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WORKERS' COMPENSATION COST CONTAINMENT CERTIFICATION <br />DISCLOSURE STATEMENT <br />Cost Containment Certification is available from the Colorado Workers' Compensation Cost Containment Board. If you <br />obtain certification, your policy will be subject to a premium credit which will be shown separately on your policy. <br />PLEASE CHECK ONE (1) OF THE FOLLOWING BOXES BASED UPON YOUR BUSINESS ENTITY QUALIFICATION: <br />❑ I am aware if my business does qualify for experience and/or schedule rating under my workers' compensation <br />insurance policy and my business has implemented a certified workers' compensation risk management program, my <br />policy is subject to a 5% premium credit if the loss experience has improved since the last renewal date of workers' <br />compensation insurance. This 5% premium credit is in addition to any schedule rating for which i may qualify. <br />or, <br />❑ I am aware if my business does not qualify for experience and/or schedule rating under my workers' compensation <br />insurance policy and my business entity has implemented a certified workers' compensation risk management program, <br />my policy is subject to the following premium credit: <br />Premium Dividend <br />Dividend Criteria <br />10% <br />If my business has been loss free for at least the last <br />year immediately preceding the effective date of the <br />premium credit. <br />8% <br />If my business had one medical loss exceeding $250 in <br />the last year immediately preceding the effective date <br />of the premium credit. <br />6% <br />If my business had two medical losses, each exceeding <br />$250, in the last year immediately preceding the <br />effective date of the premium credit. <br />4% <br />If my business had three medical losses, each <br />exceeding $250, in the last year immediately preceding <br />the effective date of the premium credit. <br />2% <br />If my business had three medical losses, each <br />exceeding $250, and one claim for loss of time in the <br />last year immediately preceding the effective date of <br />the premium credit. <br />0% <br />If my business had more than three medical losses and <br />one claim for loss of time in the last year immediately <br />preceding the effective date of the premium credit. <br />Insured Signature <br />Policy Number <br />Issuing Office <br />Issuing Office <br />Address <br />***PLEASE SIGN AND RETURN*** <br />59 WEC AC9055 <br />THE HARTFORD BUSINESS SERVICE CENTER <br />3600 WISEMAN BLVD <br />SAN ANTONIO TX 78251 <br />Form WC 66 03 06 Printed in U.S.A. <br />Process Date: 05/25/20 <br />ew cF RAMwagementDMsian <br />Jy/\'x REVIEWED & APPROVED BY.- <br />v <br />POlicl R.Wjanagementftalpt <br />