TSSW_Subrogation_Waiver.pdf
PDF 130 KB Posted
- Attached to
- Master Agreement AZ|CTR043289
- Contract number
- CTR043289
- Issued by
- Arizona
About this file
This document is a Workers Compensation and Employers Liability Insurance Policy endorsement issued by CopperPoint General Insurance Company for Terrasystems Southwest Inc, effective 03/25/2019. The policy specifically covers the State of Arizona, including its departments, agencies, boards, commissions, universities, and associated officers, officials, agents, and employees. The endorsement includes a waiver of the insurance company's right to recover payments from parties named in the schedule, which applies only to work performed under a written contract.
The policy details a classification for "CMPTR SYSTM DESGNRS OR PRGMRS-OFFICE" with code number 8810 for the state of Arizona. The total estimated annual remuneration is $66,695, with a rate of $0.16 per $100 of remuneration, resulting in an estimated annual premium of $107. The total estimated annual premium for the policy is $651, with an additional premium cost change of $250. The endorsement modifies certain policy information and rates while maintaining coverage for workplace-related injuries and liability for the insured organization.
View the file
Other files
Show all 29
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
(Ed. 4-84)
WC 00 03 13
(Ed. 4-84)
© 1983 National Council on Compensation Insurance.
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.)
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
Schedule State Blanket/Schedule/State
AZ STATE
State Waiver: State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees’ losses arising from work performed by or on behalf of the Contractor
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.)
03/25/2019Endorsement Effective 1005927Policy No. 9Endorsement No.
Terrasystems Southwest IncInsured 250 Premium $
CopperPoint General Insurance CompanyInsurance Company Countersigned by
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B
(Version 7/01)
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.)
03/25/2019Endorsement Effective 1005927Policy No. 10Endorsement No.
Terrasystems Southwest IncInsured $250Premium Cost Change
CopperPoint General Insurance CompanyInsurance Company Countersigned by
WC 89 06 00 B
(Version 7/01)
© Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved.
POLICY INFORMATION PAGE ENDORSEMENT
The following item(s)
Insured’s Name (WC 89 06 01) Expiration Date (WC 89 06 04) Insured’s Mailing Address (WC 89 06 05) Experience Modification (WC 89 04 06) Producer’s Name (WC 89 06 07) Change in Workplace of Insured (WC 89 06 08) Insured’s Legal Status (WC 89 06 10) Item 3.A. States (WC 89 06 11)
Item 3.B. Limits (WC 89 06 12) Item 3 .C. States (WC 89 06 13)
✔ Item 3.D. Endorsement Numbers (WC 89 06 14) ✔ Item 4.* Class, Rate, Other (WC 89 04 15) ✔ Interim Adjustment of Premium (WC 89 04 16)
Interstate/Intrastate Risk ID Number (WC 89 06 18) Issuing Agency/Producer Office Address (WC 89 06 25)
Is changed to read:
*Item 4: Add
State Classification Code No Premium Basis
Total Estimated Annual Remuneration
Rate Per $100 of Remuneration
Estimated Annual Premium
AZ CMPTR SYSTM DESGNRS
OR PRGMRS-OFFICE 8810 $66,695 $0.16 $107
*Item 4: Remove
State Classification Code No Premium Basis
Total Estimated Annual Remuneration
Rate Per $100 of Remuneration
Estimated Annual Premium
AZ CMPTR SYSTM DESGNRS
OR PRGMRS-OFFICE 8810 $66,695 $0.16 $107
Total Estimated Annual Premium: $651
File details come from the government source that posted it. Updated .