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PROM : MUClfi FOX NO. : 18002S79G71 Dao. IS 2003 12:0£PM P2 <br />BBTsam <br />QiMHyf*revl<Mrorin>orm«tionftS«rvtOH <br />MinnMOta Workers* Compensation <br />insurers Association, inc <br />7701 France Avenue South > Suite 450 <br />Minneapolis. MN SS43S-3200 <br />AfN: .1134693 <br />December 15> 2003 <br />cc:JACK H DIESINC <br />niS£,K INS ACCt <br />PO BOX 427 <br />MOUND, MN SS364 <br />PJM TRCST <br />5040 ENCHANTED BLVO <br />MOtmo. MN SS364 <br />We have received ycur applicacicn foe workers' compensation insurance <br />coverage through the Minnesota Assigned Risk Plan. <br />The application and/or mrorsiacion presently In our files is not complete <br />Rather than deny coverage, however, we are binding coverogo through the <br />Minnesota Risk Plan with: <br />BERKLEV RISK ADMINISTRATORS COMPANY, LLC <br />P 0 BOX 59143 <br />MINNEAPOLIS, MN 55459-0143 <br />Phone; (612> 766-3000 x <br />Coverage will become effective 12t01 a.m. 01/01/04, and will remain in <br />force for 30 days from the date of this letter, pending receipt of the <br />following Information: <br />Does the employer lease employees to or from another company? <br />0. <br />The Merit Rating sheet ie attached. <br />YOUR PROMPT ATTENTION IS REQUIRED. <br />COVERAGE WILL BE CANCELLED IJ THE REQUIlRED INFORMATION IS NOT PROVIDED <br />WITHIN THIRTY (30) DAYS. <br />If ysu have any questions ragerding tha additional information ws are <br />requesting, or if there is any reason that the information cannot be <br />submitted within 30 days, please contact tha sarvioing contraotor <br />immediately, a return envelope is enclosed for your convenience. <br />Print Datei 12/15/93 <br />M2.M7.1737 PR 952.837.1495 fX <br />A [