Filing at a Glance - A.M. Best Company€¦ · · 2013-09-03Filing at a Glance Companies ... We will be introducing a single Defense within Limits ... following objections in accordance

Filing at a Glance Companies: Harleysville Insurance Company

Harleysville Preferred Insurance CompanyHarleysville Worcester Insurance CompanyNationwide Mutual Insurance Company (Harleysville Operations)

Product Name: MA BOP Defense within limits

State: Massachusetts

TOI: 05.0 CMP Liability and Non-Liability

Sub-TOI: 05.0002 Businessowners

Filing Type: Form/Rate/Rule

Date Submitted: 07/02/2013

SERFF Tr Num: HRLV-129090680

SERFF Status: Closed-Placed on File

State Tr Num:

State Status: Closed-Placed On File

Co Tr Num: BOMH12202012-1

Effective DateRequested (New):

01/01/2014

Effective DateRequested (Renewal):

01/01/2014

Author(s): Michelle Hanson

Reviewer(s): Daniel Smith (primary)

Disposition Date: 07/17/2013

Disposition Status: Placed on File

Effective Date (New): 01/01/2014

Effective Date (Renewal): 01/01/2014

SERFF Tracking #: HRLV-129090680 State Tracking #: Company Tracking #: BOMH12202012-1

State: Massachusetts First Filing Company: Harleysville Insurance Company, ...

TOI/Sub-TOI: 05.0 CMP Liability and Non-Liability/05.0002 Businessowners


Project Name/Number: BOP/

PDF Pipeline for SERFF Tracking Number HRLV-129090680 Generated 08/09/2013 01:48 PM

General Information

Company and Contact

Project Name: BOP Status of Filing in Domicile:

Project Number: Domicile Status Comments:

Reference Organization: Reference Number:

Reference Title: Advisory Org. Circular:

Filing Status Changed: 07/17/2013

State Status Changed: 07/17/2013 Deemer Date:

Created By: Michelle Hanson Submitted By: Michelle Hanson

Corresponding Filing Tracking Number:

Filing Description:

It is our intent to submit the following revisions to apply to our Business Owners program.

We will be introducing a single Defense within Limits option as well as continuing to offer the separate limits for damage anddefense expense that we have currently filed and approved. The BOP-7058 (Ed. 02-09) Employment Practices Liabilityendorsement will be introduced to apply when a single limit applies to both damages and defense expenses. We will also beintroducing BOP-7079 (Ed 02-09) Split Prior Acts Coverage Endorsement. The manual will be updated to coincide with theintroduction of the new damage and defense expense option.

Attached for your review is a comparison of the changes occurring to our manual as well as the revised manual.

Attached: (MA) BO-Contents-1(MA) BO-E-23-36BOP-7058 Ed 02-09 Employment Practices Liability EndorsementBOP-7079 Ed 02-09 Split Prior Acts Coverage Endorsement

Withdrawn: (MA) BO-Contents-1, approved November 2012(MA) BO-E-23-26, approved January 2014(MA) BO-E-27-35, approved November 2012

Rule of application: These changes shall be applicable to all policies effective on or after January 1, 2014.

Your favorable approval will be appreciated.

For your information, the attached form does not contain company names as our policy jackets are on file with the DOI undercompany form filing #K4E-06-0094, SRB Serial #99344 for the HWIC & PREF; For HIC except CA #HRLV-125749237 SRBSerial #115938 for HIC CA; #HRLV-125777014, SRB Serial #116278. For NMIC under SERFF Tracking number HRLV-128544198 .

The Examiner has waived the filing fees for the re-submission of this filing - (Previously submitted under HRLV-129084804)

Filing Contact InformationMichelle Hanson, CL Product Analyst [email protected]

355 Maple Ave

Harleysville, PA 19438-2297

215-256-5104 [Phone]

215-256-5678 [FAX]







Filing Fees

State Specific

Filing Company InformationHarleysville Insurance Company

355 Maple Avenue

Harleysville, PA 19438

(215) 256-5000 ext. [Phone]

CoCode: 23582

Group Code: 140

Group Name:

FEIN Number: 41-0417250

State of Domicile:Pennsylvania

Company Type:

State ID Number:

Harleysville Preferred InsuranceCompany

355 Maple Avenue


(215) 256-5000 ext. [Phone]

CoCode: 35696

Group Code: 140

Group Name:



Company Type:

State ID Number:

Harleysville Worcester InsuranceCompany

355 Maple Avenue


(215) 256-5000 ext. [Phone]

CoCode: 26182

Group Code: 140

Group Name:



Company Type:

State ID Number:

Nationwide Mutual InsuranceCompany (Harleysville Operations)

One Nationwide Plaza, 1-19-101

Columbus, OH 43216

(215) 256-5000 ext. 5427[Phone]

CoCode: 23787

Group Code: 140

Group Name:


State of Domicile: Ohio

Company Type:

State ID Number:

Fee Required? No

Retaliatory? No

Fee Explanation:

1.) All Lines: Please see the State Submissions List requirement under Supporting Documentation.: acknowledged2.) Property/Casualty: Please see the Policy Endorsement List requirement under Supporting Documentation.: acknowledged3.) Property/Casualty: Please see Comment C.5 in the Massachusetts General Instructions.: acknowledged4.) Life: Please see the Specific Markets requirement under Supporting Documentation.: n/a







Correspondence Summary DispositionsStatus Created By Created On Date Submitted

Placed on File Daniel Smith 07/17/2013 07/17/2013

Objection Letters and Response LettersObjection Letters Response Letters

Status Created By Created On Date Submitted Responded By Created On Date Submitted

Pending

Industry

Response

Daniel Smith 07/17/2013 07/17/2013 Michelle Hanson 07/17/2013 07/17/2013

Pending

Industry

Response


Pending

Industry

Response


Pending

Industry

Response


Incomplete Daniel Smith 07/03/2013 07/03/2013 Michelle Hanson 07/03/2013 07/03/2013

Incomplete Daniel Smith 07/02/2013 07/02/2013 Michelle Hanson 07/03/2013 07/03/2013

Filing NotesSubject Note Type Created By Created On Date Submitted

SERFF Tracking Number: HRLV-129090680 Note To Filer Carla Kelton 07/02/2013 07/02/2013







Disposition

Disposition Date: 07/17/2013

Effective Date (New): 01/01/2014

Effective Date (Renewal): 01/01/2014

Status: Placed on File

Comment:

Company

Name:

Overall %

Indicated

Change:

Overall %

Rate

Impact:

Written Premium

Change for

this Program:

# of Policy

Holders Affected

for this Program:

Written

Premium for

this Program:

Maximum %

Change

(where req'd):

Minimum %

Change

(where req'd):

Harleysville Insurance

Company

% 0.000% $0 % %

Harleysville Preferred

Insurance Company

% 0.000% $0 % %

Harleysville Worcester

Insurance Company

% 0.000% $0 % %

Nationwide Mutual

Insurance Company

(Harleysville Operations)

% 0.000% $0 % %

Overall Rate Information for Multiple Company Filings

Overall Percentage Rate Indicated For This Filing 0.000%

Overall Percentage Rate Impact For This Filing 0.000%

Effect of Rate Filing-Written Premium Change For This Program $0

Effect of Rate Filing - Number of Policyholders Affected 0

Schedule Schedule Item Schedule Item Status Public Access

Supporting Document State Submissions List Yes

Supporting Document Policy Endorsement List Yes

Supporting Document Annotated Comparison Yes








Supporting Document Form Utilization List Yes

Supporting Document (revised) Certification of Compliance Yes

Supporting Document Certification of Compliance Yes

Supporting Document (revised) Checklist(s) Yes

Supporting Document Checklist(s) Yes

Supporting Document Checklist(s) Yes

Supporting Document Actuarial Memorandum - Property and Casualty

Insurance

Yes

Supporting Document (revised) Rate Filing Abstract (SRB-RA) Yes

Supporting Document Rate Filing Abstract (SRB-RA) Yes

Supporting Document Loss Cost Adoption Form (SRB-LC) Yes

Supporting Document Rate Deviation Abstract (SRB-DV) Yes

Supporting Document Statement of Variability Yes

Supporting Document Letter of Authorization Yes

Supporting Document (revised) Applications Yes

Supporting Document Applications Yes

Form Employment Practices Liability Endorsement Yes

Form Split Prior Acts Coverage Endorsement Yes

Form (revised) New Business Application Employment Practices Liability

Application

Yes

Form New Business Application Employment Practices Liability

Application

Yes

Form (revised) Renewal Application Employment Practices Liability

Application

Yes








Form Renewal Application Employment Practices Liability

Application

Yes

Rate Contents Yes

Rate manual pages Yes







Objection Letter Objection Letter Status Pending Industry Response

Objection Letter Date 07/17/2013

Submitted Date 07/17/2013

Respond By Date 08/22/2013

Dear Michelle Hanson,

Introduction: Your previous response did not sufficiently address all objections, and is not considered complete. Please respond to thefollowing objections in accordance with SERFF procedures for responding to an Objection Letter:

Objection 1 - New Business Application Employment Practices Liability Application, BOP-7094, 08-12 (Form)

- Renewal Application Employment Practices Liability Application, BOP-7095, 08-12 (Form)

Comments: Please ensure all company names are at the top of these endorsements, and advise how the name of thecompany that will/does provide the insurance is specifically identified. (ONLY ONE COMPANY IS LISTED)

Conclusion: Upon receipt of your response, this filing will be scheduled for review. Our goal is to have your filing under our review for nomore than 60 days.

This filing will be closed for lack of action if a response is not received on or before the Respond By Date indicated in this ObjectionLetter, which has not changed from the previous Objection Letter.

Should you decide to withdraw this filing, please notify us via response to this objection. Thank you.

Sincerely,

Daniel Smith












Introduction: Additional documentation, clarification, or changes to the documents submitted are required in order for our review to continue.Please respond to the following objections in accordance with SERFF procedures for responding to an Objection Letter:



Comments: Please ensure all company names are at the top of these endorsements, and advise how the name of thecompany that will/does provide the insurance is specifically identified.


Comments: Please advise if there are any questions whose answer would automatically render the applicant ineligible forcoverage, and if so how that fact is disclosed to the applicant.


Comments: Page 3 requests that certain items be attached to the application "if they exist." Please advise under whatcircumstances the referenced items would not exist.


This filing will be closed for lack of action if a response is not received on or before the Respond By Date indicated in this ObjectionLetter.


Sincerely,

Daniel Smith













Objection 1 - Applications (Supporting Document)

- Employment Practices Liability Endorsement, BOP-7058, 02-09 (Form)

Comments: Please submit to the Form Schedule a copy of the application that would be used for this coverage. (ATTACH TOFORM SCHEDULE FOR REVIEW)


This filing will be closed for lack of action if a response is not received on or before the Respond By Date indicated in this ObjectionLetter, which has not changed from the previous Objection Letter.


Sincerely,

Daniel Smith












Introduction: Additional documentation, clarification, or changes to the documents submitted are required in order for our review to continue.Please respond to the following objections in accordance with SERFF procedures for responding to an Objection Letter:

Objection 1 - Employment Practices Liability Endorsement, BOP-7058, 02-09 (Form)

Comments: Please advise regarding the circumstances in which an application would and would not be completed for thiscoverage.

Objection 2 - Employment Practices Liability Endorsement, BOP-7058, 02-09 (Form)

Comments: Please submit to the Form Schedule a copy of the application that would be used for this coverage.


This filing will be closed for lack of action if a response is not received on or before the Respond By Date indicated in this ObjectionLetter.


Sincerely,

Daniel Smith







Objection Letter Objection Letter Status Incomplete






Objection 1 - Checklist(s) (Supporting Document)

Comments: Please complete the two Rate sections. (EXPLANATIONS NOT PROVIDED FOR RS3 AND RS4)

Conclusion: Upon receipt of your response, this filing will be scheduled for review. This filing will be closed for lack of action if a response isnot received on or before 3:30 PM EDT on the Respond By Date indicated in this Objection Letter, which has not changed from theprevious Objection Letter.


Sincerely,

Daniel Smith







Objection Letter Objection Letter Status Incomplete





Introduction: This filing submission is incomplete. Please respond to the following objections in accordance with SERFF procedures forresponding to an Objection Letter:

Objection 1 - Certification of Compliance (Supporting Document)

Comments: Please update the certification to provide current filing information and a current date.

Objection 2 - Checklist(s) (Supporting Document)

Comments: Please complete the two Rate sections.

Objection 3 - Rate Filing Abstract (SRB-RA) (Supporting Document)

Comments: Please submit the required expense exhibit to this schedule component.

Conclusion: Upon receipt of your response, this filing will be scheduled for review. This filing will be closed for lack of action if a response isnot received on or before 3:30 PM EDT on the Respond By Date indicated in this Objection Letter.


Sincerely,

Daniel Smith







Response Letter Response Letter Status Submitted to State

Response Letter Date 07/17/2013


Dear Daniel Smith,

Introduction: In response to your objection letter we offer the following

Response 1

Comments: Attached please find updated applications that list the company names at the top. An agent will identify the company by placing a mark in the box beside the companyname.

Related Objection 1 Applies To:

- New Business Application Employment Practices Liability Application, BOP-7094, 08-12 (Form)


Comments: Please ensure all company names are at the top of these endorsements, and advise how the name of the company that will/does provide the insurance isspecifically identified. (ONLY ONE COMPANY IS LISTED)

Changed Items:

No Supporting Documents changed.







Form Schedule Item Changes

Item

No.

Form

Name

Form

Number

Edition

Date

Form

Type

Form

Action

Action

Specific

Data

Readability

Score Attachments Submitted

1 New Business

Application

Employment

Practices

Liability

Application

BOP-7094 08-12 ABE New BOP-7094 _Ed.

8-12_ EPLI

Application.pdf

Date Submitted:

07/17/2013

By: Michelle

Hanson

Previous Version

1 New Business

Application

Employment

Practices

Liability

Application

BOP-7094 08-12 ABE New BOP-7094 _Ed

08-12_ EPLI

Application -

update.pdf

Date Submitted:

07/08/2013

By: Michelle

Hanson

2 Renewal

Application

Employment

Practices

Liability

Application

BOP-7095 08-12 ABE New BOP-7095 _Ed.

8-12_ EPLI

Renewal

Application.pdf

Date Submitted:

07/17/2013

By: Michelle

Hanson

Previous Version

2 Renewal

Application

Employment

Practices

Liability

Application


08-12_ EPLI

Renewal

Application -

UPDATE.pdf

Date Submitted:

07/08/2013

By: Michelle

Hanson







No Rate/Rule Schedule items changed.

Conclusion: Hopefully this response will allow you to complete your review of the filing.

Sincerely,

Michelle Hanson










Dear Daniel Smith,

Introduction: In response to your recent objection letter we offer the following reply

Response 1

Comments: All of our company names are listed at the top of the applications. The listing provides a choice of the applicatblecompanies for the agent to choose from.




Comments: Please ensure all company names are at the top of these endorsements, and advise how the name of thecompany that will/does provide the insurance is specifically identified.

Changed Items:


No Form Schedule items changed.


Response 2

Comments: We do not have any such questions



Comments: Please advise if there are any questions whose answer would automatically render the applicant ineligible forcoverage, and if so how that fact is disclosed to the applicant.

Changed Items:




Response 3

Comments: We would anticipate this situation when the employer does not have such documents.

Related Objection 3







Applies To:


Comments: Page 3 requests that certain items be attached to the application "if they exist." Please advise under whatcircumstances the referenced items would not exist.

Changed Items:




Conclusion: Hopefully this response allows you to complete your review of the filing. Please contact me with any additional questions orconcerns.

Sincerely,

Michelle Hanson










Dear Daniel Smith,

Introduction: In response to your recent objection letter we offer the following

Response 1

Comments: The applications have been attached to the forms schedule as requested.



- Applications (Supporting Document)

Comments: Please submit to the Form Schedule a copy of the application that would be used for this coverage. (ATTACH TO FORM SCHEDULE FOR REVIEW)

Changed Items:

Supporting Document Schedule Item Changes

Satisfied - Item: Applications

Comments: see forms scheduleAttachment(s):

Previous Version

Satisfied - Item: ApplicationsComments:

Attachment(s): BOP-7094 _Ed 08-12_ EPLI Application - update.pdf

BOP-7095 _Ed 08-12_ EPLI Renewal Application - UPDATE.pdf







Form Schedule Item Changes

Item

No.

Form

Name

Form

Number

Edition

Date

Form

Type

Form

Action

Action

Specific

Data

Readability

Score Attachments Submitted

1 New Business

Application

Employment

Practices

Liability

Application


08-12_ EPLI

Application -

update.pdf

Date Submitted:

07/08/2013

By: Michelle

Hanson

2 Renewal

Application

Employment

Practices

Liability

Application


08-12_ EPLI

Renewal

Application -

UPDATE.pdf

Date Submitted:

07/08/2013

By: Michelle

Hanson


Conclusion: Hopefully this response will allow you to complete your review of the filing. Please contact me with any further questions or concerns.

Sincerely,

Michelle Hanson










Dear Daniel Smith,

Introduction: In response to your recent objection we offer the following

Response 1

Comments: Applications are required if: 1) Limit is $250,000; 2) there are more than 30 employees; or 3) Third Party Liability coverage is provided



Comments: Please advise regarding the circumstances in which an application would and would not be completed for this coverage.

Changed Items:




Response 2

Comments: Attached please find copies of the New Business and Renewal applications



Comments: Please submit to the Form Schedule a copy of the application that would be used for this coverage.

Changed Items:








Satisfied - Item: ApplicationsComments:

Attachment(s): BOP-7094 _Ed 08-12_ EPLI Application - update.pdf

BOP-7095 _Ed 08-12_ EPLI Renewal Application - UPDATE.pdf



Conclusion: Hopefully this response will allow you to complete your review of the filing. Please contact me with any further questions or concerns.

Sincerely,

Michelle Hanson










Dear Daniel Smith,


Response 1

Comments: Attached please find the updated checklist which provide an explanation for RS3 & RS4


- Checklist(s) (Supporting Document)

Comments: Please complete the two Rate sections. (EXPLANATIONS NOT PROVIDED FOR RS3 AND RS4)

Changed Items:








Satisfied - Item: Checklist(s)

Comments:

Additional comments for GR-4: For your information, signatures are contained on our policy jackets and are on file with the DOI

under company form filing #K4E-06-0094, SRB Serial #99344 for the HWIC & PREF; For HIC except CA #HRLV-125749237

SRB Serial #115938 for HIC CA; #HRLV-125777014, SRB Serial #116278. For NMIC under SERFF Tracking number HRLV-

128544198 .

Attachment(s): P & C Checklist 01 13.pdf

P & C Checklist 01 13 BOP-7079 (1).pdf

Previous Version


Comments:




128544198 .



Previous Version


Comments:




128544198 .


P & C Checklist 01 13 BOP-7079.pdf









Conclusion: Hopefully this response allows you to complete your review of the filing. Please contact me with any additional questions or concerns.

Sincerely,

Michelle Hanson










Dear Daniel Smith,


Response 1

Comments: The certification of compliance has been updated as requested.


- Certification of Compliance (Supporting Document)

Comments: Please update the certification to provide current filing information and a current date.

Changed Items:


Satisfied - Item: Certification of ComplianceComments:

Attachment(s): Cert of compliance.pdf

Previous Version


Attachment(s): Cert of compliance.pdf









Response 2

Comments: The rate sections of the checklist have been updated


- Checklist(s) (Supporting Document)

Comments: Please complete the two Rate sections.

Changed Items:



Comments:




128544198 .



Previous Version


Comments:




128544198 .











Response 3

Comments: The required exhibits have been attached to this schedule component.


- Rate Filing Abstract (SRB-RA) (Supporting Document)

Comments: Please submit the required expense exhibit to this schedule component.

Changed Items:


Satisfied - Item: Rate Filing Abstract (SRB-RA)Comments:

Attachment(s):

Rate abstract HIC.pdf

Rate abstract HPRF.pdf

Rate abstract HWIC.pdf

Rate abstract NMICHO.pdf

ExhibitA.pdf

Previous Version


Attachment(s):







Conclusion: Hopefully this response will allow you to continue your review of the filing. Please contact me with any further questions or concerns.







Sincerely,

Michelle Hanson







Note To Filer

Created By:

Carla Kelton on 07/02/2013 08:10 AM

Last Edited By:

Daniel Smith

Submitted On:

07/17/2013 12:48 PM

Subject:

SERFF Tracking Number: HRLV-129090680

Comments:

Thank you for your filing submission. Your filing is now assigned to an analyst for review. Our goal is to have your filing underour review for no more than 60 days







Form Schedule

Item

No.

Schedule Item

Status

Form

Name

Form

Number

Edition

Date

Form

Type

Form

Action

Action Specific

Data

Readability

Score Attachments

1 Employment Practices

Liability Endorsement

BOP-7058 02-09 END New BOP-7058 Ed 02-

09 EPL Endr

_DWL_.pdf

2 Split Prior Acts Coverage

Endorsement

BOP-7079 02-09 END New BOP-7079 _Ed

02-09_ Split

Limits Prior Acts

Coverage

Endor….pdf

3 New Business Application

Employment Practices

Liability Application

BOP-7094 08-12 ABE New BOP-7094 _Ed.

8-12_ EPLI

Application.pdf

4 Renewal Application

Employment Practices


BOP-7095 08-12 ABE New BOP-7095 _Ed.

8-12_ EPLI

Renewal

Application.pdf

Form Type Legend:

ABE Application/Binder/Enrollment ADV Advertising

BND Bond CER Certificate

CNR Canc/NonRen Notice DEC Declarations/Schedule

DSC Disclosure/Notice END Endorsement/Amendment/Conditions

ERS Election/Rejection/Supplemental Applications OTH Other







BOP-7058 (Ed. 2-09) Page 1 of 9

BUSINESSOWNERS BOP-7058 (Ed. 2-09)

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

EMPLOYMENT PRACTICES LIABILITY COVERAGE

IMPORTANT

THIS ENDORSEMENT PROVIDES CLAIMS-MADE AND REPORTED COVERAGE AND, SUBJECT TO ALL OF ITS PROVISIONS, APPLIES TO CLAIMS FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD. NO

COVERAGE EXISTS FOR CLAIMS FIRST MADE AFTER THE END OF THE POLICY PERIOD UNLESS ONE OF THE EXTENDED REPORTING PERIODS APPLIES.

DEFENSE COSTS APPLY AGAINST THE LIMITS OF INSURANCE AND ARE SUBJECT TO A DEDUCTIBLE.

IF YOU HAVE COMPLETED AN APPLICATION FOR THIS INSURANCE, THEN WE HAVE ISSUED THIS COVERAGE

BASED UPON THAT APPLICATION. SUCH APPLICATION IS INCORPORATED INTO THIS COVERAGE BY REFERENCE AND BECOMES A PART OF THE COVERAGE. THE APPLICATION IS ON FILE WITH US OR OUR

AGENT AND IS A REPRESENTATION OF THE CORRECTNESS OF THE INFORMATION BASED UPON WHICH WE HAVE ISSUED THIS COVERAGE.

PLEASE READ THE POLICY PROVISIONS CAREFULLY.

This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM

SCHEDULE* LIMITS OF INSURANCE

AGGREGATE LIMIT EACH “CLAIM” LIMIT

$ $

DEDUCTIBLE EACH “CLAIM”

$

RETROACTIVE DATE Retroactive Date: __/__/____

This insurance does not apply to “Employment Practices” which occurred prior to the retroactive date shown above. *Information required to complete this Schedule, if not shown above, will be shown in the Declarations. This coverage is subject to all the provisions of Section II – Liability and Section III – Common Policy Conditions, except as amended below: A. COVERAGE

The following is added to paragraph A. Coverages: 1. Insuring Agreement

a. We will pay on behalf of the insured "damages" in excess of the Deductible arising out of any "employment practices" to which this insurance applies. We have no obligation under this insurance to make payments or perform acts or services except as provided for in this paragraph and in paragraph A.2. below.

b. This insurance applies to such "damages" only if: (1) The "damages" result from "claims" made by "employees", "leased workers", "temporary workers", former

"employees" or applicants for employment by you; (2) The "employment practices" take place in the "coverage territory"; (3) Such "employment practices" occurred on or after the Retroactive Date, if any, shown in the Schedule of this

endorsement and before the end of the policy period; and (4) A "claim" is both:

BOP-7058 (Ed. 2-09) Page 2 of 9

(a) First made against any insured, in accordance with paragraph A.1.c. below, during the policy period or an

Extended Reporting Period we provide under section F. of this endorsement; and (b) Reported to us either (i) during the policy period or within thirty (30) days thereafter, or (ii) with respect to

any "claim" first made during an Extended Reporting Period we provide under section F. of this endorsement, during such Extended Reporting Period.

c. A "claim" will be deemed to have been made at the earlier of the following times: (1) When notice of such "claim" is received and recorded by you or by us, whichever comes first; or (2) When we make settlement in accordance with paragraph A.2.a.(2) below.

d. All "claims" for "damages" based on or arising out of: (1) One "employment practice"; or (2) An “interrelated” series of "employment practices" by one or more insureds shall be deemed to be one "claim" and to have been made at the time the first of those "claims" is made against any insured.

e. Each payment we make for "damages" or "defense expense" reduces the amount of insurance available, as provided under section C. of this endorsement.

2. Defense of Claims, Administrative Hearings and Settlement Authority Subject to the limits of insurance, deductible, conditions, exclusions, definitions, and other terms of this endorsement: a. We have the right and duty to defend "claims" against the insured seeking "damages" to which this insurance

applies and to pay for related "defense expense” even if the allegations of such “claims” are groundless, false or fraudulent. However, we have no duty to (i) defend "claims" against the insured seeking "damages", or (ii) pay for related "defense expense", when this insurance does not apply. We may, at our sole discretion: (1) Investigate any "employment practice" that may result in "damages"; and (2) Settle any "claim" which may result, provided:

(a) We have the insured’s written consent to settle; and (b) The settlement is within the applicable Limit of Insurance available.

b. Our liability will be limited as described below if: (1) The insured refuses to consent to any settlement we recommend, and (2) Such recommended settlement is acceptable to the claimant. After such refusal, our liability under this coverage for such "claim" shall not exceed the amount we would have paid for "damages" and "defense expense" if the insured had consented to our settlement recommendation. The insured shall thereafter be responsible for the negotiation and defense of that "claim" at their own cost and without our involvement.

c. Our right and duty to defend such "claims" ends when we have used up the Limit of Insurance available, as provided under section C. of this endorsement. This applies both to "claims" pending at that time and any that may be made.

d. (1) When we control defense of a "claim", we will pay associated "defense expense" and choose a counsel of our choice from the panel of attorneys we have selected to deal with "employment practices" "claims”. If you give us a specific written request at the time a "claim" is first made: (a) You or any involved insured may select one of our panel of employment law attorneys; or (b) You or such insured may ask us to consider the approval of a defense attorney of your or that insured’s

choice who is not on our panel. We will then use the attorney selected in A.2.d.(1)(a) above, or consider the request in A.2.d.(1)(b) above, if we deem it appropriate to engage counsel for such "claim”.

(2) If by mutual agreement or court order the insured assumes control of the defense before the applicable Limit of Insurance is used up, the insured will be allowed to select defense counsel and we will reimburse the insured for reasonable "defense expense”. You and any involved insured must continue to comply with section E. Conditions paragraph 2. Duties in Event of “Employment Practices” or “Claims” of this endorsement. Additionally, you or such insured must direct defense counsel to: (a) Furnish us with the additional information we request to evaluate the “employment practices” or “claim”;

and (b) Cooperate with any counsel we may select to monitor or associate in the defense of the “employment

practices” or “claim”. If we defend any insured under a reservation of rights, both such insured’s counsel and our counsel will be required to maintain records pertinent to "defense expenses". These records will be used to determine the allocation of any "defense expenses" for which you or any insured may be solely responsible, including defense of an allegation not covered by this insurance.

BOP-7058 (Ed. 2-09) Page 3 of 9

We will notify you in writing when the applicable limit of insurance has been used-up by the payment of judgments, settlements, or “defense expense”. We will also initiate and cooperate in the transfer of defense of any “claim” to an appropriate insured for whom the duty to defend has ended by reason of paragraph A.2.b. above.

e. Upon notice to us and with our prior approval, the first Named Insured is authorized to act on behalf of all insureds with respect to the payment of "damages" in settlement of any Administrative Hearing or other non-judicial proceeding before the Federal Equal Employment Opportunity Commission, or any similar Federal, state or local body or commission. This authorization is limited to (i) "damages" covered by this coverage, together with (ii) "defense expenses" as defined under part 5.d. of the definition of "defense expenses" in a total amount not to exceed two times the amount of the Deductible stated in the Schedule of this endorsement.

3. Exclusions The insurance provided under this endorsement does not apply to "claims" based on, arising out of, or in any way involving: a. (1) "Employment practices" which were the subject of any demand, suit or other proceeding which was initiated

against any insured; or (2) Facts and circumstances which would cause a reasonable person to believe a "claim" would be made and

which were known to any insured; prior to the effective date of the earlier of (i) the first coverage of this type that we issued to you of which this coverage was an uninterrupted renewal of this type of coverage, or (ii) this coverage.

b. Loss of any benefit conferred or loss of any obligation imposed under an express contract of employment. c. Any obligation to pay "damages" by reason of the assumption of liability in any contract or agreement. This

exclusion does not apply to liability for "damages" that the insured would have in the absence of the contract or agreement.

d. Liability arising under any of the following laws: (1) Any workers compensation, disability benefits or unemployment compensation law, or any similar law,

provided however, this exclusion shall not apply to any "claim" based upon, arising from or in consequence of any actual or alleged retaliatory treatment of the claimant by the Insured on account of the claimant's exercise of rights pursuant to any such law;

(2) Employees' Retirement Income Security Act of 1974, Public Law 93-406, (ERISA) as now or hereafter amended, or any similar state or other governmental law. This includes fiduciary liability, liability arising out of the administration of any employee benefit plan and any other liability under any such laws;

(3) The Fair Labor Standards Act, or any state or common law wage or hour law, including, but not limited to laws governing minimum wages, hours worked, overtime compensation, and including any recordkeeping and reporting related thereto. This exclusion includes actions or claims brought by or on behalf of individuals or agencies seeking wages, fines, penalties, taxes, disgorgement, or other affirmative relief or compensation, but does not include claims based on the Equal Pay Act, or retaliation; or

(4) The National Labor Relations Act of 1938, the Worker Adjustment and Retraining Notification Act (Public Law 100-37991988), the Consolidated Omnibus Budget Reconciliation Act of 1985, or the Occupational Safety and Health Act.

Exclusions A.3.d.(1) – (4) above also apply to any rules or regulations promulgated under any of the foregoing and amendments thereto or any similar provisions of any federal, state or local law, and to that part of any "damages" awarded for the cost or replacement of any insurance benefits due or alleged to be due to any current or former “employee”.

e. Oral or written publication of material, if such material: (1) Was published by or at the direction of the insured with knowledge of the material's falsity; or (2) Was first published before the Retroactive Date, if any, shown in the Schedule of this endorsement.

f. Dishonest, criminal or fraudulent acts of the insured or the willful failure by the insured or with the insured’s consent to comply with any law or any governmental or administrative order or regulation relating to “employment practices”. Willful, as used in this exclusion, means acting with intentional or reckless disregard for such employment related laws, orders or regulations. The enforcement of this exclusion against any insured shall not be imputed to any other insured.

g. "Bodily injury”. h. "Employment practices" which occur when or after:

(1) You file for or are placed in any bankruptcy, receivership, liquidation or reorganization proceeding; or (2) Any other business entity acquires an ownership interest in you, which is greater than fifty percent.

i. Costs of complying with physical modifications to your premises or any changes to your usual business operations as mandated by the Americans with Disabilities Act of 1990 including any amendment thereto, or any similar federal, state or local law.

j. Lockout, strike, picket line, related worker replacements or other similar actions resulting from labor disputes or labor negotiations.

BOP-7058 (Ed. 2-09) Page 4 of 9

B. WHO IS AN INSURED For the purposes of the coverage provided by this endorsement, Section II. C. Who Is An Insured is replaced by the following: 1. If you are designated in the Declarations as:

a. An individual, you and your spouse are insureds, but only with respect to the conduct of a business of which you are the sole owner.

b. A partnership or joint venture, you are an insured. Your current or former members, your partners, and their spouses are also insureds, but only with respect to the conduct of your business.

c. A limited liability company, you are an insured. Your current or former members are also insureds, but only with respect to the conduct of your business. Your current or former managers are insureds, but only with respect to their duties as your managers.

d. An organization other than a partnership or joint venture, you are an insured. Your current or former directors are insureds, but only with respect to their duties as your directors.

2. Each of the following is also an insured: a. Your current or former "employees" but only for acts within the scope of their employment by you or while

performing duties related to the conduct of your business. b. Your legal representative if you die, but only with respect to duties as such. That representative will have all your

rights and duties under this Coverage. 3. Any heirs, executors, administrators, assignees or legal representatives of any individual insured in subparagraphs

a. and b. of B.1. and 2. above, in the event of the death, bankruptcy or incapacity of such insured, shall be insureds, but only to the extent this insurance would have been available to such insured but for their death, bankruptcy or incapacity.

4. Any organization you newly acquire or form, other than a partnership, joint venture or limited liability company, and over which you maintain ownership or majority interest, will qualify as a Named Insured if there is no other similar insurance available to that organization. However: a. You must provide us notice of such acquisition or formation within 30 days of the effective date of your

acquisition or formation; b. Coverage under this provision is afforded only until the 90th day after you acquire or form the organization or the

end of the policy period, whichever is earlier; c. Coverage does not apply to any "employment practices" that occurred before you acquired or formed the

organization; and d. You must pay us any additional premium due as a condition precedent to the enforceability of this additional

extension of coverage. This paragraph does not apply to any organization after it is shown in the Declarations.

No person or organization is an insured with respect to the conduct of any current or past partnership, joint venture or limited liability company that is not shown as a Named Insured in the Declarations.

C. LIMITS OF INSURANCE

For the purposes of the coverage provided by this endorsement, Section II. D. Liability And Medical Expenses Limits Of Insurance is replaced by the following: 1. The amount of insurance stated as Aggregate Limit in the Schedule of this endorsement is the most we will pay for

the sum of all: a. “Damages” for all “claims” arising out of any actual or alleged "employment practices" covered by this insurance;

and b. “Defense expense” for all "claims" seeking "damages" payable under paragraph C.1.a. above. Each payment we make for such "damages" or defense expenses" reduces the Aggregate Limit by the amount of the payment. This reduced limit will then be the amount of insurance available for further "damages" and "defense expenses" under this coverage.

2. Subject to C.1. above, the amount of insurance stated as the Each "Claim" Limit of Insurance in the Schedule of this endorsement is the most we will pay in excess of the Deductible as further described in section D. of this endorsement for the sum of all: a. "Damages" for injury arising from "employment practices" covered by this insurance arising out of one "claim"

whether such "claim" is brought by one or more claimants: and b. "Defense expense" associated with that specific "claim" in item C.2.a. above.

3. In addition to the payments for "damages" and "defense expense" in paragraphs C.1. and 2. above, we will also pay all interest on the full amount of any judgment that accrues after entry of the judgment and before we have paid, offered to pay, or deposited in court the amount available for the judgment under the provisions of paragraphs C.1. and 2. above.

BOP-7058 (Ed. 2-09) Page 5 of 9

The Limits of Insurance of this coverage apply separately to each consecutive annual period and to any remaining period of less than 12 months, starting with the beginning of the policy period shown in the Declarations, unless the policy period is extended after issuance for an additional period of less than 12 months. In that case, the additional period will be deemed part of the last preceding period for purposes of determining the Limits of Insurance.

D. DEDUCTIBLE

For the purposes of the coverage provided by this endorsement, the following provisions are added: 1. A deductible applies to all "damages" for injury arising from "employment practices" and any "defense expense"

however caused. 2. Our obligation under this Employment Practices Liability Insurance to pay "damages" and "defense expense" on

behalf of any insured applies only to the sum of the amount of "damages" and "defense expense" for each "claim" which are in excess of the deductible amount stated in the Schedule of this endorsement.

3. Your obligation is to pay the deductible applicable to each "claim" made against this insurance. That deductible applies to the sum of all "damages" because of injury arising from "employment practices" paid for each "claim" and applicable "defense expense" associated therewith. If there should be no "damages" paid for a "claim", you are still obligated to pay the applicable deductible for any "defense expense" incurred by us in connection with that "claim".

4. The terms of this insurance apply irrespective of the application of the deductible, including those with respect to: a. Our right and duty to defend any “claims” seeking those “damages”; and b. Your and any involved insured’s duties in the event of a “claim”.

5. We may pay any part or all of the deductible to effect settlement of any "claim" or to defend any “claim” and, upon notification of the action taken, you shall promptly reimburse us for such part of the deductible as we may have paid for "damages" or "defense expense".

6. The application of the deductible does not reduce the applicable Limits of Insurance. E. CONDITIONS

For the purposes of the coverage provided by this endorsement, all of the Liability And Medical Expenses General Conditions and Common Policy Conditions apply to this coverage, except to the extent expressly amended below. Conditions which are included below but which are not included in either the Liability And Medical Expenses General Conditions section or the Common Policy Conditions section apply only to the coverage provided by this endorsement. To the extent that the terms of any Condition are changed from the terms of that same Condition provided by either the Liability And Medical Expenses General Conditions section or the Common Policy Conditions section, the changes to the Condition only apply to the coverage provided by this endorsement. 1. Bankruptcy

Section II E. Liability And Medical Expenses General Conditions paragraph 1. is replaced by the following: Subject to exclusion A.3.h. above, the bankruptcy or insolvency of the insured or of the insured's estate will not relieve us of our obligations under this insurance.

2. Duties in the Event of "Employment Practices" or "Claims" Section II E. Liability And Medical Expenses General Conditions paragraph 2. is replaced by the following: a. You must see to it that we are notified as soon as practicable of any specific "employment practices" which you

believe may result in an actual "claim". Your belief must be reasonably certain as the result of specific allegations made by a potential claimant or such potential claimant's representative, or as the result of specifically identifiable injury sustained by a potential claimant. Notices of “employment practices” should include the following detailed information: (1) How, when and where such "employment practices" took place; (2) The names and addresses of any potential claimants and witnesses; and (3) The nature of any injury arising out of such "employment practices". Notice of such "employment practices" is not notice of a "claim", but preserves any insured's rights to future coverage for subsequent "claims" arising out of such "employment practices" as described in the Basic Extended Reporting Period provisions under section F. of this endorsement.

b. If a "claim" is received by any insured: (1) You must immediately record the specifics of the "claim" and the date received; (2) You and any other involved insured must see to it that we receive written notice of the "claim", as soon as

practicable, but in any event we must receive notice either: (a) During the policy period or within thirty (30) days thereafter; or (b) With respect to any "claim" first made during any Extended Reporting Period we provide under section F.

of this endorsement, during such Extended Reporting Period. (3) You and any other involved insured must:

(a) Immediately send us copies of any demands, notices, summonses or legal papers received in connection with the "claim";

(b) Authorize us to obtain records and other information;

BOP-7058 (Ed. 2-09) Page 6 of 9

(c) Cooperate with us in the investigation, settlement or defense of the "claim"; and (d) Assist us, upon our request, in the enforcement of any right against any person or organization, which

may be liable to the insured because of injury or damage to which this insurance may also apply. As a condition precedent for coverage under this insurance, notices of “claims” must include the detailed information required in items E.2.a.(1), (2) and (3) above.

c. No insureds will, except at their own cost, voluntarily make a payment, assume any obligation, or incur any expense without our consent, other than those specific payments authorized under section A. 2. Defense of Claims, Administrative Hearings and Settlement Authority of this endorsement.

3. Inspections and Surveys We have the right but are not obligated to: a. Make inspections and surveys at any time; b. Give you reports on the employment conditions we find; and c. Recommend procedures, guidelines and changes. Any inspections, surveys, reports or recommendations relate only to insurability and the premiums to be charged. We do not undertake to perform the duty of any person or organization to provide for the health or safety of, or lawful practices towards your workers or the public. We do not warrant that conditions:

(i) Are safe or healthful; or (ii) Comply with laws, regulations, codes or standards as they relate to the purpose of this or any other

insurance. This condition applies not only to us, but also to any rating, advisory, rate service or similar organization, which makes insurance inspections, surveys, reports or recommendations on our behalf.

4. Legal Action Against Us Section II E. Liability And Medical Expenses General Conditions paragraph 4. is replaced by the following: No person or organization has a right under this coverage: a. To join us as a party or otherwise bring us into a "claim" seeking "damages" from any insured; or b. To sue us on this coverage unless all of its terms have been fully complied with. Any person or organization may sue us to recover on an agreed settlement or on a final judgment against an insured obtained after an actual trial, but we will not be liable for "damages" that are not payable under the terms of this coverage or that are in excess of the applicable limit of insurance. An agreed settlement means a settlement and release of liability signed by us, the insured and the claimant or the claimant's legal representative.

5. Other Insurance Section III Common Policy Conditions paragraph H. is replaced with the following: If other valid and collectible insurance is available to the insured for "damages" or "defense expense" we cover under this coverage, our obligations are limited as follows: a. As this insurance is primary insurance, our obligations are not affected unless any of the other insurance is also

primary. Then, we will share with all that other insurance by the method described in b. below. b. If all of the other insurance permits contribution by equal shares, we will follow this method also. Under this

method, each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first. If any of the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer's share is based on the ratio of its applicable limit of insurance to the total applicable limits of insurance of all insurers.

6. Payment of Premiums and Deductibles Section III Common Policy Conditions paragraph I. is replaced by the following: a. We will compute all premiums for this insurance in accordance with our rules and rates; and b. The first Named Insured shown in the Declarations is responsible for the payment of all premiums, and

deductibles due and will be the payee for any return premiums we pay. 7. Representations

Section III Common Policy Conditions paragraph C. is replaced by the following: By accepting this coverage you agree: a. The statements in the Declarations and the Schedule of this endorsement are accurate and complete; and b. That if you have completed an application for this insurance, then we have issued this coverage based upon that

application. Such application is incorporated into this coverage by reference and becomes a part of the coverage. The application is on file with us or our agent and is a representation of the correctness of the information based upon which we have issued this coverage; and

c. Since we have issued this insurance in reliance upon your representations, this coverage can be cancelled or coverage for a claim denied if any material fact or circumstance relating to the subject of this insurance is omitted or misrepresented in your application.

BOP-7058 (Ed. 2-09) Page 7 of 9

8. Separation Of Insureds Except with respect to the Limits of Insurance, and any rights or duties specifically assigned in this endorsement to the first Named Insured, this insurance applies:

a. As if each Named Insured were the only Named Insured; and b. Separately to each insured against whom "claim" is made.

9. Sole Agent The first Named Insured is authorized to act on behalf of all insureds as respects the giving or receiving of notice of cancellation or nonrenewal, receiving premium refunds, requesting any Supplemental Extended Reporting Period and agreeing to any changes in this Coverage.

10. Transfer of Your Rights and Duties Under This Coverage Your rights and duties under this Coverage may not be transferred without our written consent. If you die, the rights of your legal representative are set forth in paragraph 2.b. under B. Who Is Insured of this endorsement.

11. When We Do Not Renew If we decide not to renew this insurance, we will mail or deliver to the first Named Insured shown in the Declarations written notice of the nonrenewal not less than 30 days before the expiration date. If notice is mailed, proof of mailing will be sufficient proof of notice.

12. Policy Period For This Coverage For purposes of the coverage provided by this Employment Practices Liability endorsement, the policy period shall be the period of time this endorsement is in effect if such period is less than the policy period for the policy to which this endorsement is attached. However, this provision does not apply to the last paragraph of C. Limits Of Insurance.

F. EXTENDED REPORTING PERIODS For the purposes of the coverage provided by this endorsement, the following provisions are added: 1. We will provide Extended Reporting Periods, as described below, if:

a. This coverage is cancelled or not renewed; or b. We renew or replace this coverage with insurance that:

(1) Has a Retroactive Date later than the date shown in the Schedule of this endorsement; or (2) Does not apply on a claims-made basis.

2. Extended Reporting Periods do not extend the policy period or change the scope of coverage provided. They apply only to "claims" as the result of "employment practices" committed after the Retroactive Date, if any, shown in the Schedule of this endorsement and before the end of the policy period. Once in effect, Extended Reporting Periods may not be cancelled.

3. Extended Reporting Periods do not reinstate or increase the Limits of Insurance. 4. A Basic Extended Reporting Period is automatically provided without additional charge. This period starts with the

end of the policy period and lasts for: a. Five years with respect to "claims" arising out of "employment practices" which had been properly reported to us

during the policy period in accordance with section E.2. Duties in the Event of "Employment Practices" or "Claims" of this endorsement.

b. Sixty-days with respect to "claims" arising from "employment practices" not previously reported to us. The Basic Extended Reporting Period does not apply to "claims" that are covered under any subsequent insurance you purchase, or that would be covered but for exhaustion of the amount of insurance applicable to such claims.

5. A Supplemental Extended Reporting Period of either twelve (12) or thirty-six (36) months duration is available, but only by endorsement and for an extra charge. This supplemental period starts when the Basic Extended Reporting Period set forth in paragraph F.4.b. above ends. You must give us a written request for the endorsement, and its length, within 30 days after the end of the policy period. The Supplemental Extended Reporting Period will not go into effect unless you pay the additional premium when due. We will determine the additional premium in accordance with our rules and rates. In doing so, we may take into account the following: a. The exposures insured; b. Previous types and amounts of insurance; c. Limits of Insurance available under this coverage for future payment of "damages" or "defense expense"; and d. Other related factors. The additional premium will not exceed 200% of the annual premium for this coverage.

6. The Supplemental Extended Reporting Period Endorsement we issue shall set forth the terms, not inconsistent with this section F. Extended Reporting Periods, including a provision to the effect that the insurance afforded for "claims" first received during such period is excess over any other valid and collectible insurance available under policies in force after the Supplemental Extended Reporting Period begins.

BOP-7058 (Ed. 2-09) Page 8 of 9

G. DEFINITIONS

For the purposes of the coverage provided by this endorsement, the Section II F. Liability And Medical Expenses Definitions apply except to the extent such definitions are expressly amended below. Definitions which are included below but which are not included in the Section II F. Liability And Medical Expenses Definitions section apply only to the coverage provided by this endorsement. To the extent that any Definition for any term is changed from the Definition provided for that same term in the Section II F. Liability And Medical Expenses Definitions section, the change to the Definition only applies to the coverage provided by this endorsement. 1. "Bodily injury" means physical injury to the body, sickness or disease sustained by a person as the result of direct

physical injury to the body, including mental anguish or death resulting from any of these at any time. "Bodily injury" does not include mental anguish to the extent that such mental anguish results from an "employment practice" rather than from physical injury to the body or from sickness or disease.

2. "Claim" means written or oral notice presented by: a. Any "employee”, "leased worker”, "temporary worker”, former "employee" or applicant for employment by you; or b. The EEOC or any other Federal, state or local administrative or regulatory agency on behalf of a person

described in item G.2.a. above, alleging that the insured is responsible for "damages" as a result of injury arising out of any "employment practices." "Claim" includes any civil proceeding in which either "damages" are alleged or fact finding will take place, when either is the result of any "employment practice" to which this insurance applies. This includes: (i) An arbitration proceeding in which such "damages" are claimed and to which the insured submits with our

consent; (ii) Any other alternative dispute resolution proceeding in which such "damages" are claimed and to which the

insured submits with our consent; or (iii) Any administrative proceedings to which an insured must submit as established under federal, state or local

laws applicable to "employment practices" covered under this insurance. 3. "Coverage territory" means:

a. The United States of America (including its territories and possessions) and Puerto Rico; or b. Anywhere in the world with respect to the activities of a person whose place of employment is in the territory

described in E.3.a. above, while he or she is away for a short time on your business, provided that the insured’s responsibility to pay "damages" is determined in a suit on the merits (or any type of civil proceeding described under the definition of "claim") in and under the substantive law of the United States of America (including its territories and possessions) or Puerto Rico.

4. "Damages" means monetary amounts to which this insurance applies and which the insured is legally obligated to pay as judgments or awards, or as settlements to which we have agreed in writing. "Damages" include (i) "pre-judgment interest" awarded against the insured on that part of the judgment we pay, (ii) any portion of a judgment or award, to the extent allowed by law, that represents a multiple of the compensatory amounts, punitive or exemplary damages which are awarded with respect to “employment practices” to which this coverage applies, and (iii) statutory attorney fees awarded with respect to “employment practices” to which this coverage applies. "Damages" do not include: a. Civil, criminal, administrative or other fines or penalties; b. Equitable relief, injunctive relief, declarative relief or any other relief or recovery other than money; or c. Judgments or awards because of acts deemed uninsurable by law.

5. "Defense expense" means payments allocated to a specific "claim" for its investigation, settlement, or defense, including: a. Attorney fees and all other litigation expenses. b. The cost of bonds to appeal a judgment or award in any "claim" we defend. We do not have to furnish these

bonds. c. The cost of bonds to release attachments, but only for bond amounts within the Limit of Insurance available. We

do not have to furnish these bonds. d. Reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of any

"claim", including actual loss of earnings up to $250 a day because of time off from work. e. Costs taxed against the insured in the "claim". "Defense expense" does not include: (i) Salaries and expenses of our employees or your "employees", other than:

(a) That portion of our employed attorneys' fees, salaries and expenses allocated to a specific "claim" for the defense of the insured; and

(b) The expenses described in E.5.d. above; and (ii) Interest on the full amount of any judgment that accrues after entry of the judgment and before we have paid,

offered to pay, or deposited in court the amount available for the judgment under the provisions of section C. Limits of Insurance of this endorsement.

BOP-7058 (Ed. 2-09) Page 9 of 9

6. "Employee" means a person (i) employed by you for wages or salary or (ii) who is a current or former member of your board of directors. But "employee" does not include any independent contractor, any employees of any independent contractor while acting within the scope of their employment, any "leased worker" or any "temporary worker".

7. "Employment Practices" means any of the following actual or alleged practices (i) which are directed against any of your "employees", "leased workers", "temporary workers", former "employees" or any applicant for employment by you and (ii) for which remedy is sought under any federal, state or local statutory or common civil employment law: a. Wrongful refusal to employ a qualified applicant for employment; b. Wrongful failure to promote, or wrongful deprivation of career opportunity; c. Wrongful demotion, evaluation, reassignment or discipline; d. Wrongful termination of employment, including retaliatory or constructive discharge; e. Employment related misrepresentation; f. Harassment, coercion, discrimination or humiliation as a consequence of race, color, creed, national origin,

marital status, medical condition, gender, age, physical appearance, physical and/or mental impairments, pregnancy, sexual orientation or sexual preference or any other protected class or characteristic established by any applicable federal, state, or local statute; or

g. Oral or written publication of material that slanders, defames or libels, or violates or invades a right of privacy. 8. "Interrelated” means having as a common nexus any fact, circumstance, situation, event, transaction, cause or

series of related facts, circumstances, situations, events, transactions or causes. 9. "Pre-judgment interest" means interest added to a settlement, verdict, award or judgment based on the amount of

time prior to the settlement, verdict, award or judgment, whether or not made part of the settlement, verdict, award or judgment.

BUSINESSOWNERSBOP-7079 (Ed. 2-09)

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

BOP-7079 (Ed. 2-09) Includes copyrighted material of the Insurance Services Office with its permission © ISO Properties, Inc., 2005

Page 1 of 2

SPLIT LIMITS PRIOR ACTS COVERAGE ENDORSEMENT This endorsement modifies insurance provided under the following:

EMPLOYMENT PRACTICES LIABILITY COVERAGE

SCHEDULE* LIMITS OF INSURANCE

PRIOR ACTS AGGREGATE LIMIT PRIOR ACTS EACH “CLAIM” LIMIT

$ $

PRIOR ACTS DATE Prior Acts Date: / /

*Information required to complete this Schedule, if not shown above, will be shown in the Declarations 1. Paragraph 1.b.(3) of the Employment Practices Liability Coverage Insuring Agreement under section A. Coverage is

replaced by the following: (3) Such “employment practices” occurred:

(a) After the Retroactive Date, if any, shown in the Schedule of the Employment Practices Liability Coverage endorsement;

(b) During the “prior acts period”, if any; and (c) Before the end of the policy period; and

2. The following paragraphs are added to section C. Limits Of Insurance: 1. Subject to the Aggregate Limit(s) shown in the Schedule of the Employment Practices Liability Coverage endorse-

ment, the Limit Of Insurance stated in the Schedule above as the Prior Acts Aggregate Limit is the most we will pay for the sum of: a. “Damages” for all “claims” arising out of any actual or alleged "employment practices" covered by this insur-

ance; and b. “Defense expense” for all "claims" seeking "damages" payable under paragraph a. above; arising out of “employment practices” committed during the “prior acts period”, if any. Each payment we make for such "damages" or “defense expenses" reduces the Prior Acts Aggregate Limit by the amount of the payment. This reduced limit will then be the amount of insurance available for further "damages" and "defense expenses" under this coverage for “employment practices” committed during the “prior acts period”.

2. Subject to paragraph 2.1. above, the Limit Of Insurance stated in the Schedule above as the Prior Acts Each "Claim" Limit is the most we will pay in excess of the Deductible as further described in section D. Deductible for the sum of:

a. "Damages" for injury arising from "employment practices" covered by this insurance arising out of one "claim" whether such "claim" is brought by one or more claimants; and

b. "Defense expense" associated with that specific "claim" in item 2.2.b. above; arising out of “employment practices” committed during the “prior acts period”, if any. The Each “Claim” Limit(s) shown in the Schedule of the Employment Practices Liability Coverage endorsement does not apply to “damages” or “defense expense” arising out of “employment practices” committed during the “prior acts period”, if any.

3. In addition to the payments for "damages" and "defense expense" in paragraphs 2.1. and 2.2. above, we will also pay all interest on the full amount of any judgment that accrues after entry of the judgment and before we have paid, offered to pay, or deposited in court the amount available for the judgment under the provisions of paragraphs 2.1. and 2.2. above.

BOP-7079 (Ed. 2-09) Includes copyrighted material of the Insurance Services Office with its permission © ISO Properties, Inc., 2005

Page 2 of 2

4. When an “interrelated” series of “employment practices” by one or more insureds includes “employment practices”

committed during the “prior acts period”, then that entire “interrelated” series of “employment practices” shall be subject to one Prior Acts Each “Claim” Limit of Insurance as described in paragraph 2.2. above. Paragraph 2.1. above does not apply to such series of “employment practices”.

3. With respect only to the coverage provided under this endorsement, the following is added to section F. Extended Reporting Periods:

An Extended Reporting Period does not extend the policy period or change the scope of coverage provided. It only applies to "claims" as the result of "employment practices" committed:

a. After the Retroactive Date, if any, shown in the Schedule of the Employment Practices Liability Coverage en-dorsement;

b. During the “prior acts period”, if any; and c. Before the end of the policy period.

Once in effect, Extended Reporting Periods may not be cancelled. 4. The following definition is added to section G. Definitions:

“Prior acts period” means the period of time between the Prior Acts Date shown in the Schedule above and the Retroactive Date shown in the Schedule of the Employment Practices Liability Coverage endorsement.

BOP-7094 (Ed. 8-12) Page 1 of 5

Harleysville Worcester Insurance Company Harleysville Insurance Company Harleysville Preferred Insurance Company Nationwide Mutual Insurance Company

NEW BUSINESS APPLICATION EMPLOYMENT PRACTICES LIABILITY

BUSINESSOWNERS POLICY Named Insured and Mailing Address:

Agent: Agent Code:

Effective Date:

Retroactive Date:

Policy Number/Quote Number/ Account Number:

THIS APPLICATION IS FOR A CLAIMS-MADE POLICY WHICH PROVIDES FOR DEFENSE WITHIN THE LIMITS OF INSURANCE. CORPORATE HISTORY Franchise holder?: No Yes Number of years in business? Describe the business operations: Does the organization have any contracts with or receive financial assistance from the Federal Government or any agency thereof? No Yes If yes, describe Is there any affirmative action plan? No Yes If yes, attach and describe reason for implementing it:

INSURANCE INFORMATION

Limit of Insurance (per claim/aggregate):

$50,000/$50,000 $100,000 / $100,000 $250,000 / $250,000

Note: This limit applies separately to Damages and Defense Expenses in AR, MA, MN, VT Deductible ($5,000 automatic):

Optional Deductible $10,000 (not available with the $50,000/$50,000 limit)

Does the applicant currently carry EPL? No Yes If yes, please supply prior coverage information and attach a copy of the prior policy declaration: Insurer: Limit of Insurance: (per claim/aggregate) Effective Date Expiration Date Deductible: Retroactive Date: If the Retroactive Date is not the same as the coverage effective date, has the coverage been provided uninterrupted up to the proposed effective date? Yes No If No, supply details N/A Has any insurer ever cancelled or non-renewed the applicants EPL coverage? Yes No If Yes, supply details including carrier name, reason and termination date

EMPLOYEES Total number of Full Time (including leased) and part time (including seasonal and temporary) employees employed during each of the last 3 years and projected to be employed next year:

2 Years ago Previous Year Current Year Next Year Full Time Part-Time Full Time Part Time Full Time Part Time Full Time Part Time

BOP-7094 (Ed. 8-12) Page 2 of 5

Percent of employees who are: Salaried % Non-Salaried %

Percent of workforce that are union members: 2 Years Ago: % Previous Year: % Current Year: %

Breakdown of current Full Time employees by their total cash compensation (salary + bonus):

Salary Ranges # of Employees % of total Employees

$30,000 or less per year $30,001–$100,000 per year

Over $100,000 per year 2 Years Ago Previous Year Current YearEmployee-initiated (voluntary termination) turnover rate % % % Employer-initiated (involuntary termination) turnover rate % % % Have there been any office, branch, facility, branch or plant closings, consolidations, layoffs or staff reductions (greater than 10% of the workforce), mergers or acquisitions within the last 24 months? No Yes If yes, describe: Are any office, branch, facility or plant closings, consolidations, layoffs or staff reductions (greater than 10% of the workforce), merger or acquisitions anticipated within the next 12 months? No Yes If Yes, describe: LOSS HISTORY

Within the last five years, has the applicant: Received any employment-related inquiry, complaint or charge from any municipal, state, or federal regulatory authority or any other governmental entity? No Yes If Yes, describe:

Had an employment-related claim, suit, grievance, or demand brought against them? No Yes If Yes, describe: Is the applicant aware of any facts or circumstances which they reasonably believe may result in employment-related practices claims being made against them? No Yes If Yes, describe:

HUMAN RESOURCES FUNCTION

Who is responsible for the Human Resources or Personnel functions?

Name: Title:

Who is designated to handle all employment-related incidents?

Name: Title:

Are there tests (i.e., psychological, personality, drug, alcohol, medical) used to screen employment applicants, promote employees, or for the purpose of continuing employment?

No Yes If Yes, describe: The type of test (s) How is it administered (i.e., to all employees or segments thereof): The company creating the test and validation documents:

BOP-7094 (Ed. 8-12) Page 3 of 5

RISK MANAGEMENT PRACTICES

Do you use an employment application during your hiring process? Yes No If yes, does it contain: An employment-at-will statement? Yes No Authorization to check references and criminal conviction records? Yes No The applicant’s signature attesting that all representations are true? Yes No An equal employment opportunity statement? Yes No

Is an Employee Handbook distributed to your employees? Yes No If yes, does it contain: An employment-at-will statement? Yes No A written equal employment opportunity statement? Yes No . A written sexual harassment and other harassment policies? Yes No A written internal complaint procedure for discrimination and sexual harassment claims? Yes No If any are no, do you have written policies on all of the above that are distributed separately? Yes No Specify any that are not. Is there a progressive disciplinary program? Yes No If yes, has it been distributed to supervisors in writing? Yes No Are all notices required by law posted in places conspicuous to all employees and applicants for employment? Yes No When requested by employees, do you distribute information as required by federal law regarding the Family Medical

Leave Act? Yes No Do you require that all employment terminations be reviewed by the personnel having human resources responsibilities?

Yes No Have supervisory personnel been informed, in writing, of their responsibility to provide you with prompt notice of any

claims, incidents or allegations? Yes No Do you provide training to your employees on any of the following employment practice topics? > Sexual Harassment Yes No > Discrimination Yes No > Americans with Disabilities Act Yes No > Family Medical Leave Act Yes No > Reporting Incidents of Complaints Yes No Have the employment policies and procedures been reviewed and approved by outside legal counsel? Yes No If yes, when?

By whom? Firm: Attorney: Have all recommendations from that review been implemented? Yes No N/A If no, explain or provide timeframe for implementation:

ADDITIONAL INFORMATION– Please attach each of the following, if they exist:

• Employee Handbook • Employee grievance, disciplinary, termination and out-placement procedures • Employment Application form(s) • Equal Employment Opportunity and Discrimination and Sexual Harassment Policy • Separation Agreement Form

THIRD PARTY LIABILITY COVERAGE SUPPLEMENT

Third Party Liability Coverage No Yes If Yes, supply: Details of all contracts with independent contractors including: number of workers; type of work; approximate average

hours per week and /or months of use; and, whether workers are primarily onsite or offsite:

BOP-7094 (Ed. 8-12) Page 4 of 5

NOTICE OF INSURANCE INFORMATION PRACTICES Personal Information about you may be collected from persons other than you in connection with this application for insurance and subsequent policy renewals. Such information as well as other personal and privileged information collected by us or our agents may in certain circumstances be disclosed to third parties without your authorization. You have the ability to review your personal information in our files and can request correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information is available upon request. Contact your agent or broker for instructions on how to submit a request to us. FRAUD STATEMENTS Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties. (Not applicable in AL, CO, DC, FL, HI, MA, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied) APPLICABLE IN ALABAMA Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. APPLICABLE IN COLORADO It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement of award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. APPLICABLE IN THE DISTRICT OF COLUMBIA WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant. APPLICABLE IN FLORIDA Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. APPLICABLE IN HAWAII For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. APPLICABLE IN OHIO Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deception statement is guilty of insurance fraud. APPLICABLE IN OKLAHOMA WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. APPLICABLE IN WASHINGTON, It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

BOP-7094 (Ed. 8-12) Page 5 of 5

NOTICE REGARDING THE CIVIL UNION AND EQUALITY ACT (DELAWARE) This is to provide notice that, pursuant to the Delaware Insurance Department Domestic/Foreign Insurers Bulletin No. 46, this policy is in compliance with the Delaware Civil Union and Equality Act of 2011, 78 Del. Laws Ch. 22 (2011) (the "Act"). The Act, which becomes effective January 1, 2012, creates a form of legal union between two persons of the same sex who establish a civil union in accordance with the requirements of Delaware law. The Act provides that parties to a civil union shall have all of the same rights, protections and benefits, and shall be subject to the same responsibilities, obligations and duties, under Delaware law as are granted to, enjoyed by, or imposed upon married spouses. The Act further provides that a party to a civil union shall be included in any definition or use of the terms "dependent", "family", "husband and wife", "immediate family", "next of kin", "spouse", "stepparent", "tenants by the entirety", and other terms, whether or not gender-specific, that denote a spousal relationship or a person in a spousal relationship, as those terms are used throughout Delaware law. For all purposes of Delaware laws that refer to marriage or marital status, other than Chapter 1 of Title 13 of the Delaware Code, parties to a civil union will be included in such reference. In addition, the Act also automatically recognizes as civil unions, for all purposes of Delaware law, legal unions between two persons of the same sex, such as civil unions, marriages and domestic partnerships that are validly formed in jurisdictions other than Delaware and are substantially similar to Delaware civil unions. The provisions of the Act apply for all purposes of Delaware law, whether derived from statutes, administrative rules or regulations, court rules, governmental policies, common law, court decisions, or any other provisions or sources of law, which includes the Insurance Code and all regulations and bulletins promulgated thereunder. NOTICE REGARDING THE RELIGIOUS FREEDOM PROTECTION AND CIVIL UNION ACT (ILLINOIS) This is to provide notice that, pursuant to Illinois Department of Insurance Company Bulletin 2011-06 (CB 2011-06), this policy is in compliance with the Illinois Religious Freedom Protection and Civil Union Act ("the Act", 750 ILL. COMP. STAT. 75/1). The Act, which became effective on June 1, 2011, creates a legal relationship between two persons of either the same or opposite sex who establish a civil union. The Act provides that parties to a civil union are entitled to the same legal obligations, responsibilities, protections and benefits that are afforded or recognized by the law of Illinois to spouses, whether they are derived from statute, administrative rule, policy, common law or any source of civil or criminal law. In addition, this law requires recognition of a same-sex civil union, marriage, or other substantially similar legal relationship, except for common law marriage, legally entered into in other jurisdictions. The Act further provides that "party to a civil union" shall be included in any definition or use of the terms "spouse", "family", "immediate family", "dependent", "next of kin" and other terms descriptive of spousal relationships as those terms are used throughout the law. According to CB 2011-06, this includes the terms "marriage" or "married" or any variations thereof. CB 2011-06 also states that if policies of insurance provide coverage for children, the children of civil unions must also be provided coverage. The undersigned warrants that the statements set forth in this application and its attachments and other material submitted to the insurer are true and correct. Although the signing of this application does not bind the applicant or insurer to effect insurance, the undersigned agrees that this application and its attachments shall be the basis of the contract should a policy be issued and shall be deemed attached to and shall form part of the policy. (Not applicable in North Carolina) The undersigned further declares that any occurrence or event taking place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any information in this application, will immediately be reported in writing to the insurer. Based on such new information, the insurer may withdraw or modify any outstanding quotations and or authorization or agreement to bind the insurance. Individual responsible for Human Resources function: ______________________ ________________________ ___________

Name (Please Print) Signature Date President or Chairman: _________________________ ________________________ ___________

Name (Please Print) Signature Date

BOP-7095 (Ed. 08-12) Page 1 of 4

Harleysville Worcester Insurance Company Harleysville Insurance Company Harleysville Preferred Insurance Company Nationwide Mutual Insurance Company

RENEWAL APPLICATION EMPLOYMENT PRACTICES LIABILITY

BUSINESSOWNERS POLICY

Named Insured and Mailing Address:

Agent: Agent Code:

Renewal Effective Date:

Policy Number/ Quote Number/ Account Number:

THIS APPLICATION IS FOR A CLAIMS-MADE POLICY WHICH PROVIDES FOR DEFENSE WITHIN THE LIMITS OF INSURANCE. EMPLOYEES

Total number of full time (including leased) and part time (including seasonal and temporary) employees employed during the last year and projected to be employed next year:

Last Year

Next Year

Full Time Part Time Full Time Part Time




Over $100,000 per year Last Year Employee-initiated (voluntary termination) turnover rate % Employer-initiated (involuntary termination) turnover rate % Provide details of any changes in the insureds operations during the past two years including any mergers/acquisitions, downsizing/layoffs (greater than 10%), new Federal Government contracts, or union participation. Are any office, branch, facility or plant closings, consolidations, layoffs or staff reductions (greater than 10% of the workforce), merger or acquisitions anticipated within the next 12 months? No Yes If Yes, describe:

LOSS HISTORY

Within the last two years, has the insured: Received any employment-related inquiry, complaint or charge from any municipal, state, or federal regulatory authority or any other governmental entity? No Yes If Yes, describe:

Had an employment-related claim, suit, grievance, or demand brought against them? No Yes If Yes, describe: Is the insured aware of any facts or circumstances which they reasonably believe may result in employment-related practices claims being made against them? No Yes If Yes, describe:

BOP-7095 (Ed. 08-12) Page 2 of 4



Name: Title:


Name: Title:

Have you made any changes to your use of any of the following tests to screen employment applicants, to promote employees, or for the purpose of continuing employment?

Psychological or personality tests: No Yes Drug or alcohol tests: No Yes Pre-employment offer medical tests: No Yes If yes, provide details regarding the test used, how it’s administered and the validation documentation.


Do you require that all employment terminations be reviewed by the personnel having human resources responsibilities? Yes No

Have supervisory personnel been informed, in writing, of their responsibility to provide you with prompt notice of any claims, incidents or allegations? Yes No

Have you made any changes to your use or content of, requirement for, or distribution or posting of any of the following? Employment applications Yes No An employment-at-will statement? Yes No Authorization to check references and criminal conviction records? Yes No Signature by job applicants attesting that all representations are true? Yes No An equal employment opportunity statement? Yes No

Employee Handbook? Yes No A written sexual harassment or other harassment policy? Yes No A written internal complaint procedure for discrimination and harassment claims? Yes No Progressive disciplinary program? Yes No

Notices required by law to be posted in places conspicuous to all employees and applicants for employment? Yes No Family Medical Leave Act information as required by federal law? Yes No If Yes, describe During the past two years, have the employment policies and procedures been reviewed and approved by outside legal counsel? Yes No If yes, when?

By whom? Firm: Attorney:

Have all recommendations from that review been implemented? Yes No N/A If no, explain or provide timeframe for implementation: ADDITIONAL INFORMATION – Please attach each of the following, if they have been created or amended in the past two years:



Supply details of any changes in the contracts with independent contractors including: number of workers; type of work; approximate average hours per week and /or months of use; and, whether workers are primarily onsite or offsite:

BOP-7095 (Ed. 08-12) Page 3 of 4

NOTICE OF INSURANCE INFORMATION PRACTICES Personal Information about you may be collected from persons other than you in connection with this application for insurance and subsequent policy renewals. Such information as well as other personal and privileged information collected by us or our agents may in certain circumstances be disclosed to third parties without your authorization. You have the ability to review your personal information in our files and can request correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information is available upon request. Contact your agent or broker for instructions on how to submit a request to us. FRAUD STATEMENTS Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties. (Not applicable in AL, CO, DC, FL, HI, MA, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied) APPLICABLE IN ALABAMA Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. APPLICABLE IN COLORADO It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement of award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. APPLICABLE IN THE DISTRICT OF COLUMBIA WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant. APPLICABLE IN FLORIDA any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. APPLICABLE IN HAWAII For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. APPLICABLE IN OHIO Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deception statement is guilty of insurance fraud. APPLICABLE IN OKLAHOMA WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. APPLICABLE IN WASHINGTON, It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

BOP-7095 (Ed. 08-12) Page 4 of 4

NOTICE REGARDING THE CIVIL UNION AND EQUALITY ACT (DELAWARE) This is to provide notice that, pursuant to the Delaware Insurance Department Domestic/Foreign Insurers Bulletin No. 46, this policy is in compliance with the Delaware Civil Union and Equality Act of 2011, 78 Del. Laws Ch. 22 (2011) (the "Act"). The Act, which becomes effective January 1, 2012, creates a form of legal union between two persons of the same sex who establish a civil union in accordance with the requirements of Delaware law. The Act provides that parties to a civil union shall have all of the same rights, protections and benefits, and shall be subject to the same responsibilities, obligations and duties, under Delaware law as are granted to, enjoyed by, or imposed upon married spouses. The Act further provides that a party to a civil union shall be included in any definition or use of the terms "dependent", "family", "husband and wife", "immediate family", "next of kin", "spouse", "stepparent", "tenants by the entirety", and other terms, whether or not gender-specific, that denote a spousal relationship or a person in a spousal relationship, as those terms are used throughout Delaware law. For all purposes of Delaware laws that refer to marriage or marital status, other than Chapter 1 of Title 13 of the Delaware Code, parties to a civil union will be included in such reference. In addition, the Act also automatically recognizes as civil unions, for all purposes of Delaware law, legal unions between two persons of the same sex, such as civil unions, marriages and domestic partnerships that are validly formed in jurisdictions other than Delaware and are substantially similar to Delaware civil unions. The provisions of the Act apply for all purposes of Delaware law, whether derived from statutes, administrative rules or regulations, court rules, governmental policies, common law, court decisions, or any other provisions or sources of law, which includes the Insurance Code and all regulations and bulletins promulgated thereunder. NOTICE REGARDING THE RELIGIOUS FREEDOM PROTECTION AND CIVIL UNION ACT (ILLINOIS) This is to provide notice that, pursuant to Illinois Department of Insurance Company Bulletin 2011-06 (CB 2011-06), this policy is in compliance with the Illinois Religious Freedom Protection and Civil Union Act ("the Act", 750 ILL. COMP. STAT. 75/1). The Act, which became effective on June 1, 2011, creates a legal relationship between two persons of either the same or opposite sex who establish a civil union. The Act provides that parties to a civil union are entitled to the same legal obligations, responsibilities, protections and benefits that are afforded or recognized by the law of Illinois to spouses, whether they are derived from statute, administrative rule, policy, common law or any source of civil or criminal law. In addition, this law requires recognition of a same-sex civil union, marriage, or other substantially similar legal relationship, except for common law marriage, legally entered into in other jurisdictions. The Act further provides that "party to a civil union" shall be included in any definition or use of the terms "spouse", "family", "immediate family", "dependent", "next of kin" and other terms descriptive of spousal relationships as those terms are used throughout the law. According to CB 2011-06, this includes the terms "marriage" or "married" or any variations thereof. CB 2011-06 also states that if policies of insurance provide coverage for children, the children of civil unions must also be provided coverage. The undersigned warrants that the statements set forth in this application and its attachments and other material submitted to the insurer are true and correct. Although the signing of this application does not bind the applicant or insurer to effect insurance, the undersigned agrees that this application and its attachments shall be the basis of the contract should a policy be issued and shall be deemed attached to and shall form part of the policy. (Not applicable in North Carolina) The undersigned further declares that any occurrence or event taking place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any information in this application, will immediately be reported in writing to the insurer. Based on such new information, the insurer may withdraw or modify any outstanding quotations and or authorization or agreement to bind the insurance. Individual responsible for Human Resources function: ______________________ ________________________ ___________

Name (Please Print) Signature Date President or Chairman: _________________________ ________________________ ___________


Rate Information Rate data applies to filing.

Filing Method: Prior approval

Rate Change Type: Neutral

Overall Percentage of Last Rate Revision: %

Effective Date of Last Rate Revision:

Filing Method of Last Filing:

Company Rate Information

Company

Name:

Overall %

Indicated

Change:

Overall %

Rate

Impact:

Written Premium

Change for

this Program:

# of Policy

Holders Affected

for this Program:

Written

Premium for

this Program:

Maximum %

Change

(where req'd):

Minimum %

Change

(where req'd):

Harleysville Insurance

Company

% 0.000% $0 % %

Harleysville Preferred

Insurance Company

% 0.000% $0 % %

Harleysville Worcester

Insurance Company

% 0.000% $0 % %

Nationwide Mutual

Insurance Company

(Harleysville Operations)

% 0.000% $0 % %







Rate/Rule Schedule

Item

No.

Schedule Item

Status Exhibit Name Rule # or Page # Rate Action

Previous State

Filing Number Attachments

1 Contents (MA)BO-Contents-1 Replacement HRLV-128306535 MA BO CONTENTS -

new.pdf

2 manual pages (MA)BO-E-23-36 Replacement HRLV-128306535 &

HRLV-129066746

New.pdf







NATIONWIDE MUTUAL INSURANCE COMPANY COMMERCIAL LINES MANUAL HARLEYSVILLE INSURANCE COMPANY DIVISION TEN – BUSINESSOWNERS HARLEYSVILLE PREFERRED INSURANCE COMPANY HARLEYSVILLE WORCESTER INSURANCE COMPANY MASSACHUSETTS (20)

TABLE OF CONTENTS

(MA) BO Contents-1 January 2014

Page

Exception Pages

Additional Rule....................................................................................................................................................(MA) BO-E-1

Rule 7. Policy Writing Minimum Premium..........................................................................................................(MA) BO E-1

Rule 8. Additional Premium Changes................................................................................................................(MA) BO E-1

Rule 9. Return Premium Changes.....................................................................................................................(MA) BO E-1

Rule 16. Mandatory Forms, Coverage and Limits.............................................................................................(MA) BO E-1

Rule 22. Eligibility ...............................................................................................................................................(MA) BO E-5

Rule 23. Premium Development – Mandatory Coverages ...............................................................................(MA) BO E-6

Rule 24. Deductibles .......................................................................................................................................(MA) BO E-10

Rule 28. Optional Coverages ...........................................................................................................................(MA) BO E-11

Rule 29. Endorsements....................................................................................................................................(MA) BO E-14

Rule 40. Application of Section V – Class-Specific Endorsements ................................................................(MA) BO E-36

Rule 41. Apartment Buildings – Class-Specific Endorsements ......................................................................(MA) BO E-36

Rule 42. Restaurants – Class-Specific Endorsements....................................................................................(MA) BO E-36 Loss Cost Multipliers and Class of Business Factors (excluding Garage)

Harleysville Insurance Company.............................................................................................................. (MA - HIC) BO R-1

Harleysville Mutual ................................................................................................................................ (MA - HMIC) BO R-1

Harleysville Preferred Insurance Company ......................................................................................... (MA - HPRF) BO R-1

Harleysville Worcester.......................................................................................................................... (MA - HWIC) BO R-1

Garage Class of Business (COB) Factors.............................................................................................................. (MA) GO-R-1 Classification Table Exceptions...........................................................................................................................(MA) BO C-1 Rate Pages (Garage) .................................................................................................................................................... (MA) R-1 Territory Exceptions .............................................................................................................................................. (MA) BO T-1 IRPM Plan Exceptions .................................................................................................................................... (MA) BO IRPM-1

NATIONWIDE MUTUAL INSURANCE COMPANY (Harleysville Operations) COMMERCIAL LINES MANUAL HARLEYSVILLE INSURANCE COMPANY DIVISION TEN — BUSINESSOWNERS HARLEYSVILLE PREFERRED INSURANCE COMPANY HARLEYSVILLE WORCESTER INSURANCE COMPANY MASSACHUSETTS (20)

EXCEPTION PAGES

(MA) BO E-23 January 2014 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Copyright 2004, Insurance Services Office

29. ENDORSEMENTS (continued)

7. Employment-Related Practices Liability This rule is replaced by the following: a. Endorsement (1) When this coverage is selected, coverage is afforded for damage arising out of employment practices

if such employment practice occurred after the Retroactive Date and before the end of the policy period and if the claim is first made against an insured during the policy period. It includes a duty to defend. The aggregate limit applies to the annual term or any applicable policy period less than one year (other than an extension of less than one year after the policy is issued). (a) There are two coverage options:

i. Attach Employment Practices Liability Coverage endorsement BOP-7059 when separate limits apply to both damages and defense expenses.

ii. Attach Employment Practices Liability Coverage endorsement BOP-7058 when a single limit applies to both damages and defense expenses.

(b) The company’s obligation to pay damages and defense expense on behalf of the insured applies only to the amount of damages and defense expense in excess of the per claim deductible amount.

(2) Also, attach State Amendatory endorsement BOP-7082 (Deductible Amendment) (3) Employment Practices Liability Coverage cannot be written under the Businessowners policy if the

number of employees exceeds 250. b. Limits of Insurance (1) When separate limits apply to both damages defense expenses (BOP-7059):

(a) The minimum Limits of Insurance are: $50,000 Aggregate Limit – Damages / $50,000 Each Claim Limit – Damages $50,000 Aggregate Limit – Defense Expense / $50,000 Each Claim Limit – Defense Expense

(b) These limits may be increased to one of the following options at the insureds request and with approval by the company: (i) $100,000 Aggregate Limit – Damages / $100,000 Each Claim Limit – Damages

$100,000 Aggregate Limit – Defense Expense / $100,000 Each Claim Limit – Defense Expense

(ii) $250,000 Aggregate Limit – Damages / $250,000 Each Claim Limit – Damages $250,000 Aggregate Limit – Defense Expense / $250,000 Each Claim Limit – Defense Expense

(2) When a single limit applies to both damages and defense expenses (BOP-7058): (a) The minimum Limits of Insurance are:

$50,000 Aggregate Limit / $50,000 Each Claim Limit (b) These limits may be increased to one of the following options at the insureds request and with

approval by the company: (i) $100,000 Aggregate Limit / $100,000 Each Claim Limit (ii) $250,000 Aggregate Limit / $250,000 Each Claim Limit

c. Deductible A minimum deductible of $5,000 applies to Employment Practices Liability Coverage. For the higher limit

options, this amount may be increased to $10,000 at the request of the insured or by the company with notice to the insured.

∗


EXCEPTION PAGES



B. Liability Endorsements (continued) 7. Employment-Related Practices Liability (continued) d. Supplemental Extended Reporting Period (1) A Supplemental Extended Reporting Period option may be purchased by the named insured when

Employment Practices Liability Coverage is terminated and in accordance with the provisions of the endorsement. The duration of the supplemental extended reporting period can be either twelve (12) or thirty-six (36) months and is shown on the Schedule of the Supplemental Extended Reporting Period Endorsement. This option provides a Supplemental Extended Reporting Period only for coverage available in the Employment Practices Liability Coverage endorsement. The claim must be for damages because of injury arising out of an employment practice and which commenced before the end of the policy period, but not before the applicable retroactive date.

(2) Use endorsement BOP-7061 (Supplemental Extended Reporting Period Endorsement). (3) If the Supplemental Extended Reporting Period is in effect, only the remaining amounts available

under the aggregate limits are available for claims first received and recorded during the Supplemental Extended Reporting Period.

e. Third Party Liability Coverage (1) This optional endorsement is available to provide coverage for Employment Practices claims made by

clients or customers or yours or employees of clients or customers of yours while acting within the scope of such employment.

(2) Use endorsement BOP-7060 (Third Party Liability Coverage). f. Premium Determination (1) Determine the basic limits premium based on the number of employees multiplied by the rate per

employee: # of Employees Rate Per Employee First 25 Employees $ 145 Next 25 Employees (26-50) 135 Next 50 Employees (51-100) 122 Next 50 Employees (101-150) 117 Next 100 Employees (151-250) 117

The number of employees is the peak number of persons employed for wages or salary during the past year plus any leased employees and current members of a board of directors. Count each person as 1.0, except count each part-time, seasonal and temporary employee as 0.75.

∗


EXCEPTION PAGES



B. Liability Endorsements (continued) 7. Employment-Related Practices Liability (continued) (2) Adjust the basic limits premium by:

(i) the Group V State Hazard Group Factor of .95; and (ii) the applicable Standard Industry Classification (SIC) code factor:

Major SIC Label 2 Digit SIC Code and Label 2 Digit

SIC Factor


SIC Factor

Agr., Forestry & Fishing Mining Construction Manufacturing Transportation & Public Utilities

01 - Agr. Production - Corps 02 - Agr. Production - Livestock 07 - Agr. Services 08 - Forestry 09 - Fishing, Hunting & Trapping 14 - Non-metal minerals, ex fuels 15 - Gen'l Building Contractors 16 - Heavy Construction, ex bldg 17 - Special Trade Contractors 20 - Food & Kindred Prods 21 - Tobacco Prods 22 - Textile, Mill Products 23 - Apparel/other Textile Prods 24 - Lumber & Wood Prods 25 - Furniture & Fixtures 26 - Paper & Allied Prods 27 - Printing & Publishing 28 - Chemicals & Allied Prods 30 - Rubber & Misc. Plastics 31 - Leather & Leather Prods 32 - Stone, Clay & Glass Prods 33 - Primary Metal Industries 34 - Fabricated Metal Prods 35 - Industrial Machy & Eqpt 36 - Electronic & Other Elec Eqpt 37 - Transportation Equipment 38 - Instruments & Related Prods 39 - Misc. Manufg Industries 41 - Local/Inter-urban Pass Trans 42 - Trucking & Warehouse 44 - Water Transportation 46 - Pipelines, ex Natural Gas 47 - Transportation Services 48 - Communications 49 - Electric, Gas & Sanitary Servs

1.00 1.00 1.00 1.50 1.50

1.10

0.90 1.00 0.80

1.20 1.50 0.90 0.75 0.80 0.90 1.10 0.90 1.30 0.90 0.90 0.90 1.30 1.00 1.00 1.20 1.30 1.00 1.10

1.10 0.90 1.20 1.50 1.30 1.30 1.40

Wholesale Trade Retail Trade Finance, Ins & Real Estate Services Public Administration

50 - Wholesale Tr - Durable Gds 51 - Wholesale Tr - Nondur Gds 52 - Bldg Matls & Garden Supp 53 - General Merchse Stores 54 - Food Stores 55 - Auto Dealers & Serv Stations 56 - Apparel & Access Stores 57 - Furn & Home furnishings Stores 58 - Eating & Drinking Places 59 - Miscellaneous Retail 60 - Depository Institutions 61 - Nondepository Institutions 62 - Security & Commod Brkrs 63 - Insurance Carriers 64 - Ins Agents, Brokers & Srvc 65 - Real Estate 67 - Holding & Other Invest Offices 70 - Hotels & Other Lodging 72 - Personal Services 73 - Business Services 75 - Auto Repair, Srvcs & Prkg 76 - Misc Repair Services 79 - Amusement & Rec Srvcs 80 - Health Services 82 - Educational Services 83 - Social Services 84 - Museums, Botncl, Zoolgcl 86 - Membership Organizations 87 - Eng'g & Mngmnt Services 89 - Services, NEC 91 - Municipalities

0.75 0.80

0.90 0.80 0.75 1.00 0.75 0.75 0.75 0.75

1.00 1.20 1.30 1.20 0.80 0.80 1.10

1.00 0.75 0.90 0.80 0.80 0.75 1.10 1.30 0.75 1.20 0.80 0.75 1.00

1.00

Determine this factor based on the 1st two digits of the SIC code. If no match, use 1.00. (3) Multiply the amount determined in step (2) by the appropriate limit factor to obtain the premium at limits:

Each Claim / Policy Aggregate

Separate Limits Factor

(BOP-7059)

Single Limits Factor

(BOP-7058) $50,000 / $50,000 .338 .270 $100,000 / $100,000 .469 .374 $250,000 / $250,000 .714 .580

(4) Adjust the premium at limits by the appropriate factor for an optional deductible, if applicable, to obtain the deductible credited or debited premium at limits.

Limit of Liability $10,000 Deductible

$ 100,000 .903 250,000 .930

∗


EXCEPTION PAGES



B. Liability Endorsements (continued) 7. Employment-Related Practices Liability (continued)

(5) If Third Party Liability Coverage is selected, multiply the amount determined in the preceding step by 1.20.

(6) The premium for this coverage is the developed premium or the coverage minimum premium, whichever is greater:

Limit of Liability Coverage Minimum Premium

$50,000 $55 $100,000 $70 $250,000 $105

(7) Supplemental Extended Reporting Period If a Supplemental Extended Reporting Period (SERP) is purchased, the premium charged for the

Supplemental Extended Reporting Period may not exceed the following percentage of the expiring annual premium for Employment Practices Liability coverage:

SERP Duration Percentage 12 mos. 100% 36 mos. 200%

g. Prior Acts Coverage If prior Employment Practices Liability coverage is provided at limits less than current limits, complete and

attach: (1) BOP-7080 (Split Limits Prior Acts Coverage Endorsement) if BOP-7059 applies; or

(2) BOP-7079 (Split Limits Prior Acts Coverage Endorsement) if BOP-7058 applies. 9. Exclusion – Silica and Silica-Related Dust This rule does not apply. Refer to Rule 16 for instructions regarding the use of the Asbestos, Silica Or Talc

endorsement BOP-7027. 11. Hired Auto And Non-Owned Auto Liability c. Premium Determination (1) Premium Refer to the multistate rates to determine the additional premium.

(2) Optional Higher Limits Of Insurance For optional higher limits of insurance, multiply the premium determined in Paragraph (1) by a factor in

Table 29.B.11.c.(2)(RF). The limit of insurance must be the same as the limit provided for Businessowners Liability and Medical Expenses Coverage.

15. Mold – Fungi or Bacteria Exclusion (Liability) Endorsement

This rule does not apply. Refer to Rule 16 for instructions regarding the use of the Fungi Or Bacteria Exclusion (Liability) endorsement BP 05 77.

16. Mold – Limited Fungi or Bacteria Coverage (Liability) Endorsement This rule does not apply.

17. Newly Acquired Organizations – Businessowners Liability Coverage This rule does not apply. Liability coverage for Newly Acquired Organizations is automatically included on a

limited basis within mandatory endorsement BOP-7000. Refer to Rule 16 for endorsement BOP-7000 rule of application.

∗


EXCEPTION PAGES



B. Liability Endorsements (continued)

18. Pollution Exclusion Endorsements a. Pollution Exclusion – Limited Exception for Short-Term Pollution Event

This rule does not apply.

b. Pollution Exclusion – Limited Exception for Designated Pollutants


e. Limited Pollution Liability Extension Endorsement

(3) Premium Determination

This coverage provides a Limited Pollution Liability Extension Aggregate Limit of $100,000. Multiply the total of all the premiums for mandatory liability coverage by the Limited Pollution Liability Extension Factor to determine the premium for this coverage. This coverage is subject to a minimum premium.

Limited Pollution Liability Extension Factor: 0.30 Minimum Premium: $150

19. Waiver of Transfer of Rights of Recovery Against Others to Us Endorsement The following is added to this rule:

This coverage is automatically included within mandatory endorsement BOP-7000. Refer to Rule 16 for endorsement BOP-7000 rule of application. However, the Waiver of Transfer of Rights of Recovery Against Others to Us Endorsement is still available to designate a specific entity when required to do so.

20. Year 2000 Computer-Related Endorsements – Businessowners Liability Coverage a. Option One – Exclusion – Date or Time Computer-Related and Other Electronic Problems

Endorsement BOP-7002

To exclude coverage for all liability risks associated with a computer or computer-related, actual or alleged failure, malfunction, inadequacy or inability to correctly recognize, distinguish, interpret or accept any date or time attach Exclusion – Date or Time Computer-Related And Other Electronic Problems Endorsement BOP-7002 to the Businessowners Coverage Form.

b. Option Two – Exclusion – Year 2000 Computer-Related and Other Electronic Problems (Products-Completed Operations Hazard) Endorsement BP 10 06


c. Option Three – Year 2000 Computer-Related and Other Electronic Problems – Limited Coverage Options Endorsement BP 04 64


d. Option Four – Exclusion – Year 2000 Computer-Related and Other Electronic Problems – With Exception for Bodily Injury On Your Premises


e. Option Five – Year 2000 Computer-Related and Other Electronic Problems – Exclusion of Specified Coverages for Designated Locations, Operations, Products Or Services


Additional Endorsements – Liability

The following rules are added:

(1) Per Location Aggregate Limit endorsement BOP-7013 may be used to amend the ‘other than products-completed operations’ aggregate to apply per location.

Premium Determination – Refer to Company.


EXCEPTION PAGES



Additional Endorsements – Liability (continued)

(2) Voluntary Property Damage Coverage endorsement BOP-7020 can be used to provide coverage for claims arising out of property damage to property of others in the insureds care, custody and control which occurs away from the insureds premises. The occurrence/aggregate limit options are: $5,000/$25,000; $25,000/$50,000; $50,000/$100,000; and, $100,000/$200,000. Losses under this coverage are included within the policy occurrence and aggregate limits and are not in addition to those limits. A $500 deductible applies.

Premium Determination: Charge the flat premium based upon the limit. This premium is not subject to deviations or rating plans.

Occurrence Limit Aggregate Limit Flat Premium $ 5,000

25,000 50,000

100,000

$ 25,000 50,000

100,000 200,000

$100 140 180 225

(3) Exclusion – Tobacco Health Hazards endorsement BOP-7021 is available for use on policies issued to

businesses with operations that include the incidental sale of tobacco products.

(4) Per Project Aggregate Limit endorsement BOP-7114 may be used to amend the “other than products-completed operations” aggregate to apply per project.

Premium Determination – $150 flat charge times the applicable increased limit factor.

(5) Business Liability Coverage – Amendment Of Aggregate Limits Of Insurance endorsement BOP-7035 is available to increase both the aggregate limit that applies to the products/completed operations hazard and the aggregate that applies to the ‘other than’ products/completed operations hazard to three times the Liability and Medical Expenses Limit.

Premium Determination – Use the following table to determine the applicable Increased Limit Factor:

Liability And Medical

Expenses Limit

Aggregate Limit For Products/Completed

Operations

Aggregate Limit For ‘Other Than’ Products/Completed

Operations

Increased Limits Factors

$ 300,000 $ 900,000 $ 900,000 1.002 500,000 1,500,000 1,500,000 1.096

1,000,000 3,000,000 3,000,000 1.209 2,000,000 6,000,000 6,000,000 1.334

(6) Snow And Ice Removal Coverage endorsement BOP-7036 is available to provide products / completed

operations coverage on policies where the insured performs snow and ice removal for others. Refer to company for Flat Charge.

(7) Exclusion – Retread Or Recapped Tires endorsement BOP-7037 is available to exclude products liability coverage on policies where the insured sells, manufactures or processes retread or recapped tires.

(8) Customer Gasoline Spill Liability Coverage endorsement BOP-7098 is available to insureds whose operations include the retail dispensing of gasoline. The endorsement provides bodily injury and property damage liability coverage for loss sustained by a retail gasoline customer which is caused by a retail gasoline spill on the insureds premises. Coverage is subject to each accident / aggregate limits.

Premium Determination – Apply the appropriate flat charge based on limits selected for this coverage times the number of retail gasoline sales locations:

Limits Flat Charge (per location) $5,000 Each Accident / $10,000 Aggregate $100 $10,000 Each Accident / $20,000 Aggregate $200


EXCEPTION PAGES



Additional Endorsements – Liability (continued) C. Additional Insured Endorsements (Liability and Medical Expenses Coverage)

The following rules are amended:

1. Additional Insured – Managers or Lessors of Premises

This rule is replaced by the following:

Additional Insured status for manager or lessors of premises is automatically included within mandatory endorsement BOP-7000. Refer to Rule 16 for endorsement BOP-7000 rule of application.

Optional endorsement BOP-7119 (Additional Insured – Designated Managers or Lessors of Premises) is available to specifically name an Additional Insured if necessary. There is no charge for this endorsement.

2. Additional Insured – Controlling Interest

c. Premium Determination

For each additional insured, multiply the flat premium charge by the applicable increased limit factor. Flat Premium Charge: $25.00 3. Additional Insured – State or Political Subdivisions – Permits Relating To Premises


For each additional insured, multiply the flat premium charge by the applicable increased limit factor. Flat Premium Charge: $25.00

5. Additional Insured – Mortgagee, Assignee or Receiver c. Premium Determination


6. Additional Insured – Owner or Other Interests from Whom Land Has Been Leased c. Premium Determination


7. Additional Insured – Co-Owner of Insured Premises c. Premium Determination


8. Additional Insured – Engineers, Architects or Surveyors c. Premium Determination


9. Additional Insured – Lessor of Leased Equipment This rule is replaced by the following:

Additional Insured status for lessors of leased equipment is automatically included within mandatory endorsement BOP-7000. Refer to Rule 16 for endorsement BOP-7000 rule of application.

Optional endorsement BOP-7120 (Additional Insured – Designated Lessors of Leased Equipment) is available to specifically name an Additional Insured if necessary. There is no charge for this endorsement.


EXCEPTION PAGES



C. Additional Insured Endorsements (Liability and Medical Expenses Coverage) (continued) 10. Additional Insured – Vendors c. Premium Determination

For each additional insured, multiply the vendor’s annual gross sales of the named insureds products (per $1,000) by a rate of $0.16 and the applicable increased limit factor. This coverage is subject to a minimum premium of $30.

11. Additional Insured – Designated Person or Organization c. Premium Determination


12. Additional Insured – Engineers, Architects, or Surveyors Not Engaged By the Named Insured c. Premium Determination


13. Additional Insured – Owners, Lessees or Contractors c. Premium Determination

For each additional insured, multiply the flat premium charge by the applicable increased limit factor. Flat Premium Charge: $75.00 14. Additional Insured – Owners, Lessees or Contractors – With Additional Insured Requirement In

Construction Contract c. Premium Determination Multiply the flat premium charge by the applicable increased limit factor. Flat Premium Charge: $200.00

15. Additional Insured – State or Political Subdivisions – Permits c. Premium Determination

For each additional insured, multiply the flat premium charge by the applicable increased limit factor. Flat Premium Charge: $25.00 Additional Endorsements – Additional Insured

The following rule is added:

(1) Additional Insured – Grantor of Franchise endorsement BOP-7031 is available to include scheduled persons or organizations as insureds but only for their liability as grantor of a franchise to the insured. For each additional insured, multiply the flat premium charge by the applicable increased limit factor.

Flat Premium Charge: $25.00

(2) Additional Insured – Designated Person Or Organization – With Additional Insured Requirement In Written Contract – Broad Form endorsement BOP-7052 is available to include as additional insureds designated persons or organizations who have signed a contract or an agreement that requires them to be added as additional insureds on a policy covering a contractor, subcontractor or service provider with respect to liability in connection with the insured’s ongoing operations and products / completed operations performed for that additional insured. With some exceptions, this coverage is primary and non-contributory. For each additional insured, multiply the flat premium charge by the applicable increased limit factor.

Flat premium charge: $100.00


EXCEPTION PAGES



Additional Endorsements – Additional Insured (continued)

(3) Additional Insured – Owners, Lessees Or Contractors – With Additional Insured Requirement In Written Contract – Broad Form endorsement BOP-7053 is available to include as additional insureds any owner, lessee or contractor who has signed a contract or an agreement that requires them to be added as additional insureds on a policy covering a contractor, subcontractor or service provider with respect to liability in connection with the insured’s ongoing operations and products / completed operations performed for that additional insured. With some exceptions, this coverage is primary and non-contributory. Multiply the flat premium charge by the applicable increased limit factor.


D. Endorsements Applicable To Specific Classes


1. Contractors' Optional Coverages


2. Motels


3. Professional Liability Endorsements

a. Barbers And Beauticians Professional Liability


Multiply the appropriate rate (based upon type of professional and the limit of liability insurance) times the number of licensed professionals to determine the premium.

Limit of Liability Type of Professional $300,000 $500,000 $1,000,000 $2,000,000

Barbers Beauticians / Manicurists

$15.00 27.00

$16.00 30.00

$17.00 32.00

$27.20 51.20

b. Funeral Directors Professional Liability


Multiply the rate (based upon the limit of liability insurance) times the number of Funeral Home locations.

Limit of Liability $300,000 $500,000 $1,000,000 $2,000,000 $74.00 $81.00 $95.00 $152.00

c. Optical And Hearing Aid Establishments


Multiply the appropriate rate (based upon type of professional and the limit of liability insurance) times annual gross sales (per $1,000).

Limit of Liability Type of Professional $300,000 $500,000 $1,000,000 $2,000,000 Hearing Aid Specialist Optician

$0.82 $1.21

$0.92 $1.35

$1.06 $1.55

$1.70 $2.48


EXCEPTION PAGES



3. Professional Liability Endorsements (continued)

d. Pharmacists Liability Coverage Option

(1) Pharmacists Endorsement BOP-7124

(a) Description Of Coverage

This endorsement is used to provide professional liability coverage for bodily injury, property damage and personal and advertising injury caused by the rendering of, or failure to render, professional services in connection with services in the practice of a retail pharmacist or pharmacy.

Coverage only applies with respect to:

(i) Distributing, administering, dispensing and possession of controlled substances as permitted under MASS. GEN. LAWS ANN. Chapter 94C in the course of rendering, or in the failure to render, professional health care services as a pharmacist; or

(ii) Any other professional health care services a pharmacist may render in accordance with any other applicable statute or regulation of the Commonwealth of Massachusetts, including the failure to render such professional health care services as a pharmacist.

(b) Endorsement

Use Pharmacists Endorsement BOP-7124. (c) Premium Determination

(ii) Optional Higher Limits of Insurance

Per Occurrence Limit of Insurance

Aggregate Limit Increased Limit Factor

$ 300,000 $ 900,000 1.001 500,000 1,500,000 1.152

1,000,000 3,000,000 1.324 2,000,000 6,000,000 1.494

e. Printer's Errors and Omissions Liability


Multiply the rate (based upon the limit of liability insurance) times annual gross sales (per $1,000). This coverage is subject to a minimum premium.

Limit of Liability $300,000 $500,000 $1,000,000 $2,000,000

$0.14 $0.16 $0.26 $0.42 Minimum Premium: $500


EXCEPTION PAGES




e. Printer's Errors and Omissions Liability (continued)

(4) Correction of Work Coverage

Use Printers Errors and Omissions Liability Correction of Work Coverage Endorsement BOP-7097. This endorsement provides coverage to reimburse the costs of printing and printing material to correct an insureds negligent act, error or omission in the providing printing services. This coverage is subject to the Printers Errors and Omissions limit.

Premium Determination – Multiply the Printers Errors and Omissions Gross Sales (per 1,000) by the Printers Errors and Omissions Correction of Work rate then by the appropriate deductible factor to determine the annual premium.

Liability Limit (Occurrence) Correction of Work Rate $300,000 0.270 $500,000 0.300

$1,000,000 0.490 $2,000,000 0.800

Correction of Work

Deductible Deductible Factor $500 1.000

$1,000 0.920 f. Veterinarians Professional Liability Coverage

(4) Endorsement

Use Veterinarians Professional Liability Endorsement BP 08 05. Also attach endorsement BOP-7032, Veterinarian Professional Liability Coverage Extension – State Review Board Expenses. This endorsement provides $10,000 coverage for certain expenses incurred if the insured is required to appear before any state veterinary review board of board of medical examiners.

(7) Optional Higher Limits of Insurance Per Occurrence Limit of

Insurance Aggregate Limit Increased Limit

Factor 300,000 900,000 1.001 500,000 1,500,000 1.152

1,000,000 3,000,000 1.324 2,000,000 6,000,000 1.494

Additional Endorsements – Applicable to Specific Classes The following rules are added:

(1) Condominium Association Directors and Officers Coverage endorsement BOP-7023 is available to provided claims-made coverage to condominium associations for Management Liability, Association Reimbursement and Association Liability arising from wrongful acts committed by their directors and officers. The Directors and Officers Liability Annual Aggregate Limit of Insurance options are $300,000, $500,000 and $1,000,000. The standard deductible is $500 with optional amounts of $250, $1,000, $3,000, $5,000 and $10,000 being available. An Extended Reporting Period is available for an additional premium when this coverage is cancelled or nonrenewed. The additional premium for the Extended Reporting Period is 100% of the annual premium charged on the cancelled or nonrenewed policy.


EXCEPTION PAGES



Additional Endorsements – Applicable to Specific Classes (continued) (1) Condominium Association Directors and Officers Coverage (continued) Premium Determination – Multiply the Condo Association D & O rate by the number of condominium units then by

the appropriate deductible factor to determine the annual premium. The resulting premium is subject to a coverage minimum premium.

Limit of Insurance Condo Association D & O Rate Per Unit Minimum Premium

$ 300,000 500,000

1,000,000

$2.05 2.30 2.75

$120 135 165

Deductible Factor

$ 250 1.025 500 1.000

1,000 0.950 3,000 0.895 5,000 0.875

10,000 0.825

(2) Opticians And Optometrists Professional Liability endorsement BOP7050 is available to provide professional liability coverage on an occurrence basis for bodily injury, property damage, personal injury and advertising injury arising out of the rendering of or failure to render professional services by a licensed optician and / or optometrist while performing services at designated premises. Temporary workers and independent contractors are included as insureds, however, coverage is excess over any other professional liability insurance available to these entities.

This coverage is available to eligible franchised or owner operated optical goods stores with one optometrist on site during business hours. The practice of optometry must be limited to the prescription of glasses and contact lenses. All professionals must be properly licensed.

Premium Determination – Select the per professional Flat Charge based upon the liability each occurrence limit and the type of professional. Multiply the appropriate Flat Charge by the number of opticians and, separately, multiply the appropriate Flat Charge by the number of optometrists. The sum of these two amounts is the premium for this coverage. Do not include temporary workers or independent contractors if they carry their own professional liability coverage.


Per Optician Flat Charge $ 30 $ 40 $ 50 $ 200

Per Optometrist Flat Charge 250 350 450 1,000 (3) Dry Cleaners’ Customers’ Property Coverage endorsement BOP-7041 is available for dry cleaning

establishments under the National Dry Cleaners Program. Covered premises, coverage, limits and deductibles are scheduled using BOP-7046 (Dry Cleaners’ Customers’ Property Coverage Schedule).

Description of Coverage – (a) Goods Held For Processing – Excluding Furs And Articles Trimmed With Fur coverage is provided at

‘no stated limit’ The standard deductible is $500. Available optional deductibles are $250, $1,000, $2,500, $5,000 and $10,000.

(b) Goods Held For Processing – Furs And Articles Trimmed With Fur is provided with basic limits of $5,000 per premises, $5,000 per article and $5,000 for property off-premises. Higher per premises limits and per article limits are available up to $10,000. The standard deductible is $500. Available optional deductibles are $250, $1,000, $2,500, $5,000 and $10,000.

(c) Goods Held For Storage – Excluding Furs And Articles Trimmed With Fur is provided with basic limits of $25,000 per premises, $5,000 per article and $25,000 for property off-premises. Higher per premises limits up to $250,000 and per article limits up to $10,000 are available. The standard deductible is $500. Available optional deductibles are $250, $1,000, $2,500, $5,000 and $10,000.


EXCEPTION PAGES



Additional Endorsements – Applicable to Specific Classes (continued) (3) Dry Cleaners’ Customers’ Property Coverage (continued) (d) Goods Held For Storage – Furs And Articles Trimmed With Fur is provided with basic limits of $15,000

per premises, $500 per article and $5,000 for property off-premises. Higher per premises limits up to $50,000 and per article limits up to $10,000 are available. The standard deductible is $500. Available optional deductibles are $250, $1,000, $2,500, $5,000 and $10,000.

(e) Excess Legal Liability for the Storage of Furs and Articles Trimmed with Fur is provided with basic limits of $15,000 per premises and $5,000 per article. Higher per premises limits up to $100,000 and per article limits up to $10,000 are available. Deductibles do not apply to this coverage.

Deductible (per occurrence)

The deductible applies per occurrence. Different deductibles can be selected for different coverages. The highest deductible shown for any coverage serves as the aggregate deductible for all occurrences.

Premium Determination (per premises) Gross Annual Dry Cleaning Receipts x Flat Rate. Refer to Company.

(4) Residential Property Protection Endorsement BOP-7007 is available on policies covering residential occupancy buildings at the Level 1 OR Level 2 OR Level 3 coverage limits shown below. Covered locations, limits and deductibles are scheduled using the Residential Property Protection Endorsement Schedule (BOP-7047). Business Income and Extra Expense are included within the sub-limits.

Level 1 Level 2 Level 3 Ordinance Or Law

Coverage 1 at Building Limits Combined Coverage 2 and 3 at $250,000 per occurrence/building and $500,000 aggregate $2,500 deductible (per occurrence)

Coverage 1 at Building Limits Combined Coverage 2 and 3 at $500,000 per occurrence/building and $1,000,000 aggregate. $2,500 deductible (per occurrence)

Coverage 1 at Building Limits Combined Coverage 2 and 3 at $2,500,000 per occurrence/building and $2,500,000 aggregate. $2,500 deductible (per occurrence)

Flood, Water that Backs Up and Water Below the ground surface

$250,000 per occurrence/ building $500,000 aggregate $5,000 deductible (per occurrence)

$1,000,000 per occurrence/ building $2,000,000 aggregate $5,000 deductible (per occurrence)


Earthquake $250,000 per occurrence/ building $500,000 aggregate $5,000 deductible (per occurrence)



Aggregate Limit for all coverage provided during the policy period

$2,000,000 $2,000,000 $2,500,000


EXCEPTION PAGES



Additional Endorsements – Applicable to Specific Classes (continued)

(4) Residential Property Protection Endorsement BOP-7007 (continued)

Premium Determination – Apply a Flat Charge for up to 4 covered locations plus an additional flat charge for each covered location over 4.

Flat Charge

Level Up to 4 Covered

Locations Each Additional

Covered Location Maximum 1 $ 400 $ 50 $1,500 2 1,500 75 2,500 3 2,500 150 3,500

(5) Garage Businessowners Broad Form Coverage endorsement BOP-7038 is available to insureds whose

predominant business is Garage operations. This endorsement provides the following coverage package: • Broad Form Insured – Hired and Nonowned Auto Liability • Liability coverage territory is worldwide for Hired Autos leased, hired, rented or borrowed without a driver for

30 days or less • Hired Auto Physical Damage

• Per auto limit of insurance is lesser of ACV, cost to repair / replace with like kind or quality or $50,000 • $500 deductible; not applicable to glass repair • Loss of use covered for $50 per day up to a maximum of $1,500 • Temporary expenses incurred due to total theft of the auto is covered for $50 per day up to a maximum

of $1,500 • $500 coverage for loss of personal effects due to total theft of the auto. No deductible. • Mechanical Breakdown exclusion does not apply to the accidental discharge of an airbag • Coverage territory is worldwide for Hired Autos leased, hired, rented or borrowed without a driver for 30

days or less • Injury to co-employee coverage - Hired Auto Liability • Knowledge and Notice of an Occurrence or Offense • Unintentional Failure to Disclose Hazards • 60 days notice of cancellation (minimum)

Premium Determination – Apply a .03 factor (3%) to the total of the mandatory liability coverage premium for all locations. This is subject to a coverage minimum premium of $100.

(6) Work You Performed Coverage endorsement BOP-7102 is available to insureds whose predominant business is

Garage operations. This endorsement deletes the Damage To Your Work exclusion with respect to work performed in relation to garage operations (i.e., Mechanics E&O). It also deletes the Faulty Work exclusion under the Garage Businessowners Customer’s Auto Coverage Endorsement.

Premium Determination – Apply a .05 factor (5%) to the total of the mandatory liability coverage premium for all garage locations. This is subject to a coverage minimum premium of $100.

40. APPLICATION OF SECTION V – CLASS-SPECIFIC ENDORSEMENTS

This rule does not apply. 41. APARTMENT BUILDINGS – CLASS-SPECIFIC ENDORSEMENTS

This rule does not apply. 42. RESTAURANTS – CLASS-SPECIFIC ENDORSEMENTS


Supporting Document Schedules

Satisfied - Item: State Submissions List

Comments: This is only being submitted in MA at this timeAttachment(s):Item Status:Status Date:

Satisfied - Item: Policy Endorsement ListComments:

Attachment(s): Endorsement list.pdfItem Status:Status Date:

Satisfied - Item: Annotated ComparisonComments:

Attachment(s): contents comparison.pdf

Manual pages comparison.pdfItem Status:Status Date:

Satisfied - Item: Form Utilization ListComments:

Attachment(s): Forms utilitzation.pdfItem Status:Status Date:


Attachment(s): Cert of compliance.pdfItem Status:Status Date:








Comments:




128544198 .


P & C Checklist 01 13 BOP-7079 (1).pdfItem Status:Status Date:

Satisfied - Item: Actuarial Memorandum - Property and Casualty InsuranceComments:

Attachment(s): Explanatory Memo.pdf

ExhibitA.pdfItem Status:Status Date:


Attachment(s):





ExhibitA.pdfItem Status:Status Date:

Bypassed - Item: Loss Cost Adoption Form (SRB-LC)

Bypass Reason: n/aAttachment(s):Item Status:Status Date:







Bypassed - Item: Rate Deviation Abstract (SRB-DV)


Bypassed - Item: Statement of Variability


Bypassed - Item: Letter of Authorization


Satisfied - Item: Applications

Comments: see forms scheduleAttachment(s):Item Status:Status Date:







MASSACHUSETTS DIVISION OF INSURANCE POLICY ENDORSEMENT LIST

PFR-PEL (ed. 01/12)

INSTRUCTIONS: For filings containing or adopting Endorsements1

- In the Endorsement Name column, the name of each Endorsement submitted in the filing; , please indicate the following:

- In the Form Number column, the form number of each Endorsement submitted in the filing; - In the M/O/E, whether each Endorsement is Mandatory2 (M), Optional3 (O) or Elected4

- In the Advise to Applicant/Insured column, how the applicant/insured is advised of the option to elect or decline each Elected Endorsement; (E);

- In the Premium/Credit column, whether the Endorsement bears a premium or credit or otherwise impacts the policy rate (Yes/No). All Endorsements must be listed in the program’s filed manual/exception pages; the rules for Optional Endorsements must also state the circumstances under which the Filing Company may issue each Endorsement. _________________________________________________________________________________________________________________________________ Please enter the product name as filed. Endorsement Name Form Number M/O/E Advise to Applicant/Insured Premium/Credit Limited Food Spoilage ABC 0671 (07/11) E Advised by agent No

1 Endorsement: This is equivalent to any form whose Form Type on the SERFF Form Schedule may accurately be described as END. 2 Mandatory: The Endorsement is issued on all policies. 3 Optional: The Endorsement is issued at the sole discretion of the Filing Company based upon underwriting, with no option of the applicant/insured to decline. 4 Elected: The Endorsement may be elected or declined by the applicant/insured.

BOP-7058 Ed 02-09E

NoEmployment Practices Liability EndorsementNoBOP-7079 Ed 02-09

Advised by agentAdvised by agent

StarAdvantage Businessowners Program

Split Prior Acts Coverage Endorsement

RESET FORM

E

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TABLE OF CONTENTS

(MA) BO Contents-1 November 2012

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Exception Pages



















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EXCEPTION PAGES



7. Employment-Related Practices Liability This rule is replaced by the following: a. Endorsement (1) Attach Employment Practices Liability Coverage endorsement BOP-7059 when this coverage is

selected. This endorsement provides coverage for damage arising out of employment practices if such employment practice occurred after the Retroactive Date and before the end of the policy period and if the claim is first made against an insured during the policy period. It includes a duty to defend. The aggregate limit applies to the annual term or any applicable policy period less than one year (other than an extension of less than one year after the policy is issued). The Schedule of the endorsement provides an entry for:

(a) Limits of Insurance which provide separate limits for damages and defense expenses; (b) A deductible amount which the insured agrees to contribute per claim toward the amounts paid as

damages and as defense expense. The company’s obligation to pay damages and defense expense on behalf of the insured applies only to the amount of damages and defense expense in excess of the deductible amount.

(c) A retroactive date. (2) Also, attach State Amendatory endorsement BOP-7082 (Deductible Amendment) (3) Employment Practices Liability Coverage cannot be written under the Businessowners policy if the

number of employees exceeds 250. b. Limits of Insurance (1) The minimum Limits of Insurance are: $50,000 Aggregate Limit – Damages / $50,000 Each Claim Limit – Damages $50,000 Aggregate Limit – Defense Expense / $50,000 Each Claim Limit – Defense Expense (2) These limits may be increased to one of the following options at the insureds request and with

approval by the company: (a) $100,000 Aggregate Limit – Damages / $100,000 Each Claim Limit – Damages $100,000 Aggregate Limit – Defense Expense / $100,000 Each Claim Limit – Defense Expense (b) $250,000 Aggregate Limit – Damages / $250,000 Each Claim Limit – Damages $250,000 Aggregate Limit – Defense Expense / $250,000 Each Claim Limit – Defense Expense c. Deductible A minimum deductible of $5,000 applies to Employment Practices Liability Coverage. For the higher limit


d. Supplemental Extended Reporting Period (1) A Supplemental Extended Reporting Period option may be purchased by the named insured when






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EXCEPTION PAGES



7. Employment-Related Practices Liability This rule is replaced by the following: a. Endorsement (1) When this coverage is selected, coverage is afforded for damage arising out of employment practices

if such employment practice occurred after the Retroactive Date and before the end of the policy period and if the claim is first made against an insured during the policy period. It includes a duty to defend. The aggregate limit applies to the annual term or any applicable policy period less than one year (other than an extension of less than one year after the policy is issued). (a) There are two coverage options:

i. Attach Employment Practices Liability Coverage endorsement BOP-7059 when separate limits apply to both damages and defense expenses.

ii. Attach Employment Practices Liability Coverage endorsement BOP-7058 when a single limit applies to both damages and defense expenses.

(b) The company’s obligation to pay damages and defense expense on behalf of the insured applies only to the amount of damages and defense expense in excess of the per claim deductible amount.

(2) Also, attach State Amendatory endorsement BOP-7082 (Deductible Amendment) (3) Employment Practices Liability Coverage cannot be written under the Businessowners policy if the

number of employees exceeds 250. b. Limits of Insurance (1) When separate limits apply to both damages defense expenses (BOP-7059):

(a) The minimum Limits of Insurance are: $50,000 Aggregate Limit – Damages / $50,000 Each Claim Limit – Damages $50,000 Aggregate Limit – Defense Expense / $50,000 Each Claim Limit – Defense Expense

(b) These limits may be increased to one of the following options at the insureds request and with approval by the company: (i) $100,000 Aggregate Limit – Damages / $100,000 Each Claim Limit – Damages

$100,000 Aggregate Limit – Defense Expense / $100,000 Each Claim Limit – Defense Expense

(ii) $250,000 Aggregate Limit – Damages / $250,000 Each Claim Limit – Damages $250,000 Aggregate Limit – Defense Expense / $250,000 Each Claim Limit – Defense Expense

(2) When a single limit applies to both damages and defense expenses (BOP-7058): (a) The minimum Limits of Insurance are:

$50,000 Aggregate Limit / $50,000 Each Claim Limit (b) These limits may be increased to one of the following options at the insureds request and with

approval by the company: (i) $100,000 Aggregate Limit / $100,000 Each Claim Limit (ii) $250,000 Aggregate Limit / $250,000 Each Claim Limit

c. Deductible A minimum deductible of $5,000 applies to Employment Practices Liability Coverage. For the higher limit


∗

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EXCEPTION PAGES



B. Liability Endorsements (continued) 7. Employment-Related Practices Liability (continued) (2) Use endorsement BOP-7060 (Third Party Liability Coverage). f. Premium Determination (1) Determine the basic limits premium based on the number of employees multiplied by the rate per



(2) Adjust the basic limits premium by: (i) the Group V State Hazard Group Factor of .95; and (ii) the applicable Standard Industry Classification (SIC) code factor:


SIC Factor


SIC Factor



1.00 1.00 1.00 1.50 1.50

1.10

0.90 1.00 0.80

1.20 1.50 0.90 0.75 0.80 0.90 1.10 0.90 1.30 0.90 0.90 0.90 1.30 1.00 1.00 1.20 1.30 1.00 1.10

1.10 0.90 1.20 1.50 1.30 1.30 1.40



0.75 0.80

0.90 0.80 0.75 1.00 0.75 0.75 0.75 0.75

1.00 1.20 1.30 1.20 0.80 0.80 1.10

1.00 0.75 0.90 0.80 0.80 0.75 1.10 1.30 0.75 1.20 0.80 0.75 1.00

1.00

Determine this factor based on the 1st two digits of the SIC code. If no match, use 1.00.



















EXCEPTION PAGES



B. Liability Endorsements (continued) 7. Employment-Related Practices Liability (continued) d. Supplemental Extended Reporting Period (1) A Supplemental Extended Reporting Period option may be purchased by the named insured when






(2) Use endorsement BOP-7060 (Third Party Liability Coverage). f. Premium Determination (1) Determine the basic limits premium based on the number of employees multiplied by the rate per



∗

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EXCEPTION PAGES



B. Liability Endorsements (continued) 7. Employment-Related Practices Liability (continued) (3) Multiply the amount determined in step (2) by the appropriate limit factor to obtain the premium at limits:

Each Claim / Policy Aggregate Limit Factor

$50,000 / $50,000 .338 $100,000 / $100,000 .469 $250,000 / $250,000 .714



$ 100,000 .903 250,000 .930




$50,000 $55 $100,000 $70 $250,000 $105





attach BOP-7080 (Split Limits Prior Acts Coverage Endorsement). 9. Exclusion – Silica and Silica-Related Dust This rule does not apply. Refer to Rule 16 for instructions regarding the use of the Asbestos, Silica Or Talc

























EXCEPTION PAGES



B. Liability Endorsements (continued) 7. Employment-Related Practices Liability (continued) (2) Adjust the basic limits premium by:

(i) the Group V State Hazard Group Factor of .95; and (ii) the applicable Standard Industry Classification (SIC) code factor:


SIC Factor


SIC Factor



1.00 1.00 1.00 1.50 1.50

1.10

0.90 1.00 0.80

1.20 1.50 0.90 0.75 0.80 0.90 1.10 0.90 1.30 0.90 0.90 0.90 1.30 1.00 1.00 1.20 1.30 1.00 1.10

1.10 0.90 1.20 1.50 1.30 1.30 1.40



0.75 0.80

0.90 0.80 0.75 1.00 0.75 0.75 0.75 0.75

1.00 1.20 1.30 1.20 0.80 0.80 1.10

1.00 0.75 0.90 0.80 0.80 0.75 1.10 1.30 0.75 1.20 0.80 0.75 1.00

1.00

Determine this factor based on the 1st two digits of the SIC code. If no match, use 1.00. (3) Multiply the amount determined in step (2) by the appropriate limit factor to obtain the premium at limits:

Each Claim / Policy Aggregate

Separate Limits Factor

(BOP-7059)

Single Limits Factor

(BOP-7058) $50,000 / $50,000 .338 .270 $100,000 / $100,000 .469 .374 $250,000 / $250,000 .714 .580



$ 100,000 .903 250,000 .930

∗

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EXCEPTION PAGES




































EXCEPTION PAGES



B. Liability Endorsements (continued) 7. Employment-Related Practices Liability (continued)




$50,000 $55 $100,000 $70 $250,000 $105





attach: (1) BOP-7080 (Split Limits Prior Acts Coverage Endorsement) if BOP-7059 applies; or

(2) BOP-7079 (Split Limits Prior Acts Coverage Endorsement) if BOP-7058 applies. 9. Exclusion – Silica and Silica-Related Dust This rule does not apply. Refer to Rule 16 for instructions regarding the use of the Asbestos, Silica Or Talc









∗

New.pdf








EXCEPTION PAGES

(MA) BO E-27 November 2012 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Copyright 2004, Insurance Services Office





Premium Determination – Refer to Company. (2) Voluntary Property Damage Coverage endorsement BOP-7020 can be used to provide coverage for claims

arising out of property damage to property of others in the insureds care, custody and control which occurs away from the insureds premises. The occurrence/aggregate limit options are: $5,000/$25,000; $25,000/$50,000; $50,000/$100,000; and, $100,000/$200,000. Losses under this coverage are included within the policy occurrence and aggregate limits and are not in addition to those limits. A $500 deductible applies.



25,000 50,000

100,000

$ 25,000 50,000

100,000 200,000

$100 140 180 225








Expenses Limit


Operations


Operations


$ 300,000 $ 900,000 $ 900,000 1.002 500,000 1,500,000 1,500,000 1.096

1,000,000 3,000,000 3,000,000 1.209 2,000,000 6,000,000 6,000,000 1.334




∗







EXCEPTION PAGES




























Premium Determination – Refer to Company.

New.pdf






EXCEPTION PAGES







C. Additional Insured Endorsements (Liability and Medical Expenses Coverage)

















∗















EXCEPTION PAGES



Additional Endorsements – Liability (continued)

(2) Voluntary Property Damage Coverage endorsement BOP-7020 can be used to provide coverage for claims arising out of property damage to property of others in the insureds care, custody and control which occurs away from the insureds premises. The occurrence/aggregate limit options are: $5,000/$25,000; $25,000/$50,000; $50,000/$100,000; and, $100,000/$200,000. Losses under this coverage are included within the policy occurrence and aggregate limits and are not in addition to those limits. A $500 deductible applies.



25,000 50,000

100,000

$ 25,000 50,000

100,000 200,000

$100 140 180 225








Expenses Limit


Operations


Operations


$ 300,000 $ 900,000 $ 900,000 1.002 500,000 1,500,000 1,500,000 1.096

1,000,000 3,000,000 3,000,000 1.209 2,000,000 6,000,000 6,000,000 1.334







New.pdf














EXCEPTION PAGES



C. Additional Insured Endorsements (Liability and Medical Expenses Coverage) (continued) 8. Additional Insured – Engineers, Architects or Surveyors c. Premium Determination





10. Additional Insured – Vendors c. Premium Determination








14. Additional Insured – Owners, Lessees or Contractors – With Additional Insured Requirement In Construction Contract

c. Premium Determination Multiply the flat premium charge by the applicable increased limit factor. Flat Premium Charge: $200.00



∗













EXCEPTION PAGES



Additional Endorsements – Liability (continued) C. Additional Insured Endorsements (Liability and Medical Expenses Coverage)

















8. Additional Insured – Engineers, Architects or Surveyors c. Premium Determination





New.pdf












EXCEPTION PAGES



Additional Endorsements – Additional Insured







Flat Premium Charge: $250.00 D. Endorsements Applicable To Specific Classes




2. Motels








$15.00 27.00

$16.00 30.00

$17.00 32.00

$27.20 51.20





∗

















EXCEPTION PAGES



C. Additional Insured Endorsements (Liability and Medical Expenses Coverage) (continued) 10. Additional Insured – Vendors c. Premium Determination







For each additional insured, multiply the flat premium charge by the applicable increased limit factor. Flat Premium Charge: $75.00 14. Additional Insured – Owners, Lessees or Contractors – With Additional Insured Requirement In

Construction Contract c. Premium Determination Multiply the flat premium charge by the applicable increased limit factor. Flat Premium Charge: $200.00


For each additional insured, multiply the flat premium charge by the applicable increased limit factor. Flat Premium Charge: $25.00 Additional Endorsements – Additional Insured






New.pdf
















EXCEPTION PAGES








$0.82 $1.21

$0.92 $1.35

$1.06 $1.55

$1.70 $2.48








(b) Endorsement





$ 300,000 $ 900,000 1.001 500,000 1,500,000 1.152

1,000,000 3,000,000 1.324 2,000,000 6,000,000 1.494





$0.14 $0.16 $0.26 $0.42 Minimum Premium: $500

∗























EXCEPTION PAGES



Additional Endorsements – Additional Insured (continued)



D. Endorsements Applicable To Specific Classes




2. Motels








$15.00 27.00

$16.00 30.00

$17.00 32.00

$27.20 51.20









$0.82 $1.21

$0.92 $1.35

$1.06 $1.55

$1.70 $2.48

New.pdf






















EXCEPTION PAGES









$1,000,000 0.490 $2,000,000 0.800

Correction of Work



(4) Endorsement




Factor 300,000 900,000 1.001 500,000 1,500,000 1.152

1,000,000 3,000,000 1.324 2,000,000 6,000,000 1.494



∗



EXCEPTION PAGES











(b) Endorsement





$ 300,000 $ 900,000 1.001 500,000 1,500,000 1.152

1,000,000 3,000,000 1.324 2,000,000 6,000,000 1.494





$0.14 $0.16 $0.26 $0.42 Minimum Premium: $500

New.pdf


EXCEPTION PAGES






$ 300,000 500,000

1,000,000

$2.05 2.30 2.75

$120 135 165

Deductible Factor

$ 250 1.025 500 1.000

1,000 0.950 3,000 0.895 5,000 0.875

10,000 0.825












∗



EXCEPTION PAGES









$1,000,000 0.490 $2,000,000 0.800

Correction of Work



(4) Endorsement




Factor 300,000 900,000 1.001 500,000 1,500,000 1.152

1,000,000 3,000,000 1.324 2,000,000 6,000,000 1.494



New.pdf


EXCEPTION PAGES






















$2,000,000 $2,000,000 $2,500,000

∗



EXCEPTION PAGES






$ 300,000 500,000

1,000,000

$2.05 2.30 2.75

$120 135 165

Deductible Factor

$ 250 1.025 500 1.000

1,000 0.950 3,000 0.895 5,000 0.875

10,000 0.825












New.pdf


EXCEPTION PAGES






Flat Charge


















∗



EXCEPTION PAGES






















$2,000,000 $2,000,000 $2,500,000

New.pdf


EXCEPTION PAGES






Flat Charge


















New.pdf

Forms Utilization These endorsements will be used with the ISO Business Owners BP 00 03 01 06 adopted effective 01-15-2009.

SRB-CC (ed. 01/11)

MASSACHUSETTS DIVISION OF INSURANCE

CERTIFICATION OF COMPLIANCE _____________________________________________________________________________________________ (Please enter the corporate name of the First Filing Company, hereinafter referred to as “the Filing Entity.”) _____________________________________________________________________________________________ (Please enter the Company Tracking Number or SERFF Tracking Number, hereinafter referred to as “the Filing.”)

I, _________________________________, ___________________________________, Name Title as a representative of the Filing Entity and duly authorized to give this certification on its behalf, hereby certify under the pains and penalties of perjury that this Filing is in compliance with all relevant laws and regulations of the Commonwealth of Massachusetts. _____________________________________________ ________________________ Signature Date

Michelle HansonDigitally signed by Michelle Hanson DN: cn=Michelle Hanson, o=Harleysville Insurance, ou, [email protected], c=US Date: 2012.05.15 08:30:26 -04'00'

RESET FORM

July 3, 2013

Co Tr Number BOMH12202012-1(SERFF # HRLV-129090680

CL Product AnalystMichelle Hanson

Harleysville Insurance Company

MASSACHUSETTS DIVISION OF INSURANCE BASE CHECKLIST FOR PROPERTY AND CASUALTY INSURANCE

Page 1 of 5

PFR-B-PAC (ed. 01/13)

Policy/Coverage Form #: ____________________ (Please enter only one number per checklist; if none, leave blank.) CHECKLIST INSTRUCTIONS

1) A completed copy of this checklist is required for each Policy/Coverage Form being submitted. 2) For purposes of these instructions, a Policy/Coverage Form is:

a) a base coverage form of a property and/or casualty insurance policy; or b) an endorsement providing property or casualty insurance of a type other than that provided in the base coverage form to which it will be attached.

3) If the filing contains no Policy/Coverage Forms, please submit a checklist with the General Form Requirements, Policy Prohibitions and/or General Rate Requirements sections, as well as any other applicable sections, completed.

4) All page and paragraph references should refer back to the place in the form, memorandum or other document where compliance is demonstrated. 5) A brief explanation should be provided for all items considered not applicable to the filed materials; “N/A” is not a sufficient explanation.

PLEASE NOTE THE FOLLOWING

1) Credit property insurance and credit involuntary unemployment insurance products also require a completed Supplemental Checklist. 2) Legal service plans subject to 211 CMR 90.00 require submission of the Base Checklist for Legal Service Plans, and not this checklist. 3) Motor vehicle insurance products and workers’ compensation insurance products require submission of different checklists, and not this checklist. 4) All laws relative to the filing of policy/coverage forms apply to their endorsements and attached applications under M.G.L. 175, §192.

GENERAL FORM REQUIREMENTS If not filing forms, check here and skip section: _____ ID Brief Requirement Description Compliance Brief Explanation, if Not Applicable

GR1 10-point font, readability score of 50, and other minimum objective standards of M.G.L. 175, §2B. Check: _____

GR2 Effective date 30 days from submission. M.G.L. 175, §22A Check: _____ GR3 Form headed by corporate name of company. FGN 2006-A Check: _____ GR4 Signatures. M.G.L. 175, §33 Page _____, Para. _____

GR5 Applications constituting part of the contract designed to be attached to the policy. M.G.L. 175, §192 Check: _____

COMBINATION POLICIES – M.G.L. 175, §§102A and 111A If not filing a combination policy, check here and skip section: _____ ID Brief Requirement Description Compliance Brief Explanation, if Not Applicable

CP1 Percentage of loss or claim. Page _____, Para. _____ CP2 Required notices, sworn statements, or proofs of loss. Page _____, Para. _____ CP3 Service of process in actions or suits. Page _____, Para. _____ CP4 Return premium upon cancellation. Page _____, Para. _____ CP5 Elimination/Reduction of coverage (liability only). Page _____, Para. _____ MUTUAL COMPANY POLICY PROVISIONS If not a mutual company, check here and skip section: _____ ID Brief Requirement Description Compliance Brief Explanation, if Not Applicable

MC1 Contingent mutual liability. M.G.L. 175, §§102A(4) and 111A(4) Page _____, Para. _____ MC2 Meetings of the company. M.G.L. 175, §§76 and 102B Page _____, Para. _____ Form #: _____________________________________

✔

✔

✔

✔

Please select an option if this item does not apply.


✔

BOP-7058

RESET FORM

Other (see Comments section of Checklist component)

✔

http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter175/Section192�

http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter175/Section2B�

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Page 2 of 5


MC3 Separate classifications of business. M.G.L. 175, §§80 and 102B Page _____, Para. _____ MC4 Total amount of liability. M.G.L. 175, §81 Page _____, Para. _____ MC5 Application questions. M.G.L. 175, §§98 and 111B Page _____, Para. _____ MC6 Assessment liability. M.G.L. 175, §§§83, 93 and 111B Page _____, Para. _____ FIRE POLICY STANDARD FORM – M.G.L. 175, §99(12) If not filing property insurance, check here and skip section: _____ ID Brief Requirement Description Compliance Brief Explanation, if Not Applicable

FP1 Insurance agreement. Page _____, Para. _____ FP2 Assignment of the policy. Page _____, Para. _____ FP3 Policy subject to its provisions and stipulations. Page _____, Para. _____ FP4 Witness provision. Page _____, Para. _____ FP5 Voiding of the policy. Page _____, Para. _____ FP6 Items not covered. Page _____, Para. _____ FP7 Fire exclusions. Page _____, Para. _____ FP8 Other insurance. Page _____, Para. _____ FP9 Other exclusions. Page _____, Para. _____ FP10 Other perils insured against. Page _____, Para. _____ FP11 Extent of insurance. Page _____, Para. _____ FP12 Permission and waiver. Page _____, Para. _____ FP13 Appraisal and examinations. Page _____, Para. _____ FP14 Cancellation by insured. Page _____, Para. _____ FP15 Cancellation by company. Page _____, Para. _____ FP16 Excess premium at cancellation. Page _____, Para. _____ FP17 Cancellation after 60 days. Page _____, Para. _____ FP18 Cancellation for nonpayment of premium. Page _____, Para. _____ FP19 Policy payable to mortgagees. Page _____, Para. _____ FP20 Proportion of loss. Page _____, Para. _____ FP21 Notice and proof of loss. Page _____, Para. _____ FP22 Payment of claim. Page _____, Para. _____ FP23 Dispute resolution for claims. Page _____, Para. _____ FP24 Suits for recovery of claims. Page _____, Para. _____ FP25 Assignment of right of recovery. Page _____, Para. _____ NB: M.G.L. 175, §99 does not apply to insurance against the hazards described in the Second and Third clauses of M.G.L. 175, §47. ADDITIONAL PROPERTY PROVISIONS If not filing property insurance, check here and skip section: _____ ID Brief Requirement Description Compliance Brief Explanation, if Not Applicable

AP1 “In case of fire” notice. M.G.L. 175, §99(7) Page _____, Para. _____ AP2 Certificate of municipal liens. M.G.L. 175, §99(14) Page _____, Para. _____ AP3 Notice to building commissioner. M.G.L. 175, §99(15) Page _____, Para. _____ AP4 Cost of relocation benefit. M.G.L. 175, §99(15A) Page _____, Para. _____

20

42

20

BP 0003

5

2

BP 0003

21

1

2 BP 000320

5

1

1

6

n/a

40

4

2

47

BP 0108

BP 0003

31

BP 0003

BP 0003

2

2

4

7

4

45

BP 0003

6

40BP 0003

46

4

BP 0003

BP 0003

BP 0003

4

BP 0003

1

21

BP 0003

1

321

notice is attached to every policy

20

BP 0186

BP 0003

40

1BP 0003

contained on policy jacket

BP 0003

BP 0108

4

BP 0003

1

2

5

BP 0108

BP 0003BP 0003

13

45

5

5

5

BP 0003

BP 0003

5

2

40

BOP-70334

2






http://www.mass.gov/legis/laws/mgl/175-93.htm�




Page 3 of 5


AP5 Elimination/Reduction in coverage. M.G.L. 175, §99(16) Page _____, Para. _____

AP6 Damage by nuclear reaction or nuclear contamination. M.G.L. 175, §99A Page _____, Para. _____

AP7 Loss settlement clause. M.G.L. 175, §99B Page _____, Para. _____ AP8 Notice of non-renewal. M.G.L. 175, §193P Page _____, Para. _____ AP9 Mold exclusion requirements. Bulletin 2006-02 Page _____, Para. ___ff.

AP10 Heating oil release coverage requirements for “residential property” as defined in M.G.L. 175, §4D. Bulletin 2010-03 Page _____, Para. ___ff.

AP11 Minimum “guaranteed” replacement cost coverage cap of 125% of the amount of insurance (homeowners insurance). Page _____, Para. _____

CLAIMS-MADE GENERAL LIABILITY PROVISIONS – FGN 2011-A If not filing a general liability policy, check here and skip section: _____ ID Brief Requirement Description Compliance Brief Explanation, if Not Applicable

GL1 Retroactive Date Endorsement. 1.a Check: _____ Form #:_______________________________________ GL2 Termination of coverage. 1.b Page _____, Para. _____ GL3 Automatic extended reporting period. 1.c Page _____, Para. _____

GL4 Additional extended reporting period coverage available for purchase. 1.d.1 Page _____, Para. _____

GL5 Minimum 3-year additional extended reporting period. 1.d.ii Page _____, Para. _____

GL6 Aggregate liability limit for additional extended reporting period coverage. 1.d.iii Page _____, Para. _____

GL7 Deadline for written acceptance of additional extended reporting period coverage. 1.d.iv Page _____, Para. _____

GL8 Claims-made face page disclosure. 2 Check: _____ LEAD LIABILITY PROVISIONS – M.G.L. 175, §111H If not covering residential premises, check here and skip section: _____ ID Brief Requirement Description Compliance Brief Explanation, if Not Applicable

LL1 Premises with letter in effect. 211 CMR 131.04 Page _____, Para. _____ LL2 Premises with letter obtained and maintained. 211 CMR 131.05 Page _____, Para. _____ LL3 New owners. 211 CMR 131.06 Page _____, Para. _____ LL4 Additional requirements. 211 CMR 131.07 Page _____, Para. _____ LL5 Premises not in compliance. 211 CMR 131.08 Page _____, Para. _____ LL6 Owner-occupied single family premises. 211 CMR 131.09 Page _____, Para. _____ LL7 Coverage summary. 211 CMR 131.13(1) Check: _____ LL8 Disclosure notice. 211 CMR 131.13(2) Check: _____ ADDITIONAL LIABILITY PROVISIONS If not filing liability insurance, check here and skip section: _____ ID Brief Requirement Description Compliance Brief Explanation, if Not Applicable

AL1 Medical pay provisions. M.G.L. 175, §111C Page _____, Para. _____

15

4

3 BP 0003

N/A personal lines

4

✔

BP 0108

acknowledged

211


✔

N/a

33

BP 00034

BP 1431 & BP 1444




http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter175/Section193P�

http://www.mass.gov/ocabr/docs/doi/bulletins/bulletins-06-02.pdf�

http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter175/Section4d�

http://www.mass.gov/ocabr/business/insurance/doi-regulatory-info/doi-regulatory-bulletins/2010-doi-bulletins/2010-03-coverage-required-under-chapter-453-of.html�

http://www.mass.gov/ocabr/docs/doi/companies/checklists/2011-a.pdf�

http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter175/Section111H�

http://www.mass.gov/ocabr/docs/doi/legal-hearings/211-131.pdf�

http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter175/Section111C�


Page 4 of 5


AL2 Professional liability. M.G.L. 175, §111E Page _____, Para. _____ AL3 Liquor liability. M.G.L. 175, §112A Page _____, Para. _____

AL4 Heating oil release coverage requirements for “residential property” as defined in M.G.L. 175, §4D. Bulletin 2010-03 Page _____, Para. ___ff.

AL5a For dog exclusions, specification of all dogs/breeds deemed aggressive by the company that have a prior history of biting. Page _____, Para. _____

AL5b For dog exclusions, support for exclusion of dog from breeds specified. Page _____, Para. _____

PROHIBITIONS ID Brief Requirement Description Compliance Brief Explanation, if Not Applicable

PR1 Provisions depriving the courts of the Commonwealth of jurisdiction. M.G.L. 175, §22 Check: _____

PR2 Inclusion of motor vehicle, life, health, accident and sickness insurance. M.G.L. 175, §22A Check: _____

PR3 Mandatory binding arbitration. M.G.L. 93A, §9(6) Check: _____

PR4 Rebates and other inducements. M.G.L. 175, §182 and M.G.L. 176D, §3(8) Check: _____

PR5 Discriminating in forms and rates against health care providers based on practiced specialty (“take all comers”). M.G.L. 175, §193U

Check: _____

PR6 Inclusion of defense costs within the limits of insurance in stand-alone commercial general liability policies. Check: _____

GENERAL RATE REQUIREMENTS If not filing rates, check here and skip section: _____ ID Brief Requirement Description Compliance Brief Explanation, if Not Applicable

RR1 Effective date 15 days from submission. M.G.L. 174A, §6 and 175A, §6 Check: _____

RR2 Manual or plan of classifications, rules and rates. Ibid. Check: _____ RR3 Final calculated rate exhibits. Bulletin 2008-08 Check: _____

RR4

We hereby certify that the rates in this filing do not consist of tiers based on credit scores, not consider the insured’s credit score in the rating methodology. (This checklist item does not apply to property and casualty insurance for a business, professional or governmental organization.)

Check: _____ Check if item does not apply: _____

NB: rate filings are not required for aircraft hull and liability insurance, inland marine insurance, and ocean marine insurance. RATE FILING INFORMATION If not filing rates, check here and skip section: _____ ID Brief Requirement Description Compliance Brief Explanation, if Not Applicable

RS1 Five-year premium loss exhibit. Bulletin SRB 90-05 Check: _____

BP 1431 & BP 1444

2

✔

2 Please select an option if this item does not apply.

✔

✔

✔

31

No dog exclusions in filing


✔

Not medical malpractice insurance

✔


Please select an option if this item does not apply.✔

✔

✔

Not stand-alone general liability insurance

29Please select an option if this item does not apply.

http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter175/Section111E�






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http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter176D/Section3�


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Page 5 of 5


RS2 Three-year expense exhibit. Ibid. Check: _____ RS3 Competitor rates. Ibid. Check: _____ RS4 Judgment rates. Ibid. Check: _____

RS5 For homeowners forms only, count of Barnstable county exposures to which this insurance applies. Check: _____

RS6 For homeowners forms only, count of Dukes and Nantucket counties exposures to which this insurance applies. Check: _____

RS7 (a)-Rates Reference Guide in actuarial memorandum (see below). Check: _____ PREMIUM INSTALLMENT PAYMENT PLANS If not filing installment plan rules, check here and skip section: _____ ID Brief Requirement Description Compliance Brief Explanation, if Not Applicable

IP1 Actuarial justification for related fees and charges. Page _____, Para. _____

IP2 Prohibition of surcharges for credit card payment. M.G.L 140D, §28A Check: _____

IP3 Requirements for discounts as finance charges for credit card payment. Ibid. Page _____, Para. _____

(a)-RATES REFERENCE GUIDE If not (a)-rating, check here and skip section: _____ ID Brief Requirement Description Compliance Brief Explanation, if Not Applicable

AG1 Demonstration that risk classes lack sufficient homogeneity to calculate meaningful rates. Bulletin 2008-08 Page _____, Para. _____

AG2 The process by which the rate is determined. Page _____, Para. ___ff.

AG3 The role of judging the relative risk of one insured to another when determining the rate. Page _____, Para. _____

AG4 The role of comparing rates to rates on line for reinsurance when determining the rate. Page _____, Para. _____

AG5 The role of consideration of probable maximum loss when determining the rate. Page _____, Para. _____

AG6 The role of including a risk load or contingency factor in the rates when determining the rate. Page _____, Para. _____

AG7 A numerical example of how a sample rate for a particular risk, either real or hypothetical, would be arrived at. Page _____, Para. ___ff.

AG8 How the rate will be priced to be neither excessive nor inadequate as a stand-alone rate (i.e., the applicable coverage is stand-alone, not part of a package policy).

Page _____, Para. _____


✔

Not (a)-rating

✔


✔


Not homeowners insurance


Rates supplied by reinsurerRates supplied by reinsurer

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Page 1 of 5
















✔

✔

✔

✔



✔

BOP-7079

RESET FORM


✔














Page 2 of 5





20

42

20

BP 0003

5

2

BP 0003

21

1

2 BP 000320

5

1

1

6

n/a

40

4

2

47

BP 0108

BP 0003

31

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4

✔

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acknowledged

211


✔

N/a

33

BP 00034

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Page 4 of 5












Check: _____





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BP 1431 & BP 1444

2

✔


✔

✔

✔

31



✔


✔



✔

✔




















Page 5 of 5


















Page _____, Para. _____


✔

Not (a)-rating

✔


✔




Rates supplied by reinsurerRates supplied by reinsurer



Massachusetts Star Advantage Businessowners Program

Explanatory Memorandum

Currently, Harleysville Insurance offers an Employment Practices Liability (EPL) coverage endorsement under the BOP in Massachusetts which affords a separate limit for both damages and defense costs. To offer a lower cost option to our BOP insureds and at the request of our reinsurer, we would like to also offer EPL coverage with a single limit which is applicable to both damages and defense costs. With the exception of the application of limits, the coverage terms for both forms are identical. The rates for the newly introduced single limit coverage option are supplied by our reinsurer and are the same as those used in other states where a single limit product is offered. The rates for the current separate limits form remain unchanged. The coverage will not be changed upon renewal; i.e. if separate limits applied to the expiring policy term then separate limits will continue to apply on subsequent renewals.

Exhibit ASheet 1

HARLEYSVILLE INSURANCECountrywide Commercial Multi PerilHistorical Expense Experience Selections Summary

For the MASSACHUSETTS BOP Filing

BOP BOP BOP*Liab. Non-Liab. Expense Provisions

Provision Provision Selected for Analysisα COMMISSION 20.9% 20.9% 20.9%

α TAXES, LIC., FEES 3.5% 3.6% 3.6%

β OTHER ACQUISITION 12.4% 13.6% 13.1%

β GENERAL 0.8% 0.8% 0.8%

UW PROFIT PROVISION -0.8% 3.7% 1.9%

Expected Loss Ratio: 63.2% 57.4% 59.7%

χ ALAE 30.0% 3.5% 10.7%

β ULAE 5.0% 2.1% 3.3%

α Ratios expressed as a percentage of Written Premiumβ Ratios expressed as a percentage of Earned Premiumχ Ratios expressed as a percentage of Incurred Loss

* Volume weighted.

Exhibit ASheet 2

HARLEYSVILLE INSURANCECountrywide Commercial Multi Peril: LiabilityHistorical Expense Experience


Expense Provisions$ (000) % Ratio $ (000) % Ratio $ (000) % Ratio $ (000) % Ratio Selected for Analysis

MASSACHUSETTS DIRECT PREMIUM WRITTEN 10,696 --- 12,266 --- 12,599 --- 35,560 ---α, ε MASSACHUSETTS COMMISSION 2,081 19.5% 2,326 19.0% 2,364 18.8% 6,771 19.0% 20.9%α, φ MASSACHUSETTS TAXES, LIC., FEES 340 3.2% 413 3.4% 488 3.9% 1,240 3.5% 3.5%

COUNTRYWIDE DIRECT PREMIUM EARNED 212,711 --- 214,603 --- 240,690 --- 668,004 ---β COUNTRYWIDE OTHER ACQUISITION 27,178 12.8% 26,208 12.2% 29,259 12.2% 82,646 12.4% 12.4%β COUNTRYWIDE GENERAL 1,446 0.7% 1,370 0.6% 1,874 0.8% 4,691 0.7% 0.8%

δ Underwriting Profit Provision -0.8%

α Ratios expressed as a percentage of Written Premiumβ Ratios expressed as a percentage of Earned Premiumχ Ratios expressed as a percentage of Incurred Lossδ The profit provision was derived by Harleysville's Internal Rate of Return (IRR) Modelεφ Selected Taxes, Licenses, and Fees provision based on tax information from Harleysville Annual Statement Page 15 data for Massachusetts.

Selected Commission provision based on actual base commission plus a loading for contingent commissions.

20102009 2011 3 YEAR TOTAL

Exhibit ASheet 3

HARLEYSVILLE INSURANCECountrywide Commercial Multi Peril: Non LiabilityHistorical Expense Experience





δ Underwriting Profit Provision 3.7%



20102009 2011 3 YEAR TOTAL

Exhibit ASheet 4

HARLEYSVILLE INSURANCECountrywide Commercial Multi PerilHistorical Expense Experience: Derivation of Selected ALAE and ULAE Provisions Supplement


$ (000) % Ratio $ (000) % Ratio $ (000) % Ratio $ (000) % Ratio

COMMERCIAL MULTI PERIL: LIABILITYCountrywide* DIRECT PREMIUM EARNED 212,711 --- 214,603 --- 240,690 --- 668,004 ---Countrywide* INCURRED LOSS 122,464 --- 108,145 --- 142,521 --- 373,130 ---

χ Countrywide* LAE EXPENSE 47,000 38.4% 51,928 48.0% 77,289 54.2% 176,217 47.2% LAE χALAE** 30.0% χULAE** 5.0% β

COMMERCIAL MULTI PERIL: PROPERTYCountrywide* DIRECT PREMIUM EARNED 220,190 --- 222,340 --- 209,623 --- 652,153 ---Countrywide* INCURRED LOSS 113,862 --- 125,779 --- 174,969 --- 414,609 ---


β Ratios expressed as a percentage of Earned Premiumχ Ratios expressed as a percentage of Incurred Loss

EXPENSE PROVISION DEVELOPMENTAdditional Notes:

Expense ProvisionsSelected for Analysis

**: Selections based on pre-January 1, 1998 definitions of ALAE and ULAE.

20102009 2011 TOTAL

*: Actual selections based on experience for Harleysville's Northeast Region excluding New York.

HARLEYSVILLE INSURANCEINTERNAL RATE OF RETURN MODEL

Investment and Operating AssumptionsSummary of Results

Line Of Business: Business Owners LiabilityState: CW

Investment Assumptions Operating Requirements

Investment Dist YieldReserve to Surplus Ratio: 4.38

Cash / ST Inv 5.0% 0.05% Target Rate of Return: 10.0%U.S. Gov't Bonds 18.4% 2.24%Corporate Bonds 18.2% 9.80%Tax-Exempt Bonds (Pre 8/86) 0.0% 2.70% Model ResultsTax-Exempt Bonds (Post 8/86) 57.8% 2.70%Common Stock 0.0% 0.00% Target Rate of Return: 10.0%Other Investments 0.6% 40.00% Required Combined Ratio: 100.8%

Underwriting Profit Provision: -0.8%

EXHIBIT B: Explanation

HARLEYSVILLE INSURANCE

Internal Rate of Return Model

Explanatory Memorandum for the Determination of Underwriting Profit Provision The underwriting profit provision contained in this filing was developed from the Internal Rate of Return (IRR) Model displayed on the following pages. The IRR Model generates expected underwriting and investment results for the prospective period of the proposed rates. This provides a more appropriate reflection of anticipated profit than traditional methods that incorporate calendar year results containing contributions from prior policy years. The model is designed to simulate the underwriting and investment operations of an insurance company writing a single policy. Given specific underwriting and investment assumptions as well as certain operating constraints, the model calculates equity flows between the company and its stockholders. The interest rate for which the present value of these equity flows equals zero is defined as the IRR. Through an iterative process, the model determines the premium necessary to achieve a target rate of return. The target rate of return is selected as the return necessary to attract capital to the operation. The combined ratio associated with the required premium and all underwriting expenses and policyholder dividends provides the necessary underwriting profit provision to be included in the proposed rates (U/W profit provision = 1 - combined ratio). The operating constraints incorporated into the model are determined by a combination of Harleysville's current operations and the practical limitations of the model. The predominant constraint is the determination of a surplus amount to be maintained during the period for which obligations from the policy exist. Surplus requirements for the beginning of each year are determined by a selected reserve to surplus ratio for all years where reserves include unearned premium reserves and loss and loss adjustment expense reserves. These ratios have been selected to reflect the relative risk of the line of business being evaluated. The surplus is then increased or decreased by the statutory net income after federal income tax. The difference between the ending surplus amount and the required surplus for the beginning of the following year is the amount returned to the stockholder. This model assumes that the stockholders' funds are unlimited and further investments are made if the surplus falls below required levels. The underwriting results are based on statutory accounting principles and assumptions specific to the line of business being evaluated. The projected loss and allocated loss adjustment expense ratio, and other underwriting expenses are those developed in this filing for the prospective period. The loss, expense, and dividend payout patterns are based on historical analysis of the corresponding line of business. The model assumes premiums are earned and losses are incurred evenly over the term of the policy. Commissions are paid according to the collected premium patterns. Contingent commissions and residual market costs are assumed to be paid in the year following the year in which they are incurred


Cont.



Explanatory Memorandum for the Determination of Underwriting Profit Provision The investment results reflect current investment opportunities and company strategies. The current investment environment is the most accurate reflection of anticipated income generated from funds supplied by writing a policy today. The beginning surplus is distributed to various investment vehicles based on Harleysville's current investment strategy. The investment income earned in a particular year is based on an estimate of the average invested amount during the year and an assumed investment yield. The estimated invested amount is accomplished by incorporating 50% of the underwriting cash flow for the current year. A positive cash flow indicates additional surplus being invested during the year; whereas, a negative cash flow represents a depletion of surplus available for investment. The investment yields reflect those currently available in the market. The cash flow yield is an average based on the assumed investment distributions. Current federal tax laws and the Alternative Minimum Tax are considered in developing the operating results.


Underwriting Assumptions

Line Of Business: Business Owners LiabilitState: CW


Loss & ALAE Ratio: 58.6%Dividends Payable: 0.0%

Year after policy inception: 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20

Premium PatternsWritten 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Earned 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Collected 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Cumulative Loss & ALAE Payout PatternsWeight

Subline 1: 100.0% 5.8% 18.0% 34.0% 52.7% 69.5% 79.0% 84.5% 88.5% 91.3% 93.5% 95.3% 96.6% 97.5% 98.0% 98.4% 98.8% 99.1% 99.4% 99.7% 100.0%Subline 2: 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Subline 3: 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Subline 4: 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Weighted Average: 5.8% 18.0% 34.0% 52.7% 69.5% 79.0% 84.5% 88.5% 91.3% 93.5% 95.3% 96.6% 97.5% 98.0% 98.4% 98.8% 99.1% 99.4% 99.7% 100.0%

Loss Reserve Discounting Factors: 0.8814 0.8962 0.9011 0.8981 0.8973 0.8955 0.8893 0.9258 0.9279 0.9432 0.9586 0.9737 0.9831 0.9831 0.9831 0.9831 0.9831 0.9831 0.9831 0.9831

Paid Expense Payout Pattern: 95.0% 5.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Paid ULAE Payout Pattern: 47.9% 11.1% 8.0% 9.4% 8.4% 4.8% 2.8% 2.0% 1.4% 1.1% 0.9% 0.7% 0.5% 0.3% 0.2% 0.2% 0.2% 0.2% 0.2% 0.2%

Dividend Payout Pattern: 0.0% 97.5% 2.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Incurred Expense Ratios Variable Fixed Total

Commissions 20.00% 0.00% 20.00%Contingent Comm 0.00% 0.00% 0.00%Taxes, Licenses, & Fees 2.50% 0.00% 2.50%O/A & General 3.10% 9.30% 12.40%Unallocated Loss Expense 1.63% 4.88% 6.50%Residual Market 0.00% 0.00% 0.00%Other U/W Expense 0.00% 0.00% 0.00% Total 27.23% 14.18% 41.40%

Exhibit BPage 2


Determination of Equity Flows



Estimated Reserves (a)Unearned Premium 989.40 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Loss & LAE NA 552.01 480.52 386.76 277.18 178.73 123.06 90.83 67.39 50.98 38.09 27.54 19.92 14.65 11.72 9.38 7.03 5.27 3.52 1.76Expenses NA 41.20 26.58 21.39 15.33 9.89 6.81 5.02 3.73 2.82 2.11 1.52 1.10 0.81 0.65 0.52 0.39 0.29 0.19 0.10Policyholder Dividends NA 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Total Reserves 989.40 593.21 507.10 408.15 292.51 188.62 129.87 95.85 71.12 53.80 40.20 29.07 21.03 15.46 12.37 9.89 7.42 5.57 3.71 1.86

Required Beginning Surplus (b) 226.15 126.17 109.83 88.40 63.35 40.85 28.13 20.76 15.40 11.65 8.71 6.30 4.55 3.35 2.68 2.14 1.61 1.21 0.80 0.40

Statutory Net IncomeAdj Premiums Earned (c) 989.40 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Net Investment Gain (d) 20.75 27.05 22.69 17.54 12.15 8.00 5.64 4.17 3.11 2.35 1.73 1.25 0.91 0.69 0.55 0.43 0.32 0.23 0.14 0.05Losses and Loss Expenses (c) 586.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Underwriting Expenses (c) 411.11 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Other Expenses 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00OPERATING GAIN 13.03 27.05 22.69 17.54 12.15 8.00 5.64 4.17 3.11 2.35 1.73 1.25 0.91 0.69 0.55 0.43 0.32 0.23 0.14 0.05Policyholder Dividends (c) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00NET INCOME BEFORE FIT 13.03 27.05 22.69 17.54 12.15 8.00 5.64 4.17 3.11 2.35 1.73 1.25 0.91 0.69 0.55 0.43 0.32 0.23 0.14 0.05Federal Income Tax (e) 25.67 2.06 2.02 1.35 0.34 0.43 0.52 (0.83) 0.33 0.15 0.13 0.12 0.12 0.13 0.11 0.08 0.06 0.04 0.02 0.00NET INCOME (12.64) 24.98 20.67 16.19 11.81 7.57 5.12 5.00 2.78 2.20 1.61 1.14 0.79 0.56 0.45 0.35 0.26 0.19 0.12 0.05

Other Changes in Surplus (f) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Ending Surplus Before Dividends 213.51 151.16 130.50 104.59 75.17 48.42 33.25 25.76 18.19 13.85 10.31 7.43 5.35 3.91 3.12 2.50 1.87 1.40 0.93 0.45

Stockholder Dividends Payable (g) 87.34 41.32 42.10 41.24 34.32 20.30 12.49 10.35 6.53 5.15 4.02 2.88 2.00 1.23 0.98 0.89 0.67 0.60 0.52 0.45

Ending Surplus 126.17 109.83 88.40 63.35 40.85 28.13 20.76 15.40 11.65 8.71 6.30 4.55 3.35 2.68 2.14 1.61 1.21 0.80 0.40 0.00

MODEL RESULTS

IRR on Dividends Payable 10.0%Required Combined Ratio 100.8%U/W Profit Provision -0.8%

(a) Reserves at beginning of period. Calculation of reserves is determined from Pages 6 & 7.(b) Each years' required surplus is determined by the Reserve-to-Surplus ratio, shown on Page 1.(c) Determined on Pages 6 & 7.(d) Determined on Page 5.(e) Determined on Page 4.(f) This model assumes the only changes in surplus are due to investment and underwriting operations. Realized and Unrealized Capital Gains/Losses are not incorporated. (g) All surplus in excess of the required amount for the following year is returned to the stockholder.

Exhibit B

Page 3


Projected Federal Income Tax



Calculation Of Regular TaxProfit Before FIT (Statutory) (a) 13.03 27.05 22.69 17.54 12.15 8.00 5.64 4.17 3.11 2.35 1.73 1.25 0.91 0.69 0.55 0.43 0.32 0.23 0.14 0.05Tax-Exempt Income

100% pre 8-7-86 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.0085% post 8-7-86 3.00 9.54 8.18 6.59 4.72 3.04 2.10 1.55 1.15 0.87 0.65 0.47 0.34 0.25 0.20 0.16 0.12 0.09 0.06 0.03

20% of Change in UPR 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Chg due to Disct Loss/LAE Rsrv (b) 65.47 (15.61) (11.60) (10.00) (9.90) (5.49) (2.80) (5.06) (1.32) (1.51) (1.02) (0.62) (0.28) (0.05) (0.04) (0.04) (0.03) (0.03) (0.03) (0.03)Regular Taxable Income 75.51 1.89 2.90 0.96 (2.47) (0.54) 0.74 (2.44) 0.64 (0.04) 0.06 0.17 0.30 0.39 0.31 0.23 0.17 0.11 0.05 (0.01)

Federal Taxes at 34% 25.67 0.64 0.99 0.33 (0.84) (0.18) 0.25 (0.83) 0.22 (0.01) 0.02 0.06 0.10 0.13 0.11 0.08 0.06 0.04 0.02 (0.00)

Calculation Of Alternative Minimum Tax (AMT)Regular Taxable Income 75.51 1.89 2.90 0.96 (2.47) (0.54) 0.74 (2.44) 0.64 (0.04) 0.06 0.17 0.30 0.39 0.31 0.23 0.17 0.11 0.05 (0.01)Tax-Exempt Income 3.53 11.23 9.63 7.75 5.55 3.58 2.47 1.82 1.35 1.02 0.76 0.55 0.40 0.29 0.23 0.19 0.14 0.11 0.07 0.04Adjusted Current Earnings 79.04 13.12 12.53 8.71 3.08 3.04 3.20 (0.62) 1.99 0.99 0.82 0.72 0.69 0.68 0.55 0.42 0.32 0.22 0.12 0.0375% of Difference 2.65 8.42 7.22 5.81 4.17 2.69 1.85 1.36 1.01 0.77 0.57 0.41 0.30 0.22 0.18 0.14 0.11 0.08 0.05 0.03AMT Taxable Income 78.15 10.31 10.12 6.77 1.70 2.15 2.59 (1.07) 1.65 0.73 0.63 0.58 0.60 0.61 0.49 0.37 0.28 0.19 0.11 0.02

AMT Income Tax at 20% 15.63 2.06 2.02 1.35 0.34 0.43 0.52 (0.21) 0.33 0.15 0.13 0.12 0.12 0.12 0.10 0.07 0.06 0.04 0.02 0.00

Greater of AMT or Regular Tax (c)25.67 2.06 2.02 1.35 0.34 0.43 0.52 (0.83) 0.33 0.15 0.13 0.12 0.12 0.13 0.11 0.08 0.06 0.04 0.02 0.00

(a) Determined on Page 3.(b) Determined on Page 6.(c) If AMT is negative, then regular tax is selected. If AMT is positive the selected tax is the maximum of the AMT and the Regular Tax.

Exhibit B Page 4


Projected Investment Income



Investment IncomeBeginning of Period Invested Assets (a)Investment Portfolio Yield

Cash / ST Inv 0.05% 11.31 35.97 30.85 24.83 17.79 11.47 7.90 5.83 4.33 3.27 2.45 1.77 1.28 0.94 0.75 0.60 0.45 0.34 0.23 0.11U.S. Gov Bd 2.24% 41.61 132.37 113.52 91.37 65.48 42.22 29.07 21.46 15.92 12.04 9.00 6.51 4.71 3.46 2.77 2.21 1.66 1.25 0.83 0.42Corp Bonds 9.80% 41.16 130.93 112.28 90.37 64.77 41.76 28.76 21.22 15.75 11.91 8.90 6.44 4.66 3.42 2.74 2.19 1.64 1.23 0.82 0.41Tax-Exempt Bd 2.70% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Tax-Exempt Bd 2.70% 130.71 415.80 356.59 287.01 205.69 132.63 91.32 67.40 50.01 37.83 28.27 20.44 14.79 10.87 8.70 6.96 5.22 3.91 2.61 1.30Common Stock 0.00% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Other Inv 40.00% 1.36 4.32 3.70 2.98 2.14 1.38 0.95 0.70 0.52 0.39 0.29 0.21 0.15 0.11 0.09 0.07 0.05 0.04 0.03 0.01Total Invested Assets 226.15 719.38 616.93 496.56 355.86 229.47 157.99 116.62 86.52 65.46 48.90 35.36 25.58 18.81 15.05 12.04 9.03 6.77 4.51 2.26

Curr Cash Flow (b) 4.00% 292.75 (43.05) (49.47) (57.82) (51.95) (29.37) (17.01) (12.37) (8.66) (6.80) (5.57) (4.02) (2.78) (1.55) (1.24) (1.24) (0.93) (0.93) (0.93) (0.93)

Investment Income (c) 20.75 27.05 22.69 17.54 12.15 8.00 5.64 4.17 3.11 2.35 1.73 1.25 0.91 0.69 0.55 0.43 0.32 0.23 0.14 0.05

Cash FlowPremiums Collected (d) 989.40 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Loss and LAE Paid (d) 33.99 71.49 93.76 109.58 98.45 55.67 32.23 23.44 16.41 12.89 10.55 7.62 5.27 2.93 2.34 2.34 1.76 1.76 1.76 1.76Underwriting Expenses Paid (e) 369.92 14.62 5.19 6.06 5.45 3.08 1.78 1.30 0.91 0.71 0.58 0.42 0.29 0.16 0.13 0.13 0.10 0.10 0.10 0.10Policyholder Dividends Paid (d) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Taxes Paid (f) 25.67 2.06 2.02 1.35 0.34 0.43 0.52 (0.83) 0.33 0.15 0.13 0.12 0.12 0.13 0.11 0.08 0.06 0.04 0.02 0.00Net Investment Income Collected 20.75 27.05 22.69 17.54 12.15 8.00 5.64 4.17 3.11 2.35 1.73 1.25 0.91 0.69 0.55 0.43 0.32 0.23 0.14 0.05Other Changes in Surplus (g) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Net Cash Flow From Operations 580.57 (61.13) (78.28) (99.45) (92.08) (51.18) (28.89) (19.74) (14.53) (11.41) (9.52) (6.90) (4.77) (2.53) (2.03) (2.12) (1.59) (1.66) (1.73) (1.81)

Stockholder Dividends Paid (g) 87.34 41.32 42.10 41.24 34.32 20.30 12.49 10.35 6.53 5.15 4.02 2.88 2.00 1.23 0.98 0.89 0.67 0.60 0.52 0.45

Net Cash Flow After Dividends 493.23 (102.45) (120.38) (140.69) (126.40) (71.47) (41.38) (30.09) (21.07) (16.55) (13.54) (9.78) (6.77) (3.76) (3.01) (3.01) (2.26) (2.26) (2.26) (2.26)

(a) Invested assets are determined by applying the distribution of assets shown on Page 1 to the sum of the surplus at the beginning of each year and the net cash flow after dividends from the previous year.(b) 50 % of the underwriting cash flow from the current year (excluding taxes paid, investment income, and stockholder dividends) is incorporated to estimate the average amount of invested assets

throughout the year for which investment income is received. This prcedure accounts for the transition of the surplus from the beginning of the year to the end of the year. This amount is applied to aninvestment yield equal to the weighted average of the current portfolio.

(c) Investment income determined by multiplying the yield rate by the invested assets.(d) Determined on Page 6.(e) Determined on Page 7.(f) Determined on Page 4.(g) Other Changes in Surplus and Stockholder Dividends are shown on Page 3.

Exhibit BPage 5


Premium, Loss, and Dividend Projections



Incurred and Paid LossesLosses and ALAE Incurred (a): 586.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Weighted Average Payment Development: 5.8% 12.2% 16.0% 18.7% 16.8% 9.5% 5.5% 4.0% 2.8% 2.2% 1.8% 1.3% 0.9% 0.5% 0.4% 0.4% 0.3% 0.3% 0.3% 0.3%

Losses and ALAE Paid: 33.99 71.49 93.76 109.58 98.45 55.67 32.23 23.44 16.41 12.89 10.55 7.62 5.27 2.93 2.34 2.34 1.76 1.76 1.76 1.76

Loss and ALAE Reserves: 552.01 480.52 386.76 277.18 178.73 123.06 90.83 67.39 50.98 38.09 27.54 19.92 14.65 11.72 9.38 7.03 5.27 3.52 1.76 0.00

Loss Reserve Discounting Factors (b): 0.8814 0.8962 0.9011 0.8981 0.8973 0.8955 0.8893 0.9258 0.9279 0.9432 0.9586 0.9737 0.9831 0.9831 0.9831 0.9831 0.9831 0.9831 0.9831 0.9831

Discounted Loss and ALAE Reserves: 486.54 430.66 348.50 248.92 160.37 110.20 80.77 62.39 47.31 35.93 26.40 19.40 14.40 11.52 9.22 6.91 5.19 3.46 1.73 0.00

Change in Loss and ALAE Reserves: 552.01 (71.49) (93.76) (109.58) (98.45) (55.67) (32.23) (23.44) (16.41) (12.89) (10.55) (7.62) (5.27) (2.93) (2.34) (2.34) (1.76) (1.76) (1.76) (1.76)Change in Disct Loss and ALAE Rsv: 486.54 (55.88) (82.16) (99.58) (88.55) (50.18) (29.43) (18.38) (15.08) (11.38) (9.52) (7.00) (5.00) (2.88) (2.30) (2.30) (1.73) (1.73) (1.73) (1.73)Change due to Discounting: 65.47 (15.61) (11.60) (10.00) (9.90) (5.49) (2.80) (5.06) (1.32) (1.51) (1.02) (0.62) (0.28) (0.05) (0.04) (0.04) (0.03) (0.03) (0.03) (0.03)

Written, Earned, and Collected PremiumsBase Adj (c)

Written Premium 1,000 989

Written PremiumPercent Written 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%$ - Base 1000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0$ - Adjusted 989.39886 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Earned PremiumPercent Earned 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%$ - Base 1000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0$ - Adjusted 989.39886 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Collected Premium% of Written Collected 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%$ - Base 1000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0$ - Adjusted 989.39886 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Policyholder Dividends

% Adj Earned Premium 0.0%$ Incurred 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0% Paid 0.0% 97.5% 2.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%$ Paid 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

(a) Incurred Loss & ALAE ratio mulpiplied by the adjusted earned premium.(b) Discount factors are those distributed by the Internal Revenue Service.(c) The adjusted premium represents the amount of premium necessary to achieve the target rate of return. This premium is determined through an iterative process.

Exhibit BPage 6


Projected ExpensesLine Of Business: Business Owners LiabilityState: CW

Year after policy inception 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20

Underwriting Expenses IncurredVariable (a)

Commissions 20.00% 197.88 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Contingent Comm 0.00% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Taxes/Lic/Fees 2.50% 24.73 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00O/A & General 3.10% 30.67 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00ULAE 1.63% 16.08 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Residual Market 0.00% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Other U/W Expense 0.00% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Total Variable 27.23% 269.36 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Fixed (b)Taxes 0.00% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00O/A & General 9.30% 93.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00ULAE 4.88% 48.75 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Other U/W Expense 0.00% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Total Fixed 14.18% 141.75 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Total Expenses Incurred 411.11 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Underwriting Expenses PaidU/W Expenses Payout 0.95 0.05 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00ULAE Payout Pattern 0.48 0.11 0.08 0.09 0.08 0.05 0.03 0.02 0.01 0.01 0.01 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Variable

Commissions (c) 197.88 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Contingent Comm (d) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Taxes/Lic/Fees 23.50 1.24 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00O/A & General 29.14 1.53 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00ULAE 7.70 1.78 1.29 1.50 1.35 0.76 0.44 0.32 0.23 0.18 0.14 0.10 0.07 0.04 0.03 0.03 0.02 0.02 0.02 0.02Residual Market (d) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Other U/W Expense 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Total Variable 258.22 4.55 1.29 1.50 1.35 0.76 0.44 0.32 0.23 0.18 0.14 0.10 0.07 0.04 0.03 0.03 0.02 0.02 0.02 0.02

FixedTaxes 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00O/A & General 88.35 4.65 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00ULAE 23.35 5.41 3.90 4.56 4.10 2.32 1.34 0.98 0.68 0.54 0.44 0.32 0.22 0.12 0.10 0.10 0.07 0.07 0.07 0.07Other U/W Expense 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Total Fixed 111.70 10.06 3.90 4.56 4.10 2.32 1.34 0.98 0.68 0.54 0.44 0.32 0.22 0.12 0.10 0.10 0.07 0.07 0.07 0.07

Total Expenses Paid 369.92 14.62 5.19 6.06 5.45 3.08 1.78 1.30 0.91 0.71 0.58 0.42 0.29 0.16 0.13 0.13 0.10 0.10 0.10 0.10

(a) Variable expenses are related to the adjusted premium.(b) Fixed expenses are related to the base premium.(c) Incurred Commissions are paid in proportion to the ratio of collected to written premiums .(d) Contingent Commissions and Residual Market costs are assumed to be paid in the year after such expenses are incurred.

Exhibit BPage 7



Line Of Business: Business Owners PropertyState: CW




Underwriting Profit Provision: 3.7%



Line Of Business: Business Owners PropertState: CW














Exhibit BPage 9





Estimated Reserves (a)Unearned Premium 1,053.19 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Loss & LAE NA 186.00 13.64 1.86 1.24 1.24 0.62 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Expenses NA 12.06 0.21 0.03 0.02 0.02 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Policyholder Dividends NA 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Total Reserves 1,053.19 198.06 13.85 1.89 1.26 1.26 0.63 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


Statutory Net IncomeAdj Premiums Earned (c) 1,053.19 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Net Investment Gain (d) 20.34 6.99 0.52 0.09 0.07 0.06 0.02 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Losses and Loss Expenses (c) 620.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Underwriting Expenses (c) 394.03 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Other Expenses 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00OPERATING GAIN 59.50 6.99 0.52 0.09 0.07 0.06 0.02 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Policyholder Dividends (c) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00NET INCOME BEFORE FIT 59.50 6.99 0.52 0.09 0.07 0.06 0.02 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Federal Income Tax (e) 20.29 0.33 0.01 0.02 0.02 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00NET INCOME 39.21 6.66 0.50 0.07 0.05 0.05 0.02 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00




Ending Surplus 68.89 5.05 0.69 0.46 0.46 0.23 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

MODEL RESULTS

IRR on Dividends Payable 10.0%Required Combined Ratio 96.3%U/W Profit Provision 3.7%







100% pre 8-7-86 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.0085% post 8-7-86 5.17 3.54 0.25 0.03 0.02 0.02 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

20% of Change in UPR 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Chg due to Disct Loss/LAE Rsrv (b) 5.36 (4.90) (0.42) (0.01) 0.00 (0.01) (0.01) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Regular Taxable Income 59.69 (1.45) (0.16) 0.05 0.05 0.02 (0.00) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Federal Taxes at 34% 20.29 (0.49) (0.05) 0.02 0.02 0.01 (0.00) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Calculation Of Alternative Minimum Tax (AMT)Regular Taxable Income 59.69 (1.45) (0.16) 0.05 0.05 0.02 (0.00) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Tax-Exempt Income 6.09 4.17 0.30 0.04 0.03 0.03 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Adjusted Current Earnings 65.77 2.71 0.14 0.09 0.07 0.05 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.0075% of Difference 4.57 3.12 0.22 0.03 0.02 0.02 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00AMT Taxable Income 64.25 1.67 0.06 0.08 0.07 0.04 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

AMT Income Tax at 20% 12.85 0.33 0.01 0.02 0.01 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Greater of AMT or Regular Tax (c)20.29 0.33 0.01 0.02 0.02 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


Exhibit B Page 11







Curr Cash Flow (b) 4.00% 118.61 (92.10) (5.98) (0.31) 0.00 (0.31) (0.31) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


Cash FlowPremiums Collected (d) 1,053.19 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Loss and LAE Paid (d) 434.00 172.36 11.78 0.62 0.00 0.62 0.62 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Underwriting Expenses Paid (e) 381.97 11.85 0.18 0.01 0.00 0.01 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Policyholder Dividends Paid (d) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Taxes Paid (f) 20.29 0.33 0.01 0.02 0.02 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Net Investment Income Collected 20.34 6.99 0.52 0.09 0.07 0.06 0.02 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Other Changes in Surplus (g) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Net Cash Flow From Operations 237.27 (177.55) (11.46) (0.55) 0.05 (0.58) (0.61) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


Net Cash Flow After Dividends (123.12) (248.04) (16.33) (0.86) 0.00 (0.86) (0.86) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00




Exhibit BPage 12











Change in Loss and ALAE Reserves: 186.00 (172.36) (11.78) (0.62) 0.00 (0.62) (0.62) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Change in Disct Loss and ALAE Rsv: 180.64 (167.46) (11.36) (0.61) 0.00 (0.61) (0.61) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Change due to Discounting: 5.36 (4.90) (0.42) (0.01) 0.00 (0.01) (0.01) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


Written Premium 1,000 1,053







Exhibit BPage 13


Projected ExpensesLine Of Business: Business Owners PropertyState: CW











Exhibit BPage 1 4

MASSACHUSETTS DIVISION OF INSURANCE RATE FILING ABSTRACT

Page 1 of 2

SRB-RA (ed. 01/11)

NOTE: This abstract is a summary of the submitted Rate Type filing. It is not a substitute for any Rate Type filing materials required by M.G.L. 174A, §6, M.G.L. 175A, §6, or Bulletin 2008-08, nor for any Supplementary Rating Information or Supporting Information as defined within Bulletin SRB 90-05. Exhibit citations alone are insufficient to answer any question. INSTRUCTIONS: Please complete one abstract per Filing Company for all Rate Type filings EXCEPT those requiring the Loss Costs Adoption Form or the Rate Deviation Abstract. If requested data differs by category, separate abstracts or combined figures are required. ______________________________________________________________________________________ Please enter the corporate name and nine-digit NAIC number of the Filing Company (e.g. 0000-00000). ______________________________________________________________________________________ Please enter the program name as filed. Sub-type of Insurance: ___________________________________________________________________ Latest Year Massachusetts Direct Written Premium: ____________________________________________ **************************************************************************************

Please complete items 1 through 8 as applicable to this filing. 1. OVERALL RATE LEVEL CHANGE: Formula Indicated__________% Proposed/Selected_________% If the Proposed/Selected is different from the Formula Indicated, please explain why. ____________________________________________________________________________________________________________________________________________________________________________ 2. PROGRAM RATE LEVEL HISTORY: Please provide data starting with the most recent revision. Date (MM/DD/YY) % Change

_______________ _______% _______________ _______% _______________ _______% _______________ _______% _______________ _______%

3. NUMBER OF EXPERIENCE YEARS ANALYZED: ________ 4. CREDIBILITY STANDARDS AND METHODS: Please complete all that apply. Most recent year’s experience: ______% Massachusetts versus countrywide experience: ______% Other credibility standards/methods used: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 5. Have premium exposures have been trended? _________ 6. Have historical premiums been adjusted to reflect past rate changes? If “Yes,” please explain. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

RESET FORM

n\a

$1,522,898

n\a

Harleysville Insurance Company (0140-23582)

5.0002, 5.1002 & 5.2002 Businessowners

n\a

Star Advantage Business Owners

n\an\a

n\a

http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter174A/Section6


http://www.mass.gov/Eoca/docs/doi/Bulletins/bulletins_08_08.pdf�

http://www.mass.gov/Eoca/docs/doi/Bulletins/Bulletins_90_05.pdf�




Page 2 of 2

SRB-RA (ed. 01/11)

7. LOSS TRENDING: Please provide data starting with the most recent experience year. Year Factor Derived ______ ____________ ______ ____________ ______ ____________ Method and annual rate of change: __________________________________________________________ 8. LOSS DEVELOPMENT: Please provide data starting with the most recent experience year. Year Maturity Factor-Ultimate ______ _________ _____________ ______ _________ _____________ ______ _________ _____________ Based on Massachusetts data, countrywide data, or both? ________________________________________

Items 9 through 13 are required for all Rate Type filings. Is the following based on Massachusetts data, countrywide data, or both? ___________________________ Provision Flat or Variable? 9. UNDERWRITING PROFIT: _______% ______________ 10. EXPENSES: Please include a three-year expense exhibit. Provision Flat or Variable? General Expense _______% ______________ Commissions/Brokerage _______% ______________ Other Acquisition _______% ______________ Taxes, Licenses, Fees _______% ______________ Other Expenses _______% ______________ 11. LOSS ADJUSTMENT EXPENSE FACTORS: Allocated ______% Unallocated ______% 12. UNTRENDED EXPECTED LOSS RATIO: _______% 13. If investment income is reflected in the filing, please indicate the method/model used. ______________________________________________________________________________________ 14. Please briefly describe any changes in coverage since the last Rate Level Change. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

************************************************************************************** _______________________________________________________ _____________________ Signature of Officer in Charge Date _______________________________________________________ Name and Title of Officer in Charge _______________________________________________________ Name and Title of Person Completing This Abstract

Both

3.3

1.9

13.1

Michelle Hanson, CL Product Analyst

July 2, 2013

n\a

75% F /25% V0.820.9

David Bond Digitally signed by David Bond DN: cn=David Bond, o, ou, [email protected], c=US Date: 2013.07.02 07:28:56 -04'00'


100% V75% F /25% V

3.61.5

AVP - CL Middle Market

10.7

100% V

100% V

n\a

n\a

n\a

59.7

100% V

n\a


Page 1 of 2

SRB-RA (ed. 01/11)



_______________ _______% _______________ _______% _______________ _______% _______________ _______% _______________ _______%


RESET FORM

n\a

$4,299,376

n\a

Harleysville Preferred Insurance Company (0140-35696)

5.0002, 5.1002 & 5.2002 Businessowners

n\a


n\an\a

n\a








Page 2 of 2

SRB-RA (ed. 01/11)




Both

3.3

1.9

13.1


July 2, 2013

n\a

75% F /25% V0.820.9



100% V75% F /25% V

3.61.5

David Bond, AVP Middle Market

10.7

100% V

100% V

n\a

n\a

n\a

59.7

100% V

n\a


Page 1 of 2

SRB-RA (ed. 01/11)



_______________ _______% _______________ _______% _______________ _______% _______________ _______% _______________ _______%


RESET FORM

n\a

$3,194,234

n\a

Harleysville Worcester Insurance Company (0140-26182)

5.0002, 5.1002 & 5.2002 Businessowners

n\a


n\an\a

n\a








Page 2 of 2

SRB-RA (ed. 01/11)




Both

3.3

1.9

13.1


July 2, 2013

n\a

75% F /25% V0.820.9



100% V75% F /25% V

3.61.5


10.7

100% V

100% V

n\a

n\a

n\a

59.7

100% V

n\a


Page 1 of 2

SRB-RA (ed. 01/11)



_______________ _______% _______________ _______% _______________ _______% _______________ _______% _______________ _______%


RESET FORM

n\a

$1,312,971

n\a

Nationwide Mutual Insurance Company (0140-23787): Harleysville Operations

5.0002, 5.1002 & 5.2002 Businessowners

n\a


n\an\a

n\a








Page 2 of 2

SRB-RA (ed. 01/11)




Both

3.3

1.9

13.1


July 2, 2013

n\a

75% F /25% V0.820.9



100% V75% F /25% V

3.61.5


10.7

100% V

100% V

n\a

n\a

n\a

59.7

100% V

n\a

Exhibit ASheet 1

HARLEYSVILLE INSURANCECountrywide Commercial Multi PerilHistorical Expense Experience Selections Summary


BOP BOP BOP*Liab. Non-Liab. Expense Provisions

Provision Provision Selected for Analysisα COMMISSION 20.9% 20.9% 20.9%

α TAXES, LIC., FEES 3.5% 3.6% 3.6%

β OTHER ACQUISITION 12.4% 13.6% 13.1%

β GENERAL 0.8% 0.8% 0.8%

UW PROFIT PROVISION -0.8% 3.7% 1.9%

Expected Loss Ratio: 63.2% 57.4% 59.7%

χ ALAE 30.0% 3.5% 10.7%

β ULAE 5.0% 2.1% 3.3%

α Ratios expressed as a percentage of Written Premiumβ Ratios expressed as a percentage of Earned Premiumχ Ratios expressed as a percentage of Incurred Loss

* Volume weighted.

Exhibit ASheet 2

HARLEYSVILLE INSURANCECountrywide Commercial Multi Peril: LiabilityHistorical Expense Experience





δ Underwriting Profit Provision -0.8%



20102009 2011 3 YEAR TOTAL

Exhibit ASheet 3

HARLEYSVILLE INSURANCECountrywide Commercial Multi Peril: Non LiabilityHistorical Expense Experience





δ Underwriting Profit Provision 3.7%



20102009 2011 3 YEAR TOTAL

Exhibit ASheet 4

HARLEYSVILLE INSURANCECountrywide Commercial Multi PerilHistorical Expense Experience: Derivation of Selected ALAE and ULAE Provisions Supplement


$ (000) % Ratio $ (000) % Ratio $ (000) % Ratio $ (000) % Ratio

COMMERCIAL MULTI PERIL: LIABILITYCountrywide* DIRECT PREMIUM EARNED 212,711 --- 214,603 --- 240,690 --- 668,004 ---Countrywide* INCURRED LOSS 122,464 --- 108,145 --- 142,521 --- 373,130 ---


COMMERCIAL MULTI PERIL: PROPERTYCountrywide* DIRECT PREMIUM EARNED 220,190 --- 222,340 --- 209,623 --- 652,153 ---Countrywide* INCURRED LOSS 113,862 --- 125,779 --- 174,969 --- 414,609 ---


β Ratios expressed as a percentage of Earned Premiumχ Ratios expressed as a percentage of Incurred Loss

EXPENSE PROVISION DEVELOPMENTAdditional Notes:

Expense ProvisionsSelected for Analysis

**: Selections based on pre-January 1, 1998 definitions of ALAE and ULAE.

20102009 2011 TOTAL

*: Actual selections based on experience for Harleysville's Northeast Region excluding New York.







Underwriting Profit Provision: -0.8%




Explanatory Memorandum for the Determination of Underwriting Profit Provision The underwriting profit provision contained in this filing was developed from the Internal Rate of Return (IRR) Model displayed on the following pages. The IRR Model generates expected underwriting and investment results for the prospective period of the proposed rates. This provides a more appropriate reflection of anticipated profit than traditional methods that incorporate calendar year results containing contributions from prior policy years. The model is designed to simulate the underwriting and investment operations of an insurance company writing a single policy. Given specific underwriting and investment assumptions as well as certain operating constraints, the model calculates equity flows between the company and its stockholders. The interest rate for which the present value of these equity flows equals zero is defined as the IRR. Through an iterative process, the model determines the premium necessary to achieve a target rate of return. The target rate of return is selected as the return necessary to attract capital to the operation. The combined ratio associated with the required premium and all underwriting expenses and policyholder dividends provides the necessary underwriting profit provision to be included in the proposed rates (U/W profit provision = 1 - combined ratio). The operating constraints incorporated into the model are determined by a combination of Harleysville's current operations and the practical limitations of the model. The predominant constraint is the determination of a surplus amount to be maintained during the period for which obligations from the policy exist. Surplus requirements for the beginning of each year are determined by a selected reserve to surplus ratio for all years where reserves include unearned premium reserves and loss and loss adjustment expense reserves. These ratios have been selected to reflect the relative risk of the line of business being evaluated. The surplus is then increased or decreased by the statutory net income after federal income tax. The difference between the ending surplus amount and the required surplus for the beginning of the following year is the amount returned to the stockholder. This model assumes that the stockholders' funds are unlimited and further investments are made if the surplus falls below required levels. The underwriting results are based on statutory accounting principles and assumptions specific to the line of business being evaluated. The projected loss and allocated loss adjustment expense ratio, and other underwriting expenses are those developed in this filing for the prospective period. The loss, expense, and dividend payout patterns are based on historical analysis of the corresponding line of business. The model assumes premiums are earned and losses are incurred evenly over the term of the policy. Commissions are paid according to the collected premium patterns. Contingent commissions and residual market costs are assumed to be paid in the year following the year in which they are incurred


Cont.



Explanatory Memorandum for the Determination of Underwriting Profit Provision The investment results reflect current investment opportunities and company strategies. The current investment environment is the most accurate reflection of anticipated income generated from funds supplied by writing a policy today. The beginning surplus is distributed to various investment vehicles based on Harleysville's current investment strategy. The investment income earned in a particular year is based on an estimate of the average invested amount during the year and an assumed investment yield. The estimated invested amount is accomplished by incorporating 50% of the underwriting cash flow for the current year. A positive cash flow indicates additional surplus being invested during the year; whereas, a negative cash flow represents a depletion of surplus available for investment. The investment yields reflect those currently available in the market. The cash flow yield is an average based on the assumed investment distributions. Current federal tax laws and the Alternative Minimum Tax are considered in developing the operating results.

















Exhibit BPage 2





Estimated Reserves (a)Unearned Premium 989.40 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Loss & LAE NA 552.01 480.52 386.76 277.18 178.73 123.06 90.83 67.39 50.98 38.09 27.54 19.92 14.65 11.72 9.38 7.03 5.27 3.52 1.76Expenses NA 41.20 26.58 21.39 15.33 9.89 6.81 5.02 3.73 2.82 2.11 1.52 1.10 0.81 0.65 0.52 0.39 0.29 0.19 0.10Policyholder Dividends NA 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Total Reserves 989.40 593.21 507.10 408.15 292.51 188.62 129.87 95.85 71.12 53.80 40.20 29.07 21.03 15.46 12.37 9.89 7.42 5.57 3.71 1.86


Statutory Net IncomeAdj Premiums Earned (c) 989.40 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Net Investment Gain (d) 20.75 27.05 22.69 17.54 12.15 8.00 5.64 4.17 3.11 2.35 1.73 1.25 0.91 0.69 0.55 0.43 0.32 0.23 0.14 0.05Losses and Loss Expenses (c) 586.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Underwriting Expenses (c) 411.11 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Other Expenses 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00OPERATING GAIN 13.03 27.05 22.69 17.54 12.15 8.00 5.64 4.17 3.11 2.35 1.73 1.25 0.91 0.69 0.55 0.43 0.32 0.23 0.14 0.05Policyholder Dividends (c) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00NET INCOME BEFORE FIT 13.03 27.05 22.69 17.54 12.15 8.00 5.64 4.17 3.11 2.35 1.73 1.25 0.91 0.69 0.55 0.43 0.32 0.23 0.14 0.05Federal Income Tax (e) 25.67 2.06 2.02 1.35 0.34 0.43 0.52 (0.83) 0.33 0.15 0.13 0.12 0.12 0.13 0.11 0.08 0.06 0.04 0.02 0.00NET INCOME (12.64) 24.98 20.67 16.19 11.81 7.57 5.12 5.00 2.78 2.20 1.61 1.14 0.79 0.56 0.45 0.35 0.26 0.19 0.12 0.05




Ending Surplus 126.17 109.83 88.40 63.35 40.85 28.13 20.76 15.40 11.65 8.71 6.30 4.55 3.35 2.68 2.14 1.61 1.21 0.80 0.40 0.00

MODEL RESULTS

IRR on Dividends Payable 10.0%Required Combined Ratio 100.8%U/W Profit Provision -0.8%


Exhibit B

Page 3






100% pre 8-7-86 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.0085% post 8-7-86 3.00 9.54 8.18 6.59 4.72 3.04 2.10 1.55 1.15 0.87 0.65 0.47 0.34 0.25 0.20 0.16 0.12 0.09 0.06 0.03

20% of Change in UPR 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Chg due to Disct Loss/LAE Rsrv (b) 65.47 (15.61) (11.60) (10.00) (9.90) (5.49) (2.80) (5.06) (1.32) (1.51) (1.02) (0.62) (0.28) (0.05) (0.04) (0.04) (0.03) (0.03) (0.03) (0.03)Regular Taxable Income 75.51 1.89 2.90 0.96 (2.47) (0.54) 0.74 (2.44) 0.64 (0.04) 0.06 0.17 0.30 0.39 0.31 0.23 0.17 0.11 0.05 (0.01)

Federal Taxes at 34% 25.67 0.64 0.99 0.33 (0.84) (0.18) 0.25 (0.83) 0.22 (0.01) 0.02 0.06 0.10 0.13 0.11 0.08 0.06 0.04 0.02 (0.00)

Calculation Of Alternative Minimum Tax (AMT)Regular Taxable Income 75.51 1.89 2.90 0.96 (2.47) (0.54) 0.74 (2.44) 0.64 (0.04) 0.06 0.17 0.30 0.39 0.31 0.23 0.17 0.11 0.05 (0.01)Tax-Exempt Income 3.53 11.23 9.63 7.75 5.55 3.58 2.47 1.82 1.35 1.02 0.76 0.55 0.40 0.29 0.23 0.19 0.14 0.11 0.07 0.04Adjusted Current Earnings 79.04 13.12 12.53 8.71 3.08 3.04 3.20 (0.62) 1.99 0.99 0.82 0.72 0.69 0.68 0.55 0.42 0.32 0.22 0.12 0.0375% of Difference 2.65 8.42 7.22 5.81 4.17 2.69 1.85 1.36 1.01 0.77 0.57 0.41 0.30 0.22 0.18 0.14 0.11 0.08 0.05 0.03AMT Taxable Income 78.15 10.31 10.12 6.77 1.70 2.15 2.59 (1.07) 1.65 0.73 0.63 0.58 0.60 0.61 0.49 0.37 0.28 0.19 0.11 0.02

AMT Income Tax at 20% 15.63 2.06 2.02 1.35 0.34 0.43 0.52 (0.21) 0.33 0.15 0.13 0.12 0.12 0.12 0.10 0.07 0.06 0.04 0.02 0.00

Greater of AMT or Regular Tax (c)25.67 2.06 2.02 1.35 0.34 0.43 0.52 (0.83) 0.33 0.15 0.13 0.12 0.12 0.13 0.11 0.08 0.06 0.04 0.02 0.00


Exhibit B Page 4







Curr Cash Flow (b) 4.00% 292.75 (43.05) (49.47) (57.82) (51.95) (29.37) (17.01) (12.37) (8.66) (6.80) (5.57) (4.02) (2.78) (1.55) (1.24) (1.24) (0.93) (0.93) (0.93) (0.93)


Cash FlowPremiums Collected (d) 989.40 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Loss and LAE Paid (d) 33.99 71.49 93.76 109.58 98.45 55.67 32.23 23.44 16.41 12.89 10.55 7.62 5.27 2.93 2.34 2.34 1.76 1.76 1.76 1.76Underwriting Expenses Paid (e) 369.92 14.62 5.19 6.06 5.45 3.08 1.78 1.30 0.91 0.71 0.58 0.42 0.29 0.16 0.13 0.13 0.10 0.10 0.10 0.10Policyholder Dividends Paid (d) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Taxes Paid (f) 25.67 2.06 2.02 1.35 0.34 0.43 0.52 (0.83) 0.33 0.15 0.13 0.12 0.12 0.13 0.11 0.08 0.06 0.04 0.02 0.00Net Investment Income Collected 20.75 27.05 22.69 17.54 12.15 8.00 5.64 4.17 3.11 2.35 1.73 1.25 0.91 0.69 0.55 0.43 0.32 0.23 0.14 0.05Other Changes in Surplus (g) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Net Cash Flow From Operations 580.57 (61.13) (78.28) (99.45) (92.08) (51.18) (28.89) (19.74) (14.53) (11.41) (9.52) (6.90) (4.77) (2.53) (2.03) (2.12) (1.59) (1.66) (1.73) (1.81)


Net Cash Flow After Dividends 493.23 (102.45) (120.38) (140.69) (126.40) (71.47) (41.38) (30.09) (21.07) (16.55) (13.54) (9.78) (6.77) (3.76) (3.01) (3.01) (2.26) (2.26) (2.26) (2.26)




Exhibit BPage 5











Change in Loss and ALAE Reserves: 552.01 (71.49) (93.76) (109.58) (98.45) (55.67) (32.23) (23.44) (16.41) (12.89) (10.55) (7.62) (5.27) (2.93) (2.34) (2.34) (1.76) (1.76) (1.76) (1.76)Change in Disct Loss and ALAE Rsv: 486.54 (55.88) (82.16) (99.58) (88.55) (50.18) (29.43) (18.38) (15.08) (11.38) (9.52) (7.00) (5.00) (2.88) (2.30) (2.30) (1.73) (1.73) (1.73) (1.73)Change due to Discounting: 65.47 (15.61) (11.60) (10.00) (9.90) (5.49) (2.80) (5.06) (1.32) (1.51) (1.02) (0.62) (0.28) (0.05) (0.04) (0.04) (0.03) (0.03) (0.03) (0.03)


Written Premium 1,000 989







Exhibit BPage 6


Projected ExpensesLine Of Business: Business Owners LiabilityState: CW











Exhibit BPage 7







Underwriting Profit Provision: 3.7%

















Exhibit BPage 9





Estimated Reserves (a)Unearned Premium 1,053.19 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Loss & LAE NA 186.00 13.64 1.86 1.24 1.24 0.62 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Expenses NA 12.06 0.21 0.03 0.02 0.02 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Policyholder Dividends NA 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Total Reserves 1,053.19 198.06 13.85 1.89 1.26 1.26 0.63 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


Statutory Net IncomeAdj Premiums Earned (c) 1,053.19 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Net Investment Gain (d) 20.34 6.99 0.52 0.09 0.07 0.06 0.02 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Losses and Loss Expenses (c) 620.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Underwriting Expenses (c) 394.03 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Other Expenses 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00OPERATING GAIN 59.50 6.99 0.52 0.09 0.07 0.06 0.02 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Policyholder Dividends (c) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00NET INCOME BEFORE FIT 59.50 6.99 0.52 0.09 0.07 0.06 0.02 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Federal Income Tax (e) 20.29 0.33 0.01 0.02 0.02 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00NET INCOME 39.21 6.66 0.50 0.07 0.05 0.05 0.02 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00




Ending Surplus 68.89 5.05 0.69 0.46 0.46 0.23 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

MODEL RESULTS

IRR on Dividends Payable 10.0%Required Combined Ratio 96.3%U/W Profit Provision 3.7%







100% pre 8-7-86 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.0085% post 8-7-86 5.17 3.54 0.25 0.03 0.02 0.02 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

20% of Change in UPR 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Chg due to Disct Loss/LAE Rsrv (b) 5.36 (4.90) (0.42) (0.01) 0.00 (0.01) (0.01) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Regular Taxable Income 59.69 (1.45) (0.16) 0.05 0.05 0.02 (0.00) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Federal Taxes at 34% 20.29 (0.49) (0.05) 0.02 0.02 0.01 (0.00) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Calculation Of Alternative Minimum Tax (AMT)Regular Taxable Income 59.69 (1.45) (0.16) 0.05 0.05 0.02 (0.00) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Tax-Exempt Income 6.09 4.17 0.30 0.04 0.03 0.03 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Adjusted Current Earnings 65.77 2.71 0.14 0.09 0.07 0.05 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.0075% of Difference 4.57 3.12 0.22 0.03 0.02 0.02 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00AMT Taxable Income 64.25 1.67 0.06 0.08 0.07 0.04 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

AMT Income Tax at 20% 12.85 0.33 0.01 0.02 0.01 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Greater of AMT or Regular Tax (c)20.29 0.33 0.01 0.02 0.02 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


Exhibit B Page 11







Curr Cash Flow (b) 4.00% 118.61 (92.10) (5.98) (0.31) 0.00 (0.31) (0.31) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


Cash FlowPremiums Collected (d) 1,053.19 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Loss and LAE Paid (d) 434.00 172.36 11.78 0.62 0.00 0.62 0.62 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Underwriting Expenses Paid (e) 381.97 11.85 0.18 0.01 0.00 0.01 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Policyholder Dividends Paid (d) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Taxes Paid (f) 20.29 0.33 0.01 0.02 0.02 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Net Investment Income Collected 20.34 6.99 0.52 0.09 0.07 0.06 0.02 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Other Changes in Surplus (g) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Net Cash Flow From Operations 237.27 (177.55) (11.46) (0.55) 0.05 (0.58) (0.61) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


Net Cash Flow After Dividends (123.12) (248.04) (16.33) (0.86) 0.00 (0.86) (0.86) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00




Exhibit BPage 12











Change in Loss and ALAE Reserves: 186.00 (172.36) (11.78) (0.62) 0.00 (0.62) (0.62) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Change in Disct Loss and ALAE Rsv: 180.64 (167.46) (11.36) (0.61) 0.00 (0.61) (0.61) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Change due to Discounting: 5.36 (4.90) (0.42) (0.01) 0.00 (0.01) (0.01) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


Written Premium 1,000 1,053







Exhibit BPage 13


Projected ExpensesLine Of Business: Business Owners PropertyState: CW











Exhibit BPage 1 4

Superseded Schedule Items Please note that all items on the following pages are items, which have been replaced by a newer version. The newest version is located with the appropriate scheduleon previous pages. These items are in date order with most recent first.

Creation Date

Schedule Item

Status Schedule Schedule Item Name

Replacement

Creation Date Attached Document(s)

07/08/2013 Form New Business Application Employment

Practices Liability Application

07/17/2013 BOP-7094 _Ed 08-12_ EPLI

Application - update.pdf

(Superceded)

07/08/2013 Form Renewal Application Employment Practices


07/17/2013 BOP-7095 _Ed 08-12_ EPLI

Renewal Application - UPDATE.pdf

(Superceded)

07/08/2013 Supporting

Document

Applications 07/08/2013 BOP-7094 _Ed 08-12_ EPLI

Application - update.pdf

(Superceded)

BOP-7095 _Ed 08-12_ EPLI

Renewal Application - UPDATE.pdf

(Superceded)


Document

Checklist(s) 07/03/2013 P & C Checklist 01 13.pdf

(Superceded)

P & C Checklist 01 13 BOP-7079

(1).pdf (Superceded)


Document

Certification of Compliance 07/03/2013 Cert of compliance.pdf (Superceded)


Document

Checklist(s) 07/03/2013 P & C Checklist 01 13.pdf

(Superceded)


(Superceded)







Creation Date

Schedule Item

Status Schedule Schedule Item Name

Replacement

Creation Date Attached Document(s)


Document

Rate Filing Abstract (SRB-RA) 07/03/2013 Rate abstract HIC.pdf










BOP-7094 (Ed. 08-12) Page 1 of 5

Harleysville Worcester Insurance Company NEW BUSINESS APPLICATION

EMPLOYMENT PRACTICES LIABILITY BUSINESSOWNERS POLICY


Agent: Agent Code:

Effective Date:

Retroactive Date:


THIS APPLICATION IS FOR A CLAIMS-MADE POLICY WHICH PROVIDES FOR DEFENSE WITHIN THE LIMITS OF INSURANCE.

CORPORATE HISTORY Franchise holder?: No Yes Number of years in business? Describe the business operations: Does the organization have any contracts with or receive financial assistance from the Federal Government or any agency thereof? No Yes If yes, describe Is there any affirmative action plan? No Yes If yes, attach and describe reason for implementing it:



$50,000/$50,000 $100,000 / $100,000 $250,000 / $250,000

Note: This limit applies separately to Damages and Defense Expenses in AR, MA, MN, VT. Deductible ($5,000 automatic):


Does the applicant currently carry EPL? No Yes If yes, please supply prior coverage information and attach a copy of the prior policy declaration: Insurer: Limit of Insurance: (per claim/aggregate)

Effective Date Expiration Date Deductible: Retroactive Date: If the Retroactive Date is not the same as the coverage effective date, has the coverage been provided uninterrupted up to the proposed effective date? Yes No If No, supply details N/A Has any insurer ever cancelled or non-renewed the applicants EPL coverage? Yes No If Yes, supply details including carrier name, reason and termination date



BOP-7094 (Ed. 08-12) Page 2 of 5






Over $100,000 per year 2 Years Ago Previous Year Current YearEmployee-initiated (voluntary termination) turnover rate % % % Employer-initiated (involuntary termination) turnover rate % % % Have there been any office, branch, facility, branch or plant closings, consolidations, layoffs or staff reductions (greater than 10% of the workforce), mergers or acquisitions within the last 24 months? No Yes If yes, describe: . Are any office, branch, facility or plant closings, consolidations, layoffs or staff reductions (greater than 10% of the workforce), merger or acquisitions anticipated within the next 12 months? No Yes If Yes, describe:

LOSS HISTORY





Name: Title:


Name: Title:

Are there tests (i.e. psychological, personality, drug, alcohol, medical) used to screen employment applicants, promote employees, or for the purpose of continuing employment?

No Yes If Yes, describe: The type of test (s) How is it administered (i.e. to all employees or segments thereof): The company creating the test and validation documents:

BOP-7094 (Ed. 08-12) Page 3 of 5











Third Party Liability Coverage No Yes If Yes, supply: Details of all contracts with independent contractors including: number of workers; type of work; approximate average hours per week and /or months of use; and, whether workers are primarily onsite or offsite:

BOP-7094 (Ed. 08-12) Page 4 of 5


BOP-7094 (Ed. 08-12) Page 5 of 5

NOTICE REGARDING THE CIVIL UNION AND EQUALITY ACT (DELAWARE) This is to provide notice that, pursuant to the Delaware Insurance Department Domestic/Foreign Insurers Bulletin No. 46, this policy is in compliance with the Delaware Civil Union and Equality Act of 2011, 78 Del. Laws Ch. 22 (2011) (the "Act"). The Act, which becomes effective January 1, 2012, creates a form of legal union between two persons of the same sex who establish a civil union in accordance with the requirements of Delaware law. The Act provides that parties to a civil union shall have all of the same rights, protections and benefits, and shall be subject to the same responsibilities, obligations and duties, under Delaware law as are granted to, enjoyed by, or imposed upon married spouses. The Act further provides that a party to a civil union shall be included in any definition or use of the terms "dependent", "family", "husband and wife", "immediate family", "next of kin", "spouse", "stepparent", "tenants by the entirety", and other terms, whether or not gender-specific, that denote a spousal relationship or a person in a spousal relationship, as those terms are used throughout Delaware law. For all purposes of Delaware laws that refer to marriage or marital status, other than Chapter 1 of Title 13 of the Delaware Code, parties to a civil union will be included in such reference. In addition, the Act also automatically recognizes as civil unions, for all purposes of Delaware law, legal unions between two persons of the same sex, such as civil unions, marriages and domestic partnerships that are validly formed in jurisdictions other than Delaware and are substantially similar to Delaware civil unions. The provisions of the Act apply for all purposes of Delaware law, whether derived from statutes, administrative rules or regulations, court rules, governmental policies, common law, court decisions, or any other provisions or sources of law, which includes the Insurance Code and all regulations and bulletins promulgated thereunder. NOTICE REGARDING THE RELIGIOUS FREEDOM PROTECTION AND CIVIL UNION ACT (ILLINOIS) This is to provide notice that, pursuant to Illinois Department of Insurance Company Bulletin 2011-06 (CB 2011-06), this policy is in compliance with the Illinois Religious Freedom Protection and Civil Union Act ("the Act", 750 ILL. COMP. STAT. 75/1). The Act, which became effective on June 1, 2011, creates a legal relationship between two persons of either the same or opposite sex who establish a civil union. The Act provides that parties to a civil union are entitled to the same legal obligations, responsibilities, protections and benefits that are afforded or recognized by the law of Illinois to spouses, whether they are derived from statute, administrative rule, policy, common law or any source of civil or criminal law. In addition, this law requires recognition of a same-sex civil union, marriage, or other substantially similar legal relationship, except for common law marriage, legally entered into in other jurisdictions. The Act further provides that "party to a civil union" shall be included in any definition or use of the terms "spouse", "family", "immediate family", "dependent", "next of kin" and other terms descriptive of spousal relationships as those terms are used throughout the law. According to CB 2011-06, this includes the terms "marriage" or "married" or any variations thereof. CB 2011-06 also states that if policies of insurance provide coverage for children, the children of civil unions must also be provided coverage. The undersigned warrants that the statements set forth in this application and its attachments and other material submitted to the insurer are true and correct. Although the signing of this application does not bind the applicant or insurer to effect insurance, the undersigned agrees that this application and its attachments shall be the basis of the contract should a policy be issued and shall be deemed attached to and shall form part of the policy. (Not applicable in North Carolina) The undersigned further declares that any occurrence or event taking place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any information in this application, will immediately be reported in writing to the insurer. Based on such new information, the insurer may withdraw or modify any outstanding quotations and or authorization or agreement to bind the insurance. Individual responsible for Human Resources function: ______________________ ___________________ ___________


President or Chairman: _________________________ ___________________ ___________ Name (Please Print) Signature Date

BOP-7095 (Ed. 08-12) Page 1 of 4

Harleysville Worcester Insurance Company RENEWAL APPLICATION



Agent: Agent Code:





Last Year

Next Year






LOSS HISTORY



BOP-7095 (Ed. 08-12) Page 2 of 4



Name: Title:


Name: Title:








Notices required by law to be posted in places conspicuous to all employees and applicants for employment? Yes No Family Medical Leave Act information as required by federal law? Yes No If Yes, describe During the past two years, have the employment policies and procedures been reviewed and approved by outside legal counsel? Yes No If yes, when? By whom? Firm: Attorney:

Have all recommendations from that review been implemented? Yes No N/A If no, explain or provide timeframe for implementation: ADDITIONAL INFORMATION– Please attach each of the following, if they have been created or amended in the past two years:




BOP-7095 (Ed. 08-12) Page 3 of 4


BOP-7095 (Ed. 08-12) Page 4 of 4




BOP-7094 (Ed. 08-12) Page 1 of 5

Harleysville Worcester Insurance Company NEW BUSINESS APPLICATION



Agent: Agent Code:

Effective Date:

Retroactive Date:


THIS APPLICATION IS FOR A CLAIMS-MADE POLICY WHICH PROVIDES FOR DEFENSE WITHIN THE LIMITS OF INSURANCE.

CORPORATE HISTORY Franchise holder?: No Yes Number of years in business? Describe the business operations: Does the organization have any contracts with or receive financial assistance from the Federal Government or any agency thereof? No Yes If yes, describe Is there any affirmative action plan? No Yes If yes, attach and describe reason for implementing it:



$50,000/$50,000 $100,000 / $100,000 $250,000 / $250,000

Note: This limit applies separately to Damages and Defense Expenses in AR, MA, MN, VT. Deductible ($5,000 automatic):


Does the applicant currently carry EPL? No Yes If yes, please supply prior coverage information and attach a copy of the prior policy declaration: Insurer: Limit of Insurance: (per claim/aggregate)

Effective Date Expiration Date Deductible: Retroactive Date: If the Retroactive Date is not the same as the coverage effective date, has the coverage been provided uninterrupted up to the proposed effective date? Yes No If No, supply details N/A Has any insurer ever cancelled or non-renewed the applicants EPL coverage? Yes No If Yes, supply details including carrier name, reason and termination date



BOP-7094 (Ed. 08-12) Page 2 of 5






Over $100,000 per year 2 Years Ago Previous Year Current YearEmployee-initiated (voluntary termination) turnover rate % % % Employer-initiated (involuntary termination) turnover rate % % % Have there been any office, branch, facility, branch or plant closings, consolidations, layoffs or staff reductions (greater than 10% of the workforce), mergers or acquisitions within the last 24 months? No Yes If yes, describe: . Are any office, branch, facility or plant closings, consolidations, layoffs or staff reductions (greater than 10% of the workforce), merger or acquisitions anticipated within the next 12 months? No Yes If Yes, describe:

LOSS HISTORY





Name: Title:


Name: Title:

Are there tests (i.e. psychological, personality, drug, alcohol, medical) used to screen employment applicants, promote employees, or for the purpose of continuing employment?

No Yes If Yes, describe: The type of test (s) How is it administered (i.e. to all employees or segments thereof): The company creating the test and validation documents:

BOP-7094 (Ed. 08-12) Page 3 of 5











Third Party Liability Coverage No Yes If Yes, supply: Details of all contracts with independent contractors including: number of workers; type of work; approximate average hours per week and /or months of use; and, whether workers are primarily onsite or offsite:

BOP-7094 (Ed. 08-12) Page 4 of 5


BOP-7094 (Ed. 08-12) Page 5 of 5




BOP-7095 (Ed. 08-12) Page 1 of 4

Harleysville Worcester Insurance Company RENEWAL APPLICATION



Agent: Agent Code:





Last Year

Next Year






LOSS HISTORY



BOP-7095 (Ed. 08-12) Page 2 of 4



Name: Title:


Name: Title:








Notices required by law to be posted in places conspicuous to all employees and applicants for employment? Yes No Family Medical Leave Act information as required by federal law? Yes No If Yes, describe During the past two years, have the employment policies and procedures been reviewed and approved by outside legal counsel? Yes No If yes, when? By whom? Firm: Attorney:

Have all recommendations from that review been implemented? Yes No N/A If no, explain or provide timeframe for implementation: ADDITIONAL INFORMATION– Please attach each of the following, if they have been created or amended in the past two years:




BOP-7095 (Ed. 08-12) Page 3 of 4


BOP-7095 (Ed. 08-12) Page 4 of 4





Page 1 of 5
















✔

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BOP-7058

RESET FORM


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20

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Check: _____





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Not (a)-rating

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Page 4 of 5












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Page _____, Para. _____


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Not (a)-rating

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n/an/a



SRB-CC (ed. 01/11)

MASSACHUSETTS DIVISION OF INSURANCE

CERTIFICATION OF COMPLIANCE _____________________________________________________________________________________________ (Please enter the corporate name of the First Filing Company, hereinafter referred to as “the Filing Entity.”) _____________________________________________________________________________________________ (Please enter the Company Tracking Number or SERFF Tracking Number, hereinafter referred to as “the Filing.”)

I, _________________________________, ___________________________________, Name Title as a representative of the Filing Entity and duly authorized to give this certification on its behalf, hereby certify under the pains and penalties of perjury that this Filing is in compliance with all relevant laws and regulations of the Commonwealth of Massachusetts. _____________________________________________ ________________________ Signature Date

Michelle HansonDigitally signed by Michelle Hanson DN: cn=Michelle Hanson, o=Harleysville Insurance, ou, [email protected], c=US Date: 2012.05.15 08:30:26 -04'00'

RESET FORM

June 20, 2013

Co Tr Number BOMH12202012-1(SERFF # HRLV-129084804)

CL Product AnalystMichelle Hanson

Harleysville Insurance Company


Page 1 of 5
















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BOP-7058

RESET FORM


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Page 2 of 5





20

42

20

BP 0003

5

2

BP 0003

21

1

2 BP 000320

5

1

1

6

n/a

40

4

2

47

BP 0108

BP 0003

31

BP 0003

BP 0003

2

2

4

7

4

45

BP 0003

6

40BP 0003

46

4

BP 0003

BP 0003

BP 0003

4

BP 0003

1

21

BP 0003

1

321


20

BP 0186

BP 0003

40

1BP 0003


BP 0003

BP 0108

4

BP 0003

1

2

5

BP 0108

BP 0003BP 0003

13

45

5

5

5

BP 0003

BP 0003

5

2

40

BOP-70334

2










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15

4

3 BP 0003

N/A personal lines

4

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BP 0108

acknowledged

211


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N/a

33

BP 00034

BP 1431 & BP 1444













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Check: _____





RR4





BP 1431 & BP 1444

2

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31




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Page _____, Para. _____


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Page 1 of 5
















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BOP-7079

RESET FORM


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Page 2 of 5





20

42

20

BP 0003

5

2

BP 0003

21

1

2 BP 000320

5

1

1

6

n/a

40

4

2

47

BP 0108

BP 0003

31

BP 0003

BP 0003

2

2

4

7

4

45

BP 0003

6

40BP 0003

46

4

BP 0003

BP 0003

BP 0003

4

BP 0003

1

21

BP 0003

1

321


20

BP 0186

BP 0003

40

1BP 0003


BP 0003

BP 0108

4

BP 0003

1

2

5

BP 0108

BP 0003BP 0003

13

45

5

5

5

BP 0003

BP 0003

5

2

40

BOP-70334

2










Page 3 of 5
















15

4

3 BP 0003

N/A personal lines

4

✔

BP 0108

acknowledged

211


✔

N/a

33

BP 00034

BP 1431 & BP 1444













Page 4 of 5












Check: _____





RR4





BP 1431 & BP 1444

2

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31




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Page 5 of 5


















Page _____, Para. _____


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