RFP - Workers Compensation - Addendum 2 Attachment A.pdf

www.saif.com

Pol_PC1_REN

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

June 30, 2025

SPRINGFIELD SCHOOL DISTRICT 19

640 A ST

SPRINGFIELD, OR 97477-4609

SAIF policy: 749975

Thank you for again choosing SAIF as your workers’ comp carrier. Enclosed you’ll find your workers' compensation policy, effective July 01, 2025.

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 $461,605.77 are listed below.

Installment payment plan Due date Amount

07/25/2025 $461,605.77

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.

Springfield School District 19 June 30, 2025

749975 Springfield School District 19

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 Jennifer King at 541.342.4441. You can also contact SAIF at the phone number or email address below.

Sincerely, /s/ Erin Matot Underwriter P: 503.373.8446 F: 503.584.8446

ERIMAT@SAIF.COM

c: Jennifer King

Carrier no: 20001

Information Page Policy no: 749975

Employer identification no: 93-6000575 NCCI Risk ID no: 360216853

WC000001A (Ed. 04-2025) Pol_PC1_P401

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

Item 1. The Insured: Entity Type:

Springfield School District 19 Political Subdivision: School

Mailing address:

SPRINGFIELD SCHOOL DISTRICT 19

640 A ST

SPRINGFIELD, OR 97477-4609

Agent:

JENNIFER KING

WHA INSURANCE AGENCY INC

2930 CHAD DR

EUGENE, OR 97408

Other workplaces not shown above:

Springfield School District 19 Administrative Offices 640 A Street Springfield, OR 97477-4548

Springfield School District 19 Two Rivers-Dos Rios Elementary 1084 G St Springfield, OR 97477-4106

Springfield School District 19 Walterville School 40589 Mckenzie Hwy Springfield, OR 97478-7630

Springfield School District 19 Yolanda Elementary 2350 Yolanda Ave Springfield, OR 97477-1752

Springfield School District 19 Agnes Stewart Middle School 900 S 32nd St Springfield, OR 97478-6527

Springfield School District 19 Briggs Middle School 2355 Yolanda Ave Springfield, OR 97477-6715

Springfield School District 19 Hamlin Middle School 326 Centennial Blvd Springfield, OR 97477-3043

Springfield School District 19 Thurston Middle School 6300 Thurston Rd Springfield, OR 97478-7057

Springfield School District 19 Gateways High School 665 Main St Springfield, OR 97477-4764

SAIF policy: 749975

WC000001A (Ed. 04-2025)

Springfield High School 875 7th St Springfield, OR 97477-4064

Springfield School District 19 Thurston High School 333 58th St Springfield, OR 97478-6959

Springfield School District 19 Academy of Arts & Academics 615 Main St Springfield, OR 97477-4764

Springfield School District 19 Centennial Elementary 1315 Aspen St Springfield, OR 97477-7615

Springfield School District 19 1890 N 42nd St Maintenance Center Springfield, OR 97477

Springfield School District 19 Gateways High 425 10th St Springfield, OR 97477-4756

180 D St Springfield, OR 97477-4596

1030 G St Springfield, OR 97477-4106

Health Services 1050 10th St Springfield, OR 97477-4003

Warehouse 1898 42nd St Springfield, OR 97477-5602

Sky Camp Oregon 83930 Peninsula Rd Fall Creek, OR 97438-9716

Springfield School District 19 Douglas Gardens Elementary 3680 Jasper Rd Springfield, OR 97478-6554

Springfield School District 19 Guy Lee 755 Harlow Rd Springfield, OR 97477-1136

WC000001A (Ed. 04-2025)

Maple Elementary 2109 J St Springfield, OR 97477-4334

Springfield School District 19 Mt Vernon Elementary 935 Filbert Ln Springfield, OR 97478-6508

Springfield School District 19 Page Elementary 1300 Hayden Bridge Rd Springfield, OR 97477-1560

Springfield School District 19 Ridgeview Elementary 526 66th St Springfield, OR 97478-7108

Springfield School District 19 Riverbend Elementary 320 51st St Springfield, OR 97478-6024

Springfield School District 19 Thurston Elementary 7345 Thurston Rd Springfield, OR 97478-7202

Item 2. The policy period is from 07/01/2025, 12:01 A.M. to 07/01/2026, 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 $1,000,000 each accident Bodily Injury by Disease $1,000,000 each employee Bodily Injury by Disease $1,000,000 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:

WC000424 Audit Noncompliance Charge Endorsement WC000414A 90-Day Reporting Requirement-Notification of Change in Ownership Endorsement WC990401C Premium Payment Rating Plan Endorsement WC360604 Oregon Amendatory Endorsement WC990616 Confidentiality Endorsement WC360601E Oregon Cancellation 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

Item 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating

WC000001A (Ed. 04-2025)

Plans. The experience rating modification factor and other rating plan factors, if any, may change on your rating effective date of 7/1/2026. All information required below is subject to verification and change by audit.

WC000001A (Ed. 04-2025)

Rating period: 07/01/2025 to 07/01/2026 Location 1: Springfield School District 19

Classification description Class Subject payroll Rate Premium

School-Bus Drivers 7380 $3,000,000.00 3.75 $112,500.00 School-Professional Emp & Clerical 8868 $73,200,000.00 0.29 $212,280.00 Work Experience-No Manual Labor 8868 $0.00 0.29 $0.00 Child Day Care Centr-All Employees 8869 $170,000.00 0.78 $1,326.00 School-All Other Employees 9101 $4,500,000.00 2.1 $94,500.00 Work Experience-Manual Labor 9101 $0.00 2.1 $0.00 School-Cafeteria/Kitchen Empl 9349 $1,700,000.00 2.1 $35,700.00

Total manual premium $82,570,000.00 $456,306.00

Description Basis Factor Premium EL Increased Limits premium (Part II) $456,306.00 1.004 $1,825.22

Total subject premium $458,131.22

Description Basis Factor Premium Experience Rating $458,131.22 1.12 $54,975.75

Total modified premium $513,106.97

Description Basis Factor Premium Pre-pay credit $513,106.97 0.965 -$17,958.74

Total standard premium $495,148.23

Description Basis Factor Premium Oregon Total Premium $495,148.23 Premium Discount $495,148.23 0.1756 -$86,951.68 Terrorism Premium $82,570,000.00 0.005 $4,128.50 Catastrophe Premium $82,570,000.00 0.01 $8,257.00 DCBS Assessment $418,609.35 1.098 $41,023.72

Total premium and assessment $461,605.77

Policy Minimum Premium: $500

Part Two Coverage Increased Limits Minimum Premium: $120

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

WC000001A (Ed. 04-2025)

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 June 30, 2025 at Salem, Oregon

Chip Terhune President and Chief Executive Officer

WC 000000C (Ed. 04-2025) 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: 749975

WC 000000C (Ed. 04-2025) 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;

WC 000000C (Ed. 04-2025) 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.

WC 000000C (Ed. 04-2025) 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.

WC 000000C (Ed. 04-2025) 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.

Pol_PC1_CLADD

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

SAIF policy: 749975

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, 2025:

7380 06 School-Bus Drivers

7380 School-Drivers, Chauffeurs, Messengers and Their Helpers. Applies to operation of school buses by professional drivers, their helpers, and bus aides. Does not apply to teachers or coaches driving students and/or equipment to a school activity. Applies to non-classroom activities of truck driving schools.

Class 7380 applies to your employees involved in direct labor, supervision, and driving who are engaged in the operation of your school buses, transportation of students and faculty as well as pickup and delivery work. Class 7380 applies employees engaged in maintenance and repair of your vehicles and garage equipment.

8868 BQ Work Experience-No Manual Labor

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. Wages for such workers should be reported by multiplying the number of hours worked by the pay rate in effect for the policy term.

8868 07 School-Professional Emp & Clerical

8868 Schools - Professional & Clerical. Applies to teachers and aides and classroom time of truck driving schools. Includes teachers and coaches driving students and/or equipment to a school activity.

Applies to unpaid apprenticeship trainees in work experience attending classroom or laboratory sessions. Includes unpaid trainees in work experience or school directed professional programs who would ordinarily qualify for Class 8868 if they were paid employees.

Class 8868 includes employees involved in direct labor and supervision who are engaged in professional and clerical activities as, but not limited to, professors, administrators, teachers, guidance counselors, social workers, therapists, nurses, athletic coaches, secretaries and bookkeepers for your college or school. The term colleges or schools applies to any academic, trade, or vocational institution

Classification addendum of learning including seminaries, military schools, veterinary schools, art schools, modeling schools, dance schools (including the operation of an incidental dance hall), driver training schools, and correspondence schools.

Class 8868 applies to clerical workers working in offices located away from your school and to teachers at agricultural schools, who, as part of their teaching activities, demonstrate various planting techniques on farms operated by your school, provided the farms are not operated as commercial enterprises.

Class 8868 does not apply to instructors of aeronautical schools who actually fly or professionals engaged in demonstrations in hazardous employment, such as operating heavy equipment in actual roadwork. Such instructors are to be classified in accordance with the classification that would be applicable to a business engaged in that type of operation.

Professional bus drivers, bus aides, pickup and delivery of supplies and materials, and truck driving instruction away from the classroom to be separately classed as 7380 - Bus Drivers. Independent contractors engaged in transportation of students and faculty for colleges and schools to be separately classed as 7382 - Bus Company. Employees engaged in maintenance and repair of grounds, buildings and equipment to be separately classed as 9101 - School-Non-Professional Employees. Cafeteria or kitchen employees to be separately classed as 9349 - School-Cafeteria/Kitchen.

8869 01 Child Day Care Centr-All Employees

8869 - Child Day Care Center-All Employees Including Clerical, Salespersons Child Day Camp-All Employees Including Clerical, Salesperson & Drivers. Applicable to insureds engaged in child care for preschool and/or school-age children. The age of the children is not a factor. These facilities are intended to provide care for children outside of the traditional school. Activities for the children may include, but are not limited to, playtime, storytelling, reading, instructional work, homework-type activities and teaching about religious beliefs. Although the centers may teach, instruct and/or provide lessons for the children these centers are not the same as a traditional school. Many of these centers provide all-day care for the children along with care before and/or after attendance at a traditional school.Class 8869 applies to your employees involved in direct labor, supervision and driving or delivery, who are engaged in the operation, care, custody, and maintenance of your child day care or day camp; pre-school, pre-kindergarten, or kindergarten buildings, grounds, equipment and vehicles.

Class 8869 also applies to office clerical employees and outside sales or public relations personnel. In situations where there is also a traditional school (not including kindergarten) in addition to a child care facility, a head count of the children must be used to determine the proper classification. If the average or larger percentage of children are enrolled in the child care center program Class 8869 is applicable for all employees. A child enrolled in both children care and traditional school at the same location will be counted in the school count. Refer to Class 8868 for an explanation of the classification treatment of traditional school employees.Child care centers providing residential care and/or medical care are to be separately rated. Camps providing overnight accommodations or specialty day camps otherwise classified are to be separately rated.

9101 AK Work Experience-Manual Labor

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. Wages for such workers should be reported by multiplying the number of hours worked by the pay rate in effect for the policy term.

9101 07 School-All Other Employees

Class 9101 applies to your employees involved in direct labor and supervision who are engaged in the

Classification addendum care, custody, security and maintenance of your college or school buildings, grounds, and equipment.

Buildings would include dormitories, mess halls, and recreational facilities maintained and operated by you. Non-professional employees of agricultural schools that operate farms are included in Class 9101 provided the farms are not operated as commercial enterprises. Professional and clerical employees to be separately classed as 8868 - School-Professional Employees and Clerical. School bus drivers and pickup or delivery work to be separately classed as 7380 - School Bus Drivers. Independent contractors engaged in transportation of students and faculty for colleges and schools to be separately classed as 7382 - Bus Company. Cafeteria or kitchen employees to be separately classed as 9349 - School-Cafeteria.

9349 01 School-Cafeteria/Kitchen Empl

Class 9349 applies to your employees involved in direct labor and supervision who are engaged in the operation of your cafeteria or kitchen. Class 9349 applies to cooks, bakers, busboys, waitresses, nutritionists, counterpersons, butchers, and dishwashers.

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

Pol_PC1_E210A

Carrier no: 20001 Endorsement no: WC360601E (Ed. 210A)

SAIF policy: 749975 Springfield School District 19

Oregon Cancellation Endorsement

This endorsement applies only to the insurance provided by the policy because Oregon is shown in Item 3.A. of the Information Page.

The Cancellation Condition of the policy is replaced by this Condition:

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. If you provide for other insurance or self-insurance, your cancellation of coverage will take effect upon the effective date of that insurance.

2. We may cancel this policy. We will mail to you advance written notice stating when the cancellation is to take effect.

a. If we cancel based on our decision not to offer insurance to all employers within your premium category, we will mail the notice of cancellation at least 90 days before the cancellation is to take effect.

b. If we cancel for other reasons, we will mail the notice of cancellation at least 45 days before the cancellation is to take effect.

c. If we cancel for nonpayment, we will mail notice of cancellation at least 10 days before the cancellation is to take effect.

3. Mailing notice to you at your last known mailing address will be sufficient to prove notice.

4. The policy period will end at 12:01 AM on the day stated in the cancellation notice.

5. When coverage is placed with another carrier as of the policy expiration date, a rejected renewal policy shall be withdrawn without charge, provided notice of nonrenewal is mailed and postmarked on or before the expiration date and is received from the insured by the insurer no later than 10 calendar days after said expiration date.

Effective date: July 01, 2025

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

WC360601E

(Ed. 210A)

Countersigned June 30, 2025 at Salem, Oregon

Salem, OR 97312 P: 800.285.8525 F: 503.373.8020

Pol_PC1_E211F

Carrier no: 20001 Endorsement no: WC000421F (Ed. 04-2025)

SAIF policy: 749975 Springfield School District 19

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 defined below.

Your policy provides coverage for workers’ compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism). Coverage for such losses is subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement attached to this policy.

For purposes of this endorsement, Catastrophe (Other Than Certified Acts of Terrorism) is defined as:

A single event or peril resulting in a group of claims with aggregate workers compensation losses in excess of $50 million. This $50 million threshold applies per occurrence, across all states for which claims arise from a single event or peril.

The premium charge for the coverage your policy provides for workers’ compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism) is shown in Item 4 of the Information Page or in the Schedule below.

Schedule

State Rate per $100 of payroll Oregon 0.01

Effective date: July 01, 2025

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

WC000421F

(Ed. 04-2025)

Countersigned June 30, 2025 at Salem, Oregon

Salem, OR 97312 P: 800.285.8525 F: 503.373.8020

Pol_PC1_E212C

Carrier no: 20001 Endorsement no: WC000422C (Ed. 04-2025)

SAIF policy: 749975 Springfield School District 19

Terrorism Risk Insurance Program Reauthorization Act Disclosure endorsement.

This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2019. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging a premium for losses that may occur in the event of an Act of Terrorism.

Your policy provides coverage for workers’ compensation losses caused by Acts of Terrorism, including workers’ compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations.

Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply.

"Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto, including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2019.

"Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States as meeting all of the following requirements:

a. The act is an act of terrorism.

b. The act is violent or dangerous to human life, property or infrastructure.

c. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels.

d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion.

"Insured Loss" means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers’ compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels.

"Insurer Deductible" means, for the period beginning on January 1, 2021, and ending on December 31, 2027, an amount equal to 20% of our direct earned premium, during the immediately preceding calendar year.

Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a calendar year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury.

Terrorism Risk Insurance Program Reauthorization Act Disclosure endorsement.

Policyholder Disclosure Notice

1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses occurring in any calendar year exceed $200,000,000, the United States Government would pay 80% of our Insured Losses that exceed our Insurer Deductible.

2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100,000,000,000.

3. The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in Item 4 of the Information Page or in the Schedule below.

Schedule

State Rate per $100 of payroll Oregon 0.005

Effective date: July 01, 2025

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

WC000422C

(Ed. 04-2025)

Countersigned June 30, 2025 at Salem, Oregon

Salem, OR 97312 P: 800.285.8525 F: 503.373.8020

Pol_PC1_E213A

Carrier no: 20001 Endorsement no: WC000414A (Ed.