HomeMy WebLinkAbout07-117 - Association of Washington Cities - Workers Compensation Group Retro Program AG /r7
ASSOCIATION
OF W 1076 Franklin St. SE Olympia, WA 98501 -1346
C i T i E S (360) 753 -4137 Toll Free: 1- 800 562 -8981 Fax: (360) 753 -0149 Insurance Services Fax (360) 753 -0148
www.awcnet org
Association of Washington Cities
WORKERS' COMPENSATION GROUP RETRO PROGRAM
PARTICIPATION AGREEMENT AND GROUP ENROLLMENT APPLICATION,
Government, Utilities Related Services
As a member in good standing with the Association of Washington Cities
CITY OF TUKWILA
Member Name
108,069-00
L &I Account Number
Enrolls by this agreement as a participating member in the Group Retrospective Rating Plan Agreement
submitted by AWC.
This contract agreement renews provided the member submits, and is approved by Labor Industries, a valid
"Application For Group Membership And Authorization For Release Of Insurance Data" (L &I retro application
form).
1. Goals of the Plan:
A. Offer participants an opportunity to qualify for refunds on Standard Premium paid to the
Department of Labor Industries
B. Reduce the frequency and severity of industrial injuries; and
C. Reduce participants' experience factor
2. Administration Management of the Plan:
AWC will be responsible for the day -to -day operation of the Plan. Duties include, but are not limited to:
A. Assisting plan participants in reducing the frequency and severity of industrial injuries;
B. Educating plan participants in the most appropriate ways to control costs;
C. Claims Management Services;
D. Introduction and training materials;
E. Annual Retrospective Review; and
F. Administration of State Fund claims while enrolled in AWC Group Program.
G. Loss Control and Risk Management Services.
R f
AWC Retro Advis Committee
A committee consisting of no more than seven member cities /towns will be assembled to advise the
AWC Retro Plan Administrator on operational issues including contract terms, distribution of refunds,
program enhancements, conditions for continued participation and other issues. This committee shall
meet at least once per year to develop policy, review participants, adjust the contract terms or address
any other issues regarding the successful administration of the plan.
3. Member Agrees To:
A. During contract term, maintain an individual account for workers' compensation insurance in good
standing with the Department of Labor Industries;
B. Comply with all applicable laws, rules and regulations set forth by L
C. Participate in safety and loss control programs available as an AWC Retro Plan member;
D. Maintain membership in the Association of Washington Cities through the final retro year
adjustment;
E. Pay a Service Fee of six and one half percent (6.5 of total Industrial Insurance Premium, billed
annually in January.
F. If you do not pay your service fee as agreed the member will forfeit any refund.
4. Refunds /Adjustments:
A. It is understood and agreed by the employer that all refunds, exceeding Service Fees of six and one
half percent (6.5 of Industrial Insurance Premium, will be made on the basis of a merit rated
formula based on performance. However, should the Member's retro premium exceed their
standard premium, the member will not be eligible for a refund beyond their service fee. Plan
participants also acknowledge that returns are based on a number of factors, such as premium size,
claim costs, and related factors, therefore returns are not guaranteed.
B. Employers acknowledge that AWC is enrolled in Plan A2 with a Maximum Premium Ratio (MPR) of
1.15. If a group assessment develops for any Plan Year, those members that caused the
assessment will be assessed first, up to a maximum liability of fifteen percent (15 of the
participating member's Standard Premium. If necessary to cover the assessment, the remaining
members shall pay the balance on the basis of their individual percentage of the total group
premium. Penalties become due and payable within 30 days of notification of the amount. If you do
NOT re- enroll in the program, any refund will be held until the final adjustment of that Retro year.
5. Indemnification /Liability:
Each party shall indemnify and hold harmless the other and its directors, officers, employees, agents,
parents, subsidiaries, successors and assigns from and against any and all liabilities, claims, suits,
actions, demands, settlements, losses, judgments, costs, damages, and expenses (including
reasonable attorney's fees) arising out of or resulting from, in whole or part, the acts or omissions of the
indemnifying party, its employees, agents or contractors and the indemnifying party's affiliated
companies and their employees, agents or contractors.
Authorized By:
STEVE MULLET MAYOR
(Print Name) (Title)
Y� 6200 SOUTHCENTER BLVD.
(Signature) I v (Address/Street)
:'S
(Dgte)
TUKWILA, WA 98188
(City/Town Applicant)
Department of Labor and Industries 4 APPLICATION FOR GROUP MEMBERSHIP
Retrospective Rating AND AUTHORIZATION FOR RELEASE OF
www.LNI.wa.gov ,ate oy°
INSURANCE DATA
Mail to association
Association of Washington Cities Retro ID 122
1076 S. Franklin St.
Olympia WA 98501 UBI 179 000 -208
Account ID 108,069 -00
Application Deadline 9 -15 -07
Employer Coverage Year Beginning 01 -01 -07
CITY OF TUKWILA
If you have more than one L &I industrial insurance account you must enroll all sub accounts that are of a similar business
nature. You may elect to enroll all dissimilar businesses.
If you want to enroll dissimilar businesses, please check the sub account box.
If you have questions about this requirement please contact the business association listed above or L &I at (360) 902 -4851.
As a member of the sponsoring organization listed above, this employer applies for enrollment in
the retrospective rating group sponsored by the organization. L &I will notify the sponsoring
organization of acceptance or denial of your application to participate in the group. It is the
responsibility of the sponsoring organization to notify you of this acceptance or denial. As a pre-
requisite of enrollment each of your industrial insurance accounts must be in good standing at the
time of enrollment or you will not be allowed to participate in retrospective rating.
By signing this application, the employer named above agrees with all of the following conditions:
L &I will automatically re- enroll the employer as a member of the group in future coverage periods provided the
employer's industrial insurance account is in good standing at the time of re- enrollment. If the employer does not
want to participate in future coverage periods the employer or sponsoring organization must notify L &I in writing
prior to the beginning of the respective coverage period.
The employer authorizes L &I to furnish the sponsoring organization or their designee with data and information
obtained from the employer's industrial insurance account(s).
The sponsoring organization will represent the employer in all matters applicable to retrospective rating participation
and the employer's industrial insurance account(s).
The employer agrees to comply with L &I rules, regulations and laws and is bound by the terms of the agreement
between the sponsoring organization and L &I.
The employer will cooperate with L &I claims management activities and will participate in the sponsoring
organization's claims management and workplace safety initiatives.
All retrospective rating adjustments that may be earned by the employer will be given to the sponsoring organization.
L &I is not involved in the distribution of a group refund to the individual group members except in the case of defunct
group.
These conditions are in effect immediately and will remain in effect through the term of any agreement between the sponsoring
organization and L &I.
NOTE: L &I disclaims any interest in any other contract you may enter into with the sponsoring organization as their pre-
requisite of your participation in the retrospective rating group that they sponsor, and L &I neither approves or disapproves of
any language or provision contained in these other contracts.
RETURN this application directly to the above organization.
DO NOT send this a>anlication directiv to L &I.
Signature of an owner, partner or corporate officer of the employer named above is required to participate in
this retrospective rating group.
Type or print name Title
STEVE MULLET MAYOR
Date Owner, partner, corporate officer sigqb4 V1% iN1 VN 1 Dk J--
F250- 016 -000 app for group membership and authorization for release of insurance data 4 -04