Laserfiche WebLink
<br />19rac <br /> <br />IlookIoy Ri6l AdmiI1iolJabs Company. LLC <br /> <br />Minnesota Workers' Compensation Assigned Risk Plan <br />Standard Workers' Compensation and Employers' Liability Policy <br />Contract Administrator <br />Berkley Risk Administrators Company, LLC <br />P.O. Box 59143 Minneapolis, Minnesota 55459-0143 <br />Phone (612) 766-3000 NCC! Carrier Code 21466 <br /> <br />Enclosed is your: <br />~ Coverage Document for Minnesota Worker's Compensation <br />Please carefully review your policy or Agreement, the Information Page and any Endorsements to <br />ensure that the coverages you want or need are included and that they are accurately prepared. <br />Your agent will also receive copies of your Information Page and any Endorsements. Please <br />communicate with your agent or Berkley Risk Administrators Company, LLC if there are errors <br />or if changes are necessary. Also included for your review are the forms and instructions <br />you need to report all workers' compensation claims to us. <br /> <br />~ Minnesota Workers' Compensation Renewal Document <br />Please carefully review your renewal Policy or Agreement, the Information Page and any <br />Endorsements to ensure that the coverages you want or need are included and that they are <br />accurately prepared. <br /> <br />D New supply of First Report of Injury forms andlor the other information you requested. <br /> <br />MANDATORY FRAUD NOTICE <br /> <br />A person who submits an application or files a claim with intent to defraud or helps <br />commit fraud against an insurer is guilty of a crime. Minnesota Status 60A.955. <br /> <br />I <br />I <br />I <br /> <br />YOU MUST MAINTAIN AN ADEQUATE SUPPLY OF FIRST REPORT OF INJURY FORMS. <br /> <br />They should be kept where they are accessible to the person who is responsible for completing the form and <br />sending it to us. If you run out of forms or can't find your supply, please complete the form below and return <br />it to Berkley Risk Administrators Company, llC. We will gladly send you a supply of forms and provide any <br />other information you request. Please do it today because you never know when an injury might be reported <br />by one of your employees. <br /> <br />CUT ON LINE <br /> <br />, WC-22-04-159728-03 <br />GNAW INC <br />Centerville Liquor Barrel <br />7093 20th Ave <br />Centervllle, MN 55038 <br />L <br /> <br />I <br /> <br />Please send the following information to the <br />attention of: <br /> <br />at the address at left <br /> <br />--.J <br /> <br />o First Report of Injury Forms <br /> <br />o Supervisor's Report of Accident forms <br /> <br />o Deductible Information <br /> <br />o Employer's Injury Management Guide <br /> <br />o MN Worker's Compensation System <br />Employee Information Sheet <br /> <br />Clip and mail to: <br /> <br />BERKLEY RISK ADMINISTRATORS COMPANY, lLC <br />PO BOX 59143 <br />MINNEAPOLIS, MN 55459-0143 <br /> <br />BA3110 (11/01) <br />3836 639064 <br />