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PA. <br />IMPORTANT NOTICE <br />COLORADO WORKERS' COMPENSATION INSURANCE <br />MEDICAL AND INDEMNITY DEDUCTIBLE ELECTION FORM <br />Colorado Workers' Compensation Law permits an employer to purchase workers' compensation insurance with a <br />deductible. The deductible is for medical and indemnity benefits only. There are nine "Per Claim" deductible options <br />available. They are: <br />NONE <br />$ 500 <br />1,000 <br />1,500 <br />2,000 <br />2,500 <br />5,000 <br />10,000 <br />13,500 <br />15,500 <br />16,000 <br />16,500 <br />17,000 <br />17,500 <br />All medical and indemnity claims shall be paid by the company. In such case, the law requires that you reimburse the <br />company for any deductible amounts so paid. <br />If you have any questions, or desire one of these deductible amounts to apply to your coverage, please call your Agent for <br />a quote. This offer is valid for thirty days after the effective date of the policy with which this notice is enclosed. <br />Policy Number <br />59 WEC AC9055 <br />Employer Name <br />BAY SPROUTS LLC <br />Agent Name <br />FIRSTMARK INSURANCE GROUP INC <br />Return to <br />Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER <br />Address: 3600 WISEMAN BLVD <br />SAN ANTONIO TX 78251 <br />Form WC 66 01 49 H Printed in U.S.A. <br />Process Date: 05/25/20 <br />Date I Signature and Title <br />Date I Signature <br />ew cF RAMwagementDMsian <br />Jy/ \'x REVIEWED & APPROVED BY.- <br />V"° <br />Policy E _� RFskPjanagementAnalpt <br />