## Endorsement for Workers' Compensation or Disability Benefits

### Conditions

1. **Policy Provisions:** None of the Insuring Agreements, Exclusions, or Conditions of the policy shall apply as the insurance afforded by this endorsement except as provided herein.

2. **Premiums:** During the policy period, if the number of automobiles owned by the named insured or spouse and registered in New York or the number of New York dealer's license plates or transporter plates issued to the named insured changes, the named insured shall notify the company during the policy period of any change and the premium shall be adjusted as of the date of such change in accordance with the maximum rates by the company. If the earned premium thus computed exceeds the amount paid by the named insured, the named insured shall pay the excess to the company; if less, the company shall return to the named insured the unearned portion paid by such insured.

3. **Notice and Proof of Claim: Medical Reports:** Within 90 days or as soon as practicable, the insured or other person making claim shall give to the company written notice of claim under this endorsement. As soon as practicable after receiving such notice, the company or its representative shall require the insured or other person making claim to submit to examination under oath by any person named by the company and to furnish all medical records upon request by the company unless the company has failed to furnish such form within 15 days after receiving notice of claim. The injured person shall submit to physical examinations by physicians selected by the company when and as the company may reasonably require him or her, or in the event of his incapacity his legal representative, or in the event of his death his legal representative. The company shall promptly forward all such request from the company execute authorization to enable the company to obtain medical reports and copies of records.

4. **Notice of Legal Action:** If before the company makes payment of loss hereunder, the insured or his legal representative shall institute any legal action for bodily injury against any person or organization legally responsible for the use of an automobile involved in the accident, a copy of the summons and complaint or other process served in connection with such legal action shall be forwarded immediately to the company by the insured or his legal representative.

5. **Limits of Liability:** (a) The limit of liability of the company for all damages, including damages for care or loss of services, because of bodily injury sustained by one person as the result of any one accident is $10,000 and subject to the above provision, the total limit of liability of the company for all damages, including damages for care or loss of services, because of bodily injury sustained by two or more persons, whether insured or qualified persons under the New York Motor Vehicle Accident Indemnification Corporation law, as the result of any one accident is $20,000. (b) Any amount payable under the terms of this endorsement, including amounts payable for care or loss of services, because of bodily injury, shall not exceed (1) all sums paid to one or more insureds on account of such bodily injury by or on behalf of (a) the owner or operator of the uninsured automobile and (b) any other person or persons jointly or severally liable together with such owner or operator for such bodily injury, (2) all sums paid to one or more insureds on account of bodily injury sustained in the same accident by one or more persons on account of bodily injury similar to that provided by this endorsement, and (c) another and the present value of all amounts payable on account of such bodily injury under any workers' compensation law, exclusive of non-occupational disability benefits.

6. **Other Insurance:** With respect to bodily injury to an insured while occupying an automobile not owned by the named insured, this insurance shall apply only as excess insurance over any other similar insurance available to such insured and applicable to such automobile as primary insurance, and this endorsement shall not apply in the amount by which the limit of liability for the consequences of such bodily injury exceeds the liability of such other insurance. Except as provided in the foregoing paragraph, if the insured has other similar insurance available to him and applicable to the accident, the damages shall be deemed not to exceed the higher of the applicable limits of liability of this insurance and such other insurance, and the company shall not be liable for a greater proportion of any loss to which this coverage applies than the limit of liability hereunder bears to the sum of the applicable limits of liability of this insurance and such other insurance.

7. **Arbitration:** If any person making claim hereunder and the company do not agree that such person is legally entitled to recover damages from the owner or operator of an uninsured automobile because of bodily injury to the insured or do not agree as to the amount of payment which should be made using this endorsement, then, upon written demand of either party, the matter will be settled by arbitration in accordance with the rules of the American Arbitration Association, and judgment upon the award rendered by the Arbitrators may be entered in any Court having jurisdiction thereof. Such person and the company each agree to consider itself bound and be bound by any award made by the arbitrators pursuant to this endorsement.

8. **Trust Agreement:** In the event of payment to any person under this endorsement:
   - (a) The company shall be entitled to the extent of such payment to the proceeds of any settlement or judgment that may result from the exercise of any rights to recover from such person against any person or organization legally responsible for the bodily injury, for which such payment is made.
   - (b) Such person shall hold in trust for the benefit of the company all rights of recovery which he shall have against such other person or organization because of such bodily injury.
   - (c) Such person shall do whatever is proper to secure and shall do nothing after loss to prejudice such rights.
   - (d) If requested in writing by the company, such person shall take, through any representative designated by the company such action as may be necessary or appropriate to recover such payment as damages from such other person or organization, such action to be taken in the name of such person; in the event of a recovery, the company shall be reimbursed out of such recovery for expenses, costs and attorneys fees incurred by the company therewith.
   - (e) Such person shall execute and deliver to the company such instruments and papers as may be appropriate to secure the rights and obligations of such person and the company established by this provision and, upon request of the company, shall attend hearings and trials and assist in securing and giving evidence, obtaining the attendance of witnesses and in the conduct of any legal proceedings.

9. **Payment of Loss by Company:** Any amount due hereunder is payable (a) to the insured, or (b) if the insured is a minor to his parent or guardian, or (c) if the insured be deceased to his surviving spouse, otherwise (d) to a person authorized by law to receive payments due to or on a person legally entitled to recover the damages which the payment represents, provided, the company may at its option pay any amount due hereunder in accordance with sub-division (a) hereof.

10. **Action Against Company:** No action shall lie against the company unless, as a condition precedent thereto, the insured or his legal representative has fully complied with all the terms of this endorsement.

11. **Changes:** This endorsement embodies all agreements existing between the insured and the company relating to this insurance. Notice to or knowledge possessed by the company, any agent or any other person shall not effect a waiver or a change in this endorsement or estop the company from asserting any right under the terms of this endorsement.

12. **Assignment:** Assignment of interest under this endorsement shall not bind the company until its consent is endorsed hereon; if, however, the assignee is a spouse or a resident of the same household, shall die, this endorsement shall cover the assignor as named insured, (2) his legal representative as named insured but only while acting within the scope of his duties as such, and (3) any relative who was an insured at the time of such death.

13. **Policy Period—Termination:** This endorsement applies only to accidents which occur on and after the effective date hereof and during the policy period and shall terminate upon (1) termination of the policy of which it forms a part or (2) termination of New York registration on all automobiles owned by the named insured or spouse.