Workers' Compensation Board Agreement

WORKERS' COMPENSATION BOARD AGREEMENT

Parties and Identification

Employer / Insured Name:

Employer / Insured Contact Person:    Telephone:

Insured Date of Birth:    Employer Identification Number (EIN):

Policy Details

Policy Number:    Policy Type:

Coverage Limit (Aggregate): $    Per-Occurrence Limit: $

Deductible: $    Annual Premium: $

Policy Period From:    To:    Policy Territory:

Coverage Selection

Select the coverages provided under this policy (check all that apply):

Medical Benefits (reasonable and necessary treatment) Wage Replacement / Temporary Total Disability Permanent Partial Disability Benefits Rehabilitation and Vocational Services Death Benefits (survivor compensation) Employers' Liability (third-party claims)

Exclusions and Limitations

The insurer expressly excludes coverage for losses arising from the following circumstances unless specifically endorsed: (a) injuries intentionally inflicted by the employer; (b) employment by the insured in violation of law; (c) punitive or exemplary damages where prohibited by statute; (d) occupational disease claims excluded by statutory exception. By signing this Agreement, the insured acknowledges and accepts the standard exclusions and any endorsements attached to the policy.

Confirm acknowledgement of standard exclusions: I acknowledge and accept the exclusions and limitations set forth above.

Beneficiary Designation (Death Benefits)

Primary Beneficiary Name:

Relationship:    Allocation Percentage: %

Claims Reporting and Notice Requirements

The insured agrees to report any workplace injury or occupational disease to the insurer and to the Workers' Compensation Board in accordance with statutory timelines and within three (3) business days of the insured's knowledge of the incident or claim. Failure to timely report may affect coverage to the extent permitted by law.

Date of Loss:    Time of Loss:    Location of Loss:

Estimated Loss / Medical Expense (if known): $

Documentation Checklist (attach copies to claim):

Medical records / physician reports Witness statements Photographs of incident site or injury Payroll and wage records Other supporting documentation

Premium, Audit and Adjustment

Premium shall be subject to adjustment upon audit of actual payroll and classifications. The insured authorizes the insurer or its authorized representative to examine payroll, employment and other records pertinent to premium determination for the policy period. Any additional premium due as a result of audit shall be payable upon billing.

Audit Contact Person:    Auditor Telephone:

Employer Obligations and Cooperation

The insured certifies that it will (a) maintain a safe workplace and comply with applicable safety and workers' compensation laws; (b) notify the insurer immediately of any claim, suit or proceeding that may involve coverage under this policy; (c) cooperate with claim investigations, medical examinations and return-to-work programs; and (d) not admit liability or settle claims without the insurer's written consent when such consent is contractually required.

Subrogation, Indemnity and Dispute Resolution

The insurer reserves all rights of subrogation to the extent permitted by law. The insured agrees to indemnify and hold harmless the insurer for any losses arising from the insured's intentional misconduct or breach of this Agreement. Any disputes concerning coverage under this Agreement shall be governed by the applicable workers' compensation statutes and resolved in the forum required by those statutes or, where permitted, by arbitration in accordance with a mutually agreed procedure.

Privacy and Records Authorization

By executing this Agreement, the insured authorizes the insurer and the Workers' Compensation Board to collect and use medical, employment and other relevant records necessary to evaluate claims and administer benefits, subject to applicable privacy protections. The insured further acknowledges that claims information may be disclosed to reinsurers, adjusters and other authorized parties for claims handling and audit purposes.

Certification and Authorization

I certify under penalty of perjury that the information provided in this Agreement and any attachments is true, correct and complete to the best of my knowledge. I further authorize the insurer and the Workers' Compensation Board to rely upon this information in determining coverage, premium and benefits. I understand that material misrepresentation, omission or failure to comply with reporting obligations may result in denial of claims, rescission of coverage or other remedies permitted by law.

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