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City Of Decatur <br /> i . .._ <br /> Program Details <br /> Coverage: Excess Workers Compensation <br /> Carrier: Liberty Mutual Insurance Company <br /> Policy Period: 10/1/2016 to 10/1/2017 <br /> Form Type: <br /> • •- -• � � � � •- � • <br /> Excess Workers Compensation Per Occurrence Not Applicable Not Applicable. <br /> Coverage: <br /> . • � <br /> Workers Compensation Limit Statutory <br /> Employee Liability Limit $1,000,000 <br /> Deductibles/SIR: <br /> • � <br /> Retention Workers Compensation $500,000 <br /> Retention Employee Liability $500,000 <br /> Experience Modification Factor(s): <br /> . • •- <br /> I L 1.6780 <br /> States: <br /> � • <br /> States Covered: IL <br /> Endorsements include,but are not limited to: <br /> . - - • <br /> Amendatory Endorsement(Paragraph D in Part Seven)GPO 4323(Schedule of States where applicable: IL) <br /> Amendatory Endorsement-Notice of Accident GPO 4328 <br /> Amendatory Endorsement(Change in TPA)GPO 4330 � <br /> ----- ._..-- ---- --- <br /> Definition of Remuneration GPO 4986 08 09 <br /> Employers Liability Insurance Endorsement GPO 4321 ! <br /> Excess Insurance Policy for Self-Insurer of Workers Compensation and Employers Liability GPO 4244 <br /> FELA Exclusion Endorsement GPO 4354 <br /> Knowledge Of Occurrence GPO 4351 <br /> Maritime Exclusion Endorsement GPO 4313 <br /> - -.._ _ _. --- --__— — ----- --- - � <br /> Arthur J.Gallagher Risk Management Services,Inc. <br /> 38 <br />