CCR1986000aAPPLICATION FOR PARTICIPATION IN
THE LEAGUE OF WISCONSIN MUNICIPALITIES INSURANCE
PLAN AND ASSIGNMENT OF DIVIDENDS.
WHEREAS, The Leagueof Wisconsin Municipalities Insurance Trust (a Trust)
(hereinafter referred to as the Plan) was created by written Agreement and
Declaration of Trust on October 19. 1983, between the League of Wisconsin
Municipalities (hereinafter referred to as the League), the Trust and the Trustees
thereof. to:
1 Research the insurance and risk management needs of Wisconsin
municipalities.
2. Negotiate and make available to members of the League complete
programsof insurancecoverages including any form of permitted group
insurance at a favorable net cost to participants in the Trust and to
monitor such programs and coverages.
3. Provide risk management services, and
WHEREAS, the Trust has contracted with EMPLOYERS INSURANCE OF
WAUSAU A Mutual Company (hereinafter referred to as Employers) to make
available the League Insurance Plan, to:
1 Provide workers compensation, property and liability insurance pro-
grams and coverages to meet the needs of Wisconsin municipalities.
2. Cooperate with the Trust and its designared insurance consultant in
providing loss prevention and other related risk management services.
3. Provide these programs, coverages and services at a negotiated net cost
of operations basis, and
4. Return to the persons entitled thereto dividends, if any. on policies
issued pursuant to the Plan and based on favorable loss experience, and
all other refunds which may become payable.
WHEREAS, the below named municipalitywishes to participate as a member
of the Trust, pursuant to the terms and provisions thereof, and secure workers .. ~ compensation and such other available coveragas as applicant may desire and
is qualified to receive under the Plan, and
WHEREAS, applicant further wishes to avail itself to such loss prevention and
. risk management services as may be offered by Employers and other consultants
designated by the Trust and share in any distributions which are declared by the
Trust relating to any insurance obtained through the Plan in which this applicant
has participated.
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NOW, THEREFORE:
1 The below named municipality hereby:
a. Makes application for participation in the Insurance Trust.
b. Agrees to cooperate with the Trust, its designated consultants and
Employers in loss prevention.
c. Authorizes Employers to release to the League all loss control and loss
information and reports relating to the insurance subject to the
member, so long as the member participates in such plan.
League's safety group dividend plan issued by Employers to the
Member agrees that Employers shall not be liable to any person for
releasing the above information or reports.
d. Assigns to the Trust any and all dividendsand other refunds which may
become payable to the applicant at any time hereafter on any policy of
insurance issued to applicant by Employers under the Plan, and hereby
authorizes and directs Employers to pay over and deliver tothe Trust all
such dividends and other refunds which shall hereafter become
payable.
2. Theapplicant understandsthat thetrusteesoftheTrustwiII, pursuant to the
Trust Agreement:
a. Provide for monitoring the coverages, claims procedure, operational
b. Facilitate the availabi!ity to participants of various risk management
costs and services of Employers.
services.
c. Distribute from time to time to the below named municipality. as pro-
vided by and pursuant to the Trust Agreement, its pro rata share of
dividends and other refunds declared by Employers under policies
issued through the Plan and paid to the Trust under this and all other
similar assignments.
Authortzed Signature Etle Dale
The above application for participation is accepted. Applicant notified thereof by
mail on this day of .I9
League of Wisconsin
Municipalities Insurance Trust