The_Hartford_Workers_Compensation_07082021.pdf

SCPHS016

THE HARTFORD

BUSINESS SERVICE CENTER

3600 WISEMAN BLVD

SAN ANTONIO TX 78251 May 18, 2021

PILGRIM REST FOUNDATION INC

1401 EAST JEFFERSON ST

PHOENIX AZ 85034

Policy Information:

Policy Number: 76 WEG RY0658 Contact Us

Business Service Center Business Hours: Monday - Friday (7AM - 7PM Central Standard Time) Phone: (877) 287-1312 Fax: (888) 443-6112 Email: agency.services@thehartford.com Website: www.thehartford.com

INSURANCE ENDORSEMENT ATTACHED

*** PLEASE REVIEW THE CHANGE ***

Enclosed is an endorsement for your business insurance policy. Please review it at your convenience. If you have questions or need to make further changes, Please contact us.

The premium billing will be mailed to you separately. You can expect to receive it soon.

Thank you for allowing us to service your business needs.

Sincerely, Your Hartford Service Team

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

Countersigned by

Authorized Representative

Form WC 99 00 06 A (1) Printed in U.S.A. Page 1 Process Date: 05/18/21 Policy Expiration Date: 02/01/22

CHANGE IN INFORMATION PAGE

INSURER: Hartford Insurance Company of Illinois NCCI Company Number: 20613 Audit Period: ANNUAL Policy Effective Date: 02/01/21 Policy Expiration Date: 02/01/22 Policy Number: 76 WEG RY0658 Endorsement Number: 1 Effective Date: 02/01/21 Effective hour is the same as stated on the Information Page of the policy.

Named Insured and Address: PILGRIM REST FOUNDATION INC

1401 EAST JEFFERSON ST

PHOENIX AZ 85034

FEIN Number: 86-0885862 Producer Name: PAYCHEX INSURANCE AGENCY INC Producer Code: 76210705 It is agreed that the policy is amended as follows:

This is NOT a bill. However, any changes in your premium will be reflected in your next billing statement. You will receive a separate bill from The Hartford. If you are enrolled in repetitive EFT draws from your bank account, changes in premium will change future draw amounts.

In consideration of a return premium of ($7,432), it is agreed that:

Policy is amended to reflect an adjustment in premium basis due to a recent audit completed for this Insured.

Policy is amended to delete the following class(es) from AZ, Schedule Number 01-02-01:

9063 08 - MASSAGE SALONS

Policy is amended to change the payroll associated to 8840 for AZ, Schedule Number 01-02-01 from 455,900.00 to 1,431,359.00

Policy is amended to change the payroll associated to 9101 for AZ, Schedule Number 01-02-01 from 297,500.00 to 41,858.00

Policy is amended to change the payroll associated to 8840 for AZ, Schedule Number 01-02-02 from $300 to If any

Policy is amended to change the payroll associated to 9101 for AZ, Schedule Number 01-02-02 from $100 to If any

Policy is amended to change the payroll associated to 9101 for AZ, Schedule Number 01-02-03 from 104,000.00 to If any

CHANGE IN INFORMATION PAGE (Continued)

Policy Number: 76 WEG RY0658

Form WC 99 00 06 A (1) Printed in U.S.A. Page 2 Process Date: 05/18/21 Policy Expiration Date: 02/01/22

Policy is amended to change the payroll associated to 9101 for AZ, Schedule Number 01-02-04 from 104,000.00 to If any

Policy is amended to add the following Endorsement Forms reflecting the changes made to your policy.

WC990006A(.1P)

WC990006A(.2)

WC000406A

Policy is amended to delete the following Endorsement Forms reflecting the changes made to your policy.

WC020401C

CHANGE IN INFORMATION PAGE (Continued)

Policy Number: 76 WEG RY0658

SCHEDULE

IT IS AGREED THAT THE POLICY IS AMENDED AS FOLLOWS:

CLASS CODE NUMBER AND DESCRIPTION ESTIMATED

TOTAL ANNUAL

REMUNERATION

RATES PER 100

OF

REMUNERATION

ESTIMATED

ANNUAL

PREMIUMS

Form WC 99 00 06 A (1) Printed in U.S.A. Page 3 Process Date: 05/18/21 Policy Expiration Date: 02/01/22

AZ - Location 1

RELIGIOUS ORGANIZATION: PROFESSIONAL

EMPLOYEES & CLERICAL

1,431,359.00 0.800000 11,451

RELIGIOUS ORGANIZATION: PROFESSIONAL

EMPLOYEES & CLERICAL

455,900.00 0.800000 -3,647

MASSAGE SALONS

200.00 1.110000 -2

RELIGIOUS ORGANIZATION: ALL OTHER EMPLOYEES

297,500.00 3.850000 -11,454

RELIGIOUS ORGANIZATION: ALL OTHER EMPLOYEES

41,858.00 3.850000 1,612

AZ - Location 2

RELIGIOUS ORGANIZATION: PROFESSIONAL

EMPLOYEES & CLERICAL

300.00 0.800000 -2

RELIGIOUS ORGANIZATION: ALL OTHER EMPLOYEES

100.00 3.850000 -4

AZ - Location 3

RELIGIOUS ORGANIZATION: ALL OTHER EMPLOYEES

104,000.00 3.850000 -4,004

AZ - Location 4

RELIGIOUS ORGANIZATION: ALL OTHER EMPLOYEES

104,000.00 3.850000 -4,004

Total State Summary

Total Class Premium -10,054 Waiver charge 0.00 0 Experience modifier 020937335 0.00 0.790000 2,111 Premium discount 0.00 0.024000 453 Premium discount 0.00 0.004000 -44 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement

511,217.00 0.010000 51

Catastrophe (other than certified acts of terrorism) 511,217.00 0.010000 51 Arizona Total Cost -7,432

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

Countersigned by Authorized Representative

Form WC 00 04 06 A Printed in U.S.A.

Process Date: 05/18/21 Policy Expiration Date: 02/01/22

PREMIUM DISCOUNT ENDORSEMENT

Policy Number: 76 WEG RY0658 Endorsement Number: 1 Effective Date: 02/01/21 Effective hour is the same as stated on the Information Page of the policy.

Named Insured and Address: PILGRIM REST FOUNDATION INC

1401 EAST JEFFERSON ST

PHOENIX AZ 85034

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 Item 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

1. Table of States

Alaska Idaho Massachusetts Rhode Island X Arizona Indiana Minnesota Wisconsin

Florida Iowa Nevada or any other State that has approved the premium discount plan applicable to the total policy premium on an interstate basis at the effective date of the policy.

2. Average percentage discount: 0.40 %

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: