WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 19 06 03

(Ed. 01-2021)

Maryland Benefits Deductible Endorsement

This endorsement applies because Maryland is shown in Item 3.A. of the Information Page.
Part One—Workers Compensation Insurance applies only to benefits in excess of the deductible amount shown in
the Schedule below.
The deductible amount shown in the Schedule below applies separately to each claim for bodily injury by accident
or disease.
We will pay the deductible amount for you, but you must reimburse us within 30 days after we send you notice that
payment is owed to us.
Deductibles are not to be treated as premium and we cannot cancel the policy for nonpayment of premium due to your
failure to pay the deductible amount. However, we can protect ourselves from your failure to pay the deductible in
the following ways:
1. If you fail to timely pay a deductible when owed to us, then we may issue a nonrenewal notice in advance of the
next policy renewal date; and/or
2. If you fail to timely pay a deductible when owed to us, then we may send you a notice revoking the premium credit
for the deductible option chosen by you and may bill you for the additional premium owed as a result of the lost
premium credit. If you then fail to timely pay the additional premium owed, we may cancel the policy for nonpayment
of premium.

Schedule

Indemnity and Medical

Deductible Amount

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
Insured Policy No. Endorsement No.
Premium

Insurance Company Countersigned by

WC 19 06 03
(Ed. 01-2021)

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