specific business or legal purpose. Readers seeking resolution of specific questions should consult their business and/or legal advisors. Coverages may vary by location. Contact your local RSM for more information.

MKT6310 06/23

Timely Reporting When a work-related injury occurs, it is important to act immediately. Timely reporting of a new claim helps to provide a smooth and successful claim process for both you and your injured worker.

We’re Here To Help After your claim has been filed, we may be in touch to obtain additional information. Our goal is to offer a smooth and hassle-free experience – from your first contact to the claims conclusion. Feel free to also call us with any questions. We’re here to help.

Relax And Stay Positive You have the assurance of our knowledge, expertise, and understanding of the claim process. We’re with you all the way.

Workers’ Compensation Claim Reporting Information

How do I help my injured worker find a doctor?

How does my injured employee receive prescription medications related to the accident/injury?

• Refer to the claims kit for your state at www.talispoint.com/amtrust/external for a First Fill card for your injured employee to use at the pharmacy to cover the cost of approved medication.

Early claim reporting is essential to a better claim outcome. Don’t delay reporting if you do not have all the details.

mailto:WorkersCompClaimReport%40AmTrustgroup.com?subject= http://www.amtrustfinancial.com https://www-lv.talispoint.com/amtrust/external/ https://www-lv.talispoint.com/amtrust/campn/ https://www-sf.talispoint.com/amtrust/external/

AmTrust Claims Kit FAQs

© 2022, AmTrust Financial Services, Inc.

59 Maiden Lane, New York, NY 10038 I 877.528.7878 I www.amtrustfinancial.com

AmTrust is AmTrust Financial Services, Inc., located at 59 Maiden Lane, New York, NY 10038. Coverages are provided by its affiliated property and casualty insurance companies. Consult the applicable policy for specific terms, conditions, limits and exclusions to coverage. For full legal disclaimer information, including Texas and Washington writing companies, visit: www.amtrustfinancial.com/about-us/legal-disclaimer.

MKT5948 02/22

Thank you for placing your Workers’ Compensation Coverage with AmTrust. For your convenience, we now offer electronic versions of our Claims Kits. Please see the instructions and FAQs below for more information.

I have a question about a claim or injured worker, who do I contact?

Customer Service can direct you to the appropriate person. Please contact them at 888-239-3909.

Where’s my claims kit?

All the States’ Claims Kits are online for insured to download which contains all the necessary WC notices. Visit the Talispoint Direct Link at www.talispoint.com/amtrust/external/

• Click State Rules/Kits, choose corresponding state and open the PDF link to view and print.

I have an injured worker, how do I find a doctor?

We will provide completed Panel of Physicians for the 4 states that require a panel to be posted (CO, GA, PA & TN). We offer our online physician search for all other states.

There are 3 ways to access this information:

1. Visit the Talispoint Direct Link at www.talispoint.com/amtrust/external/

2. California MPN: www.talispoint.com/amtrust/campn/

3. Visit the AmTrust Financial Website at www.amtrustfinancial.com

• Click Claims

• Click Provider Directory or California MPN under “Find a Provider”

• State specific laws for directing medical treatment are listed on the State Rules Tab

• Search for physicians by Name, Address or Region

Where are my posting notices?

All states claim kits are available online, including applicable postings. There are 4 states (CO, CT, FL & MD) we cannot place online. For these states, we will mail additional posting notices to the main address on the policy.

I have a question about my claims kit, posting notice, panel or accessing the website’s physician searches, who do I contact?

You may send an email to clientservices@amtrustgroup.com. Please make sure to include your policy number along with your request.

Mogollon Water Management, LLC 5072 Sunrise Ct Lakeside, AZ 85929

RE: Workers' Compensation Policy Policy: WWC3729398 Payroll Company: AP Intego Insurance Services LLC

Dear Mogollon Water Management, LLC, Thank you for choosing AmTrust PAYO (Pay-As-You-Owe) as your workers' compensation payment plan. PAYO provides you a way to pay your workers' compensation premium based on your actual reported payroll. Your payroll company will remit your payroll reports directly to AmTrust on your behalf. Please see the payroll company listed above. If it is not your current payroll provider, or you decide to change your payroll provider any time during the policy period, please notify us immediately at (855) 829-1948.

Below is a list of the classification codes currently on your workers’ compensation policy, along with a description of each.

When assigning your employees to a specific classification code, please keep in mind that each classification code has a specific description of operations, as well as their own rate per $100 of payroll. If your employees are not properly classified throughout the policy period, it will be corrected at audit and may create an additional premium amount due.

Please contact your agent if you have any questions regarding the classification of your employees.

If an employee’s duties span multiple class codes, i.e.: a bookkeeper who also bakes bread, place their entire payroll in the higher rated classification code.

State Class Code Description of Operations

Estimated Annual Payroll Net Rate

AZ 7520 Waterworks Operation & Drivers $70,890 0.021846

800 Superior Avenue East, 21st Floor - Cleveland, OH 44114

(p) 877-528-7878 • (f) 800-487-9654 • www.amtrustnorthamerica.com

1)

2)

3) a.

b.

4)

A few important things to keep in mind when using the AmTrust PAYO payment plan:

PAYO does not eliminate the need for a Workers' Compensation policy audit.

However, if the employees are coded correctly and the payroll reported properly, PAYO will greatly reduce the chance of any large premium difference at time of audit.

The net rates for your policy are calculated by AmTrust using the estimated annual payroll provided by you and your agent during the quoting process. It is important that you contact your agent immediately if your estimated annual premium shown above is incorrect, or if your payroll changes significantly during the policy period. Failure to do so will result in an inaccurate net rate factor causing a premium discrepancy, which will be captured at audit. If you notice your estimated annual payroll is either higher or lower than originally estimated, let your agent know so an endorsement request can be made to adjust your payroll and possibly your net rate.

Owner/Officer Exemptions and Minimum Payroll Threshold:

Owner/Officer exemptions - As rules vary by state. Business owners may need to file additional paperwork to exclude themselves from the policy.

Owner/Officer minimum and maximum payroll thresholds- These payroll threshold requirements vary by state. If Owner/Officers are "included" on the policy yet are not reported through payroll, the Owner/Officer premium will be collected based on the state minimum requirements at the time of audit.

If you use independent contractors or subcontractors be sure to obtain a copy of their workers' compensation certificate of insurance. Failure to provide these documents at the time of audit may result in additional premium due.

Please discuss these items with your insurance agent.

Sincerely, Your AmTrust PAYO Team

800 Superior Avenue East, 21st Floor - Cleveland, OH 44114

(p) 877-528-7878 • (f) 800-487-9654 • www.amtrustnorthamerica.com

800 Superior Avenue E • 21st Floor • Cleveland, OH 44114

(p) 866.203.3037 • (f) 800.487.9654 • www.amtrustnorthamerica.com

Dear Policyholder, In an effort to continue to provide AmTrust customers with a variety of billing options, we have updated our fee structure to help customers meet payment due dates, ensure that valid and properly funded payments are submitted, and provide an incentive for paid-in-full options.

Our updated fee structure is as follows:

Fee Title Fee Amount Description

Returned Payment Fee $25 A returned payment fee applied to any returned payment.

Late Fee $20 Late fee applied if payment not received on or before payment due date.

Installment Fee $15 A “paper” billing fee that is assessed for each mailed installment invoice. Excludes down payment and annual payment plans. Fee is billed at the account level.

Reinstatement Fee $50 Fee applied upon reinstatement of a non-payment cancellation.

EFT Fee $3 An “electronic” billing fee that is assessed for each ACH Direct Debit transaction. Fee is billed at the account level.

*Fee amount may vary by state and program of business

For policyholders who choose to pay their annual premium on installments, we plan to implement an installment fee, which will be displayed on your renewal invoice.

Thank you for your attention to this fee structure change. If you have any questions, feel free to contact our Customer Service Department at 877.528.7878.

We value you as a policyholder and appreciate the opportunity to serve you.

Sincerely, AmTrust North America

Customer Service Department

June 28, 2024

A Stock Insurance Company

WORKERS COMPENSATION WC 99 00 01 B

AND EMPLOYERS LIABILITY 1 of 5

INSURANCE POLICY INFORMATION PAGE

Ncci Code: 26135

1. Insured:

Mogollon Water Management, LLC 5072 Sunrise Ct Lakeside, AZ 85929

Other workplaces not shown above:

None

Producer:

AP Intego Insurance Group, LLC - NY 1601 Trapelo Rd.

Waltham, MA 02451

Policy Number: WWC3729398

Individual Partnership

Corporation X LLC

Federal Tax ID: 881156395 Risk Id:

Renewal of: KWC1326981

2. The policy period is from 8/2/2024 to 8/2/2025 12:01 a.m. at the insured's mailing address.

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

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:

State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease

$1,000,000 each accident $1,000,000 policy limit $1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:

All states except ND, OH, WA, WY and State(s) Designated in Item 3.A D. This policy includes these endorsements and schedules: See Extension of Information Page

4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit.

See Extension of Information Page

TOTAL ESTIMATED ANNUAL PREMIUM 1,549

STATE ASSESSMENT 0

TOTAL ESTIMATED COST 1,549

Minimum Premium 443 Issue Date: 6/28/2024 Countersigned by:

Authorized Representative

Wesco Insurance Company WC 99 00 01 B

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE

POLICY INFORMATION PAGE

Insured: Mogollon Water Management, LLC Policy Number: WWC3729398

EXTENSION OF INFORMATION PAGE FOR ITEM #1

ITEM 1: NAMED INSURED and WORKPLACES

NAMED INSURED: Mogollon Water Management, LLC Fein: 881156395 WORKPLACES: Location Number 1.

5072 Sunrise Ct Lakeside, AZ 85929

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE

POLICY INFORMATION PAGE

Insured: Mogollon Water Management, LLC Policy Number: WWC3729398

EXTENSION OF INFORMATION PAGE FOR ITEM #3.D

ITEM 3.D: ENDORSEMENT SCHEDULE

State Form Number Description

WC990001B DECLARATIONS PAGE

WC000000C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

WC000308 PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT

WC000404 PENDING RATE CHANGE ENDORSEMENT

WC000406A PREMIUM DISCOUNT ENDORSEMENT

WC000414A NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT

WC000419A PREMIUM DUE DATE ENDORSEMENT

WC000421F CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM

ENDORSEMENT

WC000422C TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT

DISCLOSURE ENDORSEMENT

WC000424 AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT

AZ WC020601C AZ Cancellation and Nonrenewal Endorsement AZ WC020603A Arizona Amendatory Endorsement

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE

POLICY INFORMATION PAGE

Insured: Mogollon Water Management, LLC Policy Number: WWC3729398

EXTENSION OF INFORMATION PAGE FOR ITEM #4

ITEM 4: SCHEDULE OF PREMIUMS

Classifications # of

Emps Code No.

Premium Basis Total Est. Annual

Remuneration

Rate Per $100 of

Remuneration

Estimated Annual

Premium

Arizona Waterworks Operation & Drivers 1 7520 70,890 1.77 1,255 Manual Premium 1,255

Total Manual Premium 1,255 Premium for Increased Limits Part Two: 1.1% (1000/1000/1000) 9812 14 Premium to Equal Increased Limits Minimum Charge 9848 106 Total Premium Subject To Experience Modification 1,375 Experience Modification N/A 1,375 Terrorism 1% 9740 7 Catastrophe (other than Terrorism) 1% 9741 7 Expense Constant 0900 160 Total AZ Premium 1,549 Total AZ Cost 1,549

TOTAL ESTIMATED ANNUAL PREMIUM 1,549

STATE ASSESSMENT 0

TOTAL COST 1,549

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE

POLICY INFORMATION PAGE

Insured: Mogollon Water Management, LLC Policy Number: WWC3729398

PAYMENT SCHEDULE

Statement Closing Date

Payment Due Date Description Amount Due

9/10/2024 Pay Period 1 of 12 $130.00 10/10/2024 Pay Period 2 of 12 $129.00 11/10/2024 Pay Period 3 of 12 $129.00 12/10/2024 Pay Period 4 of 12 $129.00 1/10/2025 Pay Period 5 of 12 $129.00 2/10/2025 Pay Period 6 of 12 $129.00 3/10/2025 Pay Period 7 of 12 $129.00 4/10/2025 Pay Period 8 of 12 $129.00 5/10/2025 Pay Period 9 of 12 $129.00 6/10/2025 Pay Period 10 of 12 $129.00 7/10/2025 Pay Period 11 of 12 $129.00 8/10/2025 Pay Period 12 of 12 $129.00

Total Cost $1,549.00

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C

(Ed. 1-15)

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

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

GENERAL SECTION

A. The Policy

This policy includes at its effective date the Infor-mation Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Infor-mation Page) and us (the insurer named on the In-formation 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 em-ployer 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 fed-eral 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 ag-gravated by the conditions of your employment.

The employee’s last day of last exposure to the conditions causing or aggravating such bodily in-jury 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 in-vestigate 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

Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.

WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

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.

G. Recovery From Others

We have your rights, and the rights of persons enti-tled 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 du-ties under this insurance after an injury occurs.

3. We are directly and primarily liable to any per-son entitled to the benefits payable by this in-surance. Those persons may enforce our duties;

so may an agency authorized by law. Enforce-ment 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 oth-er 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 du-ties 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 inci-dental 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 ag-gravated by the conditions of your employment.

The employee’s last day of last exposure to the conditions causing or aggravating such bodily in-jury 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 ac-cident or by disease must be brought in the United States of America, its territories or pos-sessions, or Canada.

B. We Will Pay

We will pay all sums that you legally must pay as damages because of bodily injury to your employ-ees, provided the bodily injury is covered by this Employers Liability Insurance.

The damages we will pay, where recovery is permit-ted by law, include damages:

1. For which you are liable to a third party by rea-son 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 em-ployee;

2. For care and loss of services; and

3. For consequential bodily injury to a spouse, child, parent, brother or sister of the injured em-ployee; provided that these damages are the di-rect 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 exclu-sion does not apply to a warranty that your work will be done in a workmanlike manner;

2. Punitive or exemplary damages because of bodi-ly 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 offic-ers;

4. Any obligation imposed by a workers compensa-tion, occupational disease, unemployment com-pensation, or disability benefits law, or any simi-lar 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, de-motion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimina-tion against or termination of any employee, or any personnel practices, policies, acts or omis-sions;

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 Nonap-propriated 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. Sec-tions 51 et seq.), any other federal laws obligat-ing 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;

10. Bodily injury to a master or member of the crew of any vessel, and does not cover punitive dam-ages 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 Sea-sonal 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 ex-pense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceed-ings 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 in-surance or self-insurance. Subject to any limits of li-ability that apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is ex-hausted, 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 dis-ease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for “bodily injury by disease—each em-ployee” 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 dis-ease 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 un-der 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 poli-cy; 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 deter-mine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obliga-tions 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 Infor-mation Page.

2. If you begin work in any one of those states after the effective date of this policy and are not in-sured 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 pol-icy in any state not listed in Item 3.A. of the In-formation 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 ser-vices required by the workers compensation law.

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 re-quest, in the investigation, settlement or defense of any claim, proceeding or suit.

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

6. Do not voluntarily make payments, assume obli-gations 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 classifica-tions. We may change our manuals and apply the changes to this policy if authorized by law or a gov-ernmental agency regulating this insurance.

B. Classifications

Item 4 of the Information Page shows the rate and premium basis for certain business or work classifi-cations. 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. Remu-neration is the most common premium basis. This premium basis includes payroll and all other remu-neration 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 Com-pensation Insurance) of this policy. If you do not have payroll records for these persons, the con-tract 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 em-ployers 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 compensa-tion 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, premi-um 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 bal-ance. 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 canceled, final premium will be de-termined 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 cancelation table and procedure. Final premium will not be less than the minimum premium.

F. Records

You will keep records of information needed to com-pute 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 ledg-ers, journals, registers, vouchers, contracts, tax re-ports, payroll and disbursement records, and pro-grams for storing and retrieving data. We may con-duct the audits during regular business hours during the policy period and within three years after the pol-icy 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 insurabil-ity 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 organiza-tions have the same rights we have under this provision.

B. Long Term Policy

If the policy period is longer than one year and six-teen 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.

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 af-ter your death, we will cover your legal representa-tive as insured.

D. Cancelation

1. You may cancel this policy. You must mail or de-liver advance written notice to us stating when the cancelation is to take effect.

2. We may cancel this policy. We must mail or de-liver to you not less than ten days advance writ-ten notice stating when the cancelation 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 cancelation notice.

4. Any of these provisions that conflict with a law that controls the cancelation of the insurance in this policy is changed by this statement to com-ply 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 cancelation.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 08

(Ed. 4-84)

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

Blake Anderson

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 8/2/2024 Policy No. WWC3729398 Endorsement No. 0 Insured Mogollon Water Management, LLC Premium $ 1,549 Insurance Company Wesco Insurance Company

Countersigned by

WC 00 03 08

(Ed. 4-84)

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 04

(Ed. 04-84)

PENDING RATE CHANGE ENDORSEMENT

A rate change filing is being considered by the proper regulatory authority. The filing may result in rates different from the rates shown on the policy. If it does, we will issue an endorsement to show the new rates and their effective date.

If only one state is shown in Item 3.A. of the Information Page, this endorsement applies to that state. If more than one state is shown there, this endorsement applies only in the state shown in the Schedule.

Schedule

State

AZ

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 8/2/2024 Policy No. WWC3729398 Endorsement No. 0 Insured Mogollon Water Management, LLC Premium $ 1,549 Insurance Company Wesco Insurance Company

Countersigned by

WC 00 04 04

(Ed. 04-84)

PREMIUM DISCOUNT ENDORSEMENT

The premium for this policy and the policies, if any, listed in Item 3 of the Schedule may be eligible for a discount. This endorsement shows your estimated discount in Items 1 or 2 of the Schedule. The final calculation of premium discount will be determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective rating is not subject to premium discount.

Schedule

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 06 A

(Ed. 7-95)

1. State Estimated Eligible Premium

First Next Next

$10,000 $200,000 $1,750,000 Balance Arizona 0% 9.1% 11.3% 12.3%

2. Average percentage discount: 0 %

3. Other policies:

4. If there are no entries in Items 1, 2 and 3 of the Schedule, see the Premium Discount Endorsement attached to your policy number:

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 8/2/2024 Policy No. WWC3729398 Endorsement No. 0 Insured Mogollon Water Management, LLC Premium $ 1,549 Insurance Company Wesco Insurance Company

Countersigned by

WC 00 04 06 A

(Ed. 7-95)

90-DAY REPORTING REQUIREMENT—NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT

You must report any change in ownership to us in writing within 90 days of the date of the change. Change in ownership includes sales, purchases, other transfers, mergers, consolidations, dissolutions, formations of a new entity, and other changes provided for in the applicable experience rating plan. Experience rating is mandatory for all eligible insureds. The experience rating modification factor, if any, applicable to this policy, may change if there is a change in your ownership or in that of one or more of the entities eligible to be combined with you for experience rating purposes.

Failure to report any change in ownership, regardless of whether the change is reported within 90 days of such change, may result in revision of the experience rating modification factor used to determine your premium.

This reporting requirement applies regardless of whether an experience rating modification is currently applicable to this policy.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 14 A

(Ed. 01-19)

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 8/2/2024 Policy No. WWC3729398 Endorsement No. 0 Insured Mogollon Water Management, LLC Premium $ 1,549 Insurance Company Wesco Insurance Company

Countersigned by

WC 00 04 14 A

(Ed. 01-19)

© Copyright 2017 National Council on Compensation Insurance, Inc. All Rights Reserved.

This endorsement amends Part Five-Premium of the policy as follows:

Part Five-Premium, Section A. (Our Manuals) is replaced by the following provision:

A. Our Manuals All premium for this policy will be determined by our manuals of rules, rates and loss costs (as applicable), rating plans, forms, endorsements, and classifications, and such manuals are expressly incorporated by reference into, and apply to, this policy and any renewals (our manuals). As used in this policy and any renewals, our manuals means manuals that have been:

1. Developed in any format and filed by the state-designated workers compensation rating or advisory organization on our behalf with the appropriate state insurance regulatory authority; or

2. Developed in any format and filed by the respective state rating bureau on our behalf with the appropriate state insurance regulatory authority; or

3. Developed in any format and filed by us with the appropriate state insurance regulatory authority; and

4. For each or any of the three scenarios above, the manuals also must be approved for use by the appropriate state insurance regulatory authority, or as otherwise authorized by law as applicable.

We may change our manuals and apply the changes to this policy and any renewals if such manual changes are approved for use by the appropriate state insurance regulatory authority, or as otherwise authorized by law as applicable.

Part Five-Premium, Section D. (Premium Payments) is replaced by the following provision:

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. The due date for audit and retrospective premiums is the due date specified in the billing for the policy.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 19 A

(Ed. 08-2022)

Part Five-Premium Amendatory Endorsement

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 8/2/2024 Policy No. WWC3729398 Endorsement No. 0 Insured Mogollon Water Management, LLC Premium $ 1,549 Insurance Company Wesco Insurance Company

Countersigned by

WC 00 04 19 A

(Ed. 08-2022)

© Copyright 2021 National Council on Compensation Insurance, Inc. All Rights Reserved.

Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement

This endorsement is notification that we are charging premium to cover the losses that may occur in the event of a Catastrophe (Other Than Certified Acts of Terrorism) as that term is…