2007-11-28 Set Agenda - Laserfiche WebLink

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1. The Insured: Minnesota Workers' Compensation Assigned Risk Plan Standard Workers' Compensation and Employers' Liability Policy Contract Administrator Berkley Risk Administrators Company, LLC P.O. Box 59143 Minneapolis, Minnesota 55459-0143 Phone (612) 766-3000 NCCI Carrier Code 21466 MINNESOTA CANCELLATION AND NONRENEWAL ENDORSEMENT Page 1 of 2 WCIP Policy Number: WC-22-Q4-159728-03 Association File Number: 3201395 tT>rac Berldey R.k ~",n15"'''''' Company. LLC Tax 10#: F 830385468 UIC #: 068707550000 Policy Period: From: 1/6/2008 To: 1/6/2009 Endorsement Eff. Date: 1/6/2008 Date of Mailing: 1112/2007 This endorsement applies only to the insurance provided because Minnesota is shown in Item 3A of the information page. GNAW INC dba: Centerville Liquor Barrel 7093 20th Ave Centerville, MN 55038 CANCELLATION OF A NEW POLICY If this policy is a new policy and has been in effect for fewer than 90 days, we may cancel for any reason by giving you notice at least 60 days before the effective date of cancellation. CANCELLATION OF OTHER POLICIES If this Policy has been in effect for 90 days or more, or if it is a renewal of a policy we issued, we may cancel for one or more of the following reasons: (1) Nonpayment of Premium; (2) Misrepresentation or fraud made by you or with your knowledge in obtaining the policy or in pursuing a claim under the policy; (3) An Act or omission by you that substantially increases or changes the risk insured; (4) Refusal by you to eliminate known conditions that increase the potential for loss after notification by us that the condition must be removed; (5) Substantial change in the risk assumed, except to the extent t,hat we should reasonably have foreseen the change or contemplated the risk in writing this policy; (6) Loss of reinsurance by us which provided coverage to us for a significant amount of the underlying risk insured. Any notice of cancellation pursuant to this item shall advise you that you have 10 days from the date of receipt of the notice to appeal the cancellation to the commissioner of commerce and that the commissioner will render a decision as to whether the cancellation is justified because of the loss of reinsurance within 30 business days after receipt of the appeal; (7) A determination by the commissioner that the continuation of the policy could place us in violation of the Minnesota insurance laws; or (8) Nonpayment of dues to an association or organization, other than an insurance association or organization, payment of dues is prerequisite to your obtaining or continuing this policy. This item shall not apply to persons who are retired at 62 years of age or older or who are disabled according to Social Security standards. If we cancel your policy for any of the reasons listed in (2) through (8), we will give notice at least 60 days before the effective date of cancellation. NOTICE OF CANCELLATION Any notice of cancellation under this endorsement shall be in writing and shall be sent by first class mail or delivered to you and any agent, to the last mailing addresses known to us. A cancellation notice for nonpayment of premium must be sent at least 30 days before the actual date of cancellation and shall state the amount of premium due and the due date, and shall state the effect of nonpayment by the due date. Cancellation shall not be effective if payment of the amount due is made prior to the effective date of cancellation in the notice. A cancellation notice for some other reason shall state the specific reason for cancellation and shall state the effective date of cancellation. The policy will end on that date. All other terms and conditions of this policy remain unchanged. Aqencv Name and Address Ross Nesbit Agencies lnc Paulet Slater Agency 2610 University Ave W 5t Paul, MN 55114 WC 22-06-01 D 3836 639064