2021-22 Workers Comp CoverageDeclarations – Workers’ Compensation Coverage
2021-22 Workers’ Compensation Coverage Documents Page:1 of 3 Tel 800.537.7790
Special District Risk Management Authority Fax 916.231.4111
Rev. 07/1/2021 www.sdrma.org
MEMBER COVERED:Costa Mesa Sanitary District
290 Paularino Avenue
Costa Mesa, California 92626
Your District/Agency/City has elected to participate in the workers'
compensation coverage and employer liability coverage program
described below as “THE PACKAGE PROGRAM” and in such other
programs as are indicated herein. These DECLARATIONS together with
(1) the Workers’ Compensation and Employers Liability Coverage
Agreement attached as Exhibit I, (2) the terms and conditions of the
Public Risk Innovation, Solutions, and Management (“PRISM”) Excess
Workers’ Compensation Program Core Tower Memorandum of
Coverage Declarations, Excess Workers Compensation Program
Memorandum of Coverage and endorsements attached thereto are
attached as Exhibit J, and (3) the terms and conditions of the Sixth
Amended and Restated Joint Powers Agreement and Bylaws, or
successor documents thereto, constitute the entire agreement
concerning risk-financing coverage between the Special District Risk
Management Authority and your District/Agency/City.
Please read the Sixth Amended and Restated Joint Powers Agreement
and Bylaws of the Special District Risk Management Authority
(hereinafter “SDRMA”), or successor documents thereto, together
with the Workers’ Compensation and Employers Liability Coverage
Agreement and the PRISM Memorandum of Coverage attached as
Exhibits I and J to ascertain all of your District's/Agency's/City’s rights
and obligations regarding its relationship with the Special District Risk
Management Authority.
COVERAGE PERIOD: July 1, 2021 at 12:01 a.m. to July 1, 2022 at 12:01 a.m.
STATE California
COVERAGE(S)SDRMA will pay those sums sustained by the “Covered Party” because
of liability imposed upon the “Covered Party” by:
A.The “Workers’ Compensation Act” of California or the
Workers’ Compensation Act of any state other than California,
provided that California is the injured employee’s normal state
of employment or residence; or
B.“Employers’ Liability”;
on account of “Bodily Injury” or “Occupational Disease” sustained by
an “Employee” of the “Covered Party”, while engaged in operations of
the “Covered Party”, as a result of an “Occurrence”, taking place
Declarations – Workers’ Compensation Coverage
2021-22 Workers’ Compensation Coverage Documents Page:2 of 3 Tel 800.537.7790
Special District Risk Management Authority Fax 916.231.4111
Rev. 07/1/2021 www.sdrma.org
during the “Coverage Period” and while the Workers’ Compensation
and Employers Liability Coverage Agreement is in force.
The “Loss” will be paid, subject to the terms, conditions, deductibles
and exclusions as provided in the Workers’ Compensation and
Employers Liability Coverage Agreement attached as Exhibit I, and
subject further to the terms, conditions and exclusions of the PRISM
Memorandum of Coverage attached as Exhibit J.
The indemnity afforded by the Workers’ Compensation and Employers
Liability Coverage Agreement Coverage B “Employers Liability” and
the PRISM agreement providing coverage under Coverage Agreement
I.B. for “Loss” because of liability imposed for “Employers’ Liability”
apply only as a result of Occurrences taking place during the coverage
period on account of “Bodily Injury” or “Occupational Disease”
sustained by “Employees” of the “Covered Party” who are regularly
engaged in such operations in California but who may be temporarily
outside of California in connection with such operations.
As respects liability imposed by “Employers Liability”, SDRMA shall
have no obligation to indemnify the “Covered Party” for damages
imposed in any lawsuit brought in, or any judgment rendered by, any
court outside of the United States of America, its territories or
possessions, or Canada, or to any action on such judgment wherever
brought.
EXCLUSIONS Please refer to the exclusions as per the terms of the attached Exhibits
I and J.
RETENTION AND INDEMNITY
“Employers Liability”$5,000,000 Annual Aggregate shared by all SDRMA Covered Parties
combined due to an “Occurrence”, as a result of “Employers Liability”,
subject to a deductible of «Deduct».
Workers’ Compensation An “Occurrence” arising out of Workers’ Compensation, is subject to
statutory limits, and subject to a deductible of «Deduct».
This information is provided as a general description only, and is not intended to supersede specific
policy documents. In the event of a conflict in language, the policy(ies) will be the controlling document.
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