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Company Name: <br />Policy Number: <br />Policy Period: <br />Offer Expiration Date: <br />City of Louisville <br />265 <br />01/01/2013 to 01/01/2014 <br />02/15/2013 <br />Conditions <br />In order to effect the Loss Control Dividend Plan for the above policy, you must complete and sign the acceptance <br />section below and return the original to the Pinnacol Assurance address on this document BEFORE THE OFFER <br />EXPIRATION DATE ABOVE. Without securing your signed agreement before the expiration date, Pinnacol <br />Assurance will not add the Loss Control Dividend Plan to your policy. <br />Pinnacol Assurance will calculate the dividend as soon as practicable, using all loss information we have as of 21 <br />months after the rating plan period begins. <br />Acceptance of Loss Control Dividend Plan <br />1 agree to comply with the provisions of the Pinnacol Assurance Loss Control Dividend Plan and wish to have my <br />policy endorsed to include this provision. 1 also understand the Loss Control Dividend Plan will automatically renew <br />for subsequent policy periods if all eligibility requirements are met. In the event the Loss Control Dividend Plan is no <br />longer desired for future policy periods, I will notify Pinnacol Assurance of this decision within 45 days of my policy <br />renewal date. <br />I further understand that if I am approved for this plan, an endorsement will be issued within 60 days of the policy <br />period effective date. <br />Thank you for selecting this pricing option for your policy and we look forward to partnering with you to aid in <br />realizing a possible dividend based on the successful management of your risk and future losses. <br />Signature <br />Aa L$ <br />Print Name <br />7474 \17 —._ <br />Da e <br />'0-:? C R iii �i r - JL_ <br />Print Title <br />Pinnace! Assurance' 7s01 E Lawry Blvd' Danner, CO 80230 <br />Page 4 et 5 G.4 EWOOJ - Underwriter 12/1912012 09:04:10 Z55 i_GFOU <br />10 <br />