The URL can be used to link to this page

Home My WebLink AboutWorkers Compensation Policy Renewal 2016-17BlNNEVILL-/, o r Nr sc H 0 01"._Dj?IF,r,c"_T.",I g E.93 To: From Date: Re: 3497 North Ammon Road, ldaho Falls, ldaho,83401 0 (208) 525-4400 0 Fax (208) 529-0104 0 www.d93schools.org Dr. Charles L Shackett, Superintendent Marjean McConnell, Deputy Superintendent Board of Trustees April Burton, Chief Financial Operations/Officer June 8,2016 Approval of Workers Compensation Policy Attached is the renewal ofthe Workers Compensation Policy issued by State lnsurance Fund. This renewal reflects a reduction in the premium. The Experience Modification rate has decreased from 1 .48%o to | .l lYo. Board of Trusteer 0 Annette Winchester O Kip Nelson O Amy Landers 0 Erian McBride 0 leff Bird Bonneville loint School Dislrict No. 93 is an Equal Opportunity Employer ate daho 1001s 97 0 00 0 072 0106 00 0 00 00 0 Ei:::TT tilir+ I Srarr INsunnNcr FuNt THIS IS NOT A BILL May 25,2016 Bonneville Joint School District g3 3497 N Ammon Rd ldaho Falls, ID 83401-'1303 Re: Bonneville Joint School District 93 Workers Compensation Policy #293320 Your workers compensation policy with the State lnsurance Fund is scheduled to renew on 0710112016 Please review the enclosed renewal documents. The payroll and premium shown on the Extension of lnformation Page is an estimate, and may be adjusted when the final payroll is repo(ed for the current yeat. lf there are changes needed for the renewal period or if you do not plan to renew your policy, please contact your agent or undeMriter right away. lf there are no changes to report, your policy will renew as scheduled and you do not need to contact us lf there is a balance due, we will send you a statement after the policy renews Sincerely, fuQ** Janel Penning Underwriter (208)332-2319 l2l5 w. SrArE STREET . P.O. Box 83720 . BorsE.lDAHo 83720-0044 PHoNE (208) 332-2100 . (800) 334-2370 . www.IDAHoSlF.org Policy Number Policy Period From To 293320 07t0112016 0710112017 lnformation Page Renewal/Rewrite of Policy Number 1 . Named lnsured and Address Agency lnformation Bonneville Joint School District 93 3497 N Ammon Rd ldaho Falls, lD 83401-1303 Direct Policy Carrier No FEIN Risk lD Entity Type 19992 82-6001206 1 101 14656 Public Entity 1001597 000 0 072 02 06 00 000 000 (rw4ll lri::;rS IiH ldaho State lnsurance Fund 1215 W. State Street PO Box 83720 Boise, ldaho 83720-0044 (208) 332-2100 - (800) 334-2370 Workers Compensation and Employers Liability lnsurance Policy Additional Workplaces not shown above: Refer to Schedule of Locations Endorsement WC 99 06 02 (01-06) 2. The Policy Period is from 07l0112016lo 0710112017 12:01 A.lvl. at the insured's mailing address 3. A. Workers Compensation lnsurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: IDAHO B. Employers Liability lnsurance: Part Two of the policy applies to work in each state listed in ltem 3.A. The limits of our liability under part Two are: Bodily lnjury by Accident Bodily lnjury by Disease Bodily lnjury by Disease $100,000.00 $s00,000.00 $100,000.00 each accident policy limit each employee 4 C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: NONE D. This policy includes these endorsements and schedules: SEE ATTACHED SCHEDULE OF ENDORSEMENTS The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All lnformation required below is subject to verification and change by audit. SEE ATTACHED CLASSIFICATIONS OF OPERATIONS Minimum Premium $300.00 Total Estimated Annual Premium $436,703.00 Deposit Premium/lnitial lnstallment $436,703.00 lnstallment Plan: One Pay Payment Plan Premium Adjustment Period: @ Annual Q Semi Annual C Ouarterly C Monthly lssue Date: 0512512016 Underwriter: Janel Penning Policy Declaration Number: 13069029 wc 00 oo o1 A (05-88) /.*,,uQ"*l+- Authorized Representative lncludes copyright material of the National Council on Compensation lnsurance, lnc. used with its permission O 1996 National Councilon Compensation lnsurance, lnc. 1001597 0 00 0 072 03 05 00 000 000 Ef..: tI EtrJ'E ldaho State Insurance Fund 1215 W. State Street PO Box 83720 Boise, ldaho 837 20-0044 (208\ 332-2100 - (800) 334-2370 Workers Compensation and Employers Liability lnsurance Policy Policy Number:293320 Named lnsured:Bonneville Joint School District 93 Agency Name:Direct Policy Extension of lnformation Page Classification of Operations Class Code No.Class Description Rate Per $100 of Exposure Remuneration Estimated Annual Premium INSURED: Bonneville Joint School District 93 Bonneville Joint School District 93 3497 N Ammon Rd ldaho Falls 738OOO3 SCHOOL 8US & ACTIVITY DRIVERS 8811010 SCHOOL BOARD MEMBERS 8868000 COLLEGE: PROFESSIONAL EMPLOYEES & CLERICAL 910'1000 COLLEGE: ALL OTHER EMPLOYEES 9101OO7 WORK EXPERIENCE STUDENT-NOT PAID Experience Modification Premium Total Standard Premium Premium Discount lssue Date: May 25,2016 $1,119,145 $9,973 $35,252,179 $3,098,193 $2,378 $4.52 $0.23 $0.62 $5.45 $5.45 1.11 $0.10 $50,585.00 $23.00 $218,s64.00 $168,8s2.00 $130.00 $48,197.00 $486,351.00 ($49,648.00) wc 99 06 00 (01-06) 10015 970 0 00 0 72 04 06 000 000 00 uw6.15 Workers Compensation and Employers Liability lnsurance Policy Policy Number:293320 Named lnsured:Bonneville Joint School District 93 Agency Name:Direct Policy Schedule of Endorsements Form Title H.it 8ft1 ldaho State lnsurance Fund 12'15 W. State Street PO Box 83720 Boise, ldaho 837 20-0044 (208) 332-2100 - (800) 334-2320 State Form Number ID ID ID ID ID UW413 UW547 UW644 UW645 UW646 lssue Date: May 25,2016 Policy lnformation Page Premium Discount Endorsement Extension of lnformation Page Classification of Operations Schedule of Endorsements Schedule of Locations wc 99 06 01 (01-06) ldaho State lnsurance Fund 1215 W. State Street PO Box 83720 Boise, ldaho 83720-0044 (208) 332-2100 - (800) 334-2370 Location No.Location Address 1001597 000 0072 0s050 0 00 0 00 0 trw646 triI fiti ItH Workers Gompensation and Employers Liability lnsurance Policy Policy Number:293320 Named lnsured:Bonneville Joint School District 93 Agency Name:Direct Policy Schedule of Locations 1 3497 N Ammon Rd, ldaho Falls lD 83401 '1303 lssue Date: May 25,2016 wc 99 06 02 (01-06) STATE INSURANCE FUND r 0 015 970 00 0 072 06 0 50 00 0 00 00 0.123 Balance Lq,';i$ E+t l2l 5 w. sTArE STREET , m BOX 8l?:0 - AOTSE. IDAHO 33720-00U PHONE (208) 132-1rm - (800) ll,1-r170 Policy Number: 293320- 07/01/2016 INSURED Bonneville Joint School District 93 3497 N Ammon Rd ldaho Falls, lD 83401-1303 THIS ENDORSEMENT CHANGES THE POLICY TO WHICH IT IS ATTACHED AND IS EFFECTIVE ON THE DATE ISSUED UNLESS OTHERWISE STATED PREMIUM DISCOUNT ENDORSEMENT The premium for this policy and the policies, if any, listed in ltem 3 of the Schedule may be eligible for a discount. This endorsement shows your estimated discount in ltems 1 or 2 of the Schedule. The final calculation of premium discount will be determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective rating is not subject to premium discount. Schedule 1. State Estimated Eligible Premium ID 0 First $10,000.00 0.091 Next $190,000.0 0.113 Next $1,550,000 2. Average percentage discount: 10 Yo 3. Other policies 4. lf there are no entries in ltems 1 , 2 and 3 of the Schedule, see the Premium Discount Endorsement attached to your policy number: ISSUE DATE: May 25,2016 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY COPYRIGHT I995 NATIONAL COUNCIL ON COMPENSATION INSURANCE BATCU O5t2512o16 wc000406A ADVISORY UndePriler: Janei Penning E N D o R S E tvt E N T