ONE TOWER SQUARE HARTFORD, CT 06183 (IAUB-5F95737-9-15) 02-26-15 POLICY NUMBER: NEW YORK SECURITY FUND SURCHARGE Dear Policyholder: "Companies writing workers compensation insurance business in New York are required to participate in the New York Workers' Compensation Security Fund. If a company becomes insolvent, the security fund settles unpaid claims and assesses each insurance company for its fair share. New York law requires all companies to surcharge policies to recover these assessments. If your policy is surcharged "NY surcharge", an amount will be displayed on your premium notice." DATE OF ISSUE: W31N2E04
Transcript
ONE TOWERSQUAREHARTFORD, CT 06183
(IAUB-5F95737-9-15)
02-26-15
POLICY NUMBER:
NEW YORK SECURITY FUND SURCHARGE
Dear Policyholder:
"Companies writing workers compensation insurance business in New York are requiredto participate in the New York Workers' Compensation Security Fund. If a company becomesinsolvent, the security fund settles unpaid claims and assesses each insurance company for itsfair share.
New York law requires all companies to surcharge policies to recover these assessments.If your policy is surcharged "NY surcharge", an amount will be displayed on your premiumnotice."
DATE OF ISSUE:
W31N2E04
Report Claims Immediately by Calling*1-800-238-6225
Speak directly with a claim professional24 hours a day, 365 days a year
Written*Unless Your Policy Requires Notice or Reporting
LA FAMILIA FOOD CORP.1553 WESTCHESTER AVENUEBRONX NY 10472
WORKERS COMPENSATIONAND
EMPLOYERS LIABILITY POLICY
A Custom Insurance Policy Prepared for:
ONE TOWERSQUAREHARTFORD, CT 06183
V
(IAUB-5F95737-9-15)
NEW-15
TRAVELERSCASUALTYAND SURETY COMPANY
11223
LA FAMILIA FOODCORP.1553 WESTCHESTERAVENUEBRONXNY 10472
J J FARBER LOTTMANCOPO BOX 613PALISADES PARK NJ 07650
A CORPORATION
02-26-15 02-26-16
NY
100000010000001000000
AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MIMN MO MS MT NC NE NH NJ NM NV OK OR PA RI SC SD TN TX UT VA VT WIWV
SEE LISTING OF ENDORSEMENTS- EXTENSION OF INFO PAGE
ANNUALLY.
02-26-15 N3NORTHJERSEY 295 DIRECT BILLJ J FARBER LOTTMANCO G8430
WORKERS COMPENSATIONAND
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.
2. The policy period is from to 12:01 A.M. at the insured’s mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the WorkersCompensation Law of the state(s) listed here:
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed initem 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ Each AccidentBodily Injury by Disease: $ Policy LimitBodily Injury by Disease: $ Each Employee
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 RatingPlans. All required information is subject to verification and change by audit to be made
0.00% NY CONTR. CLASS PREM. ADJ. PLAN NONETOTAL ESTIMATED ANNUAL STANDARDPREMIUM 990
EXPENSECONSTANT(0900) 200TERRORISM(9740) 21
CAT(OTHER THAN CERT ACTS OF TERRORISM) 9741 413.20% NY STATE ASSESSMENT(0932) 134
TOTAL ESTIMATED PREMIUM 1349DEPOSIT AMOUNTDUE 1349
02-26-15 N3 1 LAST
WORKERS COMPENSATIONAND
EMPLOYERS LIABILITY POLICY
POLICY NUMBER:
DATE OF ISSUE: SCHEDULE NO: OF
ONE TOWERSQUAREHARTFORD, CT 06183
(IAUB-5F95737-9-15)
WC00 00 01 A - 001 INFORMATION PAGEWC00 00 01 A - 001 INFORMATION PAGE 2WC00 00 01 A - 001 EXTENSION OF INFORMATION PAGE - SCHEDULEWC00 00 01 A - 001 ENDORSEMENTLISTINGWC00 04 14 00 - 001 NOTIFICATION OF CHANGEIN OWNERSHIPENDTWC00 04 22 A - 001 TERRORISM-REAUTHORIZATIONACT DISCLOSUREWC00 04 21 C - 001 CATASTROPHE(O/T CERT. ACTS OF TERR)ENDTWC00 04 19 00 - 001 PREMIUMDUE DATE ENDORSEMENTWC31 03 05 B - 001 NY EXCL OF EXECUTIVE OFFICER ENDTWC31 03 08 00 - 001 NEWYORK LIMIT OF LIABILITY ENDORSEMENTWC31 03 19 G - 001 NY CONSTCLASS PREMADJUST PROG
LAST102-26-15
WORKERS COMPENSATIONAND
EMPLOYERS LIABILITY POLICY
ENDORSEMENT WC 00 00 01 (A )
POLICY NUMBER:
LISTING OF ENDORSEMENTSEXTENSION OF INFO PAGE
We agree that the following listed endorsements form a part of this policy on its effective date.
Page ofDATE OF ISSUE: ST ASSIGN:
ONE TOWERSQUAREHARTFORD, CT 06183
(IAUB-5F95737-9-15)
02-26-15
WORKERS COMPENSATIONAND
EMPLOYERS LIABILITY POLICY
ENDORSEMENT WC 00 04 14 (00)
POLICY NUMBER:
NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT
Experience rating is mandatory for all eligible insureds. The experience rating modification factor, if any, applicableto this policy, may change if there is a change in your ownership or in that of one or more of the entities eligibleto be combined with you for experience rating purposes. Change in ownership includes sales, purchases, othertransfers, mergers, consolidations, dissolutions, formations of a new entity and other changes provided for in theapplicable experience rating plan manual.
You must report any change in ownership to us in writing within 90 days of such change. Failure to report suchchanges within this period may result in revision of the experience rating modification factor used to determineyour premium.
DATE OF ISSUE: ST ASSIGN:
ONE TOWERSQUAREHARTFORD, CT 06183
(IAUB-5F95737-9-15)
02-26-15
WORKERS COMPENSATIONAND
EMPLOYERS LIABILITY POLICY
ENDORSEMENT WC 00 04 22 ( A)
POLICY NUMBER:
TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACTDISCLOSURE ENDORSEMENT
This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended andextended by the Terrorism Risk Insurance Program Reauthorization Act of 2007. It serves to notify you of certainlimitations under the Act, and that your insurance carrier is charging premium for losses that may occur in theevent of an Act of Terrorism.
Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workerscompensation 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, orregulations.
Definitions
The definitions provided in this endorsement are based on and have the same meaning as the definitions in theAct. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act willapply.
"Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and anyamendments thereto resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2007.
"Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in concurrence with theSecretary of State, 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 thepremises 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 popula-tion of the United States or to influence the policy or affect the conduct of the United States Government bycoercion.
"Insured Loss" means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an actof war, in the case of workers compensation) that is covered by primary or excess property and casualty insur-ance issued by an insurer if the loss occurs in the United States or at the premises of United States missions orto certain air carriers or vessels.
"Insurer Deductible" means, for the period beginning on January 1, 2008, and ending on December 31, 2014, anamount equal to 20% of our direct earned premiums, over the calendar year immediately preceding the applica-ble Program Year.
"Program Year" refers to each calendar year between January 1, 2008 and December 31, 2014, as applicable.
Limitation of Liability
The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in aProgram Year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of theamount 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 ofthe Treasury.
Page 1 of 2DATE OF ISSUE: ST ASSIGN:
ONE TOWERSQUAREHARTFORD, CT 06183
(IAUB-5F95737-9-15)
02-26-15
WORKERS COMPENSATIONAND
EMPLOYERS LIABILITY POLICY
WC 00 04 22 ( A)ENDORSEMENT
POLICY NUMBER:
Policyholder Disclosure Notice
1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industryInsured Losses exceed $100,000,000 in a Program Year, the United States Government would pay 85% ofour Insured Losses that exceed our Insurer Deductible.
2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act forany 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 amountshown in Item 4 of the Information Page or in the Schedule below.
Schedule
State Rate Premium
This endorsement changes the poli to which it is att and is ef ect v on the date issued unless otherwisecy ached f i estated.
( in on lo is req o w his nd issue ubseq to paratio ofThe formati be w uired nly hen t e orsement is d s uent pre nthe p icy.)ol
Policy No.Endorsement E f i e Endorsement No.f ect vPrem miu $Insured
Insurance Company Countersigned by
Page 2 of 2DATE OF ISSUE: ST ASSIGN:
ONE TOWERSQUAREHARTFORD, CT 06183
(IAUB-5F95737-9-15)
02-26-15
WORKERS COMPENSATIONAND
EMPLOYERS LIABILITY POLICY
WC 00 04 21 ( C)ENDORSEMENT
POLICY NUMBER:
CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM)PREMIUM ENDORSEMENT
This endorsement is notification that your insurance carrier is charging premium to cover the losses that mayoccur in the event of a Catastrophe (other than Certified Acts of Terrorism) as that term is defined below. Yourpolicy provides coverage for workers compensation losses caused by a Catastrophe (other than Certified Acts ofTerrorism). This premium charge does not provide funding for Certified Acts of Terrorism contemplated underthe Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 A), attachedto this policy.
For purposes of this endorsement, the following definitions apply:
Catastrophe (other than Certified Acts of Terrorism): Any single event, resulting from an Earthquake,Noncertified Act of Terrorism, or Catastrophic Industrial Accident, which results in aggregate workers com-pensation losses in excess of $50 million.
Earthquake: The shaking and vibration at the surface of the earth resulting from underground movementalong a fault plane or from volcanic activity.
Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary ofTreasury pursuant to the Terrorism Risk Insurance Act of 2002 (as amended) but that meets all of the follow-ing criteria:
a. It is an act that is violent or dangerous to human life, property, or infrastructure;
b. The act results in damage within the United States, or outside of the United States in the case of thepremises of United States missions or air carriers or vessels as those terms are defined in the TerrorismRisk Insurance Act of 2002 (as amended); and
c. It is an act that has been committed by an individual or individuals as part of an effort to coerce the civil-ian population of the United States or to influence the policy or affect the conduct of the United StatesGovernment by coercion.
Catastrophic Industrial Accident: A chemical release, large explosion, or small blast that is localized in natureand affects workers in a small perimeter the size of a building.
The premium charge for the coverage your policy provides for workers compensation losses caused by aCatastrophe (other than Certified Acts of Terrorism) is shown in Item 4 of the Information Page or in the Sched-ule below.
Schedule
State Rate Premium
This endorsement changes the poli to which it is att and is ef ect v on the date issued unless otherwisecy ached f i estated.
( in on lo is req o w his nd issue ubseq to paratio ofThe formati be w uired nly hen t e orsement is d s uent pre nthe p icy.)ol
Policy No.Endorsement E f i e Endorsement No.f ect vPrem miu $Insured
Insurance Company Countersigned by
Page 1 of 1DATE OF ISSUE: ST ASSIGN:
ONE TOWERSQUAREHARTFORD, CT 06183
(IAUB-5F95737-9-15)
02-26-15
WORKERS CO TIMPENSA ONAND
EMPL L T OOYERS IABILI Y P LICY
ENDORSEMEN WC 00 04T 19 (00)
POLICY :NUMBER
PREMIUM DUE DATE ENDORSEMENT
This endorsement is used to amend:
Section D f t F v o the pol is replaced by v. o Par i e f icy this pro ision.
PART FIVE
PREMIUM
D. Premium is amended to read:
You will pay a pre iu when due. You wil pay the pre iu e en i part or a o a workers compensationll m m l m m v f ll flaw is not a .v lid T due for a it a retrospective is t date he lli .he date ud nd premiums he of t bi ng
DATE I ST A GN: Page 1 o 1OF SSUE: SSI f
ONE TOWERSQUAREHARTFORD, CT 06183
001
(IAUB-5F95737-9-15)
DELVYS ESPINAL PRESIDENT
02-26-15
WORKERS COMPENSATIONAND
EMPLOYERS LIABILITY POLICY
ENDORSEMENT WC 31 03 05 ( B)
POLICY NUMBER:
NEW YORK EXCLUSION OF EXECUTIVE OFFICER ENDORSEMENT
The policy does not cover bodily injury to the sole executive officer and only stockholder of the insured corporation,or one or two executive officers who together are the only stockholders of the insured corporation with each officerholding at least one share of stock in the corporation, when such corporation has other employees who are requiredto be covered by law, and the corporation has elected to exclude from coverage the sole officer or one or bothofficers of a two person corporation described in the Schedule.
The premium basis for the policy does not include the remuneration of the excluded executive officer or officers.
You will reimburse us for any payment we must make because of bodily injury to such person.
SCHEDULE
Name Of Officer(s) Title
DATE OF ISSUE: ST ASSIGN:
ONE TOWERSQUAREHARTFORD, CT 06183
(IAUB-5F95737-9-15)
02-26-15
WORKERS COMPENSATIONAND
EMPLOYERS LIABILITY POLICY
ENDORSEMENT WC 31 03 08 (00)
POLICY NUMBER:
NEW YORK LIMIT OF LIABILITY ENDORSEMENT
This endorsement applies only to the insurance provided by Part Two (Employers Liability Insurance) becauseNew York is shown in Item 3.A of the Information Page.
We may not limit our liability to pay damages for which we become legally liable to pay because of bodily injuryto your employees if the bodily injury arises out of and in the course of employment that is subject to and iscompensable under the Workers Compensation Law of New York.
DATE OF ISSUE: ST ASSIGN:
ONE TOWERSQUAREHARTFORD, CT 06183
(IAUB-5F95737-9-15)
02-26-15
WORKERS COMPENSATIONAND
EMPLOYERS LIABILITY POLICY
ENDORSEMENT WC 31 03 19 ( G)
POLICY NUMBER:
NEW YORK CONSTRUCTION CLASSIFICATION PREMIUM ADJUSTMENTPROGRAM EXPLANATORY ENDORSEMENT
The New York Construction Classification Premium Adjustment Program (NYCCPAP) allows premium credits forsome employers in the construction industry. These credits exist to recognize the difference in wage ratesbetween employers within the same construction industries in New York.
The declarations section of this policy will show a credit of 0.00% if you are not eligible for this credit, or if youare eligible for this credit and have not yet applied for a credit. Credits are earned for average wages in excess of$23.24 per hour for each eligible class. If your policy shows one of the following classification codes, and you areexperience rated, you are eligible to apply for an NYCCPAP credit:
0042 5057 5193 5429 5491 5606 6003 6229 6325 9526
3365 5059 5213 5443 5506 5610 6005 6233 6400 9527
3724 5069 5221 5445 5507 5645 6017 6235 6701 9534
3726 5102 5222 5462 5508 5648 6018 6251 7536 9539
3737 5160 5223 5473 5536 5651 6045 6252 7538 9545
5000 5183 5348 5474 5538 5701 6204 6260 7601 9549
5022 5184 5402 5479 5545 5703 6216 6306 7855 9553
5037 5188 5403 5480 5547 5709 6217 6319 8227
5040 5190 5428
The basis for determining the credit is the limited payroll of each employee for the number of hours worked(excluding overtime premium pay) for each construction classification (other than employees engaged in theconstruction of one or two-family residential housing) for the third quarter, as reported to taxing authorities, forthe year preceding the policy date. Total payroll is to continue to be reported for employees engaged in theconstruction of one or two-family residential housing. For example:
POLICY EFFECTIVE DATE THIRD QUARTER PAYROLL
4/1/12 thru 3/31/13 2011
4/1/13 thru 3/31/14 2012
4/1/14 thru 3/31/15 2013
4/1/15 thru 3/31/16 2014
4/1/16 thru 3/31/17 2015
4/1/17 thru 3/31/18 2016
If you have any eligible classes on your policy, you should have been notified by your insurance carrier or theNew York Compensation Insurance Rating Board approximately nine months prior to the inception date of thispolicy. If you believe you may be eligible for a credit and have not received an application, you should immedi-ately contact your agent, insurance carrier, or the New York Compensation Insurance Rating Board.
Credits are calculated by the New York Compensation Insurance Rating Board. You must submit a completedapplication to: Attention: Field Services Department, New York Compensation Insurance Rating Board, 733 ThirdAvenue, New York, New York 10017.
Applications must be received by the Rating Board three (3) months prior to the policy renewal effective date.The Rating Board will accept and process an application if it is received between the policy effective and expira-tion date, however, it must be accompanied by a letter stating the reason for the delay. Under no circumstanceswill an application be accepted for any policy if it is received after the expiration date of the policy. For short-termpolicies the application must be received prior to the expiration date of the short-term policy. If it is received afterthe policy expiration, no credit will be calculated.
The New York Workers Compensation and Employers Liability Insurance Manual, and not this endorsement,govern the implementation and use of the NYCCPAP.
For online entry of the information requested on this form refer to: http://cpap.nycirb.org/
This endorsement changes the poli y to which it is att ched and is ef ect vc a f i e on the date issued unless otherwisestated.
( he n ormati n be o s req ired o ly hen t is e d rsement is issue s bseq enT i f o l w i u n w h n o d u u t to pre aratio fp n othe p l cy.)o i
ect Pol cy No.i iEndorsement Eff v Endorsement No.ePrem ui mInsured
NOTICE OF ELECTION TO ACCEPT AN INSURANCE DEDUCTIBLEFOR NEW YORK WORKERS' COMPENSATION INDEMNITY AND MEDICAL BENEFITS
This medical and indemnity deductible program is being offered to policyholders with an estimated annualpremium at inception of twelve thousand dollars or more. Under this deductible program we pay all amounts intheir entirety applicable to each compensable claim under Part One of the policy.
We then obtain reimbursement from you, the policyholder, subject to the limits of the deductible amount for eachoccurrence. You are liable to us for the deductible amount in regard to benefits paid for compensable claims, andfailure by you to reimburse any deductible amounts to us shall be treated in the same manner as nonpayment ofpremium.
The deductibles paid by you during any one year period of insurance shall not exceed the estimated annualpremium at inception for such policy of insurance. A policy written under this deductible program shall haveattached the New York Benefits Deductible Endorsement WC 31 03 15 (A) to the policy. One of the followingdeductible amounts, per occurrence, is available for selection by you to activate this program.
To prevent putting you in an uninsured position, your policy has been issued at full rates with no deductibleapplied.
If you wish to have this deductible option apply to your policy, fill in the information requested at the bottom ofthis form. Retain your copy for your records and send the agent and company copies to your agent within sixty(60) days from the effective date of your policy. An endorsement will then be attached to your policy to reflect thechange.
If you decide that you do not want the deductible to apply, you may disregard this form. Your policy will continuein force as issued.
For a complete explanation of how this program operates or the savings available, please contact your agent.
YES, I WANT A DEDUCTIBLE OF $ APPLIED TO MEDICAL AND INDEMNITY BENEFITSUNDER THE NEW YORK WORKERS COMPENSATION LAW. I understand that the company shall pay thedeductible amount and seek reimbursement from the employer shown below.
I understand that in accordance with New York law, I have the option of modifying the above deductible programchoice at the time of renewal of my Workers' Compensation policy with the insurance company named below.
Date: Employer:
Name:
Title:
Signature:
Insurance Company:
W31N3C06 Page 2 of 2
THE TRAVELERSINSURANCECOMPANIES
THE TRAVELERSINSURANCECOMPANIESTHE TRAVELERSINSURANCECOMPANIES
THE TRAVELERSINSURANCECOMPANIES
PRIVACY NOTICE
PRIVACY POLICY
Thank you for selecting as your workerscompensation insurer. At a subsidiary ofTravelers, we recognize that privacy is important to you. That is why we are committed to protecting your privacythrough the adoption of the following privacy principles:
Collection Of Information
We collect, retain, and use information about you, or about participants, beneficiaries or claimants under yourworkers compensation coverage, only where we believe that it will help or is necessary to provide you productsand services or otherwise conduct our business. We collect nonpublic personal financial information about you,or about participants, beneficiaries or claimants under your workers compensation coverage, from the followingsources:
information we receive from you or through your agent or broker on applications or other forms;
information we receive from or about you in the process of adjusting claims;
information about your other transactions, including risk control and other consulting services, with us, ouraffiliates or other third parties;
information about your coverages and loss activity with other carriers; and
information we receive from a consumer reporting agency.
Such information includes identifying information such as policyholder, participant, beneficiary or claimant name,address, and social security number; financial information such as income, payment history, or credit history;and, under certain circumstances, health information such as information about an illness, disability, or injury. Itcould also include information on claims with other insurance companies and us and the condition and mainte-nance of your property.
Disclosure Of Information
We usually do not disclose nonpublic personal information about you, or about participants, beneficiaries orclaimants under your workers compensation coverage, without your consent. However, in some circumstanceswe may disclose information to others without your prior authorization. The most common disclosures are to thefollowing persons:
our affiliated property and casualty insurance companies;
state insurance departments, for their regulation of our business;
other government authorities;
our agents and brokers as necessary to conduct our business;
organizations that perform underwriting and claims investigations;
another insurance company to which you have applied for a policy or submitted a claim;
insurance support agencies, law enforcement agencies and our reinsurers; and
any other third party, as permitted or required by law.
Most importantly, does not and will notdisclose or sell nonpublic personal information about you, or about participants, beneficiaries or claimantsunder your workers compensation coverage, to anyone for marketing purposes.
WUNNAB09 Page 1 of 2
Confidentiality And Security
We restrict access to nonpublic personal information about you, or about participants, beneficiaries or claimantsunder your workers compensation coverage, to those who need it to serve your insurance needs and to maintainand improve customer service. We maintain physical, electronic, and procedural safeguards that comply withfederal and state laws and regulations to guard your nonpublic personal information.
Disclosure and Protection of Former Customers' Information
We may disclose all the personal information we have collected, as described above. However, even if you nolonger have a customer relationship with us, we will continue to follow our privacy policies and practices toprotect your information.
Changes In Privacy Policy
We may choose to modify our policy regarding the treatment of personal information at any time. Before we doso, we will notify you and provide an updated privacy notice.
WUNNAB09 Page 2 of 2
(IAUB-5F95737-9-15)
State of New YorkDetermination of Classification Change from 10/1/2011 Rates
Company CompanyCompany Name Abreviation LCM
Charter Oak Fire Insurance Company COF 1.052Travelers Indemnity Company of America TIA 1.118
Travelers Indemnity Company of Connecticut TCT 1.183Travelers Indemnity Company IND 1.249
NIPPONKOA Insurance Company JFM 1.315Travelers Casualty and Surety Company ACR 1.315
Travelers Property Casualty Company of America TIL 1.315Travelers Casualty Insurance Company of America ACJ 1.381
Phoenix Insurance Company PHX 1.446
"If you were insured with a different carrier last year, compare the current loss costs and multiplierto those used by your prior carrier".
To determine rate change from previous policy to current policy
To obtain the classification percentage change, apply the company factor from the above grid to the lossNote: cost classification percentage in the attached pages. (Small differences may exist due to rounding).
Numerical Example:Current Company = Travelers Indemnity Company of America (TIA)Proposed Company = Travelers Indemnity Company (IND)Company Factor = 1.117Class = 8742 ( Loss Cost Classification Factor = 1.103 )Classification Percentage Change = ( 1.117 X 1.103 ) - 1.000
=1.232 - 1.000= .232 or +23.2%
Narrative Example
Take the change in decimal form for class 8742 from the attached pages which is 1.103then multiply by the company factor of 1.117 determined from a current company ofTIA and a proposed company of IND.
( 1.117 X 1.103 ) - 1.000which indicates a 23.2% increase from the October 2011 rates. If the result of themultiplication was greater than 1.000, then the result is an increase. If the result of themultiplication is less than 1.000; this implies a decrease.
W31M6J13 Page 1 of 10
NEW YORK WORKERS COMPENSATION
October 1, 2011 LOSS COST REVISION
EXPLANATORY MEMORANDUM
An overall loss cost level increase of 9.5%, which includes an increase of 9.9% in the average manual loss costlevel and no change in the loss costs for terrorism and natural disasters and catastrophic industrial accidents,has been approved by the New York State Department of Financial Services to become effective on October 1,2013.
Loss Experience The latest two policy years of experience produced a 9.1% increase in the overall loss costlevel.
Legislative and Regulatory Changes This revision includes an estimate of the latest cost of the increases inthe maximum weekly benefits that were set forth in the 2007 workers compensation reform legislation. Inaddition, the 2013 enacted New York State Budget provides for the elimination of the Reopened Case Fund andfor the increase in the minimum weekly benefits. The combined overall impact of these changes is an increase of5.3% in manual loss costs.
Loss Adjustment Expenses A review of the latest data available resulted in a 1.4% decrease in the LossAdjustment Expense provision.
Future Trends The latest analysis of New York claim severity and claim frequency indicates a continuing smalldecrease in claim frequency and an upward trend in both indemnity and medical claim costs. Combined with aprojected wage trend, the resulting net trend factor is -2.3%.
Catastrophe Provision This revision contains no changes in the loss cost for terrorism and in the loss cost fornatural disasters and catastrophic industrial accidents.
Classification Loss Costs Although the average manual loss cost level is increasing by 9.9%, individualclassification loss cost changes are based on the most recently available loss experience for each classifica-tion. Both increases and decreases from the current loss costs have been actuarially calculated for eachclass. This process ensures that each classification loss cost reflects the appropriate level relative to theexperience of the other classifications.
W31M6J13 Page 2 of 10
New York Workers C m e s t oo p n a i n
LOSS COST COMPARISON OCTOBER 1, 2013 TO OCTOBER 1, 2 10 1
A Loss cost, etc., for each individual risk shall be obtained from the Rating Board.
C Refer to Miscellaneous Values in the manual for loss costs.
E Refer to Volunteer Firefighters schedule for loss costs. Loss cost change is the same for all populationgroups in this class.
Total number of classes: 571
W31M6J13 Page 10 of 10
LA FAMILIA FOODCORP.
THE TRAVELERSINSURANCECOMPANIESP.O.BOX 8924 (WC)MELVILLE, NY 11747-89241-800-238-6225
5F95737902-26-15 02-26-16
STATE OF NEW YORK WORKERS' COMPENSATION BOARDESTADO DE NUEVA YORK - JUNTA DE COMPENSACION OBRERA
NOTICE OF COMPLIANCE AVISO DE CUMPLIMIENTOTO EMPLOYEES A EMPLEADOS
IMPORTANT INFORMATION FOR EMPLOYEES WHO ARE INJURED OR INFORMACION IMPORTANTE PARA EMPLEADOS QUE SEANSUFFER AN OCCUPATIONAL DISEASE WHILE WORKING. LESIONADOS O SUFRAN UNA ENFERMEDAD OCUPACIONAL
MIENTRAS TRABAJAN.1. 1.By posting this notice and information concerning your rights as an Su patrono está cumpliendo la Ley de Compensación Obrera cuando
injured worker, your employer is in compliance with the Workers' Com- despliega este comunicado concerniente a sus derechos como traba-pensation Law. jador lesionado.
2. 2.If you do not notify your employer within 30 days of the date of your injury Si usted no notifica a su patrono dentro del término de 30 dias de haberyour claim may be disallowed, so do so immediately. sufrido su lesión su reclamación podria ser desestimada, por eso noti-
3. You are entitled to obtain any necessary medical treatment and should do fique inmediatamente.so immediately. Usted tiene derecho a recibir cualquier tratam3. iento médico necesario
4. You may choose any doctor, podiatrist, chiropractor or psychologist relacionado con su lesión y debe gestionarlo inmediatamente.referred by a medical doctor that accepts NY State Workers' Compensa- Pa4. ra el tratamiento de cualquier lesión o enfermedad relacionada con eltion patients and is Board authorized. However, if your employer is in- trabajo, usted puede escoger cualquier médico, podiatra, quiropractico óvolved in a certified preferred provider organization (PPO) you must first psicologo (si es referido por un médico autorizado) que esté autorizado ybe treated by a provider chosen by your employer and your employer must acepte pacientes de la Junta de Compensación Obrera. Sin embargo, sigive you a written statement of your rights concerning further medical su patrono está autorizado a participar en una organización certificadacare. de proveedores preferidos (PPO), usted deberá obtener tratamiento
5. You should tell your doctor to file copies of medical reports concerning inicial para cualquier lesión o enfermedad relacionada con el trabajo deyour claim with the Workers' Compensation Board and with your em- la correspondiente entidad. Patronos que participen en cualquiera deployer's insurance company, which is indicated at the bottom of this form. estos programas establecidos por ley estan obligados a proveer a sus
6. You may be entitled to lost time benefits if your work-related injury keeps empleados notificación escrita explicando sus derechos y obligacionesyou from work for more than seven days, compels you to work at lower bajo el programa a que esté acogido.wages or results in permanent disability to any part of your body. You may Usted deber5. á requerir de su Médico que radique copias de los informesbe entitled to rehabilitation services if you need help returning to work. médicos de su caso en la Junta de Compensación Obrera y en la com-
7. You should not pay any medical providers directly. They should send their pañia de seguros de su patrono, que se indica al final de esta forma.bills to your employer's insurance carrier. If there is a dispute, the provider Usted tiene6. derecho a compensación si su lesión relacionada con elmust wait until the Board makes a decision before it attempts to collect trabajo le impide trabajar por más de siete dí le obliga a tras, abajar apayment from you. If you do not pursue your claim or the Board rules that sueldo más bajo ó resulta en incapacidad permanente de cualquier parteyour injury is not work-related, you may be responsible for the payment of de su cuerpo. Usted puede tener derecho a servicios de rehabilitación sithe bills. necesita ayuda para regresar al trabajo.
8. 7.You are entitled to be represented by an attorney or licensed representa- No pague a ningun proveedor médico directamente por tratamiento detive, but it is not required. If you do hire a representative do not pay su lesión o enfermedad relacionada con el trabajo. Ellos deben enviarhim/her directly. Any fee will be set by the Board and will be deducted sus facturas al asegurador de su patrono. Si el caso es cuestionado, elfrom your award. proveedor deberá esperar hasta que la Junta decida el caso, antes de
9. If you have difficulty in obtaining a claim form or need help in filling it out, iniciar gestión de cobro alguna contra usted. Si usted no tramita su casoor if you have any other questions or problems about a job-related injury, ó la Junta falla que su lesión o enfermedad no está relacionada con elcontact any office of the Workers' Compensation Board. trabajo, usted podrí uraa ser responsable del pago de las fact s.
8. No es obligatorio el estar representado en ninguno de los procedimien-WORKERS' COMPENSATION BOARD OFFICES tos de la Junta, pero es un derecho que usted tiene, el estar represen-Albany, 12241 – 100 Broadway-Menands – (866) 750-5157 tado por abogado ó por representante licenciado si usted así lo desea. Si*Brooklyn, 11201 – 111 Livingston St. – Brooklyn – (800) 877-1373 es representado, no pague al abogado ó al representante licenciado.Binghamton, 13901 – State Office Bldg. – 44 Hawley St. – (866) 802- Cuando la Junta decida su caso, los honorarios seran determinados por3604 la Junta y descontados de sus beneficios.Buffalo, 14202 – 295 Main Street, Suite 400 - (866) 211-0645 9. Si tiene dificultad en conseguir un formulario de reclamación o necesita*Hauppauge, 11788 – 220 Rabro Drive – Suite 100 – (866) 681-5354 ayuda para llenarlo ó tiene dudas sobre cualquier situación relacionada*Hempstead, 11550 – 175 Fulton Avenue – (866) 805-3630 con una lesión o enfermedad comuniquese con la oficina mas cercana*New York, 10027 – 215 W.125th St., Manhattan – (800)-877-1373 de la Junta.*Peekskill, 10566 – 41 North Division St. (866) 746-0552*Queens, 11432 – 168-46 91st Ave., Jamaica (800) 877-1373Rochester, 14614 – 130 Main Street West – (866) 211-0644Syracuse, 13203 – 935 James St. – (866) 802-3730
ROBERT E. BELOTEN, CHAIR/PRESIDENTE* DOWNSTATE MAILING ADDRESSClaims-related mail for the Hauppauge, Hempstead, Peekskill and all NYC offices
Statewide Fax: 877-533-0337should be mailed to: PO Box 5205 Binghamton, NY 13902-5205
Workers' Compensation benefits, when due, will be paid by (Los beneficios de Compensación Obrera, cuandodebidos, seran pagados por):
Name of employer (Nombre del patrono)Name, address and telephone number of licensed insurance carrier,authorized group self-insurer or main office of authorized self-insurer
THIS NOTICE MUST BE POSTEDCONSPICUOUSLY IN AND ABOUT THEEMPLOYER'S PLACE OR PLACES OFBUSINESS.
Failure by an employer to post thisnotice in and about the employer's placeor places of business may result ina $250 penalty for each violation.For Insurance Carriers ONLY: Policy No
Policy in Force from toWorkers' Compensation Board www.wcb.state.ny.usPrescribed of by ChairmanC-105 (1-11)State New York
W31P1N11
THE TRAVELERSINSURANCECOMPANIESP.O. BOX 8924 (WC)MELVILLE, NY 11747-8924
STA E F NE Y RK W RK RS' C MPEN AT ON B ARDT O W O O E O S I OAndrew M. Cuomo, Governor Robert E. Beloten, Chair.
STATEMEN OF RIGH ST T
T ALL WORKERS WHO ARE INJURED WHILE WO KING R WHO SUF ER FR M AN OCCUPA I N LO R O F O T O ADISEASE
YOU MAY BE EN I LED O WORKERS' CO PENS TION BENE I ST T T M A F T
1. You should file a claim for benefits within two years of the date you are injured, unless your injury is very minor, requiring no medical treat-ment and causing no lost time from work. If you do not file within two years your right to benefits may be lost. Obtain and file a claim form(Form C-3, or VF-3 for volunteer firefighters, or VAW-3 for volunteer ambulance workers) with the nearest Workers' Compensation Board of-fice (see addresses below).
2. You may be entitled to lost time benefits if your work-related injury keeps you from work for more than seven days, compels you to work atlower wages or results in permanent disability to any part of your body. You may be entitled to rehabilitation services if you need help return-ing to work. (In volunteer firefighters' and volunteer ambulance workers' cases, compensation for lost time or loss of earning capacity may bepayable from date of injury.)
3. You are entitled to obtain any necessary medical treatment related to your injury and you should do so immediately.
4. For the treatment of your work-related injury or illness, you may choose any physician, podiatrist, chiropractor, or psychologist (upon referralfrom an authorized physician) who is Board authorized and who is accepting workers' compensation patients. If, however, your employer isinvolved in a certified preferred provider organization (PPO) arrangement, you must obtain initial treatment for any workers' compensation in-jury or illness from the preferred provider organization. Employers participating in this statutory program are required to provide their employ-ees with written notification describing their employees' rights and obligations under the program.
5. You should inform your doctor to file copies of medical reports concerning your claim with the Workers' Compensation Board and your em-ployer's insurance company, which is indicated at the bottom of this form.
6. You should not pay any medical providers directly for treatment of your work-related injury or illness. They should send their bills to your em-ployer's insurance carrier. If there is a dispute, the provider must wait until the Board makes a decision before it attempts to collect paymentfrom you. If you do not pursue your claim or the Board rules that your injury is not work-related, you may be responsible for the payment of thebills.
7. The employer is liable for the replacement or repair of an employee's prosthesis (e.g., artificial members, false teeth, eyeglasses), which hasbeen lost or damaged in the course of employment, whether or not there was bodily injury to the employee. You are also entitled to be reim-bursed for drugs, crutches or any apparatus properly prescribed by your doctor, and transportation and other necessary expenses going toand from your doctor's office or hospital. (You should get receipts for all such expenses.)
8. You are entitled to be represented by an attorney or licensed representative, but it is not required. If you do hire an attorney or licensed repre-sentative, you should not pay him/her directly. Any fee will be set by the Board and will be deducted from your award.
9. Lost time and medical benefits are payable directly without a formal direction from the Board, unless your claim is disputed. If your claim isdisputed on the grounds that your injury is not work-related or did not arise in the line of volunteer firefighter or ambulance worker duties, thenyou may qualify for disability benefits for non-work injuries. For more information on entitlement to disability benefits, contact the Workers'Compensation Board office nearest you.
10. You should go back to work as soon as you are able; compensation is never as high as your wage. If you need help returning to work, or withfamily or financial problems because of your injury, you should contact the nearest Board office and ask for a rehabilitation counselor or socialworker.
11. Your employer may not ask you to waive your right to compensation nor may your employer deduct any money from your pay to contribute tothe payment of workers' compensation insurance premiums. Further, you cannot be discharged or discriminated against because you filed aclaim for workers' compensation benefits.
IF Y U HAVE DIFF CUL Y IN OB AINING A CLAIM FORM OR NEED HE P IN FI L NG IO I T T L L I T OU , OR I Y U HAVET F OANY OTHER QUES I NS OR PROB EMS ABOU A JOB-RELATED INJURY OR DI EASE, CON ACTT O L T S T ANYOF ICE O HE W RKERS' C MP NSAT ON BOARD.F F T O O E I
This in or at on s a si pl f ed presentation o your r ghts under the ork-f m i i m i i f i Wers' Compensation Law. It s pro ided, as required by S ction 110 o thei v e fW rkers' Compensation Law, by your e p oyer's insurance carrier:o m l
Insert name and address of nsurance carrier.iROBERT E. BELOTEN
CHAIR
DOWNSTATE CENTRALIZED MAILING 100 Broad ay State Office ui din Statler Towersw B l g(for New York City, Hempstead, Hauppauge & Peekskill Districts) Menands 44 Haw ey Street 107 Dela are Ave. 130 Main treet . 935 Ja e St.l w S W m s
THE ORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WI H DISABILITIES WI HOUT DISCRW T T IMINATION.
C ESTE RESUMEN ESTÁ ESCRITO EN ESPAÑOL AL DORSO-430S (1-11) www.wcb.state.ny.us
W31P5N11
THE TRAVELERSINSURANCECOMPANIESP.O. BOX 8924 (WC)MELVILLE, NY 11747-8924
DECLARACION DE DERECHOS OBRERAJUNTA DE COMPENSACIONESTAD DE NUEVA YORO KRobert E. Beloten, Presidente.Andrew M. Cuomo, Gobernador
A TOD MP EADO L SI NADO EN E RABAJO O UE SUFRA DE EN ERMEDAD OCUPACIONAL:O E L E O L T Q FUS ED PU DE ENER DER CHO A BENE ICI S D COM ENSACION BRERAT E T E F O E P O
1. Usted deberá presentar una reclamación de beneficios dentro del término de dos años del dia en que fue lesionado, a menos que la lesión seatan pequeña que no requiera tratamiento médico y que no cause interrupción en su jornada de trabajo. Si no radica dentro del término de dosaños, puede perder sus derechos a beneficios. Consiga y radique una forma de reclamación (Forma C-3, o VF-3 para bomberos voluntarios, oVA -3 para empleados voluntarios de ambulW ancias) en la oficina más cercana de la Junta de Compensación Obrera (direcciones más abajo).
2. Usted tiene derecho a compensación si su lesión relacionada con el trabajo le impide trabajar por más de siete días, le obliga a trabajar asueldo más bajo ó resulta en incapacidad permanente de cualquier parte de su cuerpo. Usted puede tener derecho a servicios derehabilitación si necesita ayuda para regresar al trabajo. (Bomberos voluntarios y Trabajadores de Ambulancia Voluntarios pueden sercompensados desde el mismo dia de su lesión.)
3. Usted tiene derecho a recibir tratamiento médico relacionado con su lesión y debe obtenerlo inmediatamente.
4. Para el tratamiento de cualquier lesión o enfermedad relacionada con el trabajo, usted puede escoger cualquier médico, podiatra,quiropractico ó psicologo (si es referido por un médico autorizado) que esté autorizado y acepte pacientes de la Junta de CompensaciónObrera. Sin embargo, si su patrono está autorizado a participar en una organización certificada de proveedores preferidos (PPO), usteddeberá obtener tratamiento inicial para cualquier lesión o enfermedad relacionada con el trabajo de la correspondiente entidad. Patronos queparticipen en esta programa establecida por ley estan obligados a proveer a sus empleados notificación escrita explicando sus derechos yobligaciones bajo el programa a que esté acogido.
5. Usted deberá requerir de su Médico que radique copias de los informes médicos de su caso en la Junta de Compensación Obrera y en lacompañia de seguros de su patrono, que se indica al final de esta forma.
6. No pague a ningun proveedor médico directamente por tratamiento de su lesión o enfermedad relacionada con el trabajo. Ellos deben enviarsus facturas al asegurador de su patrono. Si el caso es cuestionado, el proveedor deberá esperar hasta que la Junta decida el caso, antes deiniciar gestión de cobro alguna contra usted. Si usted no tramita su caso ó la Junta falla que su lesión o enfermedad no está relacionada con eltrabajo, usted podr a ser responsable del pago de las facturas.
7. El patrono es responsable de la sustitución y reparación de aquellos implementos médicos que han sido perdidos o se han deteriorado comoconsecuencia del empleo, sin que importe el que el empleado haya o no sufrido lesión (Ej. miembros artificiales, dentadura postiza,espejuelos). Usted tambien tiene derecho a ser reembolsado por medicinas, muletas, o cualquier otro implemento debidamente recetado porsu médico y por transportación u otro gasto necesario para ir al médico ó al hospital. (Obtenga recibos para justificar gastos.)
8. No es obligatorio el estar representado en ninguno de los procedimientos de la Junta, pero es un derecho que usted tiene, el estarrepresentado por abogado ó por representante licenciado si usted así lo desea. Si es representado, no pague al abogado ó al representantelicenciado. Cuando la Junta decida su caso, los honorarios seran determinados por la Junta y descontados de sus beneficios.
9. La compensación se paga inmediatamente, sin esperar por la adjudicación del caso, excepto cuando la reclamación es cuestionada. Si lareclamación es cuestionada en base a que la incapacidad no fue causada por un accidente relacionado con su trabajo ó por una enfermedadocupacional ó por una lesión en el cumplimiento de su deber como bombero voluntario ó como miembro voluntario del cuerpo de ambulancia,usted puede tener derecho a recibir beneficios por incapacidad (para lesiones fuera del trabajo). Si su reclamación es cuestionada y no estárecibiendo beneficios por incapacidad, comuniquese con cualquier oficina de la Junta.
10. Regrese a su trabajo tan pronto pueda. La compensación nunca es tan alta como su sueldo. Si necesita ayuda para regresar al trabajo ó pararesolver problemas financieros ó personales por causa de la lesión sufrida, comunicate con la oficina mas cercana de la Junta y solicita hablarcon un trabajador social o con un consejero de rehabilitación.
11. Su patrono no puede solicitar que usted le releve de su derecho a compensación, ni puede descontar cantidad alguna de su paga paracontribuir al pago de las primas del seguro. Usted no podrá ser despedido ni penalizado por radicar una reclamación en la Junta.
SI T ENE D F CULTAD EN CONSE UIR UN F R ULARIO D RECLAMAC ÓN O NEC SI AI I I G O M E I E T A UDA PARAYLLENARLO Ó T ENE DUDAS S BRE CUAL UIER SI UACI N RELACI NADA C N UNA LESI N OI O Q T Ó O O Ó EN ER-FMEDAD CO UNI UESE CON L F CINA AS CE CANA DE LA JUNTAM Q A O I M R .
Este resumen es una comp lac ón de os puntos más i por antes de susi i l m tderechos bajo la ley de co pensación obrera. La secci n 110 de la eym ó lrequiere de su patrono ofrecer e esta in o mac ón.l f r i
Insert name and address of insurance carrier.ROBERT E. BELOTEN
PRESIDENTE
DOWNSTATE CENTRALIZED MAILING 100 Broad ay State Office ui din Statler Towersw B l g(for New York City, Hempstead, Hauppauge & Peekskill Districts) 935 Ja e St.m sMenands 44 Haw ey Street 107 Dela are Ave. 130 Main treet .l w S W
