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HomeMy WebLinkAboutContract Workers CompPr fOVEALI INSURANCETRUST Named Insured: City of Sebastian Issue Date: 9/13/2019 Agent: LSJ Insurance Agency Inc. DBA ISU Jallad Quote Number: WC FL1 0312002 19-04 01 - 2 Proposed Policy Period: From: 10/01/2019 To: 10101 /2020 Rating Basis Date: 10/01/2019 Emp. Liability Limits: 1,000,000/1,000,000/1,000,000 Quotation Schedule of Operations Schedule Page 1 o12 Period Effective: 10/01/2019 State: FL Experience Mod Status Effective Date 1.40 FINAL 10/01/2019 Policy Insured Premium Estimated Loc Lac Code Classifications Basis Rate Premium 0000 N/A 5509 STREET OR ROAD MAINTENANCE OR 703,000 9,85 $69,246 BEAUTIFICATION & DRIVERS 0000 N/A 7403 AVIATION: ALL OTHER EMPLOYEES & 51,250 5.14 $2,634 DRIVERS 0000 N/A 7720 POLICE OFFICERS & DRIVERS 2,865,750 3,83 $109,758 0000 N/A 8380 AUTOMOBILE SERVICE OR REPAIR CENTER 130,500 3,02 $3,941 & DRIVERS 0000 N/A 8810 CLERICAL OFFICE EMPLOYEES NOC 2,193,450 0.18 $3,948 0000 N/A 8820 ATTORNEY -ALL EMPLOYEES & CLERICAL, 99,000 0.15 $149 MESSENGERS, DRIVERS 0000 N/A 9015 BUILDING OR PROPERTY MANAGEMENT- 111,500 4,09 $4,560 ALL OTHER EMPLOYEES 0000 N/A 9060 CLUB- COUNTRY, GOLF, FISHING, OR 299,550 2,11 $6,321 YACHT- ALL EMPLOYEES & CLERICAL, SALESPERSONS, DRIVERS 0000 N/A 9102 LAWN MAINTENANCE—COMMERCIAL OR 557,000 4.21 $23,450 DOMESTIC & DRIVERS 0000 N/A 9220 CEMETERY OPERATIONS & DRIVERS 101,000 7,39 $7,464 0000 N/A 9410 MUNICIPAL, TOWNSHIP, COUNTY OR STATE 649.000 2.44 $15,836 EMPLOYEE NOC Total 7,761,000 $247,306 trefierred" VERNMENTAL INSURAN(ETRUST Named Insured: City of Sebastian Issue Date: 9/13/2019 Agent: LSJ Insurance Agency Inc. DBA ISU Jailed Quote Number: WC FL1 0312002 19-04 01 - 2 Proposed Policy Period: From: 10/01/2019 To: 10/01/2020 Rating Basis Date: 10/01/2019 Emp. Liability Limits: 1,000,000/1,000,000/1,000,000 Quotation Schedule of Operations State Level Summary coverane Manual Premium Total Manual Premium Subject Premium Safety Program Drug -Free Workplace Total Subject Premium Experience Mod Total Modified Premium Schedule Rating Factor Total Standard Premium Premium Discount Factor Deductible 2 5 1.400 Estimated Standard State Premium: Schedule Page 2 of 2 Est. Annual Premium $247,306 $247,306 $247,306 $(4,946) $(12,118) $230,242 $92,097 $322,339 $(96,702) $225,637 $(20,187) $205,450 EIeferred GOVERNMENTAL tD INSURANCE TRUST Standard Workers' Compensation and Employers' Liability Policy Agreement Number: WC FI -1 0312002 18-03 Agreement Period: 10/01/2018 to 10/01/2019 Emp. Liability Limits: 1,000,000/1,000,000/1,000,000 Coverage By: Preferred Governmental Insurance Trust Producer ID: LSJ Insurance Agency Inc. DBA ISU Jallad Previous Coverage: WC2FL1 0312002 16-01 02 Carrier ID: 38849 NAME AND ADDRESS OF MEMBER AGENT 1. City of Sebastian LSJ Insurance Agency Inc. DBA ISU Jailed 1225 Main Street 100 E. Sybelia Ave. Suite 375 Sebastian, FL 32958 Maitland, FL 32751 FEIN: 596000427 Risk ID Number. ,canoe: -ra „:,w,.as daazmws mvrm m n rmm.uxrn awa�ms w.vm h ws pokr arc rouvrce m ue am.e wlreu amass anei..ae mem rnae: sa Atort,oe sow. SCHEDULE OF OPERATIONS Policy Insured Estimated Lae Loc Code Classifications Endorsement Term :1010112018 -10/01/2019 State: FL 12.42 Experience Mod Status Effective Date $148,750 6.07 1.63 FINAL 10/01/2018 0000 N/A 5509 STREET OR ROAD MAINTENANCE OR $128,750 3.53 BEAUTIFICATION & DRIVERS $2,107,100 0.23 Class Code: 8508 Effective: 10,01/1018 Expired: 0000 N/A 7403 AVIATION: ALL OTHER EMPLOYEES & DRIVERS $111,250 4.71 Class Code. 7401 Effective: f0,0142018 Expired: 0000 N/A 7720 POLICE OFFICERS & DRIVERS $512,000 4.58 Class Cotla: 7710 Effective. 10,0142018 Expired: 0000 N/A 8380 AUTOMOBILE SERVICE OR REPAIR CENTER & DRIVERS Class Code: 8.180 Effective: 10,0142018 Expired: 0000 N/A 8810 CLERICAL OFFICE EMPLOYEES NOC Class Code: 8810 Effective: 10,01/1018 Expired: 0000 N/A 8820 ATTORNEY -ALL EMPLOYEES & CLERICAL, MESSENGERS, DRIVERS Class Coda: 8820 Effectiva: 10/01/2018 Explred, 0000 N/A 9015 BUILDING OR PROPERTY MANAGEMENT -ALL OTHER EMPLOYEES Class Coda: 8015 Effective: 10/01/1018 Explred: 0000 N/A 9060 CLUB- COUNTRY, GOLF, FISHING, OR YACHT -ALL EMPLOYEES & CLERICAL, SALESPERSONS, DRIVERS Class Code: 0060 Effective: 10,0142018 Explred: 0000 NIA 9102 LAWN MAINTENANCE—COMMERCIAL OR DOMESTIC & DRIVERS Claes Code: 8102 Effect/ve: lW142016 Eiplrad, 0000 N/A 9220 CEMETERY OPERATIONS & DRIVERS Clan Code: 0210 Effective: 10/0142018 Expired WC 00 00 so Pollcy_DED_8ceeduIaC 0peraaons.ryl Issue Data: 942442018 Copyright 1987 National Counal an Compensation Insurance Schedule Page l or 3 Premium Estimated Basis Rate Premium $810,750 12.42 $100,695 $148,750 6.07 $9,029 $2,592,750 4.16 $107,858 $128,750 3.53 $4,545 $2,107,100 0.23 $4,846 $103,200 0.17 $175 $111,250 4.71 $5,240 $289,600 2.40 $6,950 $512,000 4.58 $23,450 $106,750 9.08 $9.693 a Standard Workers' Compensation Erefrred and Employers' Liability Policy VERNMENTAL INSURANCE TRUST Agreement Number: WC FI -1 0312002 18-03 Agreement Period: 10/01/2018 to 10/01/2019 Emp. Liability Limits: 1,000,000/1,000,000/1,000,000 Coverage By: Preferred Governmental Insurance Trust Producer ID: LSJ Insurance Agency Inc. DBA ISU Jailed Previous Coverage: WC2FL1 0312002 16-0102 Carrier ID: 38849 NAME AND ADDRESS OF MEMBERRfjF 1. City of Sebastian LSJ Insurance Agency Inc. DBA (yt �a lad 1225 Main Street 100 E. Sybelia Ave. Suite 375 Sebastian, FL 32958 Maitland, FL 32751 FEIN: 596000427 Risk ID Number: ta[att`nz-IN u:,W wax pace: oz Ne Y,wre,l at a rmn whM attralKns [aertE q' INs p�6cy ai<(wJuttN at the aMre aOLoz unless aMewlse ffiIN Iwtln: $a nmam YMWle Schedule Page 2 of 3 SCHEDULE OF OPERATIONS Policy Insured Premium Estimated Lac Loe Code Classifications Basis Rale Premium State:FL 0000 WA 9410 MUNICIPAL, TOWNSHIP. COUNTY OR STATE $547,000 2.42 $13,237 EMPLOYEE NOC Crass Code: 9110 EHeadea: 1=142018 Esp/nd: 7,457,900 $285,719 VIC 00 00 so Pallcy_DEC_SchaduleMperadons.Mt Issue Date: 91242018 Copynght 1987 National Counal an Compensation Insurance we 00 00 so Policy_OEC ScheduleOfOpemtlons.Mt ISSYa Data: DIM2018 Copyright 1987 Naeonal CWWdl on Compensation Inaursnce Standard Workers' Compensation Preferred and Employers' Liability Policy GOVERNMENTAL ® INSURANCE TRUST Agreement Number: WC FI -1 0312002 18-03 Agreement Period: 10/01/2018 to 10/01/2019 Emp. Liability Limits: 1,000,000/1,000,000/1,000,000 Coverage By: Preferred Governmental Insurance Trust Producer ID: LSJ Insurance Agency Inc. DBA ISU Jallad Previous Coverage: WC2FL1 0312002 16-01 02 Carrier ID: 38849 NAME AND ADDRESS OF MEMBER AGENT 1. City of Sebastian LSJ Insurance Agency Inc. DBA ISU Jailed 1225 Main Street 100 E. Sybelia Ave. Suite 375 Sebastian, FL 32958 Maitland, FL 32751 FEIN: 59-6000427 Risk ID Number: LooWeon: - al usual w«k pace: or the msurtH at or Irom wee operzuo s mve,ed by tm: fonts are wnductM at We aWw AM -5 unless OW—iu:,abol he,., n: See Rtt .. Yhedule Sd,edvle Page 3 of 3 SCHEDULE OF OPERATIONS Policy Insured Premium Estimated Loc Lac Code Classifications Basis Rate Premium Manual Premium $285,719 Total Manual Premium $285,719 Subject Premium $285,719 Safety Program 2 $(5,714) Drug -Free Workplace 5 $(14,000) Total Subject Premium $266,005 Experience Mod 1,63 $167,583 Total Modified Premium $433,588 Schedule Rating Factor $(173,435) Total Standard Premium $260,153 FL Premium Discount $(24,087) Subtotal (State Level) for FL Period Effective: 10/1/2018 $236,066 Total Estimated Premium for FL for Period Effective: 10/1/2018 $260,153 Premium Discount $(24,087) Expense Constant $160 Pollcy Charges / Credits for the Period Effective: 10/1/2018 $(23,927) Total Estimated Standard Premium for the Period Effective: 10/1/2018 $236,226 we 00 00 so Policy_OEC ScheduleOfOpemtlons.Mt ISSYa Data: DIM2018 Copyright 1987 Naeonal CWWdl on Compensation Inaursnce