WCIRB Bulletin 2016-21 Revised Standard Limiting and ... · the use of the form is Title 10, Section 2259 (e) (5), ... WCIRB Bulletin 2016-21 Revised Standard Limiting and Restricting

WCIRB Bulletin Bulletin No. 2016-21 October 20, 2016

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Revised Standard Limiting and Restricting Endorsements On February 3, 2016, the WCIRB issued Bulletin No. 2016-03 regarding the California Department of Insurance’s (CDI) revisions to the policy and endorsement forms filing process in Title 10 of the California Code of Regulations. As a result of those revisions, the WCIRB proposed and the CDI approved several new advisory standard limiting and restricting endorsement forms to comply with the new requirements. The WCIRB recently proposed further revisions to several of these limiting and restricting standard endorsement forms to assist insurers with the electronic reporting of policy information and these revised standard forms have been approved by the CDI. The amendments to the forms listed below include adding an indicator on the forms where the basis for the use of the form is Title 10, Section 2259 (e) (5), which allows an insurer to use a limiting and restricting endorsement to exclude liability if the employer affirms in writing to the insurer that other coverage is secured for that liability or the entity is lawfully uninsured. Additional amendments to these forms clarify that alternate coverage information on the form is optional. WC 04 03 38 A Designated Employee(s) Exclusion WC 04 03 39 A Designated Operation(s) Coverage WC 04 03 40 A Designated Location(s) Coverage WC 04 03 41 A Designated Location(s) Exclusion WC 04 03 42 A Designated Operation(s) Exclusion WC 04 03 43 A Designated Operation(s) at Designated Location(s) Exclusion WC 04 03 44 A Designated Operation(s) at Designated Location(s) Coverage In addition, the CDI approved revisions to the following limiting and restricting forms where the basis for the use of the form does not require a written affirmation. The revisions remove unnecessary language and ensure consistency with other limiting and restricting forms that do not require a written affirmation. WC 04 03 13 B Labor Contractor as Named Insured – Exclusion of Leased Employees WC 04 03 14 B Labor Contractor as Named Insured – Restriction of Coverage to Client

Workers WC 04 03 15 B Labor Contractor as Named Insured with LCF Designation – Restriction of

Coverage to Client Workers WC 04 03 16 B Labor Contractor Client as Named Insured – Exclusion of Client’s Employees WC 04 03 17 B Employee Insured by General Employer Excluded WC 04 03 45 A Comprehensive Personal Liability Policy Exclusion For your ease of reference, two copies of each captioned Standard Form are attached. One copy identifies the deletions (stricken) and additions (underscored), and the other is in “final” format.

Bulletin No. 2016-21 October 20, 2016

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As with any Standard Form, an insurer may file these forms with the WCIRB electronically through SERFF and may use them after receiving the WCIRB’s notification indicating that the forms have been reviewed as to form and substance and are ready for use. When filing a Standard Form with the WCIRB through SERFF, each insurer must submit a copy of the Standard Form and a cover letter requesting authorization to use the form. Affiliated insurers must each make a separate filing. THE ATTACHED FORMS ARE ADVISORY ONLY AND INSURERS ARE THEREFORE NOT OBLIGATED OR REQUIRED TO USE THEM. Insurers that choose not to use these standard forms may, but are not obligated to, prepare their own forms. Insurers choosing to prepare their own forms must submit them to the WCIRB for review and submission to, and approval by, the Insurance Commissioner before using the forms. Copies of these new forms are available in the Knowledge Center in WCIRB Connect.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 13 AB (Ed. 04-1610-16)

ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Labor Contractor as Named Insured – Exclusion of Leased Employees

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: LIABILITY NOT INSURED

Any liability the labor contractor named in Item 1 of the policy may have with respect to employees provided to a client pursuant to an employee leasing arrangement subject to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements.

If alternate coverage information is available, complete the following: Insured Name Insurer Policy # Policy Effective Dates

Check box if liability is lawfully uninsured. Notes:

1. This endorsement may be used to exclude coverage for all workers provided to a client when such workers are required to be covered under a separate policy pursuant to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements.

2. Use of tThis limiting and restricting endorsement will require the labor contractor to affirm to the insurer in writing that the portion of its

liability for compensation excluded by this endorsement is otherwise secured or lawfully uninsured and the WCIRB may ask the insurer to provide a copy of such affirmation. (10 C.C.R.may be used only under the circumstances in §Section 2259 (a) (7)) of Title 10 of the California Code of Regulations.

3. If available, insert the insured’s name, name of the alternate coverage insurer, policy number and policy effective dates on this

endorsement. This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer affirms in writing to the insurer that coverage for the excluded liability is secured, (2) the employer actually obtains coverage for the excluded liability and (3) such coverage remains in effect for the term of this policy. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements or limitations in this endorsement. It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective Policy No. Endorsement No.

Insured Insurance Company

Countersigned By

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 13 B (Ed. 10-16)

ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Labor Contractor as Named Insured – Exclusion of Leased Employees


Any liability the labor contractor named in Item 1 of the policy may have with respect to employees provided to a client pursuant to an employee leasing arrangement subject to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements.

Notes:

1. This endorsement may be used to exclude coverage for all workers provided to a client when such workers are required to be covered under a separate policy pursuant to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements.

2. This limiting and restricting endorsement may be used only under the circumstances in Section 2259 (a) (7) of Title 10 of the California

Code of Regulations. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements or limitations in this endorsement. It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.




Countersigned By


ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Labor Contractor as Named Insured – Restriction of Coverage to Client Workers


Any liability the labor contractor named in Item 1 of the policy may have, other than with respect to employees provided to the client named below pursuant to an employee leasing arrangement subject to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements.”

Client’s Name: Client’s Address: If alternate coverage information is available, complete the following: Insured Name Insurer Policy # Policy Effective Dates


1. This endorsement may be used to limit coverage to those employees of the labor contractor thatwho are provided as workers to the client named on this endorsement when such workers are required to be covered under a separate policy pursuant to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements.

2. This endorsement must include the complete name and address of the client.


liability for compensation excluded by this endorsement is otherwise secured or lawfully uninsured and the WCIRB may ask the insurer to provide a copy of such affirmation. (10 C.C.R.may be used only under the circumstances in §Section 2259 (a) (7)) of Title 10 of the California Code of Regulations.


endorsement. This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer affirms in writing to the insurer that coverage for the excluded liability is secured, (2) the employer actually obtains coverage for the excluded liability and (3) such coverage remains in effect for the term of this policy. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements or limitations in this endorsement. It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.




Countersigned By


ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Labor Contractor as Named Insured – Restriction of Coverage to Client Workers


Any liability the labor contractor named in Item 1 of the policy may have, other than with respect to employees provided to the client named below pursuant to an employee leasing arrangement subject to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements.

Client’s Name: Client’s Address: Notes:

1. This endorsement may be used to limit coverage to those employees of the labor contractor who are provided as workers to the client named on this endorsement when such workers are required to be covered under a separate policy pursuant to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements.

2. This endorsement must include the complete name and address of the client.


Code of Regulations. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements or limitations in this endorsement. It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.




Countersigned By


ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Labor Contractor as Named Insured with LCF Designation – Restriction of Coverage to Client Workers


Any liability the labor contractor named in Item 1 of the policy may have, other than with respect to employees provided to the client shown in Item 1 (following the designation “Leased Coverage For” or “LCF”) pursuant to an employee leasing arrangement subject to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements.

LIABILITY NOT INSURED

Any liability the client shown in Item 1 may have, other than with respect to workers provided by the Labor Contractor named in Item 1 of the policy pursuant to an employee leasing arrangement subject to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements.

Name of Client shown in Item 1: Client’s Address: If alternate coverage information is available, complete the following: Insured Name Insurer Policy # Policy Effective Dates


1. This endorsement may be used to limit coverage to those employees of the labor contractor thatwho are provided as workers to the client shown in Item 1 of the policy when such workers are required to be covered under a separate policy pursuant to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements.

2. This endorsement must include the complete name and address of the client shown in Item 1.


liability for compensation excluded by this endorsement is otherwise secured or lawfully uninsured and the WCIRB may ask the insurer to provide a copy of such affirmation. (10 C.C.R.may only be used under the circumstances in §Section 2259 (a) (7)) of Title 10 of the California Code of Regulations.

4.3. If available, insert the insured’s name, name of the alternate coverage insurer, policy number and policy effective dates on this endorsement.

This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer affirms in writing to the insurer that coverage for the excluded liability is secured, (2) the employer actually obtains coverage for the excluded liability and (3) such coverage remains in effect for the term of this policy. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements or limitations in this endorsement. It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Insurance Company Countersigned By


ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Labor Contractor as Named Insured with LCF Designation – Restriction of Coverage to Client Workers


Any liability the labor contractor named in Item 1 of the policy may have, other than with respect to employees provided to the client shown in Item 1 (following the designation “Leased Coverage For” or “LCF”) pursuant to an employee leasing arrangement subject to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements.

LIABILITY NOT INSURED

Any liability the client shown in Item 1 may have, other than with respect to workers provided by the Labor Contractor named in Item 1 of the policy pursuant to an employee leasing arrangement subject to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements.

Name of Client shown in Item 1: Client’s Address: Notes:

1. This endorsement may be used to limit coverage to those employees of the labor contractor who are provided as workers to the client shown in Item 1 of the policy when such workers are required to be covered under a separate policy pursuant to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements.

2. This endorsement must include the complete name and address of the client shown in Item 1.

3. This limiting and restricting endorsement may only be used under the circumstances in Section 2259 (a) (7) of Title 10 of the California

Code of Regulations. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements or limitations in this endorsement. It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Insurance Company Countersigned By


1 of 2

ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Labor Contractor Client as Named Insured – Exclusion of Client’s Employees


Any liability the client named in Item 1 may have for any employee other than those employees provided to the client by the labor contractor named below pursuant to an employee leasing arrangement subject to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements.

ADDITIONAL INSURED ENDORSEMENT

The Labor Contractor named below is an additional insured on this policy, but only with respect to those employees provided to the client named in Item 1 pursuant to an employee leasing arrangement subject to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements. Labor Contractor’s Name: Labor Contractor’s Address: If alternate coverage information is available, complete the following: Insured Name Insurer Policy # Policy Effective Dates


1. This endorsement may be used to limit coverage to those employees of the client thatwho are provided as workers by the labor contractor when such workers are required to be covered under a separate policy pursuant to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements.

2. This endorsement must include the complete name and address of the labor contractor.

3. Use of tThis limiting and restricting endorsement will require the client (named insured) to affirm to the insurer in writing that the portion

of its liability for compensation excluded by this endorsement is otherwise secured or lawfully uninsured and the WCIRB may ask the insurer to provide a copy of such affirmation. (10 C.C.Rmay be used only under the circumstances in §Section 2259 (a) (7)) of Title 10 of the California Code of Regulations.


endorsement.

5.4. If the client (named insured) is a licensed contractor subject to the Contractors’ State License Law, please refer to Labor Code §3302.

6.5. If this endorsement is used, it may conflict with an endorsement that generically excludes special employees because it is likely that a court may find that the employees provided by the labor contractor to the client are the client’s special employees.

This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer affirms in writing to the insurer that coverage for the excluded liability is secured, (2) the employer actually obtains coverage for the excluded liability and (3) such coverage remains in effect for the term of this policy. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements or limitations in this endorsement. It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing.

WC 04 03 16 A WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 04-1610-16)

2 of 2

FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.




Countersigned By


ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Labor Contractor Client as Named Insured – Exclusion of Client’s Employees


Any liability the client named in Item 1 may have for any employee other than those employees provided to the client by the labor contractor named below pursuant to an employee leasing arrangement subject to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements.

ADDITIONAL INSURED ENDORSEMENT

The Labor Contractor named below is an additional insured on this policy, but only with respect to those employees provided to the client named in Item 1 pursuant to an employee leasing arrangement subject to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements. Labor Contractor’s Name: Labor Contractor’s Address: Notes:

1. This endorsement may be used to limit coverage to those employees of the client who are provided as workers by the labor contractor when such workers are required to be covered under a separate policy pursuant to the California Workers’ Compensation Experience Rating Plan—1995, Section V, Rule 4, Application of Experience Modification to Policies Covering Employee Leasing Arrangements.

2. This endorsement must include the complete name and address of the labor contractor.


Code of Regulations.

4. If the client (named insured) is a licensed contractor subject to the Contractors’ State License Law, please refer to Labor Code §3302.

5. If this endorsement is used, it may conflict with an endorsement that generically excludes special employees because it is likely that a court may find that the employees provided by the labor contractor to the client are the client’s special employees.

Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements or limitations in this endorsement. It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.




Countersigned By


ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Employee Insured by General Employer Excluded

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: NO LIABILITY FOR EMPLOYEE INSURED BY GENERAL EMPLOYER

Any liability you may have as the special employer of an employee who is not on your payroll at the time of injury, based upon your representation that: (1) you have entered into a valid and enforceable agreement pursuant to Labor Code Section 3602(d) with the employee’s general employer under which the general employer agrees to secure the payment of compensation for such employee and (2) the general employer has obtained workers’ compensation coverage for the employee.

If alternate coverage information is available, complete the following: Insured Name Insurer Policy # Policy Effective Dates


1. This form is a limiting and restricting endorsement and is therefore subject to the rules set forth inmay be used under the circumstances in Section 2259 (a) (7) of Title 10, of the California Code of Regulations.

2. Use of this endorsement will require the labor contractor to affirm to the insurer in writing that the portion of its liability for compensation

excluded by this endorsement is otherwise secured or lawfully uninsured. (10 C.C.R. §2259(a)(7)). 3. If available, insert the insured’s name, name of the alternate coverage insurer, policy number and policy effective dates on this

endorsement. This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer affirms in writing to the insurer that coverage for the excluded liability is secured, (2) the employer actually obtains coverage for the excluded liability and (32) such coverage remains in effect for the term of this policy. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements or limitations in this endorsement. It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). By signature below, you affirm that, with respect to any employee who is also the employee of a general employer, (1) you have entered into a valid and enforceable agreement pursuant to Labor Code Section 3602(d) with the employee’s general employer under which the general employer agrees to secure the payment of compensation for such employee and (2) the general employer has obtained workers’ compensation coverage for the employee. Countersigned By This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.




Countersigned By


ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Employee Insured by General Employer Excluded

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: NO LIABILITY FOR EMPLOYEE INSURED BY GENERAL EMPLOYER

Any liability you may have as the special employer of an employee who is not on your payroll at the time of injury, based upon your representation that: (1) you have entered into a valid and enforceable agreement pursuant to Labor Code Section 3602(d) with the employee’s general employer under which the general employer agrees to secure the payment of compensation for such employee and (2) the general employer has obtained workers’ compensation coverage for the employee.

Note:

1. This limiting and restricting endorsement may be used under the circumstances in Section 2259 (a) (7) of Title 10 of the California Code of Regulations.

This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer actually obtains coverage for the excluded liability and (2) such coverage remains in effect for the term of this policy. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements or limitations in this endorsement. It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.




Countersigned By

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 38 A (Ed. 04-1610-16)

ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Designated Employee(s) Exclusion

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: THIS POLICY DOES NOT INSURE DESIGNATED EMPLOYEE(S)

Any liability you may have for any injury to the employee(s) named below.

Employee(s) Name(s)

Check box if policyholder has affirmed in writing that other coverage is secured or the entity is lawfully uninsured.

Check box if liability is lawfully uninsured.

If alternate coverage information is available, complete the following (OPTIONAL): Insured Name Insurer Policy # Policy Effective Dates Notes:

1. Insert only the names of persons to be specifically excluded.

2. This limiting and restricting endorsement may be used only under the circumstances in Section 2259 (a) (5) of Title 10 of the California Code of Regulations.

3. To use this endorsement, the policyholder is required to affirm to the insurer in writing that the liability for compensation excluded by

this endorsement is otherwise secured or lawfully uninsured and the WCIRB may ask the insurer to provide a copy of such affirmation.

4. If available, insert the insured’s name, name of the alternate coverage insurer, policy number and policy effective dates, or indicate if the liability is lawfully uninsured on this endorsement.


WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 38 A (Ed. 10-16)

ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Designated Employee(s) Exclusion

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: THIS POLICY DOES NOT INSURE DESIGNATED EMPLOYEE(S)

Any liability you may have for any injury to the employee(s) named below.

Employee(s) Name(s)



If alternate coverage information is available, complete the following (OPTIONAL): Insured Name Insurer Policy # Policy Effective Dates Notes:

1. Insert only the names of persons to be specifically excluded.







ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Designated Operation(s) Coverage

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: THIS POLICY DOES NOT INSURE ANY EMPLOYEE(S) OTHER THAN IN CONNECTION WITH THE DESIGNATED OPERATION(S)

Any liability you may have for any injury to any employee(s) engaged in any work other than directly in connection with the operation(s) specifically described in the policy schedule or amendment of such schedule by endorsement.


Check box if liability is lawfully uninsured. If alternate coverage information is available, complete the following (OPTIONAL): Insured Name Insurer Policy # Policy Effective Dates Notes:







ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Designated Operation(s) Coverage

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: THIS POLICY DOES NOT INSURE ANY EMPLOYEE(S) OTHER THAN IN CONNECTION WITH THE DESIGNATED OPERATION(S)

Any liability you may have for any injury to any employee(s) engaged in any work other than directly in connection with the operation(s) specifically described in the policy schedule or amendment of such schedule by endorsement.









ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Designated Location(s) Coverage

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: THIS POLICY DOES NOT INSURE ANY EMPLOYEE(S) OTHER THAN AT/ OR IN DESIGNATED LOCATION(S)

Any liability you may have for any injury to any employee(s) engaged in any work not directly connected with operation(s) conducted at or in the location(s) described below.

Operation(s) Name Operation(s) Title (optional) Location(s) address



1. Insert a careful description of the operation(s) andconducted at or in the location(s) for which liability is insured.





This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer affirms in writing to the insurer that coverage for the excluded liability is secured, (2) the employer actually obtains coverage for the excluded liability and (3) such coverage remains in effect for the term of this policy. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements, or limitations of this endorsement. It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.




Countersigned By


ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Designated Location(s) Coverage

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: THIS POLICY DOES NOT INSURE ANY EMPLOYEE(S) OTHER THAN AT/ OR IN DESIGNATED LOCATION(S)

Any liability you may have for any injury to any employee(s) engaged in any work not directly connected with operation(s) conducted at or in the location(s) described below.

Operation(s) Name Operation(s) Title (optional) Location(s) address



1. Insert a careful description of the operation(s) conducted at or in the location(s) for which liability is insured.





This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer affirms in writing to the insurer that coverage for the excluded liability is secured, (2) the employer actually obtains coverage for the excluded liability and (3) such coverage remains in effect for the term of this policy. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements, or limitations of this endorsement. It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.




Countersigned By


ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Designated Location(s) Exclusion

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: THIS POLICY DOES NOT INSURE ANY EMPLOYEE(S) AT/OR IN DESIGNATED LOCATION(S)

Any liability you may have for any injury to any employee(s) engaged in any work directly connected with operation(s) conducted at or in the location(s) described below.

Operation Name Operation Title (optional) Location(s) address



1. Insert a careful description of the operation(s) conducted at or in the location(s) to be excluded.





This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer affirms in writing to the insurer that coverage for the excluded liability is secured, (2) the employer actually obtains coverage for the excluded liability and (3) such coverage remains in effect for the term of this policy. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements, or limitations of this endorsement. It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.




Countersigned By


ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Designated Location(s) Exclusion

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: THIS POLICY DOES NOT INSURE ANY EMPLOYEE(S) AT/OR IN DESIGNATED LOCATION(S)

Any liability you may have for any injury to any employee(s) engaged in any work directly connected with operation(s) conducted at or in the location(s) described below.

Operation Name Operation Title (optional) Location(s) address



1. Insert a careful description of the operation(s) conducted at or in the location(s) to be excluded.





This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer affirms in writing to the insurer that coverage for the excluded liability is secured, (2) the employer actually obtains coverage for the excluded liability and (3) such coverage remains in effect for the term of this policy. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements, or limitations of this endorsement. It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.




Countersigned By


ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Designated Operation(s) Exclusion

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: THIS POLICY DOES NOT INSURE ANY EMPLOYEE(S) ENGAGED IN DESIGNATED OPERATION(S)

Any liability you may have for any injury to any employee(s) engaged in the following operation(s) described below.

Operation(s) Standard Classification Number(s) Abbreviated Phraseology


Check box if policyholder has affirmed in writing that other coverage is secured or the entity is lawfully uninsured. If alternate coverage information is available, complete the following (OPTIONAL): Insured Name Insurer Policy # Policy Effective Dates Notes:

1. Insert a careful description of the operation(s) to be excluded and the standard classification number(s) and abbreviated phraseology from the current California Workers’ Compensation Uniform Statistical Reporting Plan—1995 applicable to such operation(s).



3. To use this endorsement, the policyholder is required to affirm to the insurer in writing that the liability for compensation excluded by this endorsement is otherwise secured or lawfully uninsured and the WCIRB may ask the insurer to provide a copy of such affirmation.

4. If available, insert the insured’s name, name of the alternate coverage insurer, policy number and policy effective dates, or indicate if

the liability is lawfully uninsured on this endorsement. This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer affirms in writing to the insurer that coverage for the excluded liability is secured, (2) the employer actually obtains coverage for the excluded liability and (3) such coverage remains in effect for the term of this policy. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements, or limitations of this endorsement. It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Insurance Company Countersigned By


ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Designated Operation(s) Exclusion

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: THIS POLICY DOES NOT INSURE ANY EMPLOYEE(S) ENGAGED IN DESIGNATED OPERATION(S)

Any liability you may have for any injury to any employee(s) engaged in the following operation(s) described below.

Operation(s) Standard Classification Number(s) Abbreviated Phraseology


Check box if policyholder has affirmed in writing that other coverage is secured or the entity is lawfully uninsured. If alternate coverage information is available, complete the following (OPTIONAL): Insured Name Insurer Policy # Policy Effective Dates Notes:

1. Insert a careful description of the operation(s) to be excluded and the standard classification number(s) and abbreviated phraseology from the current California Workers’ Compensation Uniform Statistical Reporting Plan—1995 applicable to such operation(s).





the liability is lawfully uninsured on this endorsement. This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer affirms in writing to the insurer that coverage for the excluded liability is secured, (2) the employer actually obtains coverage for the excluded liability and (3) such coverage remains in effect for the term of this policy. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements, or limitations of this endorsement. It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Insurance Company Countersigned By


ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Designated Operation(s) at Designated Location(s) Exclusion

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: THIS POLICY DOES NOT INSURE ANY EMPLOYEE(S) ENGAGED IN DESIGNATED OPERATION(S) AT OR FROM DESIGNATED LOCATION(S)

Any liability you may have for any injury to any employee(s) engaged in the following operation(s) at or from the following location(s) described below.

Operation(s) Standard Classification Number(s) Abbreviated Phraseology Location(s) Address



1. Insert a careful description of the operation(s) at or from the described location(s) to be excluded and the standard classification number(s) and abbreviated phraseology from the current California Workers’ Compensation Uniform Statistical Reporting Plan—1995 applicable to such operation(s).





the liability is lawfully uninsured on this endorsement. This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer affirms in writing to the insurer that coverage for the excluded liability is secured, (2) the employer actually obtains coverage for the excluded liability and (3) such coverage remains in effect for the term of this policy. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements, or limitations of this endorsement. It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.




Countersigned By


ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Designated Operation(s) at Designated Location(s) Exclusion

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: THIS POLICY DOES NOT INSURE ANY EMPLOYEE(S) ENGAGED IN DESIGNATED OPERATION(S) AT OR FROM DESIGNATED LOCATION(S)

Any liability you may have for any injury to any employee(s) engaged in the following operation(s) at or from the following location(s) described below.




1. Insert a careful description of the operation(s) at or from the described location(s) to be excluded and the standard classification number(s) and abbreviated phraseology from the current California Workers’ Compensation Uniform Statistical Reporting Plan—1995 applicable to such operation(s).





the liability is lawfully uninsured on this endorsement. This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer affirms in writing to the insurer that coverage for the excluded liability is secured, (2) the employer actually obtains coverage for the excluded liability and (3) such coverage remains in effect for the term of this policy. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements, or limitations of this endorsement. It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.




Countersigned By


ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Designated Operation(s) at Designated Location(s) Coverage

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: THIS POLICY DOES NOT INSURE ANY EMPLOYEE(S) OTHER THAN FOR DESIGNATED OPERATION(S) AT OR FROM DESIGNATED LOCATION(S)

Any liability you may have for any injury to any employee(s) other than those engaged in the following operation(s) at or from the following location(s) described below.




1. Insert a careful description of the operation(s) at or from the described location(s) for which liability is insured and the standard classification number(s) and abbreviated phraseology from the current California Workers’ Compensation Uniform Statistical Reporting Plan—1995 applicable to such operation(s).





the liability is lawfully uninsured on this endorsement. This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer affirms in writing to the insurer that coverage for the excluded liability is secured, (2) the employer actually obtains coverage for the excluded liability and (3) such coverage remains in effect for the term of this policy. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements, or limitations of this endorsement It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.




Countersigned By


ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Designated Operation(s) at Designated Location(s) Coverage

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: THIS POLICY DOES NOT INSURE ANY EMPLOYEE(S) OTHER THAN FOR DESIGNATED OPERATION(S) AT OR FROM DESIGNATED LOCATION(S)

Any liability you may have for any injury to any employee(s) other than those engaged in the following operation(s) at or from the following location(s) described below.




1. Insert a careful description of the operation(s) at or from the described location(s) for which liability is insured and the standard classification number(s) and abbreviated phraseology from the current California Workers’ Compensation Uniform Statistical Reporting Plan—1995 applicable to such operation(s).





the liability is lawfully uninsured on this endorsement. This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer affirms in writing to the insurer that coverage for the excluded liability is secured, (2) the employer actually obtains coverage for the excluded liability and (3) such coverage remains in effect for the term of this policy. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements, or limitations of this endorsement It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.




Countersigned By


ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Comprehensive Personal Liability Policy Exclusion

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: THIS POLICY DOES NOT INSURE ANY EMPLOYEE(S) COVERED BY A COMPREHENSIVE PERSONAL LIABILITY POLICY

Any liability you may have for any injury to any employee(s) who is covered for workers’ compensation benefits on a policy also affording comprehensive personal liability insurance which has been issued to this insured.

Note:

This limiting and restricting endorsement may be used only under the circumstances in Section 2259 (a) (6) of Title 10 of the California Code of Regulations.

This policy will be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer affirms in writing to the insurer that coverage for the excluded liability is secured, (2) the employer actually obtains coverage for the excluded liability and (3) such coverage remains in effect for the term of this policy. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements, or limitations of this endorsement It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.




Countersigned By


ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Comprehensive Personal Liability Policy Exclusion

The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: THIS POLICY DOES NOT INSURE ANY EMPLOYEE(S) COVERED BY A COMPREHENSIVE PERSONAL LIABILITY POLICY

Any liability you may have for any injury to any employee(s) who is covered for workers’ compensation benefits on a policy also affording comprehensive personal liability insurance which has been issued to this insured.

Note:

This limiting and restricting endorsement may be used only under the circumstances in Section 2259 (a) (6) of Title 10 of the California Code of Regulations.

Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements, or limitations of this endorsement It is further agreed that “remuneration” when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.




Countersigned By

Documents

WCIRB Bulletin 2016-21 Revised Standard Limiting and ... · the use of the form is Title 10, Section 2259 (e) (5), ... WCIRB Bulletin 2016-21 Revised Standard Limiting and Restricting