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PI WitCOL <br />ASSURANCE <br />7501 E Lowly Blvd <br />Denver, CO 60230 -7006 <br />Phone: (303) 361 -4000 / (B00)1373-7242 <br />Fax: (303) 361 -5000 / (888) 326 -2251 <br />www.pinnacol.com <br />Exhibit 2 <br />Loss Control Dividend Plan Proposal <br />PLEASE NOTE: This is NOT AN AGREEMENT to provide Loss Control Dividend. <br />No agreement is effective without a signed Pinnacol Conditions and Acceptance of Loss Control Dividend Plan. <br />Company Name: <br />Policy Number: <br />Policy Period: <br />Offer Expiration Date: <br />Modified Premium <br />City of Louisville <br />265 <br />01/01/2013 to 01/01/2014 <br />02/15/2013 <br />Discounts /Adjustments <br />COST CONTAINMENT CREDIT <br />LOSS CONTROL SURCHARGE <br />PREMIUM DISCOUNT <br />SCHEDULE RATING & DESIGNATED PROV <br />-5.00 % <br />5.00 % <br />-8.40 % <br />-7.50 % <br />Net Discounts /Adjustments -15.90 % <br />Estimated Loss Control Dividend Plan Premium * <br />*Excludes the Coal Mine Disease Charge and Firefighter Disease Charge. <br />$ 146,233.00 <br />$ - 6,763.00 <br />$ 6,425.00 <br />$ - 11,334.00 <br />$ - 10,967.00 <br />$ - 22,639.00 <br />$ 126,185.00 <br />Estimated Annual Premium (See Exhibit 1 for detail) $ 126,185.00 <br />NOTE: <br />It you elect the Loss Control Dividend Ran option after the renewal date on your policy but before the expiration date <br />of this offer, the Premium Discounts on this quote are subject to change. <br />The calculation of the Loss Control Dividend Plan is based upon the Loss Control Dividend Plan Premium. The Loss <br />Control Dividend Plan Premium is defined as the audited premium Pinnacol Assurance will charge during the rating <br />plan period, after application of the experience modification and applicable discounts, excluding the Coal Mine <br />Disease Charge and Firefighter Disease Charge. <br />Sample of Your Possible Loss Control Dividend <br />All factors are based on adjusted premium and may change at any time. To determine your estimated Toss control <br />percentage, locate your loss ratio and premium on the table in Exhibit 3. To determine your estimated dividend <br />amount multiply your estimated adjusted premium by the loss control percentage. <br />Loss <br />Ratio <br />O % <br />10% <br />15% <br />20 % <br />25 % <br />30 % <br />35% <br />40 % <br />Loss <br />Control <br />Percent <br />26.40 % <br />24.40 % <br />21.80 % <br />19.70 % <br />16.70 % <br />14.80 % <br />11.80% <br />10.40 % <br />8.10 % <br />Dividend <br />Amount <br />$ 33,313 <br />$ 30,789 <br />$ 27,508 <br />$ 24,858 <br />$ 21,073 <br />$ 18,675 <br />$ 14,890 <br />$ 13,123 <br />$ 10,221 <br />Pinnaccl Assurance ' 7501 E Lowry Blvd ' Denver, CO 80230 <br />Page 3 a15 okrEwow- Underwril21- 12/1912012 09:04:10 265 LCFQU <br />9 <br />