TECHNOLOGY INSURANCE COMPANY, INC.
59 Maiden Lane, 43rd Floor
New York, NY 10038
WORKERS' COMPENSATION
and
EMPLOYERS’ LIABILITY INSURANCE POLICY
In Witness Whereof, we have caused this policy to be executed and attested, and, if
required by state law, this policy shall not be valid unless countersigned by our
authorized representative.
Stephen Ungar, Secretary
Christopher H. Foy, President
To obtain information, please contact your agent or Technology Insurance Company, Inc.
at 877-528-7878. You may also write Technology Insurance Company, Inc. Consumer
Relations at:
800 Superior Avenue East, 21st Floor
Cleveland, OH 44114
WC 99 00 00 A
24/7 Toll Free Claim Reporting for All States
Information Required for All Claims Reported
(888)239-3909
WorkersCompClaimReport@AmTrustgroup.com
www.amtrustfinancial.com
© 2023, AmTrust Financial Services, Inc.
877.528.7878 I www.amtrustfinancial.com
This material is for informational purposes only and is not legal or business advice. Neither AmTrust Financial Services, Inc. nor any of its subsidiaries or affiliates
represents or warrants that the information contained herein is appropriate or suitable for any specific business or legal purpose. Readers seeking resolution of
specific questions should consult their business and/or legal advisors. Coverages may vary by location. Contact your local RSM for more information.
MKT6310 06/23
Timely Reporting
When a work-related injury occurs, it is important to act immediately. Timely reporting of a new claim helps to provide a smooth and
successful claim process for both you and your injured worker.
We’re Here To Help
After your claim has been filed, we may be in touch to obtain additional
information. Our goal is to offer a smooth and hassle-free experience – from
your first contact to the claims conclusion. Feel free to also call us with any
questions. We’re here to help.
Relax And Stay Positive
You have the assurance of our knowledge,
expertise, and understanding of the claim
process. We’re with you all the way.
1.
Name of the insured and policy number
2.
Name and contact information of injured worker
3.
Date, time and place of accident
4.
Description of accident or incident
5.
Name, phone, and/or email of person making the report
6.
Any information on the injured workers lost time
Workers’ Compensation
Claim Reporting Information
How do I help my injured worker find a doctor?
• We offer an online physician search for all states, www.talispoint.com/amtrust/external
•
For California, www-lv.talispoint.com/amtrust/campn
•
For CO, GA, PA & TN, please refer to the panel provided by AmTrust via mail or email
How does my injured employee receive prescription medications related to the accident/injury?
•
Refer to the claims kit for your state at www.talispoint.com/amtrust/external for a First Fill card for
your injured employee to use at the pharmacy to cover the cost of approved medication.
Early claim reporting is essential to a better claim outcome. Don’t delay reporting if you do not have all
the details.
AmTrust Claims Kit
FAQs
© 2022, AmTrust Financial Services, Inc.
59 Maiden Lane, New York, NY 10038 I 877.528.7878 I www.amtrustfinancial.com
AmTrust is AmTrust Financial Services, Inc., located at 59 Maiden Lane, New York, NY 10038. Coverages are provided by its affiliated property and casualty insurance companies. Consult the applicable policy for specific terms,
conditions, limits and exclusions to coverage. For full legal disclaimer information, including Texas and Washington writing companies, visit: www.amtrustfinancial.com/about-us/legal-disclaimer.
MKT5948 02/22
Thank you for placing your Workers’ Compensation Coverage with AmTrust. For your
convenience, we now offer electronic versions of our Claims Kits. Please see the instructions
and FAQs below for more information.
I have a question about a claim or injured worker, who do I contact?
Customer Service can direct you to the appropriate person. Please contact them at 888-239-3909.
Where’s my claims kit?
All the States’ Claims Kits are online for insured to download which contains all the necessary WC notices. Visit the Talispoint Direct Link
at www.talispoint.com/amtrust/external/
• Click State Rules/Kits, choose corresponding state and open the PDF link to view and print.
I have an injured worker, how do I find a doctor?
We will provide completed Panel of Physicians for the 4 states that require a panel to be posted (CO, GA, PA & TN). We offer our online
physician search for all other states.
There are 3 ways to access this information:
1. Visit the Talispoint Direct Link at www.talispoint.com/amtrust/external/
2. California MPN: www.talispoint.com/amtrust/campn/
3. Visit the AmTrust Financial Website at www.amtrustfinancial.com
• Click Claims
• Click Provider Directory or California MPN under “Find a Provider”
• State specific laws for directing medical treatment are listed on the State Rules Tab
• Search for physicians by Name, Address or Region
Where are my posting notices?
All states claim kits are available online, including applicable postings. There are 4 states (CO, CT, FL & MD) we cannot place online. For
these states, we will mail additional posting notices to the main address on the policy.
I have a question about my claims kit, posting notice, panel or accessing the
website’s physician searches, who do I contact?
You may send an email to clientservices@amtrustgroup.com. Please make sure to include your policy number along with your request.

800 Superior Avenue E • 21st Floor • Cleveland, OH 44114
(p) 866.203.3037 • (f) 800.487.9654 • www.amtrustnorthamerica.com
February XX, 2017


Dear Policyholder,

In an effort to provide AmTrust customers with a variety of billing options, the below fee structure
will be applied to your new policy.

This fee structure helps customers to meet payment due dates, ensures that valid and properly
funded payments are submitted, and provides an incentive for paid-in-full options.

Our fee structure is as follows:

Fee Title
Fee Amount Description
Returned Payment Fee
$25
A returned payment fee applied to any returned payment.
Late Fee
$20
Late fee applied if payment not received on or before
payment due date.
Installment Fee
$15
A “paper” billing fee that is assessed for each mailed
installment invoice. Excludes down payment and annual
payment plans. Fee is billed at the account level.
Reinstatement Fee
$50
Fee applied upon reinstatement of a non-payment
cancellation.
EFT Fee
$3
An “electronic” billing fee that is assessed for each ACH
Direct Debit transaction. Fee is billed at the account level.
*Fee amount may vary by state and program of business

For policyholders who choose to pay their annual premium on installments, we plan to implement
an installment fee, which will be displayed on your renewal invoice.

Thank you for your attention. If you have any questions, feel free to contact our Customer Service
Department at 877.528.7878.

We value you as a policyholder and appreciate the opportunity to serve you.

Sincerely,

AmTrust North America
Customer Service Department


Technology Insurance Company, Inc.
A Stock Insurance Company
WORKERS COMPENSATION
WC 99 00 01 B
AND EMPLOYERS LIABILITY
1 of 5
INSURANCE POLICY
INFORMATION PAGE
Ncci Code: 39071
1.
Insured:
Driftwood Sands Condominium Association Inc
7300 Park St
Seminole, FL 33777
Other workplaces not shown above:
None
Producer:
Foundation Risk Partners, Corp. dba Acentria Ins.
4634 Gulfstar Drive
Destin, FL 32541
Policy Number: TWC4509682
Individual
Partnership
X Corporation or
Federal Tax ID:
592211151
Risk Id:
Renewal of:
New
2.
The policy period is from 10/1/2024 to 10/1/2025 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 states listed here: Florida
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:
State
Bodily Injury by Accident
Bodily Injury by Disease
Bodily Injury by Disease
$500,000 each accident
$500,000 policy limit
$500,000 each employee
C.
Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
All states except ND, OH, WA, WY and State(s) Designated in Item 3.A
D.
This policy includes these endorsements and schedules: See Extension of Information Page
4.
The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All information required below is subject to verification and change by audit.
See Extension of Information Page
TOTAL ESTIMATED ANNUAL PREMIUM
2,123
STATE ASSESSMENT
0
TOTAL ESTIMATED COST
2,123
Minimum Premium
509
Deposit Premium
215
Issue Date: 9/30/2024
Countersigned by:
Authorized Representative
Technology Insurance Company, Inc.
WC 99 00 01 B
2 of 5
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE
POLICY
INFORMATION PAGE
Insured: Driftwood Sands Condominium Association Inc
Policy Number: TWC4509682
EXTENSION OF INFORMATION PAGE FOR ITEM #1
ITEM 1: NAMED INSURED and WORKPLACES
NAMED INSURED:
Driftwood Sands Condominium Association
Inc
Fein: 592211151
WORKPLACES:
Location Number 1.
2618 Gulf Blvd
Indian Rocks Beach, FL 33785


Technology Insurance Company, Inc.
WC 99 00 01 B
3 of 5
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE
POLICY
INFORMATION PAGE
Insured: Driftwood Sands Condominium Association Inc
Policy Number: TWC4509682
EXTENSION OF INFORMATION PAGE FOR ITEM #3.D
ITEM 3.D: ENDORSEMENT SCHEDULE
State
Form Number
Description
WC990001B
DECLARATIONS PAGE
WC000000C
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC000308
PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT
WC000311A
VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE
WC000404
PENDING RATE CHANGE ENDORSEMENT
WC000406A
PREMIUM DISCOUNT ENDORSEMENT
WC000414A
NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT
FL
WC090303
FLORIDA EMPLOYERS LIABILITY COVERAGE ENDORSEMENT
FL
WC090402A
FLORIDA EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT
FL
WC090403C
FLORIDA TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT
ENDORSEMENT
FL
WC090407A
FLORIDA NON-COOPERATION WITH PREMIUM AUDIT ENDORSEMENT
FL
WC090408A
FLORIDA INSUFFICIENT FUNDS ENDORSEMENT
FL
WC090409
PREMIUM DUE DATE ENDORSEMENT
FL
WC090606
FLORIDA EMPLOYMENT AND WAGE INFORMATION RELEASE ENDORSEMENT
FL
WC090609
FLORIDA CANCELLATION AND NONRENEWAL ENDORSEMENT
Technology Insurance Company, Inc.
WC 99 00 01 B
4 of 5
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE
POLICY
INFORMATION PAGE
Insured: Driftwood Sands Condominium Association Inc
Policy Number: TWC4509682
EXTENSION OF INFORMATION PAGE FOR ITEM #4
ITEM 4: SCHEDULE OF PREMIUMS
Classifications
# of
Emps
Code
No.
Premium Basis
Total Estimated
Annual
Remuneration
Rate Per
$100 of
Remun.
Estimated
Annual
Premium
Florida
Buildings—Operation by Owner, Lessee or
Real Estate Management Firm: All Other
Employees
1
9015
68,640
2.74
1,881
Manual Premium
1,881
Total Manual Premium
1,881
Premium for Increased Limits Part Two: 1.1%
(500/500/500)
9807
21
Premium to Equal Increased Limits Minimum Charge
9848
54
Total Premium Subject To Experience Modification
1,956
Experience Modification N/A
1,956
Terrorism Risk Insurance Act 1%
9740
7
Expense Constant
0900
160
Total FL Premium
2,123
Total FL Cost
2,123
TOTAL ESTIMATED ANNUAL PREMIUM
2,123
STATE ASSESSMENT
0
TOTAL COST
2,123
Technology Insurance Company, Inc.
WC 99 00 01 B
5 of 5
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE
POLICY
INFORMATION PAGE
Insured: Driftwood Sands Condominium Association Inc
Policy Number: TWC4509682
PAYMENT SCHEDULE
Printed: 9/30/2024
Statement
Closing Date
Payment
Due Date
Description
Amount Due
10/16/2024
Downpayment
$215.00
12/1/2024
Installment 1 of 9
$212.00
1/1/2025
Installment 2 of 9
$212.00
2/1/2025
Installment 3 of 9
$212.00
3/1/2025
Installment 4 of 9
$212.00
4/1/2025
Installment 5 of 9
$212.00
5/1/2025
Installment 6 of 9
$212.00
6/1/2025
Installment 7 of 9
$212.00
7/1/2025
Installment 8 of 9
$212.00
8/1/2025
Installment 9 of 9
$212.00
Total Cost $2,123.00
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 00 00 00 C





(Ed. 1-15)
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
This policy includes at its effective date the Infor-
mation Page and all endorsements and schedules
listed there. It is a contract of insurance between
you (the employer named in Item 1 of the Infor-
mation Page) and us (the insurer named on the In-
formation Page). The only agreements relating to
this insurance are stated in this policy. The terms of
this policy may not be changed or waived except
by endorsement issued by us to be part of this
policy.

B. Who is Insured
You are insured if you are an employer named in
Item 1 of the Information Page. If that employer is a
partnership, and if you are one of its partners, you
are insured, but only in your capacity as an em-
ployer of the partnership’s employees.

C. Workers Compensation Law
Workers Compensation Law means the workers or
workmen’s compensation law and occupational
disease law of each state or territory named in Item
3.A. of the Information Page. It includes any
amendments to that law which are in effect during
the policy period. It does not include any federal
workers or workmen’s compensation law, any fed-
eral occupational disease law or the provisions of
any law that provide nonoccupational disability
benefits.

D. State
State means any state of the United States of
America, and the District of Columbia.

E. Locations
This policy covers all of your workplaces listed in
Items 1 or 4 of the Information Page; and it covers
all other workplaces in Item 3.A. states unless you
have other insurance or are self-insured for such
workplaces.

PART ONE
WORKERS COMPENSATION INSURANCE
A. How This Insurance Applies
This workers compensation insurance applies to
bodily injury by accident or bodily injury by disease.
Bodily injury includes resulting death.

1. Bodily injury by accident must occur during the
policy period.

2. Bodily injury by disease must be caused or ag-
gravated by the conditions of your employment.
The employee’s last day of last exposure to the
conditions causing or aggravating such bodily in-
jury by disease must occur during the policy
period.



B. We Will Pay
We will pay promptly when due the benefits required
of you by the workers compensation law.


C. We Will Defend
We have the right and duty to defend at our expense
any claim, proceeding or suit against you for benefits
payable by this insurance. We have the right to in-
vestigate and settle these claims, proceedings or
suits.
We have no duty to defend a claim, proceeding or
suit that is not covered by this insurance.


D. We Will Also Pay
We will also pay these costs, in addition to other
amounts payable under this insurance, as part of
any claim, proceeding or suit we defend:

1. reasonable expenses incurred at our request,
but not loss of earnings;

2. premiums for bonds to release attachments and
for appeal bonds in bond amounts up to the
amount payable under this insurance;

3.
litigation costs taxed against you;

4.
interest on a judgment as required by law until
we offer the amount due under this insurance;
and

5. expenses we incur.



E. Other Insurance
We will not pay more than our share of benefits and
costs covered by this insurance and other





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 Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.
WC 00 00 00 C
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY



(Ed. 1-15)



insurance or self-insurance. Subject to any limits of
liability that may apply, all shares will be equal until
the loss is paid. If any insurance or self-insurance
is exhausted, the shares of all remaining insurance
will be equal until the loss is paid.

F. Payments You Must Make

You are responsible for any payments in excess of
the benefits regularly provided by the workers
compensation law including those required
because:

1. of your serious and willful misconduct;

2. you knowingly employ an employee in violation
of law;

3. you fail to comply with a health or safety law or
regulation; or

4. you discharge, coerce or otherwise discriminate
against any employee in violation of the workers
compensation law.

If we make any payments in excess of the benefits
regularly provided by the workers compensation
law on your behalf, you will reimburse us promptly.


G. Recovery From Others

We have your rights, and the rights of persons enti-
tled to the benefits of this insurance, to recover our
payments from anyone liable for the injury. You will
do everything necessary to protect those rights for
us and to help us enforce them.


H. Statutory Provisions

These statements apply where they are required by
law.

1. As between an injured worker and us, we have
notice of the injury when you have notice.

2. Your default or the bankruptcy or insolvency of
you or your estate will not relieve us of our du-
ties under this insurance after an injury occurs.

3. We are directly and primarily liable to any per-
son entitled to the benefits payable by this in-
surance. Those persons may enforce our duties;
so may an agency authorized by law. Enforce-
ment may be against us or against you and us.

4. Jurisdiction over you is jurisdiction over us for
purposes of the workers compensation law. We
are bound by decisions against you under that
law, subject to the provisions of this policy that
are not in conflict with that law.

5. This insurance conforms to the parts of the




workers compensation law that apply to:


a. benefits payable by this insurance;


b. special taxes, payments into security or oth-
er special funds, and assessments payable
by us under that law.

6. Terms of this insurance that conflict with the
workers compensation law are changed by this
statement to conform to that law.

Nothing in these paragraphs relieves you of your du-
ties under this policy.
PART TWO
EMPLOYERS LIABILITY INSURANCE
A. How This Insurance Applies

This employers liability insurance applies to bodily
injury by accident or bodily injury by disease. Bodily
injury includes resulting death.

1. The bodily injury must arise out of and in the
course of the injured employee’s employment by
you.

2. The employment must be necessary or inci-
dental to your work in a state or territory listed in
Item 3.A. of the Information Page.

3. Bodily injury by accident must occur during the
policy period.

4. Bodily injury by disease must be caused or ag-
gravated by the conditions of your employment.
The employee’s last day of last exposure to the
conditions causing or aggravating such bodily in-
jury by disease must occur during the policy
period.

5.
If you are sued, the original suit and any related
legal actions for damages for bodily injury by ac-
cident or by disease must be brought in the
United States of America, its territories or pos-
sessions, or Canada.



B. We Will Pay

We will pay all sums that you legally must pay as
damages because of bodily injury to your employ-
ees, provided the bodily injury is covered by this
Employers Liability Insurance.

The damages we will pay, where recovery is permit-
ted by law, include damages:

1. For which you are liable to a third party by rea-
son of a claim or suit against you by that third
party to recover the damages claimed against


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 Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 00 00 00 C





(Ed. 1-15)


such third party as a result of injury to your em-
ployee;

2. For care and loss of services; and

3. For consequential bodily injury to a spouse,
child, parent, brother or sister of the injured em-
ployee; provided that these damages are the di-
rect consequence of bodily injury that arises out
of and in the course of the injured employee’s
employment by you; and

4. Because of bodily injury to your employee that
arises out of and in the course of employment,
claimed against you in a capacity other than as
employer.



C. Exclusions

This insurance does not cover:

1. Liability assumed under a contract. This exclu-
sion does not apply to a warranty that your work
will be done in a workmanlike manner;

2. Punitive or exemplary damages because of bodi-
ly injury to an employee employed in violation of
law;

3. Bodily injury to an employee while employed in
violation of law with your actual knowledge or the
actual knowledge of any of your executive offic-
ers;

4. Any obligation imposed by a workers compensa-
tion, occupational disease, unemployment com-
pensation, or disability benefits law, or any simi-
lar law;

5. Bodily injury intentionally caused or aggravated
by you;

6. Bodily injury occurring outside the United States
of America, its territories or possessions, and
Canada. This exclusion does not apply to bodily
injury to a citizen or resident of the United States
of America or Canada who is temporarily outside
these countries;

7. Damages arising out of coercion, criticism, de-
motion, evaluation, reassignment, discipline,
defamation, harassment, humiliation, discrimina-
tion against or termination of any employee, or
any personnel practices, policies, acts or omis-
sions;

8. Bodily injury to any person in work subject to the
Longshore and Harbor Workers’ Compensation
Act (33 U.S.C. Sections 901 et seq.), the Nonap-
propriated Fund Instrumentalities Act (5 U.S.C.
Sections 8171 et seq.), the Outer Continental
Shelf Lands Act (43 U.S.C. Sections 1331 et
seq.), the Defense Base Act (42 U.S.C. Sections
1651–1654), the Federal Mine Safety and Health
Act (30 U.S.C. Sections 801 et seq. and 901–
944), any other federal workers or workmen’s
compensation law or other federal occupational
disease law, or any amendments to these laws;

9. Bodily injury to any person in work subject to the
Federal Employers’ Liability Act (45 U.S.C. Sec-
tions 51 et seq.), any other federal laws obligat-
ing an employer to pay damages to an employee
due to bodily injury arising out of or in the course
of employment, or any amendments to those
laws;

10. Bodily injury to a master or member of the crew
of any vessel, and does not cover punitive dam-
ages related to your duty or obligation to provide
transportation, wages, maintenance, and cure
under any applicable maritime law;

11. Fines or penalties imposed for violation of federal
or state law; and

12. Damages payable under the Migrant and Sea-
sonal Agricultural Worker Protection Act (29
U.S.C. Sections 1801 et seq.) and under any
other federal law awarding damages for violation
of those laws or regulations issued thereunder,
and any amendments to those laws.



D. We Will Defend

We have the right and duty to defend, at our ex-
pense, any claim, proceeding or suit against you for
damages payable by this insurance. We have the
right to investigate and settle these claims, proceed-
ings and suits.

We have no duty to defend a claim, proceeding or
suit that is not covered by this insurance. We have
no duty to defend or continue defending after we
have paid our applicable limit of liability under this
insurance.


E. We Will Also Pay

We will also pay these costs, in addition to other
amounts payable under this insurance, as part of
any claim, proceeding, or suit we defend:

1. Reasonable expenses incurred at our request,
but not loss of earnings;

2. Premiums for bonds to release attachments and
for appeal bonds in bond amounts up to the limit
of our liability under this insurance;

3. Litigation costs taxed against you;

4. Interest on a judgment as required by law until
we offer the amount due under this insurance;
and

5. Expenses we incur.


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 Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.
WC 00 00 00 C
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY



(Ed. 1-15)


F. Other Insurance

We will not pay more than our share of damages
and costs covered by this insurance and other in-
surance or self-insurance. Subject to any limits of li-
ability that apply, all shares will be equal until the
loss is paid. If any insurance or self-insurance is ex-
hausted, the shares of all remaining insurance and
self-insurance will be equal until the loss is paid.


G. Limits of Liability

Our liability to pay for damages is limited. Our limits
of liability are shown in Item 3.B. of the Information
Page. They apply as explained below.

1. Bodily Injury by Accident. The limit shown for
“bodily injury by accident—each accident” is the
most we will pay for all damages covered by this
insurance because of bodily injury to one or
more employees in any one accident.
A disease is not bodily injury by accident unless
it results directly from bodily injury by accident.

2. Bodily Injury by Disease. The limit shown for
“bodily injury by disease—policy limit” is the
most we will pay for all damages covered by this
insurance and arising out of bodily injury by dis-
ease, regardless of the number of employees
who sustain bodily injury by disease. The limit
shown for “bodily injury by disease—each em-
ployee” is the most we will pay for all damages
because of bodily injury by disease to any one
employee.


Bodily injury by disease does not include dis-
ease that results directly from a bodily injury by
accident.

3. We will not pay any claims for damages after we
have paid the applicable limit of our liability un-
der this insurance.



H. Recovery From Others

We have your rights to recover our payment from
anyone liable for an injury covered by this insurance.
You will do everything necessary to protect those
rights for us and to help us enforce them.


I. Actions Against Us

There will be no right of action against us under this
insurance unless:

1. You have complied with all the terms of this poli-
cy; and


2. The amount you owe has been determined with
our consent or by actual trial and final judgment.

This insurance does not give anyone the right to add
us as a defendant in an action against you to deter-
mine your liability. The bankruptcy or insolvency of
you or your estate will not relieve us of our obliga-
tions under this Part.
PART THREE
OTHER STATES INSURANCE
A. How This Insurance Applies

1. This other states insurance applies only if one or
more states are shown in Item 3.C. of the Infor-
mation Page.

2.
If you begin work in any one of those states after
the effective date of this policy and are not in-
sured or are not self-insured for such work, all
provisions of the policy will apply as though that
state were listed in Item 3.A. of the Information
Page.

3. We will reimburse you for the benefits required
by the workers compensation law of that state if
we are not permitted to pay the benefits directly
to persons entitled to them.

4. If you have work on the effective date of this pol-
icy in any state not listed in Item 3.A. of the In-
formation Page, coverage will not be afforded for
that state unless we are notified within thirty
days.



B. Notice

Tell us at once if you begin work in any state listed in
Item 3.C. of the Information Page.
PART FOUR
YOUR DUTIES IF INJURY OCCURS

Tell us at once if injury occurs that may be covered
by this policy. Your other duties are listed here.

1. Provide for immediate medical and other ser-
vices required by the workers compensation law.

2. Give us or our agent the names and addresses
of the injured persons and of witnesses, and
other information we may need.

3. Promptly give us all notices, demands and legal






4 of 6
 Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 00 00 00 C





(Ed. 1-15)


papers related to the injury, claim, proceeding
or suit.

4. Cooperate with us and assist us, as we may re-
quest, in the investigation, settlement or defense
of any claim, proceeding or suit.

5. Do nothing after an injury occurs that would in-
terfere with our right to recover from others.

6. Do not voluntarily make payments, assume obli-
gations or incur expenses, except at your own
cost.
PART FIVE
PREMIUM
A. Our Manuals

All premium for this policy will be determined by our
manuals of rules, rates, rating plans and classifica-
tions. We may change our manuals and apply the
changes to this policy if authorized by law or a gov-
ernmental agency regulating this insurance.


B. Classifications

Item 4 of the Information Page shows the rate and
premium basis for certain business or work classifi-
cations. These classifications were assigned based
on an estimate of the exposures you would have
during the policy period. If your actual exposures are
not properly described by those classifications, we
will assign proper classifications, rates and premium
basis by endorsement to this policy.


C. Remuneration

Premium for each work classification is determined
by multiplying a rate times a premium basis. Remu-
neration is the most common premium basis. This
premium basis includes payroll and all other remu-
neration paid or payable during the policy period for
the services of:

1. all your officers and employees engaged in work
covered by this policy; and

2. all other persons engaged in work that could
make us liable under Part One (Workers Com-
pensation Insurance) of this policy. If you do not
have payroll records for these persons, the con-
tract price for their services and materials may
be used as the premium basis. This paragraph 2
will not apply if you give us proof that the em-
ployers of these persons lawfully secured their
workers compensation obligations.


D. Premium Payments

You will pay all premium when due. You will pay the
premium even if part or all of a workers compensa-
tion law is not valid.


E. Final Premium

The premium shown on the Information Page,
schedules, and endorsements is an estimate. The
final premium will be determined after this policy
ends by using the actual, not the estimated, premi-
um 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 bal-
ance. 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 classifications covered by
this policy.

If this policy is canceled, final premium will be de-
termined in the following way unless our manuals
provide otherwise:

1.
If we cancel, final premium will be calculated pro
rata based on the time this policy was in force.
Final premium will not be less than the pro rata
share of the minimum premium.

2. If you cancel, final premium will be more than
pro rata; it will be based on the time this policy
was in force, and increased by our short-rate
cancelation table and procedure. Final premium
will not be less than the minimum premium.



F. Records

You will keep records of information needed to com-
pute premium. You will provide us with copies of
those records when we ask for them.


G. Audit

You will let us examine and audit all your records
that relate to this policy. These records include ledg-
ers, journals, registers, vouchers, contracts, tax re-
ports, payroll and disbursement records, and pro-
grams for storing and retrieving data. We may con-
duct the audits during regular business hours during
the policy period and within three years after the pol-
icy period ends. Information developed by audit will
be used to determine final premium. Insurance rate
service organizations have the same rights we have
under this provision.




5 of 6
 Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.
WC 00 00 00 C
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY



(Ed. 1-15)


PART SIX
CONDITIONS
A. Inspection

We have the right, but are not obliged to inspect
your workplaces at any time. Our inspections are not
safety inspections. They relate only to the insurabil-
ity of the workplaces and the premiums to be
charged. We may give you reports on the conditions
we find. We may also recommend changes. While
they may help reduce losses, we do not undertake
to perform the duty of any person to provide for the
health or safety of your employees or the public. We
do not warrant that your workplaces are safe or
healthful or that they comply with laws, regulations,
codes or standards. Insurance rate service organiza-
tions have the same rights we have under this
provision.


B. Long Term Policy

If the policy period is longer than one year and six-
teen days, all provisions of this policy will apply as
though a new policy were issued on each annual
anniversary that this policy is in force.


C. Transfer of Your Rights and Duties

Your rights or duties under this policy may not be
transferred without our written consent.

If you die and we receive notice within thirty days af-
ter your death, we will cover your legal representa-
tive as insured.


D. Cancelation

1. You may cancel this policy. You must mail or de-
liver advance written notice to us stating when
the cancelation is to take effect.

2. We may cancel this policy. We must mail or de-
liver to you not less than ten days advance writ-
ten notice stating when the cancelation is to take
effect. Mailing that notice to you at your mailing
address shown in Item 1 of the Information Page
will be sufficient to prove notice.

3. The policy period will end on the day and hour
stated in the cancelation notice.

4. Any of these provisions that conflict with a law
that controls the cancelation of the insurance in
this policy is changed by this statement to com-
ply with the law.



E. Sole Representative

The insured first named in Item 1 of the Information
Page will act on behalf of all insureds to change this
policy, receive return premium, and give or receive
notice of cancelation.























6 of 6
 Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 00 03 08
(Ed. 4-84)
PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT
The policy does not cover bodily injury to any person described in the Schedule.
The premium basis for the policy does not include the remuneration of such persons.
You will reimburse us for any payment we must make because of bodily injury to such persons.
Schedule
Partners
Officers
Others
Jack Berlin
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective
10/1/2024
Policy No. TWC4509682
Endorsement No. 0
Insured
Driftwood Sands Condominium Association Inc
Premium $ 2,123
Insurance Company
Technology Insurance Company, Inc.
Countersigned by
WC 00 03 08
(Ed. 4-84)
 1991 National Council on Compensation Insurance.
1 of 2
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 00 03 11 A





(Ed. 8-91)
VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT
This endorsement adds Voluntary Compensation Insurance to the policy.

A. How This Insurance Applies

This insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting
death.
1. The bodily injury must be sustained by an employee included in the group of employees described in the
Schedule.
2. The bodily injury must arise out of and in the course of employment necessary or incidental to work in a state
listed in the Schedule.
3. The bodily injury must occur in the United States of America, its territories or possessions, or Canada, and
may occur elsewhere if the employee is a United States or Canadian citizen temporarily away from those
places.
4. Bodily injury by accident must occur during the policy period.
5. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The
employee’s last day of last exposure to the conditions causing or aggravating such bodily injury by disease
must occur during the policy period.


B. We Will Pay

We will pay an amount equal to the benefits that would be required of you if you and your employees described in
the Schedule were subject to the workers compensation law shown in the Schedule. We will pay those amounts
to the persons who would be entitled to them under the law.


C. Exclusions

This insurance does not cover:
1. any obligation imposed by a workers compensation or occupational disease law, or any similar law.
2. bodily injury intentionally caused or aggravated by you.


D. Before We Pay

Before we pay benefits to the persons entitled to them, they must:
1. Release you and us, in writing, of all responsibility for the injury or death.
2. Transfer to us their right to recover from others who may be responsible for the injury or death.
3. Cooperate with us and do everything necessary to enable us to enforce the right to recover from others.
If the persons entitled to the benefits of this insurance fail to do those things, our duty to pay ends at once. If they
claim damages from you or from us for the injury or death, our duty to pay ends at once.

E. Recovery From Others

If we make a recovery from others, we will keep an amount equal to our expenses of recovery and the benefits we
paid. We will pay the balance to the persons entitled to it. If the persons entitled to the benefits of this insurance
make a recovery from others, they must reimburse us for the benefits we paid them.


F. Employers Liability Insurance

Part Two (Employers Liability Insurance) applies to bodily injury covered by this endorsement as though the State
of Employment shown in the Schedule were shown in Item 3.A. of the Information Page.
 1991 National Council on Compensation Insurance.
2 of 2

WC 00 03 11 A
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY



(Ed. 8-91)





Schedule



Employees

State of Employment
Designated Workers
Compensation Law




This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

Endorsement Effective

Policy No.

Endorsement No.

Insured

Premium $

Insurance Company



Countersigned by






10/1/2024
TWC4509682
Driftwood Sands Condominium Association Inc
Technology Insurance Company, Inc.
$2,123
All Board of Directors, Officers, and
Appointed Committee Members while
in the course and scope of duties as
directed and pre-approved by the
Association Board of Directors
Any state shown in item 3a of the
information page
State where the injury takes
place
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 00 04 04
(Ed. 04-84)
PENDING RATE CHANGE ENDORSEMENT
A rate change filing is being considered by the proper regulatory authority. The filing may result in rates different from the rates
shown on the policy. If it does, we will issue an endorsement to show the new rates and their effective date.
If only one state is shown in Item 3.A. of the Information Page, this endorsement applies to that state. If more than one state is
shown there, this endorsement applies only in the state shown in the Schedule.
Schedule
State
FL
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective
10/1/2024
Policy No. TWC4509682
Endorsement No. 0
Insured
Driftwood Sands Condominium Association Inc
Premium $ 2,123
Insurance Company
Technology Insurance Company, Inc.
Countersigned by
WC 00 04 04
(Ed. 04-84)

PREMIUM DISCOUNT ENDORSEMENT


The premium for this policy and the policies, if any, listed in Item 3 of the Schedule may be eligible for a discount. This
endorsement shows your estimated discount in Items 1 or 2 of the Schedule. The final calculation of premium
discount will be determined by our manuals and your premium basis as determined by audit. Premium subject to
retrospective rating is not subject to premium discount.


Schedule

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 00 04 06 A
(Ed. 7-95)
1. State
Estimated Eligible Premium
First
Next
Next
$10,000
$200,000
$1,750,000
Balance
Florida
0%
9.1%
11.3%
12.3%
2. Average percentage discount:
0 %
3. Other policies:
4.
If there are no entries in Items 1, 2 and 3 of the Schedule, see the Premium Discount Endorsement attached to
your policy number:
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective
10/1/2024
Policy No. TWC4509682
Endorsement No. 0
Insured
Driftwood Sands Condominium Association Inc
Premium $ 2,123
Insurance Company
Technology Insurance Company, Inc.
Countersigned by
WC 00 04 06 A
(Ed. 7-95)
90-DAY REPORTING REQUIREMENT—NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT

You must report any change in ownership to us in writing within 90 days of the date of the change. 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. 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.

Failure to report any change in ownership, regardless of whether the change is reported within 90 days of such
change, may result in revision of the experience rating modification factor used to determine your premium.

This reporting requirement applies regardless of whether an experience rating modification is currently applicable to
this policy.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 00 04 14 A
(Ed. 01-19)
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective
10/1/2024
Policy No. TWC4509682
Endorsement No. 0
Insured
Driftwood Sands Condominium Association Inc
Premium $ 2,123
Insurance Company
Technology Insurance Company, Inc.
Countersigned by
WC 00 04 14 A
(Ed. 01-19)
© Copyright 2017 National Council on Compensation Insurance, Inc. All Rights Reserved.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 09 03 03
(Ed. 8-05)
FLORIDA EMPLOYERS LIABILITY COVERAGE ENDORSEMENT
C.Exclusion 5, Section C. of Part Two of the policy, is replaced by following:
This insurance does not cover
5.bodily injury intentionally caused or aggravated by you or which is the result of your engaging in conduct
equivalent to an intentional tort, however defined, or other tortious conduct, such that you lose your immunity from
civil liability under the workers compensation laws.
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective
10/1/2024
Policy No. TWC4509682
Endorsement No. 0
Insured
Driftwood Sands Condominium Association Inc
Premium $ 2,123
Insurance Company
Technology Insurance Company, Inc.
Countersigned by
WC 09 03 03
(Ed. 8-05)
© 2005 National Council on Compensation Insurance, Inc.
 Copyright 2015 National Council on Compensation Insurance. All Rights Reserved.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 09 04 02 A
(Ed. 5-17)
FLORIDA EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT
This endorsement applies because Florida is shown in Item 3.A. of the Information Page.
A. The premium for the policy will be adjusted by an experience rating modification factor. The factor was not
available when the policy was issued. The factor, if any, shown on the Information Page is an estimate. We will
issue an endorsement to show the proper factor, if different from the factor shown, when it is calculated.
B. If the factor is an increase over that shown on the Information Page, it will apply as of the policy effective date; or if
the rating effective date is later than the policy effective date it will apply as of the rating effective date. Your
premium will be calculated:
1. Retroactively to the effective date of the policy or to the rating effective date if the rating effective date is later
than the policy effective date if the adjustment is within the first 90 days of the policy effective date;
2. On a pro rata basis from the date we endorsed the policy if the adjustment is more than 90 days after the
effective date of the policy.
The adjustment will be retroactive to the effective date of the policy or to the rating effective date if the rating
effective date is later than the policy effective date when:
a. The change in the experience rating modification factor is the result of a revision in your classifications;
b. The delay in the calculation of the experience rating modification factor is due to your failure to make
available all your records for examination and audit as provided in Part Five—Premium, Section G. (Audit)
of the policy.
C. If the factor is a decrease from that shown on the Information Page, it will apply retroactively to the policy effective
date or the rating effective date if later than the policy effective date.
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective


Policy No.
Endorsement No.
Insured
Premium
Insurance Company
Countersigned by ___________________________________________
WC 09 04 02 A
(Ed. 5-17)
10/1/2024
TWC4509682
Driftwood Sands Condominium Association Inc
$2,123
Technology Insurance
Company, Inc.
1.
2.
a.
b.
c.
d.
3.
4.
1.
2.
3.

Florida Terrorism Risk Insurance Program Reauthorization Act Endorsement


This endorsement addresses requirements of the Terrorism Risk Insurance Act of 2002 as amended by the Terrorism Risk
Insurance Program Reauthorization Act of 2019.

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,
including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2019.
"Act Of Terrorism" means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of
Homeland Security, and the Attorney General of the United States, as meeting all of the following requirements:
The act is an act of terrorism.
The act is violent or dangerous to human life, property, or infrastructure.
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.
The act has been committed by an individual or individuals as part of an effort to coerce the civilian population 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 (including an act of war, in the case of workers compensation)
that is covered by primary or excess property and casualty insurance 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, 2021, and ending on December 31, 2027, an amount equal
to 20% of our direct earned premiums during the immediately preceding calendar year.

Limitation of Liability

The Act may limit our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a calendar year
and if we have met our Insurer Deductible, we may not be 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 may only have to pay a pro rata
share of such Insured Losses as determined by the Secretary of the Treasury.

Policyholder Disclosure Notice

Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses
occurring in any calendar year exceed $200,000,000, the United States Government would pay 80% of our Insured Losses that
exceed our Insurer Deductible.
Notwithstanding item 1 above, the United States Government may not have to make any payment under the Act for any portion
of Insured Losses that exceed $100,000,000,000.
The premium charged for the coverage for Insured Losses under this policy is included in the amount shown in Item 4 of the
Information Page or the Schedule below.



WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 09 04 03 C
(Ed.01-2021)
2
1 of
WC 09 04 03 C
(Ed.01-2021)
© Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 09 04 03 C
(Ed.01-2021)
Schedule
Rate per $100 of Remuneration 0.01
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective
10/1/2024
Policy No. TWC4509682
Endorsement No. 0
Insured
Driftwood Sands Condominium Association Inc
Premium $ 2,123
Insurance Company
Technology Insurance Company, Inc.
Countersigned by
2
2 of
WC 09 04 03 C
(Ed.01-2021)
© Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 09 04 07 A
(Ed. 03-2024)
Florida Non-Cooperation With Premium Audit Endorsement
This endorsement applies because Florida is shown in Item 3.A. of the Information Page.
This endorsement adds the following provisions to Part Five - Premium, G. Audit of the policy:
We are required to complete the premium audit process no later than 90 days after policy termination. If you fail to return the final
mail audit or refuse to cooperate in completing the final physical audit or final physical onsite audit, you must pay us a premium not
to exceed three times the most recent estimated annual premium on this policy subject to the following conditions:
1. We make two good faith efforts to obtain the final mail audit or complete the final physical audit or final physical onsite audit.
2. We document the audit file regarding the two good faith attempts to obtain the required audit information.
3.
After the two good faith attempts to obtain records or gain access to your premises or your worksites, we send a letter by
certified mail to you advising you of the specific records that are required or the premises or worksites that must be accessed
and the premium that will be charged if you continue to refuse access to the records, premises, and/or worksites.
If you do not provide all the specific records required and/or fail to permit access to your premises or worksites as applicable, and if
we satisfy the conditions above on or before 90 days from the date of policy termination, we may continue to try and conduct the
audit and/or reopen the audit for up to three years from the date of policy termination. Alternatively, we may immediately bill you a
premium not to exceed three times the most recent estimated annual premium on this policy. If you provide all the specific records
required and/or permit access to the premises or worksites as applicable to complete the premium audit process within the three-
year period, we will determine your final premium in accordance with Part Five - Premium, E. Final Premium of the policy.
If we cannot complete the audit because you do not permit us to make a physical inspection of your operation or provide us with
the necessary records, you must pay us $500 to defray the costs of the audit. The $500 charge may be imposed only if we have
incurred actual travel expenses and we notified you in writing of the potential charge when access was denied. Denial of access to
records and your premises or worksites by your agent or representative is considered the same as a denial by you.
If you understate or conceal payroll, or misrepresent or conceal employee duties to avoid proper classification for premium
calculations or misrepresent or conceal information pertinent to the calculation and application of an experience rating modification
factor, then you, your agent or your attorney, must pay us a penalty charge of 10 times the difference in the amount of premium
that you paid and the amount that you should have paid and reasonable attorney’s fees. The penalty may be enforced in the
Florida circuit courts.
At the end of each quarter, you must submit to us a copy of the quarterly earnings reports you filed with the Florida Department of
Revenue and any self-audits supported by the quarterly earnings report. The report must include a sworn statement by an officer
or principal of your company attesting to the accuracy of the information in it. If you have an employee who suffered a
compensable injury and was not reported as having earned wages on your last quarterly earnings report, you must indemnify us
for all workers compensation benefits paid to or on behalf of the employee unless you establish that the employee was hired after
the filing of the quarterly report, in which case you and the employee must attest to fact that the employee was employed by you at
the time of injury.
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective
10/1/2024
Policy No. TWC4509682
Endorsement No. 0
Insured
Driftwood Sands Condominium Association Inc
Premium $ 2,123
Insurance Company
Technology Insurance Company, Inc.
Countersigned by
WC 09 04 07 A
(Ed. 03-2024)
© Copyright 2023 National Council on Compensation Insurance, Inc. All Rights Reserved.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 09 04 08 A
(Ed. 7-19)
FLORIDA INSUFFICIENT FUNDS ENDORSEMENT
This endorsement applies because Florida is shown in Item 3.A of the Information Page.
Add the following to Part Six - Conditions of the policy:
G. Insufficient Funds
Our rules allow us to impose an insufficient funds fee of up to $15 per occurrence if you make a payment of premium by debit card,
credit card, electronic funds transfer (EFT), or electronic check that Is returned, declined, or cannot be processed due to
insufficient funds. However, we will not charge you an insufficient funds fee if the failure in payment resulted from fraud or misuse
on your account from which the payment was made and such fraud or misuse was not attributed to you.
The Schedule below shows the insufficient funds fee we will impose if you make a payment of premium by debit card, credit card,
electronic funds transfer (EFT), or electronic check that Is returned, declined, or cannot be processed due to insufficient funds.
Schedule
Insufficient Funds Fee
$20
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective
10/1/2024
Policy No. TWC4509682
Endorsement No. 0
Insured
Driftwood Sands Condominium Association Inc
Premium $ 2,123
Insurance Company
Technology Insurance Company, Inc.
Countersigned by
WC 09 04 08 A
(Ed. 7-19)
© Copyright 2018 National Council on Compensation Insurance, Inc. All Rights Reserved.

This endorsement applys because Florida is shown in Item 3.A. of the Information Page.

Part Five-Premium, Section D. (Premium Payments) is replaced by the following provision:

D. Premium Payments

You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. The due
date for audit and retrospective premiums is the due date specified in the billing for the policy.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 09 04 09
(Ed. 07-2024)
Florida Premium Due Date Endorsement
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective
10/1/2024
Policy No. TWC4509682
Endorsement No. 0
Insured
Driftwood Sands Condominium Association Inc
Premium $ 2,123
Insurance Company
Technology Insurance Company, Inc.
Countersigned by
WC 09 04 09
(Ed. 07-2024)
© Copyright 2023 National Council on Compensation Insurance, Inc. All Rights Reserved.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 09 06 06
(Ed. 10-98)
FLORIDA EMPLOYMENT AND WAGE INFORMATION RELEASE ENDORSEMENT
This policy requires you to release certain employment and wage information maintained by the State of Florida
pursuant to federal and state unemployment compensation laws except to the extent prohibited or limited under
federal law. By entering into this policy, you consent to the release of the information.
We will safeguard the information and maintain its confidentiality. We will limit use of the information to verifying
compliance with the terms of the policy.
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective
10/1/2024
Policy No. TWC4509682
Endorsement No. 0
Insured
Driftwood Sands Condominium Association Inc
Premium $ 2,123
Insurance Company
Technology Insurance Company, Inc.
Countersigned by
WC 09 06 06
(Ed. 10-98)
© 1998 National Council On Compensation Insurance.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 09 06 09
(Ed. 07-2024)
Florida Cancellation and Nonrenewal Endorsement
This endorsement applies because Florida is shown in Item 3.A. of the Information Page.
Part Six—Conditions, Section D. of the policy is replaced by the following:
D. Cancellation
1.
You may cancel this policy by giving a written request to us stating when the cancellation is to take effect. If you do not
specify the cancellation effective date in your written request, the cancellation is effective on the date of your written
request. We are not required to send notice of cancellation to you if you requested the cancellation in writing. Any
retroactive assumption of coverage and liabilities under this policy may not exceed 21 days.
2. We may cancel this policy by giving the first-named insured written notice of cancellation, including in the written notice
the reason or reasons for the cancellation.
a. We must give at least 10 days’ written notice prior to the effective date of cancellation when the cancellation is
for nonpayment of premium.
b. We must give at least 30 days’ written notice prior to the effective date of cancellation when the policy has
been in effect for 60 days or less and the policy is cancelled for reasons other than nonpayment of premium,
except where there has been a material misstatement or misrepresentation or failure to comply with our
underwriting requirements, then at least 45 days’ written notice is required.
c. We must give at least 45 days’ written notice prior to the effective date of cancellation when the policy has
been in effect for 61 days or more. We may cancel the policy only when there is
(1) a material misstatement
(2) a nonpayment of premium
(3) a failure to comply with our underwriting requirements that we established within 60 days
of the effective date of coverage
(4) a substantial change in the risk covered by the policy, or
(5) a cancellation for all insureds under such policies for a given class of insureds.
3.
If we decide not to renew this policy, we must give the first-named insured written notice of nonrenewal at least 45 days
prior to the expiration date of the policy. The written notice will state the reasons for the nonrenewal.
4.
If we fail to provide written notice of cancellation or nonrenewal to the first-named insured within the required time frame,
the coverage provided to the named insured under this policy will remain in effect until 45 days after the notice is given
or until the effective date of replacement coverage obtained by the named insured, whichever occurs first. The premium
for the coverage will remain the same during any such extension period except that, in the event of failure to provide
notice of nonrenewal, if the rate filing then in effect would have resulted in a premium reduction, the premium during
such extension of coverage must be calculated based upon the later rate filing.
5.
The policy period will end on the day and hour stated in the cancellation notice
6.
Any of these provisions that conflict with a law that controls the cancellation of the insurance in this policy is changed by
this statement to comply with the law.
All other policy terms, conditions, and exclusions remain unchanged.
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective
10/1/2024
Policy No. TWC4509682
Endorsement No. 0
Insured
Driftwood Sands Condominium Association Inc
Premium $ 2,123
Insurance Company
Technology Insurance Company, Inc.
Countersigned by
1
1 of
WC 09 06 09
(Ed. 07-2024)
© Copyright 2024 National Council on Compensation Insurance, Inc. All Rights Reserved.
Technology Insurance Company, Inc.
IMPORTANT NOTICE
FLORIDA
POLICY NUMBER
POLICY PERIOD
TWC4509682
FROM: 10/1/2024 12:00:00 AM TO: 10/1/2025 12:00:00 AM
INSURED
Driftwood Sands Condominium Association Inc
If you have a Drug-Free Workplace Program established and maintained in accordance with Florida
law, and you would like to apply for the 5% premium credit that is available, please contact your
insurance agent for a Drug-Free Workplace Premium Credit Program application. Re-certification is
required annually.
The State of Florida has authorized a $2500 deductible plan. There is no premium credit associated
with this option. This deductible option may be endorsed to the policy subject to financial underwriting.
Any amounts paid by the employer shall not apply to the experience rating of such employer but shall
be reported for ratemaking purposes. If you are interested in this deductible plan, please contact your
insurance agent for further details.
Policyholder Notice
FL-DFD 01 (10/04)
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise
stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective
10/1/2024
Policy No. TWC4509682
Endorsement No. 0
Insured
Driftwood Sands Condominium Association Inc
Premium $ 2,123
Insurance Company
Technology Insurance Company, Inc.
Countersigned by