AmTrust North America 800 Superior Ave. Cleveland, OH (844)

Transcription

1 AmTrust North America 800 Superior Ave. Cleveland, OH (844) DBL NON-PAYMENT CANCELLATION NOTICE Run Date: 3/13/2017 BROOKLYN, NY Re: NY Disability Benefits Law (DBL) Cancellation of Annually Billed Policies Policy/Entity # Dear Policyholder: Our records indicate we have not received 2017 advance annual premium for your policy and have cancelled NY DBL coverage effective 4/3/2017. We enclose the required Notice of Cancellation and duplicate invoice for each billed entity allowing an opportunity to pay the past due premium to have this mandated coverage reinstated. As required by Law, Wesco will send notification of the cancellation to the New York Workers Compensation Board (WCB), making you subject to penalties for non-compliance. In addition, if a DB Certificate of Insurance has been issued, it is no longer valid after the coverage cancellation date. To reinstate pay before 4/12/2017. If your company believes our records are incorrect, please contact DL.Amtrust@amtrustgroup.com or (844) In order to expedite our review, you may be asked to provide a copy of both sides of the cancelled check and completed invoice. We thank you for your cooperation and appreciate your business. Sincerely, Accounts Receivable

2 P.O. Box 94557, Cleveland, OH Fax (216) NEW YORK DISABILITY BENEFITS LAW INSURANCE ANNUAL PREMIUM NOTICE BILL DATE 3/13/2017 PREMIUM DUE DATE FINAL NOTICE - PAST DUE PREMIUM FOR THE PERIOD 1/1/ /31/2017 (12 months) This report covers employees under the Wesco Insurance Company DBL POLICY NUMBER(S) identified in the box at right. Policy Number: POLICY AND COVERAGE INFORMATION: Statutory Plan: % up to 170 Plan/Benefit: Class of Employees: ALL Add l Coverage: INSTRUCTIONS: SECTION 1 RECONCILIATION OF ADVANCE PREMIUM PAID FOR 2016 * Indicate the number of covered employees (males and females) for each month of Do the same for covered partners/proprietors. * Add the number of male employees and enter under TOTAL. Multiply by the monthly rate and enter the premium amount in A. Do the same in B and C, if applicable. * Add A+B+C and enter the amount in D. TOTAL 2016 RECONCILED PREMIUM is subject to the printed minimum premium amount. * The advance annual premium you previously paid for 2016 is printed in E. * Determine the 2016 PREMIUM ADJUSTMENT; D minus E. Enter the difference, if any, in F. This amount is your premium credit (-) or shortage (+) for SECTION 2 ADVANCE ANNUAL PREMIUM FOR 2017 * Indicate the current number of covered employees (males and females) in their respective boxes. * Multiply current number of males by the annual rate and then enter the premium amount in G. Do the same for females in H and I, if applicable. * Add G+H+I and enter the amount in J. This amount is your advance annual premium for The policy is subject to a minimum premium of *TOTAL PREMIUM DUE = J (PLUS/MINUS) F. NOTE: IF THERE ARE NO EMPLOYEES, IT SHOULD BE INDICATED ON THE FORM. MINIMUM PREMIUM IS REQUIRED TO KEEP THE POLICY IN FORCE. QUESTIONS? PLEASE CONTACT YOUR BROKER: EASTERN BROKERAGE INC. (212) TEAR OFF THE BOTTOM PORTION AND MAIL ALONG WITH YOUR CHECK PAYABLE TO AMTRUST NORTH AMERICA IN THE ENVELOPE PROVIDED. DETACH HERE DETACH HERE ANNUAL PREMIUM REPORT NEW YORK DISABILITY BENEFITS LAW INSURANCE POLICY NUMBER PREMIUM FOR THE PERIOD NUMBER OF EMPLOYEES EACH MONTH PREMIUM DUE DATE 1/1/ /31/2017 (12 months) SECTION 1 RECONCILIATION OF ADVANCE PREMIUM PAID FOR 2016 / Employee Class: All Full Time and Part Time, as defined in the NY Disabilty Benefits Law JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL MALES FEMALES PARTNERS/ PROPRIETORS TOTAL 2016 RECONCILED PREMIUM A + B + C (MINIMUM PREMIUM ) 2016 ADVANCE PREMIUM PAID = 2016 PREMIUM ADJUSTMENT D MINUS E = SECTION 2 ADVANCE ANNUAL PREMIUM FOR 2017 ANNUAL RATE CURRENT # OF MALES FROM DECEMBER X = X = CURRENT # OF FEMALES FROM DECEMBER CURRENT # OF PARTNERS/PROPRIETORS FROM DECEMBER X N/A = 2017 premium due G + H + I (minimum premium ) = IT IS CERTIFIED THAT INFORMATION HEREIN IS CORRECT Tel.No. MONTHLY RATE X 1.65 = X 3.75 = X N/A = P.O. Box Cleveland, OH Signature FINAL NOTICE - PAST DUE Date TOTAL PREMIUM DUE J PLUS F = PREMIUM DUE N/A PREMIUM DUE N/A A B C D E F G H I J

3 Please make checks payable to Express or Overnight Mail: 800 Superior Avenue E Cleveland, OH 44114

4 S Step 1 Instructions: Annual Invoice for Disability Benefits Step 1 (Section 1) Step 1 gives a view to the total number of employees each month listed in three categories: Males, Females, & Partners/Proprietors. Fill in your actuals for each month of T Step 2 E Step 3 P Step 4 S Step 2 (Section 1) Step 2 is where you will calculate the premium due (based on actuals) for 2016: Write in your totals for each employee category The assigned monthly rate will be prepopulated Multiply to get the premium due for each employee Category (A, B, & C) Total Premium Due (D) = A+B+C Step 3 (Section 1) Step 3 is the reconciliation of what you paid in advance for 2016, and what was actually due. The premium adjustment ( F ) is the difference between what was paid ( E ) and what is due ( D ); this is the amount you owe (or are credited for) for 2016 and will be added or subtracted from your 2017 premium in section 2. Step 4 (Section 2) Step 4 is where you will calculate the premium to be paid with this invoice Bring the December employee type counts down from Step 1 & multiply by the Annual rate (pre-populated), this will give your total for G, H, & I. J is the total of the 2017 estimates (add G+H+I) TOTAL PREMIUM DUE = J (2017 estimate) + F adjustment from 2016.

5 STATE OF NEW YORK WORKERS COMPENSATION BOARD DISABILITY BENEFITS LAW CERTIFICATE/CANCELLATION OF INSURANCE Filed on behalf of Employer in compliance with Article 9 of the Workers Compensation Law Transaction Initial Cancellation Reinstatement Supersedes Effective Date 4/3/2017 A. INSURER/CARRIER Wesco Insurance Company 800 Plaza Two, 8th Floor, Jersey City, NJ B (800) INSURER/CARRIER NAME 2. INSURER/CARRIER CODE 3. INSURER/CARRIER TELEPHONE NO. 4. CONTACT NAME 5. TITLE 6. TODAY S DATE Lydia De La Rosa-Pena Associate VP 3/13/2017 B. CURRENT EMPLOYER INFORMATION 7. WCB EMPLOYER NUMBER 8. NYS UIER NUMBER 9. EMPLOYER FEIN EMPLOYER S LEGAL NAME, INCLUDING (DBA/AKA/TA) 13. LEGAL STATUS (SEE BACK OF FORM) 99 - Other ADDRESS 14. # OF EMPLOYEES CITY STATE ZIP CODE 15. TELEPHONE NO. C. POLICY *If policyholder is an Association, Union or Trustee for which Form DB is filed, do not complete item POLICY NUMBER* 17. POLICY EFFECTIVE DATE 18. POLICY FORM NUMBER* /23/2008 AH990118NY 19. WCB PLAN NUMBER (Only for Assoc., Union or Trustee with Form DB 801 on file) 20. PREMIUM AMOUNT D. REASONS FOR CANCELLATION Other To reinstate coverage, payment must be received by 4/12/2017 Non Payment of Premium Not Subject/No Eligible Employees Date: Out of Business Date: CANCELLATION OR TERMINATION Seasonal Date: SENT TO EMPLOYER: Date: 3/13/2017 E. Complete if SUPERSEDES box is checked at top of form F. POLICYHOLDER If different from Employer 21. EMPLOYER S LEGAL NAME, INCLUDING (DBA/AKA/TA) 27. POLICYHOLDER NAME 22. ADDRESS 28. POLICYHOLDER ADDRESS 23. CITY STATE ZIP CODE 29. CITY STATE ZIP CODE 24. EMPLOYER FEIN 25. POLICY EFFECTIVE DATE 30. POLICYHOLDER FEIN 26. POLICY NUMBER G. 1. The policy covers Employer s employees as follows: a. All employees eligible under the New York State Disability Benefits Law. b. All employees eligible under the New York State Disability Benefits Law except those classes of employees eligible to receive benefits under another policy or plan accepted by the Chair. c. Only the following class or classes of employees: 2. The employee contributions required and benefits insured are: a. The same in all respects as under Section 204 and not in excess of those authorized under Section 209. b. As described in the attached supplement, Form DB c. As described in Employer s Application for Acceptance of a Plan, Form DB800, filed with and accepted by the Chair. d. As described in Certificate of Insurance, Form DB820.3, filed on behalf of the Association, Union or Trustees (policyholders) on or amended form DB820.3 filed thereafter. DATE To be filed by Insurance Carrier on behalf of Employer to provide, through insurance, exactly statutory benefits, (Section 204) OR benefits under a plan accepted by the Chairman. THE WORKERS COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION DB 820/829 (5 07)