Work_Comp_Travelers_Policy.pdf
PDF 20 KB Posted
- Attached to
- Master Agreement AZ|CTR076200
- Contract number
- CTR076200
- Issued by
- Arizona
About this file
This document is a Workers Compensation and Employers Liability Policy issued by The Standard Fire Insurance Company for Longhouse Inventory Solutions, LLC, located in Claremore, Oklahoma. The policy is produced by Burrows & Burrows Agency and covers workers compensation insurance for multiple states, including OK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, NE, NH, NJ, NM, NV, NY, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WI, and WV.
The policy is effective from 12-31-24 to 12-31-25 with liability limits of $1,000,000 for bodily injury by accident per occurrence, $1,000,000 for bodily injury by disease policy limit, and $1,000,000 for bodily injury by disease per employee. The premium will be determined by the insurer's Manuals of Rules, Classifications, Rates, and Rating Plans, with annual audits to verify and potentially adjust the required information. The policy is a Type V information page with the policy number UB-A3487029-24-42-G and NCCI CO CODE 15245.
View the file
Other files
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 POLICY
TYPE INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER:
INSURER:
NCCI CO CODE:
1.
INSURED: PRODUCER:
Insured is
Other work places and identification numbers are shown in the schedule(s) attached.
Bodily Injury by Accident: $ Each Accident Bodily Injury by Disease: $ Policy Limit Bodily Injury by Disease: $ Each Employee
DATE OF ISSUE:
OFFICE:
PRODUCER:
2. The policy period is from 12-31-24 to 12-31-25 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 state(s) listed here:
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:
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
D. This policy includes these endorsements and schedules:
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY
OK
AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI
MN MO MS MT NC NE NH NJ NM NV NY OR PA RI SC SD TN TX UT VA VT WI
WV
ONE TOWER SQUARE
HARTFORD CT 06183
V
UB-A3487029-24-42-G
NEW-24
THE STANDARD FIRE INSURANCE COMPANY
15245
LONGHOUSE INVENTORY
SOLUTIONS , LLC
PO BOX 1212
CLAREMORE, OK 74018-1212
BURROWS & BURROWS AGENCY
PO BOX 867
CLAREMORE, OK 74018867
A LIMITED LIABILITY COMPANY
1,000,000 1,000,000 1,000,000
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
11-19-24 SL
TULSA OK 967
BURROWS & BURROWS AGENCY BTQ80
A Stock Company
File details come from the government source that posted it. Updated .