Sullivan et al v. The Travelers Indemnity Company of Connecticut et al

MOTION to Dismiss for Failure to State a Claim

E.D. La.October 19, 2016

UNITED STATES DISTRICT COURT EASTERN DISTRICT OF LOUISIANA SHANTEL SULLIVAN, individually and * on behalf of her minor child, * KYLE SULLIVAN, and on behalf of * the Decedent, JEREMY SULLIVAN * CIVIL ACTION NO. 216-cv-15461 * * Plaintiffs, * * VERSUS * JUDGE SUSIE MORGAN * TRAVELERS INDEMNITY COMPANY * OF CONNECTICUT, TRAVELERS * INDEMNITY COMPANY OF AMERICA, * and MICHELLE BROOME * * MAG. JUDGE MICHAEL NORTH Defendants. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * THE TRAVELERS INDEMNITY COMPANY OF AMERICA’S RULE 12(b)(6) MOTION TO DISMISS NOW INTO COURT, through undersigned counsel, comes Defendant, The Travelers Indemnity Company of America (incorrectly named as “Travelers Indemnity Company of America”) and pursuant to Rule 12(b)(6) of the Federal Rules of Civil Procedure, files this Motion to Dismiss the Complaint filed by Plaintiff, Shantel Sullivan, individually and on behalf of her minor child, Kyle Sullivan, and on behalf of the decedent, Jeremy Sullivan. 1 This Motion seeks dismissal of Sullivan’s claim because it states no cause of action against Travelers for which Sullivan can be granted relief. Dismissal is warranted because The Travelers Company of America neither issued nor administered the workers’ compensation 1 R. Doc. No. 1, Exhibit A. Case 2:16-cv-15461-SM-MBN Document 4 Filed 10/19/16 Page 1 of 2 insurance policy providing coverage for Jeremy Sullivan’s June 15, 2014 work-connected wrist injury. WHEREFORE, for the foregoing reasons, Defendant, The Travelers Indemnity Company of America, respectfully requests that the Court grant its Motion to Dismiss Sullivan’s claims against it. Respectfully submitted, BAKER, DONELSON, BEARMAN, CALDWELL & BERKOWITZ, PC By: s/ William H. Howard III WILLIAM H. HOWARD III, T.A. (7025) ALISSA J. ALLISON (17880) 201 St. Charles Avenue, Suite 3600 New Orleans, LA 70170 Telephone: (504) 566-5275 Facsimile: (504) 636-3975 bhoward@bakerdonelson.com aallison@bakerdonelson.com COUNSEL FOR THE TRAVELERS INDEMNITY COMPANY OF AMERICA Case 2:16-cv-15461-SM-MBN Document 4 Filed 10/19/16 Page 2 of 2 1 UNITED STATES DISTRICT COURT EASTERN DISTRICT OF LOUISIANA SHANTEL SULLIVAN, individually and * on behalf of her minor child, * KYLE SULLIVAN, and on behalf of * the Decedent, JEREMY SULLIVAN * CIVIL ACTION NO. 216-cv-15461 * * Plaintiffs, * * VERSUS * JUDGE SUSIE MORGAN * TRAVELERS INDEMNITY COMPANY * OF CONNECTICUT, TRAVELERS * INDEMNITY COMPANY OF AMERICA, * and MICHELLE BROOME * * MAG. JUDGE MICHAEL NORTH Defendants. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * THE TRAVELERS INDEMNITY COMPANY OF AMERICA’S MEMORANDUM IN SUPPORT OF ITS RULE 12(b)(6) MOTION TO DISMISS MAY IT PLEASE THE COURT: Shantel Sullivan, individually and on behalf of her minor child, Kyle Sullivan, and on behalf of the decedent, Jeremy Sullivan, has filed this “Petition for Damages,” which was removed to this Court on October 12, 2016. 1 Plaintiff seeks wrongful death and survival damages against, among other entities, The Travelers Indemnity Company of America (improperly named as “Travelers Indemnity Company of America”). Simply stated, The Travelers Indemnity Company of America neither issued the workers’ compensation policy providing coverage for Jeremy Sullivan’s June 15, 2014 work-connected 1 R. Doc. No. 1. Case 2:16-cv-15461-SM-MBN Document 4-1 Filed 10/19/16 Page 1 of 5 2 injury, nor did it administer Sullivan’s workers’ compensation claim. Accordingly, Plaintiff’s purported claim should be dismissed under Rule 12(b)(6). BACKGROUND On June 15, 2014, Jeremy Sullivan sustained a work-connected wrist injury for which he sought—and received—workers’ compensation benefits. 2 The Travelers Indemnity Company of Connecticut, not The Travelers Indemnity Company of America, provided workers’ compensation insurance coverage to Sullivan’s employer, MKWB, LLC (d/b/a Le Creole’ Restaurant). 3 Though statutorily required to authorize only one choice of physician, The Travelers Indemnity Company of Connecticut authorized Sullivan to receive treatment from four different physicians. 4 Sullivan clashed with several treating physicians, among other reasons, because of “the aggressive manner in which Mr. Sullivan was beginning to request his medications.” 5 Sullivan’s “pain medication dependency problem” culminated in his December 21, 2015 death from a drug overdose. 6 ANALYSIS I. Plaintiff Fails to State a Claim Against The Travelers Indemnity Company of America because The Travelers Indemnity Company of America Neither Issued Nor Administered the Relevant Insurance Policy Plaintiff fails to state a claim against The Travelers Indemnity Company of America because The Travelers Indemnity Company of America neither issued nor administered the workers’ compensation insurance policy providing coverage for Sullivan’s June 15, 2014 injury. 2 Petition at ¶¶5, et seq., R. Doc. No. 1, Exhibit A. 3 Id. at ¶7. 4 Id. at ¶¶9, et seq 5 Id. at ¶24. 6 Id. at ¶¶64, 65. Case 2:16-cv-15461-SM-MBN Document 4-1 Filed 10/19/16 Page 2 of 5 3 The Travelers Indemnity Company of Connecticut, not The Travelers Indemnity Company of America, issued and administered the workers’ compensation insurance policy for which Plaintiff now seeks judicial redress. Accordingly, The Travelers Indemnity Company of America has no business in this lawsuit. a) Rule 12(b)(6) Standard Rule 12(b)(6) of the Federal Rules of Civil Procedure permits dismissal for “failure to state a claim upon which relief can be granted.” FED. R. CIV. P. 12(b)(6). In a Rule 12(b)(6) analysis, the Court takes “all well-pleaded facts as true, viewing them in the light most favorable to the plaintiff.” Howell v. Town of Ball, 827 F.3d 515, 521 (5 th Cir. 2016). To survive dismissal under Rule 12(b)(6), Plaintiff must allege sufficient facts to “raise a right to relief above the speculative level.” Bell Atlantic Corp. v. Twombly, 550 U.S. 544, 555 (2007). Although Plaintiff’s complaint need not contain “detailed factual allegations, a plaintiff’s obligation to provide the grounds of his entitlement to relief requires more than labels and conclusions, and a formulaic recitation of the elements of a cause of action will not do.” Id. Plaintiff “must plead enough facts to state a claim to relief that is plausible on its face.” In re Katrina Canal Breaches Litigation, 495 F.3d 191, 205 (5 th Cir. 2007). “A claim has facial plausibility when the plaintiff pleads factual content that allows the court to draw the reasonable inference that the defendant is liable for the misconduct alleged.” Howell, 827 F.3d at 521 (quoting Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009)). b) The Court May, Consistent with the Rule 12(b)(6) Analysis, Consider the Attached Insurance Policy “Documents that a defendant attaches to a motion to dismiss are considered part of the pleadings if they are referred to in the plaintiff’s complaint and are central to her claim.” Bosarge v. Mississippi Bureau of Narcotics, 796 F.3d 435, 440 (5 th Cir. 2015) (quoting Causey v. Case 2:16-cv-15461-SM-MBN Document 4-1 Filed 10/19/16 Page 3 of 5 4 Sewell Cadillac-Chevrolet, Inc., 394 F.3d 285, 288 (5 th Cir. 2004)); see also Masoodi v. Lockheed Martin Corp., No. CIV.A.10-807, 2010 WL 2427741, at *1 n.1 (E.D. La. June 10, 2010). The Travelers Indemnity Company of America attaches as Exhibit A the insurance policy issued by The Travelers Indemnity Company of Connecticut to decedent’s employer, Le Creole’. 7 In so doing, Defendant “merely assists the plaintiff in establishing the basis of the suit, and the [C]ourt in making the elementary determination of whether a claim has been stated.” Collins v. Morgan Stanley Dean Witter, 224 F.3d 496, 499 (5 th Cir. 2000). Because Plaintiff’s Petition references “Le’ Creole’s [sic] workers’ compensation insurance carrier,” and the insurance policy is “central to her claim,” the attached Exhibit “A” is considered “part of the pleadings.” 8 Accordingly, the Court should consider Exhibit “A” and evaluate this Motion under Rule 12(b)(6) of the Federal Rules of Civil Procedure. c) Plaintiff Fails to State a Claim Against The Travelers Indemnity Company of America because The Travelers Indemnity Company of America Neither Issued Nor Administered the Subject Workers’ Compensation Insurance Policy Dismissal is warranted because The Travelers Indemnity Company of America is not involved in this lawsuit in any way. “[T]he question of whether a plaintiff has sued the correct defendant should ordinarily be addressed at the pleading stage by affording the plaintiff the protections provided by Rule 12(b)(6).” Davis v. Wells Fargo, 824 F.3d 333, 347 (3d Cir. 2016). Plaintiff alleges that Sullivan “initiated a claim with Le’ Creole’s [sic] workers’ compensation insurance carriers(s) and Defendants, herein, Travelers Indemnity Company of Connecticut and/or Travelers Indemnity Company of America.” 9 Plaintiff’s Petition should be 7 Undersigned counsel has knowledge that The Travelers Indemnity Company of Connecticut, not the Travelers Indemnity Company of America, issued the pertinent policy. 8 Petition at ¶7, R. Doc. No. 1, Exhibit A, 9 Id. at ¶7. Case 2:16-cv-15461-SM-MBN Document 4-1 Filed 10/19/16 Page 4 of 5 5 interpreted in the disjunctive. The Travelers Indemnity Company of Connecticut, not The Travelers Indemnity Company of America, provided workers’ compensation insurance coverage to Le Creole’. 10 Thus, The Travelers Indemnity Company of America does not belong in this lawsuit, and Plaintiff’s claim against it should be dismissed for failure to state a claim upon which relief can be granted. Respectfully submitted, BAKER, DONELSON, BEARMAN, CALDWELL & BERKOWITZ, PC By: s/ William H. Howard III WILLIAM H. HOWARD III, T.A. (7025) ALISSA J. ALLISON (17880) 201 St. Charles Avenue, Suite 3600 New Orleans, LA 70170 Telephone: (504) 566-5275 Facsimile: (504) 636-3975 bhoward@bakerdonelson.com aallison@bakerdonelson.com COUNSEL FOR THE TRAVELERS INDEMNITY COMPANY OF AMERICA 10 The Travelers Indemnity Company of Connecticut Insurance Policy No. UB-4003T368, issued to Le Creole’, attached hereto as Exhibit A. Case 2:16-cv-15461-SM-MBN Document 4-1 Filed 10/19/16 Page 5 of 5 SAFETY SERVICES Notice to policy recipient: If you are not the person directly responsible for the accident prevention activities for your company, please direct this Safety Services notice to the person that is directly responsible for them. SAFETY IS OUR CONCERN Industrial Hygiene/Health Services We have theThank you for purchasing your insurance from one of the writing companies owned or managed by The facilities and resources to answer your questions Travelers Companies, Inc. We appreciate your concerning job related industrial hygiene/health business and welcome the opportunity to be of issues and to measure exposure to industrial hygiene service. hazards. An important part of that service concerns safety and Safety Literature and Digital Media We can accident prevention. Travelers Risk Control provide you with top-notch safety-related literature, department has the experience, resources and CDs, DVDs, and videos to assist in your loss control capabilities to provide a range of safety services, efforts. Also, we can direct you to several vendors including site surveys, phone consultations, as well as who are able to provide additional safety materials, provide access to numerous safety-related materials. including brochures, pamphlets and digital media. Safety Training We offer face-to- ace classroomfWe have experience in a variety of industries, some of which include manufacturing, wholesale and retail courses, as well as distance learning programs that businesses, service organizations, technology-related explore the risks our policyholders face and ways for business, oil and gas-based business, and the public them to control losses. sector. Return-To-Work Coordination We can assist you Following are some examples of available safety with several aspects of the post injury management services: process. Accident Prevention Our staff can help you Internet Website Visit our Risk Control website for identify present and potential hazards in your access to our safety newsletters and other safety literature at: http://www.travelers.com/riskcontroloperations, premises and equipment, and recommend measures for reducing or eliminating these hazards. This website also has links to other safety-related Analysis of Accident Causes Although you Internet sites. investigate and keep records of accidents, we are Please note: For ALL loss control assistance available to assist if needed. requests, please contact your local office directly, Safety Consultations Our Consultants can help which is listed on one of the following pages. you with special problems such as ergonomics and human factors. These services are available upon request. See the remainder of this document for the Travelers' Risk Control office nearest you. These phone numbers should not be used for questions regarding your policy or claims. WUNT3B13 Page 1 of 5 © 2012 The Travelers Indemnity Company. All rights reserved. Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 1 of 52 SAFETY IS YOUR CONCERN SELF-INSPECTION PROGRAM (continued):U.S. employers spend billions of dollars each year on the direct and indirect costs of work-related accidents. Do you analyze each job to find inherent Dollar figures can't begin to reflect the pain and hazards? suffering of an injured worker and his or her family. If you discover hazards, do you follow up with But they do give some indication of the multiple immediate corrective action? consequences of a job-related accident... loss of time, Do you monitor such action to make sure it isinterrupted production, damaged materials and implemented and effective?equipment, the expense of retraining or replacing an ACCIDENT INVESTIGATION:injured worker, possible legal action from government Do you investigate each accident?...determineregulatory agencies, and increased insurance costs. the cause?It makes good sense for both employers and their Do you take immediate steps to prevent aemployees to actively participate in a sound accident recurrence?prevention program. The success of such a program Do you keep records of accident investigationsdepends to a large extent on your commitment to and follow-up measures?safety procedures and accident prevention techniques. Safety is a management concern. Maybe Do you complete accident statistics and analyze we can help. trends? EDUCATION AND TRAINING:You may want to consider the following "Safety Do you take the time to train each of yourCheckpoints" as you evaluate your organization's employees to perform tasks safely?safety activi ies:t Do more-experienced employees receive trainingSELF-INSPECTION PROGRAM: to correct bad habits that have developed over Do you conduct periodic surveys of premises?… time? equipment?... operations? Do all employees understand that safety is an important part of their jobs? WUNT3B13 Page 2 of 5 © 2012 The Travelers Indemnity Company. All rights reserved. Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 2 of 52 Please call these numbers FOR SAFETY SERVICES ONLY For all other inquiries please contact your agent, underwriter or claim representative ALABAMA CALIFORNIA HAWAII Birmingham San Diego Orange, CA 3000 Riverchase Galleria 9325 Sky Park Court, Ste. 220 333 City Blvd. W Ste. 600 San Diego, CA 92123 Suite 1100 Birmingham, AL 35244 (714) 612-0682 Orange, CA 92868 (678) 317-7708 (714) 620-0682 Claims: 1-800-238-6214 ALASKA CALIFORNIA IDAHO Portland, OR Walnut Creek Portland, OR 4000 SW Kruse Place, Suite 100 225 Lennon Lane, Ste. 105 4000 SW Kruse Place, Suite 100 Lake Oswego, OR 97035 P.O. Box 8090 Lake Oswego, OR 97035 (503) 534-4276 Walnut Creek, CA 94596-8090 (503) 534-4276 Risk Control: (925) 945-4171 Claims: (800) 842-7354 ARIZONA COLORADO ILLINOIS Phoenix Denver Chicago 2401 W Peoria Ave., Suite 130 6060 S. 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Central Avenue, 4th Floor 14200 Park Meadow Dr. 7101 Vista Dr. P.O. Box 1840 Chantilly, VA 20151 West Des Moines, IA 50266-9313 Glendale, CA 91209 (571) 287-6232 (651) 310-4422 Risk Control: (714) 620-0682 Claims: 1-800-368-3562 Claims: 800-255-5072 Claims: (909) 612-3000 CALIFORNIA FLORIDA KANSAS Los Angeles Orlando Kansas City 888 South Figueroa St., Ste. 500 2420 Lakemont Dr 7465 West 132nd Los Angeles, CA 90017 Orlando, FL 32814 Overland Park, KS 66213 (714) 620-0682 (407) 388-3307 (913) 685-5109 Risk Control: (714) 620-0682 Claims: 407-388-2400 Claims: (909) 612-3000 CALIFORNIA GEORGIA KENTUCKY Sacramento Atlanta Louisville 11070 White Rock Road, Suite 130 1000 Windward Concourse Suite 150 Rancho Cordova, CA 95670 Alpharetta, GA 30005 303 N Hurstbourne Pkwy Risk Control: (916) 852-5245 (678) 317-7708 Louisville, KY 40222 Claims: (800) 727-3995 Claims: 800-238-6214 (502) 429-7390 Claims: 800-238-6210 WUNT3B13 Page 3 of 5 © 2012 The Travelers Indemnity Company. All rights reserved. Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 3 of 52 Please call these numbers FOR SAFETY SERVICES ONLY For all other inquiries please contact your agent, underwriter or claim representative LOUISIANA MINNESOTA NEW HAMPSHIRE New Orleans St. Paul Portland, ME 3838 N. Causeway, Suite 2700 385 Washington St., MC 104P 207 Larrabee Road, Suite 3 Metairie, LA 70002 St. Paul, MN 55102 Westbrook, ME 04092 P.O. 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Box 242 Braintree, MA 02184 (503) 534-4276 Buffalo, NY 14240-0242 (781) 817-8370 (315) 424-7231 Claims: 800-832-7839 Claims: 800-842-2475 MICHIGAN NEBRASKA NEW YORK Grand Rapids Omaha Jericho-Long Island 3777 Sparks Ave. SE, Ste. 200 11516 Miracle Hills Dr., St. 400 Two Jericho Plaza P.O. Box 3010 Omaha, NE 68154 Jericho, NY 11753 Grand Rapids, MI 49501-0323 (651) 310-4422 (516) 933-3932 Claims: 800-255-5072(248) 312-7301 Claims: 800-842-2475 Claims: 800-238-6210 MICHIGAN NEVADA NEW YORK Troy Las Vegas New York 1301 W. Long Lake Rd., Ste. 300 1850 E Flamingo, Suite 202 485 Lexington Ave. Troy, MI 48098 Las Vegas, NV 89119 New York, NY 10017-2630 (248) 312-7301 (702) 669-4746 (516) 933-3932 Claims: 800-238-6210 Claims: 702-479-4200 Claims: 1-800-842-2475 WUNT3B13 Page 4 of 5 © 2012 The Travelers Indemnity Company. All rights reserved. Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 4 of 52 Please call these numbers FOR SAFETY SERVICES ONLY For all other inquiries please contact your agent, underwriter or claim representative NEW YORK PENNSYLVANIA UTAH Rochester Philadelphia Denver, CO 75 Town Centre Drive 10 Sentry Parkway, Suite 300 6060 S. Willow Drive #300 P.O. Box 23235 Blue Bell, PA 19422 Greenwood Village, CO 80111 Rochester, NY 14692-3235 (215) 274-1610 (720) 200-8306 (315) 424-7231 Claims: 800-832-0606 Claims: 800-453-3025 Claims: 1-800-842-2475 NEW YORK PENNSYLVANIA VERMONT Syracuse Pittsburgh Hartford, CT 440 South Warren Street 800 Two Chatham Center 300 Windsor Street P.O. Box 4963 Pittsburgh, PA 15219-2505 Hartford, CT 06120 Syracuse, NY 13221-4963 (412) 338-3082 (860) 954-5190 (315) 424-7231 Claims: (412) 338-3000 Claims: 800-842-2475 NORTH CAROLINA PENNSYLVANIA VIRGINIA Charlotte Reading Richmond 11440 Carmel Commons Blvd. 1105 Berkshire Blvd. 300 Arboretum Place P.O. Box 473500 P.O. Box 13426 P.O. Box 26426 Charlotte, NC 28247-3500 Wyomissing, PA 19612-3426 Richmond, VA 23260-6426 (704) 540-3438 (215) 274-1610 (804) 330-6063 Claims: (704) 544-3500 Claims: 800-832-0606 Claims: (804) 330-6000 NORTH CAROLINA RHODE ISLAND Washington, DC Raleigh Braintree 14200 Park Meadow Dr. 4504 Emperor Blvd. 350 Granite Street Chantilly, VA 20151 Durham, NC 27703 Suite 1201 (571) 287-6232 (919) 474-4811 Braintree, MA 02184 Claims: 800-368-3562 Claims: (704) 544-3500 (781) 817-8370 Claims: 800-832-7839 NORTH DAKOTA SOUTH CAROLINA WASHINGTON St. Paul, MN Charlotte Seattle 385 Washington St., MC 104P 11440 Carmel Commons Blvd. 1501 4th Avenue, Suite 400 St. Paul, MN 55102 P.O. Box 473500 Seattle, WA 98101 (651) 310-4422 Charlotte, NC 28247-3500 (206) 464-3463 Claims: 800-842-3073 (704) 540-3438 Claims: 704-544-3500 OHIO SOUTH DAKOTA WEST VIRGINIA Cincinnati St. Paul, MN Pittsburgh, PA 895 Central Ave., Ste. 800 385 Washington St. 800 Two Chatham Center Cincinnati, OH 45202 St. Paul, MN 55102 Pittsburgh, PA 15219-2502 (317) 845-1479 (651) 310-4422 (412) 338-3082 Claims: 800-238-6210 Claims: 800-842-3073 Claims: (443) 353-1000 OHIO TENNESSEE WISCONSIN Cleveland Franklin Milwaukee Skylight Office Tower 6640 Carothers Pkwy, Suite 300 13935 Bishops Drive, Suite 200 1660 W. 2nd St., Ste. 500 Franklin, TN 37067 Brookfield, WI 53005 Cleveland, OH 44113-1454 (615) 660-6036 (262) 825-9203 (317) 845-1479 Claims: (615) 660-6000 Claims: 800-842-6172 Claims: 800-238-6210 OKLAHOMA TEXAS WYOMING Tulsa Dallas Denver, CO 9820 East 41st St., Suite 401 1301 E Collins Blvd., Suite 300 6060 S. Willow Drive #300 P.O Box 3510 Richardson, TX 75081 Greenwood Village, CO 80111 Tulsa, OK 74101 (214) 570-6675 (720) 200-8306 (918) 624-2730 Claims: 214-570-6000 OREGON TEXAS Portland Houston 4000 SW Kruse Place, Suite 100 4650 Westway Park Blvd., Suite 350 Lake Oswego, OR 97035 Houston, TX 77041 (503) 534-4276 (281) 606-8534 Claims: 800-698-6883 Claims: 800-235-3610 WUNT3B13 Page 5 of 5 © 2012 The Travelers Indemnity Company. All rights reserved. Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 5 of 52 Report Claims Immediately by Calling* 1-800-238-6225 Speak directly with a claim professional 24 hours a day, 365 days a year Written*Unless Your Policy Requires Notice or Reporting LE CREOLE' MKWB, LLC DBA 18135 EAST PETROLEUM DR BATON ROUGE LA 70809 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY A Custom Insurance Policy Prepared for: Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 6 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 V (IEUB-4003T36-8-13) RENEWAL OF (IKUB-4003T36-8-12) THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT 12637 LE CREOLE’ MKWB, LLC DBA 18135 EAST PETROLEUM DR BATON ROUGE LA 70809 TYNER JETER INS AGCY LLC 5139 BLUEBONNET BLVD BATON ROUGE LA 70809 A LIMITED LIABILITY COMPANY 09-29-13 09-29-14 LA 500000 500000 500000 AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY MA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI WV SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE ANNUALLY. 08-15-13 NP ELMIRA NY SRV CTR 700 DIRECT BILL TYNER JETER INS AGCY LLC X3865 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: INSURER: NCCI CO CODE:1. INSURED: PRODUCER: Insured is Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from to 12:01 A.M. at the insured’s mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ Each Accident Bodily Injury by Disease: $ Policy Limit Bodily Injury by Disease: $ Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: D. This policy includes these endorsements and schedules: 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made DATE OF ISSUE: OFFICE: PRODUCER: Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 7 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 V (IEUB-4003T36-8-13) 5812 ------------------------------------------------------------------------------------ STANDARD TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 11453 PREMIUM DISCOUNT 69 0900-17 EXPENSE CONSTANT 210 TERRORISM 95 CAT (OTHER THAN CERT ACTS OF TERRORISM) 95 TOTAL ESTIMATED PREMIUM 11784 DEPOSIT AMOUNT DUE 11784 100673 EMPLOYERS LIABILITY MINIMUM: $ NP08-15-13 ELMIRA NY SRV CTR 700 COUNTERSIGNED-AGENTTYNER JETER INS AGCY LLC X3865 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: CLASSIFICATION SCHEDULE: PREMIUM BASIS RATES ESTIMATEDESTIMATED PER $100 OF ANNUALTOTAL ANNUAL REMUNERATIONCLASSIFICATIONS CODE NO PREMIUMREMUNERATION SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S) SIC-CODE: Minimum Premium: $ DATE OF ISSUE: OFFICE: PRODUCER: Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 8 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 EXTENSION OF INFO PAGE-SCHEDULE WC 00 00 01 ( A) (IEUB-4003T36-8-13) INSURER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT 12637-LA INSURED’S NAME: LE CREOLE’ MKWB, LLC DBA RATE BUREAU ID: 170952960 PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 01 FEIN 273278918 ENTITY CD 001 LE CREOLE’ MKWB, LLC DBA 18135 EAST PETROLEUM DRIVE BATON ROUGE, LA 70809 CLERICAL OFFICE EMPLOYEES NOC 8810 5410 .38 21 (COUNTY/TOWN CODE 0252) RESTAURANT NOC 9082 468091 2.57 12030 (COUNTY/TOWN CODE 0252) LA MANUAL PREMIUM $ 12051 ------------------------------------------------------------------------------------ 1.10% EMPL. LIAB. INCREASED LIMITS(9807) $ 133 TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 12184 EXPERIENCE MODIFICATION: .94 MODIFIED PREMIUM 11453 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 11453 .60% PREMIUM DISCOUNT(0064) 69 EXPENSE CONSTANT(0900) 210 TERRORISM (9740) 95 CAT(OTHER THAN CERT ACTS OF TERRORISM) 9741 95 TOTAL ESTIMATED PREMIUM 11784 DEPOSIT AMOUNT DUE 11784 08-15-13 NP 1 LAST WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY POLICY NUMBER: DATE OF ISSUE: SCHEDULE NO: OF Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 9 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 (IEUB-4003T36-8-13) WC 00 00 01 A - 001 INFORMATION PAGE WC 00 00 01 A - 001 INFORMATION PAGE 2 WC 00 00 01 A - 001 EXTENSION OF INFORMATION PAGE - SCHEDULE WC 00 00 01 A - 001 ENDORSEMENT LISTING WC 00 04 14 00 - 001 NOTIFICATION OF CHANGE IN OWNERSHIP ENDT WC 00 04 22 A - 001 TERRORISM-REAUTHORIZATION ACT DISCLOSURE WC 00 04 21 C - 001 CATASTROPHE (O/T CERT. ACTS OF TERR)ENDT WC 99 04 08 00 - 001 PREMIUM DISCOUNT ENDORSEMENT WC 00 04 19 00 - 001 PREMIUM DUE DATE ENDORSEMENT WC 17 06 01 E - 001 LOUISIANA AMENDATORY ENDORSEMNET WC 17 06 02 A - 001 LA COST CONTAINMENT ACT ENDORSEMENT WC 17 03 03 00 - 001 LOUISIANA DUTY TO DEFEND LAST108-15-13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 00 00 01 (A ) POLICY NUMBER: LISTING OF ENDORSEMENTS EXTENSION OF INFO PAGE We agree that the following listed endorsements form a part of this policy on its effective date. Page ofDATE OF ISSUE: ST ASSIGN: Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 10 of 52 WC 00 00 00 ( B) (Ed. 7-11) The Travelers Insurance Companies (Each a Stock Insurance Company) Hartford, Connecticut WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows: GENERAL SECTION A. The Policy ease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendmentsThis policy includes at its effective date the Informa- to that law which are in effect during the policy pe-tion Page and all endorsements and schedules listed riod. It does not include any federal workers or work-there. It is a contract of insurance between you (the men's compensation law, any federal occupationalemployer named in Item 1 of the Information Page) disease law or the provisions of any law that provideand us (the insurer named on the Information Page). nonoccupational disability benefits.The only agreements relating to this insurance are stated in this policy. The terms of this policy may not D. State be changed or waived except by endorsement issued State means any state of the United States of America, by us to be part of this policy. and the District of Columbia. B. Who Is Insured E. Locations You are insured if you are an employer named in Item This policy covers all of your workplaces listed in 1 of the Information Page. If that employer is a part- Items 1 or 4 of the Information Page; and it covers all nership, and if you are one of its partners, you are other workplaces in Item 3.A. states unless you have insured, but only in your capacity as an employer of other insurance or are self-insured for such work- the partnership's employees. places. C. Workers Compensation Law Workers Compensation Law means the workers or workmen's compensation law and occupational dis- PART ONE – WORKERS COMPENSATION INSURANCE A. How This Insurance Applies C. We Will Defend This workers compensation insurance applies to We have the right and duty to defend at our expense bodily injury by accident or bodily injury by disease. any claim, proceeding or suit against you for benefits Bodily injury includes resulting death. payable by this insurance. We have the right to inves- tigate and settle these claims, proceedings or suits.1. Bodily injury by accident must occur during the policy period. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance.2. Bodily injury by disease must be caused or aggra- vated by the conditions of your employment. The D. We Will Also Pay employee's last day of last exposure to the condi- We will also pay these costs, in addition to other tions causing or aggravating such bodily injury by amounts payable under this insurance, as part of any disease must occur during the policy period. claim, proceeding or suit we defend: B. We Will Pay 1. reasonable expenses incurred at our request, but We will pay promptly when due the benefits required not loss of earnings; of you by the workers compensation law. 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance. Page 1 of 6 © Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 11 of 52 WC 00 00 00 ( B) (Ed. 7-11) 3. litigation costs taxed against you; H. Statutory Provisions These statements apply where they are required by4. interest on a judgment as required by law until we law.offer the amount due under this insurance; and 1. As between an injured worker and us, we have5. expenses we incur. notice of the injury when you have notice.E. Other Insurance 2. Your default or the bankruptcy or insolvency ofWe will not pay more than our share of benefits and you or your estate will not relieve us of our dutiescosts covered by this insurance and other insurance or under this insurance after an injury occurs.self-insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is 3. We are directly and primarily liable to any person paid. If any insurance or self-insurance is exhausted, entitled to the benefits payable by this insurance. the shares of all remaining insurance will be equal Those persons may enforce our duties; so may an until the loss is paid. agency authorized by law. F. Payments You Must Make Enforcement may be against us or against you and us.You are responsible for any payments in excess of the benefits regularly provided by the workers compensa- 4. Jurisdiction over you is jurisdiction over us for tion law including those required because: purposes of the workers compensation law. We are bound by decisions against you under that1. of your serious and willful misconduct; law, subject to the provisions of this policy that 2. you knowingly employ an employee in violation are not in conflict with that law. of law; 5. This insurance conforms to the parts of the work- 3. you fail to comply with a health or safety law or ers compensation law that apply to: regulation; or a. benefits payable by this insurance; 4. you discharge, coerce or otherwise discriminate b. special taxes, payments into security or otheragainst any employee in violation of the workers special funds, and assessments payable by uscompensation law. under that law. If we make any payments in excess of the benefits 6. Terms of this insurance that conflict with theregularly provided by the workers compensation law workers compensation law are changed by thison your behalf, you will reimburse us promptly. statement to conform to that law. G. Recovery From Others Nothing in these paragraphs relieves you of your We have your rights, and the rights of persons entitled duties under this policy. to the benefits of this insurance, to recover our pay- ments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. PART TWO – EMPLOYERS LIABILITY INSURANCE A. How This Insurance Applies 3. Bodily injury by accident must occur during the policy period.This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily 4. Bodily injury by disease must be caused or aggra- injury includes resulting death. vated by the conditions of your employment. The employee's last day of last exposure to the condi-1. The bodily injury must arise out of and in the tions causing or aggravating such bodily injury bycourse of the injured employee's employment by disease must occur during the policy period.you. 5. If you are sued, the original suit and any related2. The employment must be necessary or incidental legal actions for damages for bodily injury by ac-to your work in a state or territory listed in Item cident or by disease must be brought in the United3.A. of the Information Page. Page 2 of 6 © Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 12 of 52 WC 00 00 00 ( B) (Ed. 7-11) States of America, its territories or possessions, or injury to a citizen or resident of the United States Canada. of America or Canada who is temporarily outside these countries;B. We Will Pay 7. Damages arising out of coercion, criticism, demo-We will pay all sums that you legally must pay as tion, evaluation, reassignment, discipline, defa-damages because of bodily injury to your employees, mation, harassment, humiliation, discriminationprovided the bodily injury is covered by this Employ- against or termination of any employee, or anyers Liability Insurance. personnel practices, policies, acts or omissions. The damages we will pay, where recovery is permitted 8. Bodily injury to any person in work subject to theby law, include damages: Longshore and Harbor Workers' Compensation 1. For which you are liable to a third party by reason Act (33 USC Sections 901-950), the Nonappro- of a claim or suit against you by that third party to priated Fund Instrumentalities Act (5 USC Sec- recover the damages claimed against such third tions 8171-8173), the Outer Continental Shelf party as a result of injury to your employee; Lands Act (43 USC Sections 1331-1356a), the 2. For care and loss of services; and Defense Base Act (42 USC Sections 1651-1654), the Federal Coal Mine Safety and Health Act (303. For consequential bodily injury to a spouse, child, USC Sections 801-945), any other federal workersparent, brother or sister of the injured employee; or workmen's compensation law or other federal provided that these damages are the direct conse- occupational disease law, or any amendments to quence of bodily injury that arises out of and in the these laws. course of the injured employee's employment by you; 9. Bodily injury to any person in work subject to theand Federal Employers' Liability Act (45 USC Sec- 4. Because of bodily injury to your employee that tions 51-60), any other federal laws obligating an arises out of and in the course of employment, employer to pay damages to an employee due to claimed against you in a capacity other than as bodily injury arising out of or in the course of employer. employment, or any amendments to those laws. C. Exclusions 10. Bodily injury to a master or member of the crew of any vessel.This insurance does not cover: 11. Fines or penalties imposed for violation of federal1. Liability assumed under a contract. This exclu- or state law.sion does not apply to a warranty that your work will be done in a workmanlike manner; 12. Damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 USC Sec-2. Punitive or exemplary damages because of bodily tions 1801-1872) and under any other federal lawinjury to an employee employed in violation of awarding damages for violation of those laws orlaw; regulations issued thereunder, and any amend-3. Bodily injury to an employee while employed in ments to those laws.violation of law with your actual knowledge or D. We Will Defendthe actual knowledge of any of your executive of- ficers; We have the right and duty to defend, at our expense, any claim, proceeding or suit against you for damages4. Any obligation imposed by a workers compensa- payable by this insurance. We have the right to inves-tion, occupational disease, unemployment com- tigate and settle these claims, proceedings and suits.pensation, or disability benefits law, or any simi- lar law; We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty5. Bodily injury intentionally caused or aggravated to defend or continue defending after we have paid ourby you; applicable limit of liability under this insurance.6. Bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily Page 3 of 6 © Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 13 of 52 WC 00 00 00 ( B) (Ed. 7-11) E. We Will Also Pay 2. Bodily Injury by Disease. The limit shown for "bodily injury by disease-policy limit" is the mostWe will also pay these costs, in addition to other we will pay for all damages covered by this insur-amounts payable under this insurance, as part of any ance and arising out of bodily injury by disease,claim, proceeding or suit we defend: regardless of the number of employees who sus- 1. Reasonable expenses incurred at our request, but tain bodily injury by disease. The limit shown for not loss of earnings; "bodily injury by disease-each employee" is the most we will pay for all damages because of bod-2. Premiums for bonds to release attachments and ily injury by disease to any one employee.for appeal bonds in bond amounts up to the limit of our liability under this insurance; Bodily injury by disease does not include disease that results directly from a bodily injury by acci-3. Litigation costs taxed against you; dent.4. Interest on a judgement as required by law until 3. We will not pay any claims for damages after wewe offer the amount due under this insurance; and have paid the applicable limit of our liability un-5. expenses we incur. der this insurance. F. Other Insurance H. Recovery From Others We will not pay more than our share of damages and We have your rights to recover our payment fromcosts covered by this insurance and other insurance or anyone liable for an injury covered by this insurance.self-insurance. Subject to any limits of liability that You will do everything necessary to protect thoseapply, all shares will be equal until the loss is paid. If rights for us and to help us enforce them.any insurance or self-insurance is exhausted, the I. Actions Against Usshares of all remaining insurance and self-insurance will be equal until the loss is paid. There will be no right of action against us under this insurance unless:G. Limits of Liability 1. You have complied with all the terms of this pol-Our liability to pay for damages is limited. Our limits icy; andof liability are shown in Item 3.B. of the Information Page. They apply as explained below: 2. The amount you owe has been determined with our consent or by actual trial and final judgement.1. Bodily Injury by Accident. The limit shown for "bodily injury by accident each accident" is the This insurance does not give anyone the right to add most we will pay for all damages covered by this us as a defendant in an action against you to deter- insurance because of bodily injury to one or more mine your liability. The bankruptcy or insolvency of employees in any one accident. you or your estate will not relieve us of our obligations under this Part.A disease is not bodily injury by accident unless it results directly from bodily injury by accident. PART THREE – OTHER STATES INSURANCE A. How This Insurance Applies 3. We will reimburse you for the benefits required by the workers compensation law of that state if we1. This other states insurance applies only if one or are not permitted to pay the benefits directly tomore states are shown in Item 3.C. of the Infor- persons entitled to them.mation Page. 4. If you have work on the effective date of this pol-2. If you begin work in any one of those states after icy in any state not listed in Item 3.A. of the In-the effective date of this policy and are not in- formation Page, coverage will not be afforded forsured or are not self-insured for such work, all that state unless we are notified within thirtyprovisions of the policy will apply as though that days.state were listed in Item 3.A. of the Information Page. B. Notice Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. Page 4 of 6 © Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 14 of 52 WC 00 00 00 ( B) (Ed. 7-11) PART FOUR – YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this 4. Cooperate with us and assist us, as we may request, in policy. Your other duties are listed here. the investigation, settlement or defense of any claim, proceeding or suit.1. Provide for immediate medical and other services 5. Do nothing after an injury occurs that would interfererequired by the workers compensation law. with our right to recover from others.2. Give us or our agent the names and addresses of the 6. Do not voluntarily make payments, assume obliga-injured persons and of witnesses, and other informa- tions or incur expenses, except at your own cost.tion we may need. 3. Promptly give us all notices, demands and legal papers related to the injury, claim, proceeding or suit. PART FIVE – PREMIUM A. Our Manuals D. Premium Payments All premium for this policy will be determined by our You will pay all premium when due. You will pay the manuals of rules, rates, rating plans and classifica- premium even if part or all of a workers compensation tions. We may change our manuals and apply the law is not valid. changes to this policy if authorized by law or a gov- E. Final Premium ernmental agency regulating this insurance. The premium shown on the Information Page, B. Classifications schedules, and endorsements is an estimate. The final Item 4 of the Information Page shows the rate and premium will be determined after this policy ends by premium basis for certain business or work classifica- using the actual, not the estimated, premium basis and tions. These classifications were assigned based on an the proper classifications and rates that lawfully apply estimate of the exposures you would have during the to the business and work covered by this policy. If the policy period. If your actual exposures are not properly final premium is more than the premium you paid to described by those classifications, we will assign us, you must pay us the balance. If it is less, we will proper classifications, rates and premium basis by refund the balance to you. The final premium will not endorsement to this policy. be less than the highest minimum premium for the classifications covered by this policy.C. Remuneration If this policy is canceled, final premium will be de- Premium for each work classification is determined by termined in the following way unless our manuals multiplying a rate times a premium basis. Remunera- provide otherwise: tion is the most common premium basis. This pre- 1. If we cancel, final premium will be calculated promium basis includes payroll and all other remunera- rata based on the time this policy was in force.tion paid or payable during the policy period for the Final premium will not be less than the pro rataservices of: share of the minimum premium. 1. All your officers and employees engaged in work 2. If you cancel, final premium will be more than covered by this policy; and pro rata; it will be based on the time this policy was in force, and increased by our short-rate can-2. All other persons engaged in work that could cellation table and procedure. Final premium willmake us liable under Part One (Workers Com- not be less than the minimum premium.pensation Insurance) of this policy. If you do not have payroll records for these persons, the con- F. Records tract price for their services and materials may be You will keep records of information needed to used as the premium basis. This paragraph 2 will compute premium. You will provide us with copies of not apply if you give us proof that the employers those records when we ask for them. of these persons lawfully secured their workers G. Audit compensation obligations. You will let us examine and audit all your records that relate to this policy. These records include ledgers, journals, registers, vouchers, contracts, tax reports, Page 5 of 6 © Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 15 of 52 WC 00 00 00 ( B) (Ed. 7-11) payroll and disbursement records, and programs for ends. Information developed by audit will be used to storing and retrieving data. We may conduct the au- determine final premium. Insurance rate service or- dits during regular business hours during the policy ganizations have the same rights we have under this period and within three years after the policy period provision. PART SIX – CONDITIONS A. Inspection D. Cancellation We have the right, but are not obliged to inspect your 1. You may cancel this policy. You must mail or workplaces at any time. Our inspections are not safety deliver advance written notice to us stating when inspections. They relate only to the insurability of the the cancellation is to take effect. workplaces and the premiums to be charged. We may 2. We may cancel this policy. We must mail or de- give you reports on the conditions we find. We may liver to you not less than ten days advance written also recommend changes. While they may help reduce notice stating when the cancellation is to take ef- losses, we do not undertake to perform the duty of any fect. Mailing that notice to you at your mailing person to provide for the health or safety of your em- address shown in Item 1 of the Information Page ployees or the public. We do not warrant that your will be sufficient to prove notice. workplaces are safe or healthful or that they comply 3. The policy period will end on the day and hourwith laws, regulations, codes or standards. Insurance stated in the cancellation notice.rate service organizations have the same rights we have under this provision. 4. Any of these provisions that conflict with a law that controls the cancellation of the insurance inB. Long Term Policy this policy is changed by this statement to comply If the policy period is longer than one year and sixteen with the law. days, all provisions of this policy will apply as though E. Sole Representativea new policy were issued on each annual anniversary that this policy is in force. The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change thisC. Transfer of Your Rights and Duties policy, receive return premium, and give or receive Your rights or duties under this policy may not be notice of cancellation. transferred without our written consent. If you die and we receive notice within thirty days after your death, we will cover your legal representa- tive as insured. In witness whereof, the company has caused this policy to be signed by its President and Secretary at Hartford, Connecticut and countersigned on the Information page by a duly authorized agent of the company. Secretary President Page 6 of 6 © Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 16 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 (IEUB-4003T36-8-13) 08-15-13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 00 04 14 (00) POLICY NUMBER: NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT Experience rating is mandatory for all eligible insureds. The experience rating modification factor, if any, applicable to this policy, may change if there is a change in your ownership or in that of one or more of the entities eligible to be combined with you for experience rating purposes. Change in ownership includes sales, purchases, other transfers, mergers, consolidations, dissolutions, formations of a new entity and other changes provided for in the applicable experience rating plan manual. You must report any change in ownership to us in writing within 90 days of such change. Failure to report such changes within this period may result in revision of the experience rating modification factor used to determine your premium. DATE OF ISSUE: ST ASSIGN: Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 17 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 (IEUB-4003T36-8-13) 08-15-13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 00 04 22 ( A) POLICY NUMBER: TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2007. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2007. "Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property or infrastructure. c. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian popula- tion of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss" means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insur- ance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2008, and ending on December 31, 2014, an amount equal to 20% of our direct earned premiums, over the calendar year immediately preceding the applica- ble Program Year. "Program Year" refers to each calendar year between January 1, 2008 and December 31, 2014, as applicable. Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a Program Year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. Page 1 of 2DATE OF ISSUE: ST ASSIGN: Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 18 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 (IEUB-4003T36-8-13) 08-15-13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY WC 00 04 22 ( A)ENDORSEMENT POLICY NUMBER: Policyholder Disclosure Notice 1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses exceed $100,000,000 in a Program Year, the United States Government would pay 85% of our Insured Losses that exceed our Insurer Deductible. 2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100,000,000,000. 3. The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate Premium This endorsement changes the poli to which it is att and is ef ect v on the date issued unless otherwisecy ached f i e stated. ( in on lo is req o w his nd issue ubseq to paratio ofThe formati be w uired nly hen t e orsement is d s uent pre n the p icy.)ol Policy No.Endorsement E f i e Endorsement No.f ect v Prem miu $Insured Insurance Company Countersigned by Page 2 of 2DATE OF ISSUE: ST ASSIGN: Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 19 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 (IEUB-4003T36-8-13) 08-15-13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY WC 00 04 21 ( C)ENDORSEMENT POLICY NUMBER: CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT This endorsement is notification that your insurance carrier is charging premium to cover the losses that may occur in the event of a Catastrophe (other than Certified Acts of Terrorism) as that term is defined below. Your policy provides coverage for workers compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism). This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 A), attached to this policy. For purposes of this endorsement, the following definitions apply: Catastrophe (other than Certified Acts of Terrorism): Any single event, resulting from an Earthquake, Noncertified Act of Terrorism, or Catastrophic Industrial Accident, which results in aggregate workers com- pensation losses in excess of $50 million. Earthquake: The shaking and vibration at the surface of the earth resulting from underground movement along a fault plane or from volcanic activity. Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary of Treasury pursuant to the Terrorism Risk Insurance Act of 2002 (as amended) but that meets all of the follow- ing criteria: a. It is an act that is violent or dangerous to human life, property, or infrastructure; b. The act results in damage within the United States, or outside of the United States in the case of the premises of United States missions or air carriers or vessels as those terms are defined in the Terrorism Risk Insurance Act of 2002 (as amended); and c. It is an act that has been committed by an individual or individuals as part of an effort to coerce the civil- ian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. Catastrophic Industrial Accident: A chemical release, large explosion, or small blast that is localized in nature and affects workers in a small perimeter the size of a building. The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism) is shown in Item 4 of the Information Page or in the Sched- ule below. Schedule State Rate Premium This endorsement changes the poli to which it is att and is ef ect v on the date issued unless otherwisecy ached f i e stated. ( in on lo is req o w his nd issue ubseq to paratio ofThe formati be w uired nly hen t e orsement is d s uent pre n the p icy.)ol Policy No.Endorsement E f i e Endorsement No.f ect v Prem miu $Insured Insurance Company Countersigned by Page 1 of 1DATE OF ISSUE: ST ASSIGN: Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 20 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 (IEUB-4003T36-8-13) 08-15-13 WORKERS CO TIMPENSA ON AND EMPL L T OOYERS IABILI Y P LICY ENDORSEMEN WC 99 04T 08 (00) POLICY :NUMBER PREMIUM DISCOUNT ENDORSEMENT The pre m the state and o states, i any, m 3.A o the In m ionmiu for ther f listed in ite f for at ig orPage may be el ible f a discount. The f l ca lat o pre m d will be deter ined by our mina lcu ion f miu iscount m m manuals and your pre iu as determ it m m to retrospecti e ing to pre iu iscount.ined by aud . Pre iu subject v rat is not subject m m d OTHER POL :ICIES DATE I ST A GN:OF SSUE: SSI Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 21 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 (IEUB-4003T36-8-13) 08-15-13 WORKERS CO TIMPENSA ON AND EMPL L T OOYERS IABILI Y P LICY ENDORSEMEN WC 00 04T 19 (00) POLICY :NUMBER PREMIUM DUE DATE ENDORSEMENT This endorsement is used to amend: Section D f t F v o the pol is replaced by v. o Par i e f icy this pro ision. PART FIVE PREMIUM D. Premium is amended to read: You will pay a pre iu when due. You wil pay the pre iu e en i part or a o a workers compensationll m m l m m v f ll f law is not a .v lid T due for a it a retrospective is t date he lli .he date ud nd premiums he of t bi ng DATE I ST A GN: Page 1 o 1OF SSUE: SSI f Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 22 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 (IEUB-4003T36-8-13) 08-15-13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 17 06 01 ( E) POLICY NUMBER: LOUISIANA AMENDATORY ENDORSEMENT This endorsement applies only to the insurance provided by the Policy because Louisiana is shown in Item 3.A. of the Information Page. PART FIVE PREMIUM Section E., Final Premium of Part Five (Premium) of the policy is replaced by the following: E. Final Premium The premium shown on the Information Page, schedules, and endorsements is an estimate. The final pre- mium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifica- tions covered by this policy. If this policy is cancelled, final premium will be determined in the following way, unless our manuals provide otherwise: 1. If we cancel, final premium will be calculated pro rata based on the time that this policy was in force. Fi- nal premium will not be less than the pro rata share of the minimum premium. 2. If you cancel, final premium will be calculated using one of the following methods as listed in the Sched- ule of this endorsement: a. Pro rata based on the time that this policy was in force. Final premium will not be less than the pro rata share of the minimum premium, or b. More than pro rata; it will be based on the time that this policy was in force, and increased by our short-rate cancellation procedure that has been filed with and approved by the commissioner. Final premium will not be less than the minimum premium. PART SIX CONDITIONS The Cancellation Condition of the policy is replaced by this Condition: D. Cancellation 1. If coverage has not been in effect for sixty days and the policy is not a renewal, cancellation shall be ef- fected by mailing or delivering a written notice to the first-named insured at the mailing address shown on the policy at least sixty days before the cancellation effective date, except in cases where cancellation is based on nonpayment of premium. Notice of cancellation based on nonpayment of premium shall be mailed or delivered at least ten days prior to the effective date of cancellation. After coverage has been in effect for more than sixty days or after the effective date of a renewal policy, no insurer shall cancel a policy unless the cancellation is based on at least one of the following reasons: a. Nonpayment of premium. b. Fraud or material misrepresentation made by or with the knowledge of the named insured in obtain- ing the policy, continuing the policy, or in presenting a claim under the policy. c. Activities or omissions on the part of the named insured which change or increase any hazard in- sured against, including a failure to comply with loss control recommendations. 2011 National Council on compensation Insurance, Inc. All Rights Reserved. Page 1 of 4DATE OF ISSUE: ST ASSIGN: Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 23 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 (IEUB-4003T36-8-13) 08-15-13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 17 06 01 ( E) POLICY NUMBER: d. Change in the risk which increases the risk of loss after insurance coverage has been issued or re- newed, including an increase in exposure due to regulation, legislation, or court decision. e. Determination by the commissioner of insurance that the continuation of the policy would jeopardize a company's solvency or would place the insurer in violation of the insurance laws of this state or any other state. f. Violation or breach by the insured of any policy terms or conditions. g. Such other reasons that are approved by the commissioner of insurance. 2. a. A notice of cancellation of insurance coverage by an insurer shall be in writing and shall be mailed or delivered to the first-named insured at the mailing address as shown on the policy. Notices of cancel- lation based on conditions 1.b. through 1.g. above shall be mailed or delivered at least thirty days prior to the effective date of the cancellation; notices of cancellations based upon condition 1.a. above shall be mailed or delivered at least ten days prior to the effective date of cancellation. The notice shall state the effective date of the cancellation. b. The insurer shall provide the first-named insured with a written statement setting forth the reason for the cancellation where the insured requests such a statement in writing and the named insured agrees in writing to hold the insurer harmless from liability for any communication giving notice of or specifying the reasons for a cancellation or for any statement made in connection with an attempt to discover or verify the existence of conditions which would be a reason for cancellation under this en- dorsement. 3. Nothing in this endorsement shall require an insurer to provide a notice of cancellation or a statement of reasons for cancellation where cancellation for nonpayment of premium is effected by a premium finance agency or other entity pursuant to a power of attorney or other agreement executed by or on behalf of the insured. 4. An insurer may decide not to renew a policy if it delivers or mails to the first-named insured at the ad- dress shown on the policy written notice it will not renew the policy. Such notice of nonrenewal shall be mailed or delivered at least sixty days before the expiration date. Such notice to the insured shall include the insured's loss run information for the period the policy has been in force within, but not to exceed the last three years of coverage. If the notice is mailed less than sixty days before expiration, coverage shall remain in effect under the same terms and conditions until sixty days after notice is mailed or delivered. Earned premium for any period of coverage that extends beyond the expiration date shall be considered pro rata based upon the previous year's rate. For purposes of this endorsement, the transfer of a policy- holder between companies within the same insurance group shall not be a refusal to renew. In addition, changes in the deductible, changes in rate, changes in the amount of insurance, or reductions in policy limits or coverage shall not be refusals to renew. 5. Notice of nonrenewal shall not be required if the insurer or a company within the same insurance group has offered to issue a renewal policy, or where the named insured has obtained replacement coverage or has agreed in writing to obtain replacement coverage. 6. If an insurer provides the notice described in paragraph 4 above and thereafter the insurer extends the policy for ninety days or less, an additional notice of nonrenewal is not required with respect to the exten- sion. 7. An insurer shall mail or deliver to the named insured at the mailing address shown on the policy written notice of any rate increase, change in deductible, or reduction in limits or coverage at least thirty days prior to the expiration date of the policy. If the insurer fails to provide such thirty-day notice, the coverage provided to the named insured at the expiring policy's rate, terms, and conditions shall remain in effect 2011 National Council on compensation Insurance, Inc. All Rights Reserved. Page 2 of 4DATE OF ISSUE: ST ASSIGN: Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 24 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 (IEUB-4003T36-8-13) 08-15-13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 17 06 01 ( E) POLICY NUMBER: until notice is given or until the effective date of replacement coverage obtained by the named insured, whichever first occurs. For the purposes of this paragraph, notice is considered given thirty days follow- ing date of mailing or delivery of the notice. If the insured elects not to renew, any earned premium for the period of extension of the terminated policy shall be calculated pro rata at the lower of the current or previous year's rate. If the insured accepts the renewal, the premium increase, if any, and other changes shall be effective the day following the prior policy's expiration or anniversary date. 8. Paragraph 7 shall not apply to the following: a. Changes in a rate or plan filed with the insurance rating commission and applicable to an entire class of business. b. Changes based upon the altered nature or extent of the risk insured. c. Changes in policy forms filed and approved with the commissioner and applicable to an entire class of business. d. Changes requested by the insured. 9. Proof of mailing of notice of cancellation, or of nonrenewal or of premium or coverage changes, to the named insured at the address shown in the policy, shall be sufficient proof of notice. 2011 National Council on compensation Insurance, Inc. All Rights Reserved. Page 3 of 4DATE OF ISSUE: ST ASSIGN: Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 25 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 (IEUB-4003T36-8-13) 08-15-13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 17 06 01 ( E) POLICY NUMBER: Section I., Actions Against Us, of Part Two (Employers Liability Insurance) of the policy is replaced by the following: I. Actions Against Us You may not bring an action against us under this insurance unless: 1. You have complied with all the terms of this policy; and 2. The amount you owe has been determined with our consent or by actual trial and final judgment. The bankruptcy or insolvency of you or your estate will not relieve us of our obligations under this Part. This Condition is added to the policy: Your Right to Remove Agent We will not change or remove the agent of record who wrote this policy prior to the termination or renewal of this policy unless you request the change or removal. If you request the change or removal of the agent, we will notify the agent in writing 15 days in advance of the change or removal. Schedule 1. If you cancel, final premium for this policy will be calculated: pro rata, or X more than pro rata This endorsement changes the poli y to which it is att ched and is ef ect vc a f i e on the date issued unless otherwise stated. ( he n ormati n be o s req ired o ly hen t is e d rsement is issue s bseq enT i f o l w i u n w h n o d u u t to pre aratio fp n o the p l cy.)o i Pol cy No.iEndorsement Effective Endorsement No. Prem u $i mInsured Insurance Company Countersigned by 2011 National Council on compensation Insurance, Inc. All Rights Reserved. Page 4 of 4DATE OF ISSUE: ST ASSIGN: Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 26 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 (IEUB-4003T36-8-13) 08-15-13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 17 06 02 ( A) POLICY NUMBER: LOUISIANA COST CONTAINMENT ACT ENDORSEMENT This endorsement applies only to the insurance provided by the Policy because Louisiana is shown in Item 3.A. of the Information Page. You may be eligible for a two (2) percent reduction in your premium if you attend a cost containment meeting conducted by the Occupational, Safety and Health administration (OSHA) Section of the Office of Workers Compensation Administration. In order for you to receive the reduction you must submit to us a certificate of attendance from the OSHA Section. The reduction will apply for a period of one year and will be applied to the policy becoming effective after the date you attended the cost containment meeting. You may also be eligible for an additional five (5) percent reduction in your premium if you have attended a cost containment meeting and have subsequently satisfactorily implemented an occupational, safety and health program prescribed by the OSHA Section. In order for you to receive the reduction you must submit to us a Certificate of Satisfactory Implementation of Occupation, Safety and Health Program from the OSHA Section. The reduction will apply for a period of one year and will be applied to the policy becoming effective after the date of your certification. DATE OF ISSUE: ST ASSIGN: Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 27 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 (IEUB-4003T36-8-13) 08-15-13 WORKERS CO TIMPENSA ON AND EMPL L T OOYERS IABILI Y P LICY ENDORSEMEN WC 17 03T 03 (00) POLICY :NUMBER LOUISIANA DUTY TO DEFEND ENDORSEMENT This endorsement appl to the v by the pol because Louisiana is shown in Ite 3.A. oies only insurance pro ided icy m f the In ma Page.for tion The duty fend pro is the pol y this pro isto de v ions of ic is replaced by v ion. Part mployer’s Liabi ityTwo E l D. We Will Defend W ha e the right and duty to de at our e any cla m, proceeding or sui against you f dae v fend, xpense, i t or mages payable by th W ha the r to v and settle ms,is insurance. e ve ight in estigate these clai proceedings and suits. Our duty to de ends when the li i o liab i has been exhausted by the pay t o a judgmen orfend m t f il ty men f t settlement. DATE I ST A GN:OF SSUE: SSI Page 1 of 1 Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 28 of 52 If Your Employee Is Injured At Work Prompt reporting of work-related injuries and illnesses and the use of Travelers national Medical Net- work Providers can achieve better outcomes and lower your overall workers compensation claim costs! Whenever an Employee suffers a work-related injury or illness, the Employer should: 1. Seek appropriate medical care for the Employee. 2. If the injury or illness is acute, the Employer should always send the Employee to the nearest medical emergency department. 3. If the injury or illness is not acute, the Employer may suggest that the Employee seek treatment from the nearest Medical Network Provider. Medical Network Providers understand work-related illnesses and injuries, are credentialed to help assure quality care, and cooperate to achieve a medically appropriate return to work for the Employee. Medical Network Providers (hospitals, initial care clinics, specialists, testing, therapy, etc.) are available in all 50 States and the District of Columbia. Even before an illness or injury occurs, it may be helpful for the Employer to build a relationship with a convenient Medical Network Clinic or Hospital that will provide initial treatment for ill or injured Employees. 4. The Employee's Supervisor should gather pertinent facts about the work-related illness or injury and may use the Worksheet For Workers' Compensation Telephone Reporting provided by Travelers as a guide. 5. As soon as possible, the Employer should report all work-related illnesses or injuries to Travelers by, using Travelers business insurance online reporting web site at travelers.com dialing our toll free number, . If needed at that time, Travelers Customer Service Repre-1-800-238-6225 sentative can provide the name of a convenient Medical Network Provider. Prompt reporting of work- related illnesses and injuries is key in helping to reduce total claim costs. At the conclusion of the phone call, the Travelers Customer Service Representative will provide a claim number that should be retained for the Employer's reference and also provided to the ill or injured Employee. The card below contains information that may be helpful in reporting work-related illnesses and injuries to Travelers and should be kept in a convenient location for use by the Employer when needed. WC Claim Reporting Promptly report your work-related injuries to Travelers: Travelers.com 800-238-6225 Learn about Travelers unique Claim Services and find a convenient medical network provider by logging on to Travelers.com. To get to Travelers website, select Business Insurance from the home page. Then choose Workers’ Compensation & Managed Care Claim Management from the menu of services in the left margin. Finally, click on Preferred Provider Network to search for a Medical Network Provider near you. \ / \ / WUNC6B08 Page 1 of 1 Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 29 of 52 WORKERS' COMPENSATION TELEPHONE REPORTING WORKSHEET THINGS TO REMEMBER WHEN COMPLETING THE INFORMATION BELOW: Call the Telephone Reporting Center to quickly and easily report all Workers' Compensation injuries. We will be asking you the following questions, so please have the information handy. We will produce and submit the necessary state forms. DO NOT DELAY IN CALLING IF YOU DO NOT HAVE ANSWERS TO ALL THE QUESTIONS. ACCOUNT/ACCIDENT INFORMATION CALLER'S NAMECALLER'S PHONE NUMBER/EXTENSION CALLER'S TITLE REPORTING STATE ( ) SUBSIDIARY NAME SUBSIDIARY'S ADDRESS (STREET, CITY, STATE & ZIP) SUBSIDIARY'S MAILING ADDRESS (STREET, CITY, STATE & ZIP) SAME DID THE ACCIDENT OCCUR AT THE LOCATION ADDRESS? YES IF NO, ADDRESS WHERE ACCIDENT OCCURREDNO PARENT COMPANY/INSURED'S NAME POLICY SYMBOL AND NUMBER NATURE OF BUSINESSLOCATION CODE DATE OF INJURY TIME OF INJURY ACCIDENT DESCRIPTION EMPLOYEE INFORMATION INJURED EMPLOYEE'S SOCIAL SECURITY NUMBER GENDEREMPLOYEE'S NAME (FIRST, MI, LAST) MALE FEMALE DATE OF BIRTH EMPLOYEE'S MAILING ADDRESS EMPLOYEE'S HOME PHONE NUMBER EMPLOYEE'S HOME ADDRESS (IF DIFFERENT FROM MAILING) ( ) EMPLOYEE JOB INFORMATION REGULAR OCCUPATIONINJURED WORKER TYPEEMPLOYMENT STATUS CODE FULL-TIME PART-TIME OTHER OCCUPATION WHEN INJURED EMPLOYEE'S WORK SCHEDULE HOURS/DAYREGULAR WORK HOURS DAYS/WEEK EMPLOYEE'S WAGE INFORMATION $____________/HOUR OR $___________/ANNUAL OR $____________/WEEKLY OVERTIME: $____________ ADDITIONAL BENEFITS: $___________ DATE OF HIRE OR LENGTH OF EMPLOYMENT BEST HOURS TO CONTACTSUPERVISOR'S NAME SUPERVISOR'S PHONE NUMBER: ( ) ACCIDENT INFORMATION IS THE EMPLOYEE BACK AT WORK?DATE CLAIM REPORTED TO EMPLOYER? DID EMPLOYEE LOSE ANY TIME FROM WORK? YES NO YES NO IF YES, DATE RETURNED TOWORK? DATE EMPLOYEE LAST WORKEDRETURN TOWORK STATUS WAS INJURY FATAL? IF YES, DATE OF DEATH LIGHT MODIFIED REGULAR YES NO CAUSE OF ACCIDENT (E.G., SLIP/FALL, LIFTING, CHEMICAL) EQUIPMENT, MATERIAL OR SUBSTANCE INVOLVED DO YOU QUESTION THE VALIDITY OF THE CLAIM? YES NO WITNESS INFORMATION/OTHERS INVOLVED NAME (FIRST, MI, LAST) ADDRESS PHONE NUMBER CONTINUED ON REVERSE SIDE WUNTCD05 Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 30 of 52 INJURY INFORMATION PART OF BODY INJURED (E.G., HEAD, NECK, ARM, LEG) NATURE OF INJURY (E.G., FRACTURE, SPRAIN, LACERATION PRIOR INJURY OR PRE-EXISTING CONDITION(S) (IF YES, DESCRIBE) YES NO TREATMENT ("X" ALL THAT APPLY) stTREATMENT AND DATE OF 1 TREATMENT FIRST AID — stNAME, ADDRESS, PHONE NUMBER, PHYSICIAN NAME, TREATMENT, DATE OF 1 TREATMENT, LENGTH OF STAY AMBULANCE USED? HOSPITAL/ CLINIC — WAS EMPLOYEE TREATED IN AN EMERGENCY ROOM? WAS EMPLOYEE HOSPITALIZED OVERNIGHT AS AN IN-PATENT? YES NO YES NO PHYSICIAN — SEE WORKERS' COMPENSATION - FIRST REPORT OF INJURY - STATE SPECIFIC QUESTIONS FOR YOUR INDIVIDUAL STATE. CUSTOMER SPECIFIC INFORMATION ADDITIONAL COMMENTS & INFORMATION WUNTCD05 (Back) Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 31 of 52 WORKERS' COMPENSATION FIRST REPORT OF INJURY STATE SPECIFIC QUESTIONS Alabama Iowa - No Additional State Questions Employee's County: KansasReturn to work (Y/N): SIC Code:At what Occupation: Was worker admitted to hospital (Y/N):At what Wage $: If Yes, Date of Admission:Return to work wage is per (Day, Week or Month): Was worker treated in emergency room only (Y/N):Employer's ID (U.C. Account) Number: Returned to work (Y/N):What Specific Product(s) does the business produce: If employee has returned to work, was return to light duty (Y/N):Alaska - No Additional State Questions Is further medical aid needed (Y/N): Is compensation now being paid (Y/N):Arizona If Yes, Date of first Initial Payment:Last Day of Work after injury: Fatal (Y/N):Number of Days per Week Company usually Works: If Yes, Name and Address of Dependents:Department Number: If Validity of Claim is Doubted, state Reason: - No Additional State QuestionsKentucky Has injured been employed for more than 12 months (Y/N): LouisianaWas employee on overtime when injured (Y/N): Employer's Federal ID Number: Arkansas - No Additional State Questions Employer's Unemployment Insurance Reporting Number: Returned to work (Y/N): California If Yes, at same wage (Y/N): State Unemployment Insurance Account Number: Last Full Day Paid: Date employee was provided Employee Claim Form: If occupational disease, Date of Initial Diagnosis: Has your employee pre-designated a primary treating physician (Y/N): Parish (county) where injury occurred: If Yes, Primary Treating Physician s MaineFirst Name: Last Name: Street Address: Employer's State Unemployment Insurance Account Number (UIAN):City: State: Zip: Phone: Federal Employer Insurance Number (FEIN):If No, did your employee require medical treatment (Y/N): If Yes, Treating Physicians Maryland - No Additional State Questions First Name: Last Name: Phone: Massachusetts If No, and employee requires medical treatment in the future, you can Federal ID Number: go to our website WWW.MYWCOMPINFO.COM to find a provider in Returned to work (Y/N): the Medical Provider Network. Did employee return to his/her regular occupation (Y/N): Describe nature of business or article manufactured (S=Service,Colorado W=Wholesale, R=Retail, M=Manufacturing):Employer Federal ID Number Date Reported as work related:Does Employer have a salary continuation program (Y/N) If “Yes” is this program registered with the state (Y/N) Michigan Federal ID Number:Connecticut - No Additional State Questions Minnesota Date employer notified of lost time:Delaware NAICS Code Number:Employer's UC Reporting Number: Employees County: Mississippi - No Additional State Questions Returned to work (Y/N): If Yes, at same wage (Y/N): Missouri - No Additional State QuestionsDistrict of Columbia Employer ID Number: Montana - No Additional State QuestionsReturned to work (Y/N): If Yes, at what Time: AM/PM Nebraska - No Additional State QuestionsAt what Wage $: Per (Day, Week or Month): Was injured hired in DC (Y/N): Nevada Was employee in his/her regular occupation when injured (Y/N): How long employed by you in Nevada Years: Months: Was injured given Form #7 DCWC (Y/N): If Validity of Claim is Doubted, state Reason: Piece or Time Worker (piece, time or blank): New Hampshire Florida - No Additional State Questions Federal I.D. Number: Was the employee injured in his/her regular occupation (Y/N):Georgia Was injured hired in New Hampshire (Y/N):Wage Rate at time of injury $: Per: Number of Full-Time Employees:First Date employee failed to work a full day: Number of Part-Time Employees:Did employee work the next day (Y/N): If leased or temporary worker, provide the Client s Business Name:Return to work Wage $: Was accident caused by injured's failure to use safeguards or followReturn to work wage is per (Day, Week or Month): regulations (Y/N): Hawaii Probable Length of Disability: Was employee furnished meals or lodging (Y/N): Returned to work (Y/N): At what Occupation:Idaho - No Additional State Questions Returned at Full Duty: Returned at Alternative/Light Duty:Illinois Initial treatment (“X” all that apply)Has the injured worker signed a medical authorization (Y/N): No medical treatment: Care provided by employer only (on-If yes, inform them to please fax the signed medical authorization to site): Emergency Care: Hospitalized: Outpatient:the med auth customer service specialist at 1-877-786-5567. Clinic: Indiana - No Additional State Questions Office Visit: Other-explain: Is there a managed care program (Y/N): WUNTDD10 Page 1 Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 32 of 52 WORKERS' COMPENSATION FIRST REPORT OF INJURY STATE SPECIFIC QUESTIONS If Yes, Name of Provider: Rhode Island Is there a written safety program in force (Y/N): Federal ID Number: Is there an active safety committee (Y/N): First Full Day Lost from work: Employee s Legal First Name (please validate): Unemployment Insurance Number: State of Hire:New Jersey - No Additional State Questions Was this injury previously an "Incident Only" with no medical treatment and no lost time (Y/N):New Mexico - No Additional State Questions If Yes, Date Employer first Notified of medical treatment or lost time: Category of Injury or Illness ("X" all that apply):New York Injury: Illness: Occupational Disease: Repetitive Trauma:Did you provide medical care (Y/N): Occupational Hearing Loss: Unknown:If Yes, When: Returned to work (Y/N): South Carolina - No Additional State Questions If Yes, at what Weekly Wage $: Injured workers Work Week (indicate days regularly worked): South Dakota Fatal (Y/N): Federal ID Number: If Yes, Name and Address of nearest relative: Number of employees: Relationship: Body Part Injured Code (2 digits): Cause of Injury Code (2 digits):North Carolina Nature of Injury Code (2 digits):Regular Wages per Day $: Was employee hired for temporary employment (Y/N):Average Weekly Wages with Overtime $: Carrier Code:Returned to work (Y/N): If Yes, at what Time: AM/PM Tennessee - No Additional State Questions If Yes, what Date: Return to work at what Wage $: Per (Day, Week or Month): Texas - No Additional State Questions Return to work at what Occupation: Utah - No Additional State QuestionsNorth Dakota - No Additional State Questions VermontOhio Federal ID Number:Time Accident Reported to employer: AM/PM: Was employee hired in Vermont (Y/N):Has employee ever filed a previous application for this injury (Y/N): Does the employer regularly employ 10 or more employees (Y/N):Has employee filed any other claims with the Bureau or Industrial Returned to work (Y/N): If Yes, at what Weekly Wage $:Commission (Y/N): Was injured paid in full for the date disability began (Y/N):If Yes, specify Claim Number and Body Parts: Was employee injured at his/her regular occupation (Y/N):Employee's County: Fatal (Y/N):Current Employer's Risk Number: If Yes, Name, Address and Relationship of Nearest Relative: Oklahoma Last Date Paid in Full: Was employment agreement made in Oklahoma (Y/N): VirginiaSIC Number: Returned to work (Y/N): If Yes, at what Wage $:Type of Ownership (P=Private, S=State Government, Federal Tax ID Number:C=County Government, L=Local Government): Washington - No Additional State QuestionsOregon Hospitalized overnight as inpatient (if emergency room only, answer West Virginia N) (Y/N): Has the employee been given "The Employees and Physicians Report Was accident caused by failure of machinery or product (Y/N): of Injury Form" (Y/N) Did someone (not worker) cause accident (Y/N): Wisconsin - No Additional State QuestionsTime worker left work: AM/PM: Pennsylvania Wyoming - No Additional State Questions Employee's County: Bureau Code: - No Additional State QuestionsU.S. Longshoreman (USDOL) NAICS Code: Employer s County: Are you aware of a 'Panel of Physicians' for your Employer? (Y/N) WUNTDD10 Page 2 Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 33 of 52 THE TRAVELERS INSURANCE COMPANIES THE TRAVELERS INSURANCE COMPANIES THE TRAVELERS INSURANCE COMPANIES THE TRAVELERS INSURANCE COMPANIES PRIVACY NOTICE PRIVACY POLICY Thank you for selecting as your workers compensation insurer. At a subsidiary of Travelers, we recognize that privacy is important to you. That is why we are committed to protecting your privacy through the adoption of the following privacy principles: Collection Of Information We collect, retain, and use information about you, or about participants, beneficiaries or claimants under your workers compensation coverage, only where we believe that it will help or is necessary to provide you products and services or otherwise conduct our business. We collect nonpublic personal financial information about you, or about participants, beneficiaries or claimants under your workers compensation coverage, from the following sources: information we receive from you or through your agent or broker on applications or other forms; information we receive from or about you in the process of adjusting claims; information about your other transactions, including risk control and other consulting services, with us, our affiliates or other third parties; information about your coverages and loss activity with other carriers; and information we receive from a consumer reporting agency. Such information includes identifying information such as policyholder, participant, beneficiary or claimant name, address, and social security number; financial information such as income, payment history, or credit history; and, under certain circumstances, health information such as information about an illness, disability, or injury. It could also include information on claims with other insurance companies and us and the condition and mainte- nance of your property. Disclosure Of Information We usually do not disclose nonpublic personal information about you, or about participants, beneficiaries or claimants under your workers compensation coverage, without your consent. However, in some circumstances we may disclose information to others without your prior authorization. The most common disclosures are to the following persons: our affiliated property and casualty insurance companies; state insurance departments, for their regulation of our business; other government authorities; our agents and brokers as necessary to conduct our business; organizations that perform underwriting and claims investigations; another insurance company to which you have applied for a policy or submitted a claim; insurance support agencies, law enforcement agencies and our reinsurers; and any other third party, as permitted or required by law. Most importantly, does not and will not disclose or sell nonpublic personal information about you, or about participants, beneficiaries or claimants under your workers compensation coverage, to anyone for marketing purposes. WUNNAB09 Page 1 of 2 Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 34 of 52 Confidentiality And Security We restrict access to nonpublic personal information about you, or about participants, beneficiaries or claimants under your workers compensation coverage, to those who need it to serve your insurance needs and to maintain and improve customer service. We maintain physical, electronic, and procedural safeguards that comply with federal and state laws and regulations to guard your nonpublic personal information. Disclosure and Protection of Former Customers' Information We may disclose all the personal information we have collected, as described above. However, even if you no longer have a customer relationship with us, we will continue to follow our privacy policies and practices to protect your information. Changes In Privacy Policy We may choose to modify our policy regarding the treatment of personal information at any time. Before we do so, we will notify you and provide an updated privacy notice. WUNNAB09 Page 2 of 2 Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 35 of 52 IMPORTANT NOTICE INDEPENDENT AGENT AND BROKER COMPENSATION NO COVERAGE IS PROVIDED BY THIS NOTICE. THIS NOTICE DOES NOT AMEND ANY PROVISION OF YOUR POLICY. YOU SHOULD REVIEW YOUR ENTIRE POLICY CAREFULLY FOR COMPLETE INFORMATION ON THE COVERAGES PROVIDED AND TO DETERMINE YOUR RIGHTS AND DUTIES UNDER YOUR POLICY. PLEASE CONTACT YOUR AGENT OR BROKER IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR ITS CONTENTS. IF THERE IS ANY CONFLICT BETWEEN YOUR POLICY AND THIS NOTICE, THE PROVISIONS OF YOUR POLICY PREVAIL. For information about how Travelers compensates independent agents and brokers, please visit www.travelers.com, call our toll-free telephone number 1-866-904-8348, or request a written copy from Marketing at One Tower Square, 2GSA, Hartford, CT 06183. WUNNDD08 Page 1 of 1 PN T4 54 01 08 Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 36 of 52 IMPORTANT Policy Audit Information Dear Pol :icyholder This pol is issued with an esti pre iu based upon infor t pro ided through your Producer.icy mated m m ma ion v This pre iu is subject to adjust at the end o the po icy per At that t me, you may recei e am m ment f l iod. i v request for for t the i a pre iu audi y contac you to re i the necessary records.in ma ion in ma l or m m tor ma t v ew The in r ion de eloped m f l earned pre iu f this pol .fo mat v is needed to deter ine the ina m m or icy Record Mai nancente In order to fac i audi ser ice it is necessary to mainta proper records and ha the a i atil tate t v , in ve m va lable the proper t me. Based on the nature o your business, some o the fo lowing data be necessary toi f f l will comp the audilete t: 1. General Ledger, inancia tateF l S ments 2. Payrol Records, T me Books, Sta Une men Returns, FICA Returns, Indi idua Earnl i te mploy t v l ings Records-Monthly tota f work and ov rt me.ls separated by type o e i 3. Cash Receipts, Sales Journal 4. Cash Disbursements Journal - Inc ing subcontractors. casual labor and terialud ma l costs. 5. Certi ica off tes Insurance IMP TANT VERAGE NO E:OR CO T I you ut ize subcontractors whose legal status is that of sole propr tner, we may charge pre iuf il ietor/par m m for these persons as prov under Part 5 o the pol contrac e en though certi i of insuranceided f icy t v f cates may e P contact your producer i you ha e any questions regarding your Wxist. lease f v orkers' Compensation co erage needs.v Work in her StatesOt Please ad ise your Producer i e loyees are hired f work in states other than those l in Ite 3. ov f mp or isted m f your pol Th wil enable your producer to consider your need for co erage in ac with stateicy. is l v cordance laws. W apprecia the opportun to ser you. I you ha e any questions about the enc policy or anye te ity ve f v losed insurance mat your Co veters please contact your producer or mpany representati . WUNN7F00 Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 37 of 52 ATTENTION The following Posting Notices must be displayed in a prominent location in the workplace. Please distribute these notices to the appropriate workplace locations. In the event that additional copies are desired, please contact your agent and request the number of copies of the particular notices that you may need. Posting notices for the states of MO, MN, NM and TX (Spanish Version) are provided in two separate forms which need to be connected to create one large notice to be posted. Please contact us at wcppn travelers.com for assistance in completing the healthcare provider information on posting notices in PA, GA, TN, and VA. WUNNNB13 PN T5 53 07 13 Page 1 of 1 Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 38 of 52 LE CR EO LE ’ MK WB , LL C DB A 18 13 5 EA ST PE TR OL EU M DR BA TO N RO UG E LA 70 80 9 TH E TR AV EL ER S IN SU RA NC E CO MP AN IE S P. O. BO X 61 12 4 NE W OR LE AN S, LA 70 16 1- 11 24 (8 00 ) 23 8- 62 25 W O R K ER S C O M PE N SA TI O N re po rt in g in ju ry A no tic e so gi ve n sh al ln ot be he ld in va lid Yo u sh ou ld re po rt to yo ur em pl oy er an y be ca us e of an y in ac cu ra cy in st at in g th e tim e, oc cu pa tio na ld is ea se or pe rs on al in ju ry th at is pl ac e, na tu re or ca us e of in ju ry ,o ro th er w is e, N ot ic e sh al lb e gi ve n by de liv er in g it or se nd in g w or k- re la te d, ev en if yo u de em it to be m in or . un le ss it is sh ow n th at th e em pl oy er w as in fa ct it by ce rti fie d m ai lo rr et ur n re ce ip tr eq ue st ed to : m is le d to hi s de tri m en tt he re by .F ai lu re to gi ve oc cu pa tio na ld is ea se or de at h Em pl oy er R ep re se nt at iv e no tic e m ay no th ar m th e em pl oy ee if th e in ca se of an oc cu pa tio na ld is ea se ,a ll cl ai m s ar e em pl oy er kn ew of th e ac ci de nt or if th e em pl oy er ba rre d un le ss th e em pl oy ee fil es a cl ai m w ith w as no tp re ju di ce d by th e de la y or fa ilu re to gi ve hi s/ he re m pl oy er w ith in on e ye ar of th e da te th at : no tic e. 1 th e di se as e m an ife st s its el f. ph ys ic ia ns 2 th e em pl oy ee is di sa bl ed as a re su lt of th e di se as e. In th e ev en ty ou ar e in ju re d, yo u ar e en tit le d to 3 th e em pl oy ee kn ow s or ha s re as on ab le gr ou nd s to se le ct a ph ys ic ia n of yo ur ch oi ce fo rt re at m en t. be lie ve th at th e di se as e is oc cu pa tio na lly re la te d. Th e em pl oy er m ay ch oo se an ot he rp hy si ci an an d In ca se of de at h ar is in g fro m an oc cu pa tio na l ar ra ng e an ex am in at io n w hi ch yo u w ou ld be di se as e, al lc la im s ar e ba rre d un le ss th e re qu ire d to at te nd . Em pl oy er de pe nd en t(s )f ile a cl ai m w ith th e de ce as ed fo rm al cl ai m em pl oy ee 's em pl oy er w ith in on e ye ar of : In or de rt o pr es er ve yo ur rig ht to be ne fit s un de r 1 th e da te of de at h. th e Lo ui si an a W or ke rs 'C om pe ns at io n La w ,y ou m us tf ile a fo rm al cl ai m w ith th e O ffi ce of 2 th e da te th e cl ai m an th as re as on ab le gr ou nd s to W or ke rs 'C om pe ns at io n Ad m in is tra tio n w ith in on e be lie ve th at th e de at h re su lte d fro m ye ar af te rt he ac ci de nt if pa ym en ts ha ve no tb ee n oc cu pa tio na ld is ea se . m ad e or w ith in on e ye ar af te rt he la st pa ym en to f fil in g no tic e be ne fit s. In ca se of in ju ry or de at h ca us ed by a w or k- re la te d In fo rm at io n ac ci de nt ,a n in ju re d em pl oy ee or an y pe rs on R .S .2 3: 13 02 st at es th at th is no tic e sh ou ld be If yo u de si re an y in fo rm at io n re ga rd in g yo ur rig ht s cl ai m in g to be en tit le d to co m pe ns at io n ei th er as a po st ed in a co nv en ie nt an d co ns pi cu ou s pl ac e in an d en tit le m en tt o be ne fit s as pr es cr ib ed by la w , cl ai m an to ra s a re pr es en ta tiv e of a pe rs on th e em pl oy er 's pl ac e of bu si ne ss .R ev is ed 05 -0 3 yo u m ay ca ll or w rit e to th e O ffi ce of W or ke rs ' cl ai m in g to be en tit le d to co m pe ns at io n, m us tg iv e C om pe ns at io n Ad m in is tra tio n, Po st O ffi ce B ox no tic e to th e em pl oy er w ith in 30 da ys of th e in ju ry . 94 04 0, Ba to n R ou ge ,L ou is ia na 70 80 4- 90 40 or LO U IS IA N A W O R K S If no tic e is no tg iv en w ith in 30 da ys ,n o pa ym en ts te le ph on e (2 25 )3 42 -7 55 5. D EP AR TM EN T O F LA BO R w ill be m ad e fo rs uc h in ju ry or de at h. In ad di tio n, w w w .L A W O R K S. ne t an y fra ud ul en ta ct io n by th e em pl oy er ,e m pl oy ee , N am e an d Ad dr es s of In su ra nc e C om pa ny or an y ot he rp er so n fo rt he pu rp os e of ob ta in in g or de fe at in g an y be ne fit or pa ym en to fw or ke rs ' co m pe ns at io n sh al ls ub je ct su ch pe rs on to cr im in al as w el la s ci vi ll ia bi lit ie s. Th e ab ov e m en tio ne d no tic e sh ou ld be fil ed w ith th e em pl oy er at th e ad dr es s sh ow n to th e rig ht . An Eq ua lO pp or tu ni ty Em pl oy er /P ro gr am .A ux ilia ry ai ds an d se rv ic es ar e av ai la bl e up on re qu es tt o in di vi du al s w ith di sa bi lit ie s. 1- 80 0- 25 9- 51 54 (T D D ) W 17 P 2I 03 Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 39 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 (IEUB-4003T36-8-13) LE CREOLE’ MKWB, LLC DBA 09-29-13 09-29-14 R 5893D0148 I I 5812 AB 0 2 R03 N 273278918 UNKNOWN LA IEUB * 9082 COMMISSION/INSTALLMENT SUMMARY ------------------------------ ACCT EFF GROSS COMM MO DATE AMT RATE 09-13 09/29/13 11784.00 .0880 TOTALS $ 11784.00 STATE PREDOMINANT COUNTY/TOWN INFORMATION ST PREDOMINANT ABBR. CNTY/TOWN CODE LA 0252 ELMIRA NY SRV CTR 700 TYNER JETER INS AGCY LLC X3865 NP 08-15-13 09-29-13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY OVERPRINT PAGE POLICY NUMBER: INSURED’S NAME: POLICY EFFECTIVE: POLICY EXPIRY: NEW/RENEWAL: SOLICITOR: SAI: RESPONSIBILITY: MSI: SIC CODE: PAYMODE/ DIRECT BILL CODE: AUDIT FREQUENCY: REINSURANCE: WATCH FILE: SURVEY CODE: NEG COMM: PROGRAM CODE: NBR OF POL IN SAI: AGENCY BILL: AMS BINDER #: PARENT FEIN: PKG POL NBR: STATE PREDOMINANT CLASS & SYMBOL (* indicates if selected as Policy predominant) ST POLICY ST ST POLICY ST ST SYMBOL PREDOM CLASS ST SYMBOL PREDOM CLASS OFFICE: PRODUCER: RATER: ISSUE DATE: CHANGE EFFECTIVE DATE: WUNT6H96 Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 40 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 (IEUB-4003T36-8-13) 09-29-13 12637 THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT LE CREOLE’ MKWB, LLC DBA 1097NIL NIL NIL A credit factor is added to the schedules for the following: STATE CREDIT FACTOR LA .1000 The Premium Discount Percent is amended as follows: STATE DISCOUNT % LA .20 The Insured’s Legal Nature is amended to read: State Location Legal Nature Code Code Description LA 001 10 Ltd Liabilty Co(LLC) The following endorsement is added: WC 89 06 14 (00)-001 OF LAST08-22-13 SS 001 001 09-29-13 09-29-14 ELMIRA NY SRV CTR 700 TYNER JETER INS AGCY LLC X3865 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CHANGE DOCUMENT WC 99 99 98 (00) POLICY NUMBER: CHANGE EFFECTIVE DATE: NCCI CO CODE: INSURER: INSURED'S NAME: This change is issued by that member of The Travelers Insurance Companies which issued the policy and forms a part of the policy. It is agreed that the policy is amended as follows: An absence of an entry in the premium spaces below means that the premium adjustment, if any, will be made at time of audit. $ADDITIONAL PREMIUM RETURN PREMIUM$ ADDITIONAL NON-PREMIUM RETURN NON-PREMIUM$ $ DATE OF ISSUE: CHANGE NO: PAGE POL. EXP. DATE:POL. EFF. DATE: OFFICE: PRODUCER: COUNTERSIGNED AGENT Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 41 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 001 (IEUB-4003T36-8-13) "See Change Document or Information Page Schedule" 08-22-13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 89 06 14 (00) POLICY NUMBER: POLICY INFORMATION PAGE ENDORSEMENT Item 3.D. Endorsement numbers is changed to read: ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. DATE OF ISSUE: ST ASSIGN: Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 42 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 (IEUB-4003T36-8-13) LE CREOLE’ MKWB, LLC DBA 09-29-13 09-29-14 R 5893D0148 I I 5812 AB 0 2 R03 N 273278918 UNKNOWN LA IEUB * THE INSTALLMENT SUMMARY BELOW REFLECTS THE ORIGINAL POLICY PREMIUM ASSOCIATED WITH THIS TRANSACTION THIS REPLACES ANY PREVIOUSLY RECEIVED SCHEDULES. YOUR NEXT BILL WILL REFLECT THESE CHANGES. ------------------------------------------------------------------------------ ACCT EFF GROSS COMM MO DATE AMT RATE 09-13 09/29/13 10687.00 .0880 TOTALS $ 10687.00 STATE PREDOMINANT COUNTY/TOWN INFORMATION ST PREDOMINANT ABBR. CNTY/TOWN CODE LA 0252 ELMIRA NY SRV CTR 700 TYNER JETER INS AGCY LLC X3865 SS 08-22-13 09-29-13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY OVERPRINT PAGE POLICY NUMBER: INSURED’S NAME: POLICY EFFECTIVE: POLICY EXPIRY: NEW/RENEWAL: SOLICITOR: SAI: RESPONSIBILITY: MSI: SIC CODE: PAYMODE/ DIRECT BILL CODE: AUDIT FREQUENCY: REINSURANCE: WATCH FILE: SURVEY CODE: NEG COMM: PROGRAM CODE: NBR OF POL IN SAI: AGENCY BILL: AMS BINDER #: PARENT FEIN: PKG POL NBR: STATE PREDOMINANT CLASS & SYMBOL (* indicates if selected as Policy predominant) ST POLICY ST ST POLICY ST ST SYMBOL PREDOM CLASS ST SYMBOL PREDOM CLASS OFFICE: PRODUCER: RATER: ISSUE DATE: CHANGE EFFECTIVE DATE: WUNT6H96 Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 43 of 52 LE CREOLE’ MKWB, LLC DBA 18135 EAST PETROLEUM DR BATON ROUGE LA 70809 (IEUB-4003T36-8-13) 09-29-13 11,453 170952960 -.10 +.00 +.00 +.00 +.00 -.10 WORKERS COMPENSATION SCHEDULE RATING WORKSHEET (LOUISIANA) ACCOUNT NAME AND ADDRESS POLICY NUMBER POLICY EFF. DATE LOSS CONTROL SURVEY COMPLETED DATE GRADE ESTIMATED ANNUAL PREMIUM BUREAU ID NUMBER ACCOUNT EXECUTIVE/UNDERWRITER RISK CHARACTERISTICS SCHEDULE RATING FACTOR RANGE PREMISES-CONDITION, CARE (+10% to -10%) REASON/BASIS RETURN TO WORK (+10% to -10%) REASON/BASIS COMMITMENT TO USE TELEPHONE REPORTING (+10% to -10%) REASON/BASIS SAFETY PROGRAM (+10% to -10%) REASON/BASIS EMPLOYEE SELECTION, TRAINING, SUPERVISION (+10% to -10%) REASON/BASIS TOTAL SCHEDULE RATING FACTOR W17K1G00 Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 44 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 (IEUB-4003T36-8-13) 09-29-13 12637 THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT LE CREOLE’ MKWB, LLC DBA 187NIL NIL NIL The following premium bases are amended to read: STATE OF LA LOCATION 001 01 ESTIMATED ANNUAL CLASSIFICATION CODE PREM. BASIS RATE PREMIUM CLERICAL OFFICE EMPLOYEES NOC (COUNTY/TOWN CODE 0252) 8810 5304 0.38 20 RESTAURANT NOC (COUNTY/TOWN CODE 0252) 9082 458913 2.57 11794 The Premium Discount Percent is amended as follows: STATE DISCOUNT % LA .00 The Terrorism charge has been amended as follows: STATE ESTIMATED PREMIUM LA 93 OF MORE09-18-13 RB 002 001 09-29-13 09-29-14 ELMIRA NY SRV CTR 700 TYNER JETER INS AGCY LLC X3865 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CHANGE DOCUMENT WC 99 99 98 (00) POLICY NUMBER: CHANGE EFFECTIVE DATE: NCCI CO CODE: INSURER: INSURED'S NAME: This change is issued by that member of The Travelers Insurance Companies which issued the policy and forms a part of the policy. It is agreed that the policy is amended as follows: An absence of an entry in the premium spaces below means that the premium adjustment, if any, will be made at time of audit. $ADDITIONAL PREMIUM RETURN PREMIUM$ ADDITIONAL NON-PREMIUM RETURN NON-PREMIUM$ $ DATE OF ISSUE: CHANGE NO: PAGE POL. EXP. DATE:POL. EFF. DATE: OFFICE: PRODUCER: COUNTERSIGNED AGENT Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 45 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 WC 99 99 98 00 (IEUB-4003T36-8-13) The CAT (other than Certified Acts of Terrorism) is amended as follows STATE ESTIMATED PREMIUM LA 93 The following endorsements are added: WC 89 06 14 (00)-002 WC 89 04 15 (00)-001 09-18-13 RB 002 002 OF LAST 09-29-13 09-29-14 ELMIRA NY SRV CTR 700 TYNER JETER INS AGCY LLC X3865 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CHANGE DOCUMENT POLICY NUMBER: DATE OF ISSUE: CHANGE NO.: PAGE: POL. EXP. DATE:POL. EFF. DATE: ST ASSIGN:OFFICE: PRODUCER: Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 46 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 001 (IEUB-4003T36-8-13) "See Change Document or Information Page Schedule" 09-18-13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 89 04 15 (00) POLICY NUMBER: POLICY INFORMATION PAGE ENDORSEMENT Item #4 is changed to the following: PREMIUM BASIS Total Estimated Rate Per Code Annual $100 of Estimated Classifications No. Remuneration Remuneration Annual Premium Total Estimated Annual Premium $ Minimum Premium $ Deposit Premium $ ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. DATE OF ISSUE: ST ASSIGN: Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 47 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 002 (IEUB-4003T36-8-13) "See Change Document or Information Page Schedule" 09-18-13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 89 06 14 (00) POLICY NUMBER: POLICY INFORMATION PAGE ENDORSEMENT Item 3.D. Endorsement numbers is changed to read: ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. DATE OF ISSUE: ST ASSIGN: Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 48 of 52 ONE TOWER SQUARE HARTFORD, CT 06183 (IEUB-4003T36-8-13) LE CREOLE’ MKWB, LLC DBA 09-29-13 09-29-14 R 5893D0148 I I 5812 AB 0 2 R03 N 273278918 UNKNOWN LA IEUB * THE INSTALLMENT SUMMARY BELOW REFLECTS THE ORIGINAL POLICY PREMIUM ASSOCIATED WITH THIS TRANSACTION THIS REPLACES ANY PREVIOUSLY RECEIVED SCHEDULES. YOUR NEXT BILL WILL REFLECT THESE CHANGES. ------------------------------------------------------------------------------ ACCT EFF GROSS COMM MO DATE AMT RATE 09-13 09/29/13 10500.00 .0880 TOTALS $ 10500.00 STATE PREDOMINANT COUNTY/TOWN INFORMATION ST PREDOMINANT ABBR. CNTY/TOWN CODE LA 0252 ELMIRA NY SRV CTR 700 TYNER JETER INS AGCY LLC X3865 RB 09-18-13 09-29-13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY OVERPRINT PAGE POLICY NUMBER: INSURED’S NAME: POLICY EFFECTIVE: POLICY EXPIRY: NEW/RENEWAL: SOLICITOR: SAI: RESPONSIBILITY: MSI: SIC CODE: PAYMODE/ DIRECT BILL CODE: AUDIT FREQUENCY: REINSURANCE: WATCH FILE: SURVEY CODE: NEG COMM: PROGRAM CODE: NBR OF POL IN SAI: AGENCY BILL: AMS BINDER #: PARENT FEIN: PKG POL NBR: STATE PREDOMINANT CLASS & SYMBOL (* indicates if selected as Policy predominant) ST POLICY ST ST POLICY ST ST SYMBOL PREDOM CLASS ST SYMBOL PREDOM CLASS OFFICE: PRODUCER: RATER: ISSUE DATE: CHANGE EFFECTIVE DATE: WUNT6H96 Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 49 of 52 TRAVELERS SERVICE CENTER DBS - 700 4003T368 UB 130929 P.O. BOX 1564 ELMIRA, NY 14902-1564 5893D0148 Page 1 of 3 700 MKWB,LLC DBA LE CREOLE' 18135 EAST PETROLEUM DR STE F&G BATON ROUGE LA 70809 Notice of Cancellation Account YOUR INSURANCE POLICY IS SUBJECT TO CANCELLATION. PLEASE SEE REVERSE SIDE FOR NOTICE OF CANCELLATION. CLDBNOC Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 50 of 52 (IEUB-4003T36-8-13) 07-01-14 LE CREOLE’ MKWB, LLC DBA 18135 EAST PETROLEUM DR BATON ROUGE LA 70809 INSUREDS REQUEST PLACED WITH ANOTHER CARRIER SHORT RATE SUBJECT TO AUDIT A THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT 273278918 LA 07-17-14 SV 09-29-13 09-29-14 ELMIRA NY SRV CTR 700 A TYNER JETER INS AGCY LLC X3865 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CANCELLATION CHANGE SLIP POLICY NUMBER: NAMED INSURED: EFFECTIVE DATE OF CANCELLATION: CANCELLATION REASON: CANCELLATION MODE: CANCELLATION METHOD: MODE OF ADJUSTMENT: INSURER: FEDERAL ID NUMBER: STATES ON POLICY: This document is issued only by the Company or Companies which issued this policy. DATE OF ISSUE: POL EFF DATE: POL EXP DATE: OFFICE: AUDIT: PRODUCER: WUNTFC01 Page 1 of 2 Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 51 of 52 (IEUB-4003T36-8-13) 07-17-14 SV 09-29-13 09-29-14 ELMIRA NY SRV CTR 700 A TYNER JETER INS AGCY LLC X3865 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CANCELLATION CHANGE SLIP POLICY NUMBER: FIGURED CANCELLATION CHANGE SLIP A/C MONTH RET.PREM COMM. ITEM DESCRIPTION TOTAL EARNED PREMIUM: TOTAL RETURN PREMIUM: PREMIUM FINANCED BY: DATE OF ISSUE: POL EFF DATE: POL EXP DATE: OFFICE: AUDIT: PRODUCER: WUNTFC01 Page 2 of 2 Case 2:16-cv-15461-SM-MBN Document 4-2 Filed 10/19/16 Page 52 of 52 4813-3468-4987 v1 2903119-000008 10/19/2016 UNITED STATES DISTRICT COURT EASTERN DISTRICT OF LOUISIANA SHANTEL SULLIVAN, individually and * on behalf of her minor child, * KYLE SULLIVAN, and on behalf of * the Decedent, JEREMY SULLIVAN * CIVIL ACTION NO. 216-cv-15461 * * Plaintiffs, * * VERSUS * JUDGE SUSIE MORGAN * TRAVELERS INDEMNITY COMPANY * OF CONNECTICUT, TRAVELERS * INDEMNITY COMPANY OF AMERICA, * and MICHELLE BROOME * * MAG. JUDGE MICHAEL NORTH Defendants. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * NOTICE OF SUBMISSION PLEASE TAKE NOTICE that undersigned counsel, on behalf of The Travelers Indemnity Company of America, has filed a 12(b)(6) Motion to Dismiss. Unless otherwise ordered by the Court, pursuant to Local Rule 7.2, the 12(b)(6) Motion to Dismiss will be submitted to the Honorable United States District Judge Susie Morgan, Eastern District of Louisiana, 500 Poydras Street, New Orleans, Louisiana 70130, on November 30, 2016, at 10:00 a.m. Case 2:16-cv-15461-SM-MBN Document 4-3 Filed 10/19/16 Page 1 of 2 2 4813-3468-4987 v1 2903119-000008 10/19/2016 Respectfully submitted, BAKER, DONELSON, BEARMAN, CALDWELL & BERKOWITZ, PC By: s/ William H. Howard III WILLIAM H. HOWARD III, T.A. (7025) ALISSA J. ALLISON (17880) 201 St. Charles Avenue, Suite 3600 New Orleans, LA 70170 Telephone: (504) 566-5275 Facsimile: (504) 636-3975 bhoward@bakerdonelson.com aallison@bakerdonelson.com COUNSEL FOR THE TRAVELERS INDEMNITY COMPANY OF AMERICA CERTIFICATE OF SERVICE I HEREBY CERTIFY that on the 19 th day of October 2016, a true and correct copy of the above and foregoing pleading was electronically filed with the Clerk of Court using the CM/ECF system, which will send notice of electronic filing to all counsel of record who have consented to electronic notification. /s/ William H. Howard III Case 2:16-cv-15461-SM-MBN Document 4-3 Filed 10/19/16 Page 2 of 2