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Information Page, coiEorage will not Lie afforded for B. Notice <br />tiE t state Bless we are notified witi�n t::Jrty days. Tell ❑5 at once if yo❑ ❑egin wor❑ in any state listed in <br />Item 3.C. of tie Information Page. <br />PART FOUR - YOUR DUTIES IF INJURY OCCURS <br />Tell C:8 at once if inky occlirs tit may :]a coEored ❑y <br />Lis policy. Yoh otDer dEties are listed ire. <br />1. Prodde for immediate medical and otter serElces <br />re❑Eired ❑y t❑e worEors compensation law. <br />2. Gi![0 F:8 or oil agent tie names and addresses of <br />tip inEred persons and of witnesses, and ot:ler <br />information we may need. <br />3. Promptly gi::o i-:8 all <br />papers related to tip <br />s ::Jt. <br />A. Our Manuals <br />notices, demands and legal <br />inky, claim, proceeding or <br />4. Cooperate wit❑ ❑5 and assist E8, as we may <br />re❑❑est, in tFie instigation, settlement or <br />defense of any claim, proceeding or sElt. <br />El Do notElng after an in❑ry occlirs tit world <br />interfere wit❑oOr rig to reco❑er from ot0ers. <br />6. Do not FoliEntarily maims payments, ass —me <br />oiJigations or inc:lr e:A)enses, e:cept at yo:lr own <br />cost. <br />PART FIVE - PREMIUM <br />All premi:1n for tiffs policy will 00 determined i❑y oij <br />manlals of rues, rates, rating plans and <br />classifications. We may c0ange oi-i- maniFials and <br />apply tip Clanges to tiEis policy if a::t❑orii-:Od ❑y law or <br />a go::Ornmental agency reg:lating t❑is ins rance. <br />B. Classifications <br />Item 4 of t0e Information Page sows t❑e rate and <br />premiErn psis for certain ❑❑siness or wor❑ <br />classifications. T❑ese classifications were assigned <br />used on an estimate of t0e e'EposEires yo❑ wo'Eld <br />E]aL:o d0ring t❑e policy period. If yob actDal <br />eEposEires are not properly descried ❑y t❑ose <br />classifications, we will assign proper classifications, <br />rates and premiE]rn Dasis ❑y endorsement to Lis <br />policy. <br />C. Remuneration <br />Premi inn for eac❑ wor❑ classification is determined i❑I <br />m:1tiplying a rate times a premi::rn Oasis. <br />RemErieration is tie most common premi::n iFlasis. <br />T❑is premiiErn :18sis incl❑des payroll and all oti-ler <br />remErieration paid or paya:le dimming tip policy period <br />for tFle ser:lces of:] <br />1. All yo:l- officers and employees engaged in wor❑ <br />co::Ored ❑y tiffs policyiland <br />2. all oti-ler persons engaged in wor❑ t0at cord <br />maims -:8 liaLle ceder Part One :Wormers <br />Compensation Insi-irance❑of tits policy. If yo❑do <br />not 08::0 payroll records for ti-lese persons, tie <br />contract price for tE]eir ser:lces and materials <br />may 00 wed as tie premi::n Oasis. T❑is <br />paragrap❑ 2 will not apply if yoi❑ gi::0 ::8 proof <br />t!1at tie employers of tFlase persons lawf:11y <br />sec!-ired t:leir worEors compensation oiJigations. <br />D. Premium Payments <br />Yo❑will pay all premiLirn wFlan d' e. Yo❑will pay tie <br />premiErn e❑en if part or all of a wormers <br />compensation law is not ❑Alid. <br />E. Final Premium <br />T❑e premi::n s::own on tip Information Page, <br />sciOadiles, and endorsements is an estimate. T❑e <br />final premiEM will 00 determined after tits policy ends <br />❑y ring t:le actin 1, not t❑e estimated, premi::n iFlasis <br />and tip proper classifications and rates tip t lawf:11y <br />apply to tip ❑iciness and wor❑ co::Ored ❑y tiJs <br />policy. If t�le final premi::n is more t:18n tip premi::n <br />yo❑ paid to ice, yo❑ milt pay ::8 tip :181ance. If it is <br />less, we will ref::nd tip :181ance to you T❑e final <br />premi::n will not Da less tin tip -Jgi-lest minim::n <br />premi::n for tie classifications coJOred :y ti❑is policy. <br />Form WC 00 00 00 C Printed in ❑.S.A. Page 5 of 6 <br />