AMERICAN FAMILY INSURANCE GROUP

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AMERICAN FAMILY INSURANCE GROUP

AMERICAN FAMILY MUTUAL INSURANCE COMPANY AMERICAN STANDARD INSURANCE COMPANY OF WISCONSINAMERICAN FAMILY LIFE INSURANCE COMPANY AMERICAN FAMILY SECURITIES, LLCAMERICAN FAMILY BROKERAGE, INC. AMERICAN FAMILY INSURANCE COMPANYAMERICAN STANDARD INSURANCE COMPANY OF OHIO AMERICAN FAMILY FINANCIAL SERVICES, INC.

Important Message to All Our Customers In Your Household

PRIVACY NOTICE

The companies of American Family Insurance Group, listed above, recognize the importance of our customers trust. Keepingour customers personal information confidential is a top priority for all American Family employees, agents and their staff. ThisNotice, which is required by state and federal law, explains our Privacy Policies.

1) We will safeguard, according to strict standards of security and confidentiality, nonpublic, personal information ourcustomers share with us. Nonpublic, personal information , for example, would include such information as your name,address, social security number, and credit information. We will maintain safeguards, physical and electronic, to protectthat information. We will conduct our business in a manner that keeps personal customer information secure.

2) We will limit the collection and use of customer information to the minimum we require to deliver superior service and toadminister our business. We collect personal information about customers from the following sources:

From customers on insurance and loan applications and related forms;From your transactions with us, our affiliates or others;From consumer reporting agencies; andFrom your transactions with non-affiliated third parties.

3) It is our policy that only authorized American Family employees, agents and their staff who need to know your personalinformation will access and use it. American Family workers who violate our Privacy Policies are subject to the disciplinaryprocess.

4) It is our policy that we will not share personal customer information (either current or former customers) outside AmericanFamily for any purpose other than the underwriting or administration of a customer s policy/account or for marketing ofadditional American Family products, unless the disclosure has been authorized by the customer or is permitted or requiredby law.

5) Whenever we retain other organizations to provide support services on behalf of American Family, we will require them toprotect customers personal information.

6) To help us keep your customer information up-to-date and accurate, please contact your agent if there is any change inyour personal information.

7) When necessary, we will review and revise our Privacy Policies to protect personal customer information.

PLM-19065

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DISCLOSURE FORMCOLORADO WORKERS COMPENSATION INSURANCE

IMPORTANT NOTICE TO POLICYHOLDERS

1. NOTICE OF CHANGE IN RATE BY CLASSIFICATIONIf you desire information whenever there is a change in your workers compensati on insurance rate by classification, you may requestsuch information from American Family Insurance. This request for information must be in writing. We are required to supply thisinformation within thirty (30) days following release of such information to us by the authorized rating organization and following approvalof the rate change by classification.

2. NOTICE OF POLICYHOLDERS’ RIGHT TO APPEAL CLASSIFICATION C.R.S. 8-44-108, 8-44-109, & 8-55-102, and 8-55-104.American Family Insurance is authorized to charge and collect any additional amou nt of money not included in the original premiumcharged due to:(1) An incorrect employee classification assignment; and/or(2) The application of an Experience Modification Factor.If you disagree with our new job classification assignment, or the Experience Modification Factor, you may submit a request to us inwriting asking for a review. We will provide a written response within 30 days of receipt of your request.

The address to write to is: Colorado Commercial Lines Underwriting Manage r, American Family Insurance Group, 4802 Mitchell Avenue,St. Joseph, MO 64507-2500. Your written request must be submitted within 30 days of:

(1) Your receipt of the change; or(2) The anniversary date of your policy.If you still disagree with us on the employee classification assignment or Experience Modification Factor, you have the right to appeal tothe Workers’ Compensation Classification Appeals Board by filing written notice wit h the Board within 30 days after receiving our reply.This request can be sent to the Secretary of the Colorado Workers’ Compensation Classification Appeals Board; c/o National Council onCompensation Insurance, INC (NCCI); 7220 West Jefferson Avenue, Suite 310; Lakewood , CO 80235. A hearing will be scheduled within30 days of the receipt of your appeal. The Board will then provide you with written notice of a hearing date. A decision of the board shallbe final and not subject to appeal unless you or American Family Insurance provide written notice to the Office of the Commissioner ofInsurance, who shall determine whether a job misclassification occurred.

This written notice may be sent to the: Commissioner of Insurance; 1560 Broadwa y, Suite 850; Denver, CO 80202, and must be madewithin 30 days after the date of the Board’s decision. The Commissioner will provide a written decision within 30 days after the requestfor such a review. You may hold disputed premium amounts in abeyance from the date an appeal is filed until either the date a finaldecision is made by the Board concerning such appeal, or the date of any wr itten decision of the Commissioner of Insurance. However,in the event you lose the appeal, you will be required to pay the disputed premium amount plus interest at the rate of one percent of thedisputed amount per month. Such interest shall accrue from the date of the premium rate increase to the date of payment.

3. NOTICE OF AVAILABILITY OF MEDICAL CASE MANAGEMENT SERVICESAmerican Family Insurance believes it is our obligation to help promote medical cost containment. The Company has a Medical ServicesDepartment which is available to review medical bills in an effort to determine whether or not the charges are usual and customary forthe treatment being rendered. American Family will use an outside medical managem ent facility if the need arises.

4. NOTICE OF COLORADO STATUTE 8-44-110Colorado Revised Statute 8-44-110 requires American Family Insurance give a 30-day notice of cancellation, except in the case of:Fraud; Material Misrepresentation; Nonpayment of Premium; Other reasons approved by the Commissioner of Insurance.

5. NOTICE OF RISK MANAGEMENT SERVICESAmerican Family Insurance offers risk management services to our Workers Compensati on Insurance policyholders who requestsuch services in writing, as required by Colorado Regulation 5-1-11. Risk managem ent services can help you identify ways tocontrol factors that affect your insurance premiums, such as your employee accident rate.If you are interested in risk management service, write to: Colorado Commercial Lines Underwriting Manager; American FamilyInsurance Group; 4802 Mitchell Avenue; St. Joseph, MO 64507-2500.Please include your policy number on all correspondence.

6. NOTICE OF COLORADO STATUTE 8-44-115 CALCULATION OF PREMIUM - MOTOR VEHICLE ACCIDENTS(1) The amount by which an employer’s experience rating is modified, if at all, as the result of a motor vehicle accident in which an

employee is injured or killed shall be reduced in accordance with this section if:(a) The employee is entitled to benefits under articles 40 to 47 of this title; and(b) The accident was not caused, wholly or in part, by the employee or the empl oyer; and(c) The use of a motor vehicle is not an integral part of the employer’s busine ss, as determined under rules promulgated by the

commissioner of insurance under section 10-4-408 (5)(e), C.R.S.(2) (a) Any modification of an employer’s experience rating resulting from an accident described in subsection (1) of this section shall

reflect the deduction of a loss limitation, the amount of which shall be determined by the commissioner of insurance under rulesadopted pursuant to section 10-4-408 (5)(e), C.R.S.

(b) All loss experience remaining after deduction of the loss limitation referred to in paragraph (a) of this subsection (2) shall bedistributed among all workers’ compensation classifications in use in the state as determined by the commissioner of insurance.For purposes of such distribution, classifications of businesses of which use of a motor vehicle is an integral part may be treateddifferently from classifications of business of which use of a motor vehicle is not an integral part.

YOUR AMERICAN FAMILY AGENT

UBLW-01406 Rev. 10/08

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LOSS CONTROL SERVICES...make business sense & save $$$$$

Can Loss Control Services really affect my premiums?

Can the information obtained be used against me?

Will this take my employees or me away from our jobs?

What if I can’t afford the improvements?

Do I have to follow all the recommendations?

What is the procedure?

Exactly what loss potentials do you help identify?

Do they really work?

We are not in business to cancel business customers or burden them with high rates. American Family’s goal is to help our businesspolicyholders reduce losses, not increase their expenses.

Since American Family values good business customers, we provide a flexible rate structure that rewards those with the safest and mostsecure practices. When a business addresses the recommendations of the Loss Control Specialist, progress is noted and factored into eachcustomer’s underwriting review.

The exact effect varies with each business we insure. Many business owners who implement loss control measures and safeguards haveseen their premiums decrease as well as other business expenses.

And again, your related savings from reducing uninsured losses and non-productive time can multiply any premium-saving benefits of losscontrol many times over.

Any information gathered during loss control surveys or consultations is kept strictly confidential. It is not provided to any public regulatorygroups or inspectors, your competitors or your employees.

PR-14163

Meetings with your Loss Control Specialist will be scheduled at your convenience. In some cases, you need not be present during physicalsurveys. Safety presentations can be made at locations you select. We will stay out of the way of your employees, customers and processesso we do not impede your business.

In fact, our Loss Control Services are a value-added reason why many business owners choose American Family for their business insuranceneeds. As a no-cost feature of your policy, you can harness the expertise of safety consultants whose counterparts in private practicecommand upwards of $100 an hour!

This is rarely the case. Many of the physical improvements involve upgrades or repairs to existing facility or equipment. Other loss controlinitiatives, such as safety programs for employees, often cost nothing. Using our experience, we can provide guidance, materials and trainingtailored to your exact requirements.

Policyholders usually welcome all cost-saving recommendations; but these are recommendations, not requirements. For both loss reductionand prevention, your Loss Control Specialist can assist you each step of the way. Many business owners accept all recommendations, butdevelop their own action plans to implement the most cost-effective recommendations first.

Driver and fleet safety programs.Ergonomic surveys to maximize employee productivity, while reducing strain injuries.Safety program development including presentations to your staff and training using our video library and other safety materials.Physical site surveys to locate areas that pose risks.

It begins with a thorough interview and physical survey of your business sites, equipment and work procedures by an American Family LossControl Specialist. Surveys are customized for each individual business. Depending on your situation, your survey could include:

General liability hazards exposing customers or visitors to harm.

To name just a few:

Virtually every business that has committed to a cooperative effort with American Family’s Loss Control Specialists has received measurable,bottom-line benefits including a drop in the costs of accidents and employee injuries. Many feel that the control measures they adopted alsosaved them from many uninsured losses.

Page 1 of 2

Criminal activity including burglary, robbery or employee theft.Fire hazards to buildings and equipment.Employee injuries from workplace conditions and procedures.

Injuries to customers from your products or services.

Follow-up visits as needed. We’ll provide you with information, including measures you can take to avoid potential injuries, accidentsor other expensive damage.

LOSS CONTROL SERVICES:WHAT BUSINESS OWNERS ARE ASKING

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CONTROL LOSSES, SAVE MONEY, PROTECT PEOPLE

NOTE: Recommendations are developed using generally accepted safety standards. Compliance with recommendations is not aguarantee that you will be in conformance with any building code or federal, state or local regulation regarding safety or fire.Compliance with recommendations does not ensure the absolute safety of your operation or business. It is the property owner’s dutyto warn any tenants or occupants of the property about the safety hazards that may exist.

Ask your American Family agent how Loss Control Services can assist with safety and security, build business stature among employees andcustomers and increase savings potential. It’s a tool no successful business should be without.

Such cost control should include your business insurance coverage as well. American Family wants you to receive the protection you need atthe lowest possible expense. That’s why we offer our Loss Control Services at no charge to business owners.

American Family Loss Control Services:they’re FREE, they’re easy to use...and they work.

Today!

WHEN CAN I START?

When you add the importance to employees and customers of a safe, secure place to work or shop, American Family’s free Loss ControlServices are a winning proposition for any business!

Premiums are only the beginning. The National Safety Council estimates that for every dollar business owners collect in worker’s compclaims, at least eight more are lost in uninsured expenses such as time taken to train an injured employee’s substitute, or productivity lostwaiting to replace key equipment destroyed by fire. An ounce of loss prevention can save a ton of loss expenses down the line.

It’s a simple truth of insurance: reducing losses such as property damage or on-site injuries helps lower premiums. The more a businessreduces potential exposure, the greater the opportunity for cost benefits.

It’s that simple. You’re a successful business owner. You know that profitability depends on not only what you make, or what service youperform, but how much you save on expenses in the process. From financing to facilities, manufacturing to marketing, you work hard tomake sure that you’re not wasting money...anywhere.

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IMPORTANT INFORMATION ---- PLEASE READ!!!!Policyholder Audit Information

WHAT IS A PREMIUM AUDIT?

When your policy is issued, you pay an estimated annual premium based on the type of business you perform and your estimateof the exposure (i.e. payroll, sales, employee months, etc.) for the policy period. A review of your records at the end of the policyperiod, called the premium audit, allows American Family Insurance to adjust your premium based on actual operations duringthat time. Your final earned premium is determined from the audit information.

WHY IS A PREMIUM AUDIT IMPORTANT?

Your initial policy premium is based on your estimate of your business operations for the policy period. The final policy premiumis not determined until after your insurance audit. If your estimates are low, your deposit premium will be low and you will pay anadditional premium after the audit. Likewise, overestimating your operations for the coming year will cause your deposit premiumto be high, tying up your money until it is refunded after the audit.

WHEN AND HOW WILL THE AUDIT BE DONE?

Audit information will be collected at the end of your policy period. For new business with premium in excess of $10,000, wecollect audit information within the first 60 days, and then again at the end of your policy period.

American Family conducts three different types of audits:

Physical Audit - A representative from either American Family or an outside audit firm hired by American Family will reviewyour records (tax reports, payroll, certificates of insurance, etc.). This type of audit takes approximately 30 minutes to twohours to complete.

Mail Audit - We will send you a form to complete and return to us in a timely fashion

Telephone Audit - An outside company will contact you or your bookkeeper to obtain the necessary information tocomplete the audit.

WHAT RECORDS DO I NEED TO COMPLETE THE AUDIT?

Ledgers, journals, vouchers, contracts, tax reports, profit and loss statements and payroll and disbursement records should giveus accurate payroll, sales and subcontracted costs. If you use subcontractors, it is very important you keep Certificates ofInsurance for each. Keeping detailed records may help you save money.

DO I NEED A CERTIFICATE OF INSURANCE FOR EACH SUBCONTRACTOR I USE?

ALWAYS keep current Certificates of Insurance for ALL subcontractors you hire. Without these certificates, you may becharged as though the subcontractors workers were your own employees increasing your premium charge.

HOW CAN I SAVE MONEY?

Keeping detailed records is the best way to make sure your premium is accurate. The following ideas may also help:

Make sure the classification on your policy describes your operations. If not, contact your American Family agent to have itcorrected.

Keep payroll records based on the type of work the employee actually performs. Without adequate records, the entirepayroll for the employee may be charged to the highest rated classification, depending on your state s requirements.

Deduct overtime only if it is summarized monthly or quarterly by employee or classification.

Exclude employee tips from gross payroll if they are separately identified.

Maintain records of the total cost and the time taken for all work let or sublet in connection with each specific project,including the cost of all labor, materials and equipment furnished, used or delivered to complete the project. Require yoursubcontractors to carry liability limits at least equal to your policy limits.

Have certificates available for the audit to ensure charges are not made unnecessarily. Remember, Certificates ofInsurance must cover the period when the subcontractor(s) worked for you.

Includes copyrighted materialPR-06287 Rev. 2/10 1995, 1997 National Council on Compensation Insurance Inc. Page 1 of 2

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WHAT SHOULD AND SHOULD NOT BE INCLUDED IN GROSS PAYROLL FIGURES?

Gross Payroll Includes:* Gross Payroll Does Not Include:*

Wages Tips and other gratuities received by employeesSalaries, including retroactive wages or salaries An employer’s payments to group insurance or pension

plansIncentive plansValue of special rewards for individual invention orSick paydiscoveryVacation payDismissal or severance payments (except for timeHoliday payworked or accrued vacation)Employer obligations for insurance or pension plans suchPayments for active military dutyas social security or Medicare.Employee discounts on good purchased from theTotal cash received by employees for commissions andemployee s employerdraws against commissionsSupper money for late workProfit sharingWork uniform allowancesPiece workEmployer-provided perks such as: use of an auto, anExtra provisions for overtimeairplane flight, an incentive vacation, discount on propertyEmployee hand or power tools used by hand provided byor services, club memberships, or tickets to entertainmentemployees either directly or through a third partyeventsCredits or any substitute for money receivedEmployer contributions to salary reduction, employeeRental value of an apartment or a house providedsaving plans, retirement or cafeteria plans (IRC 125)Bonuses including stock bonus plansExpense reimbursements to employees if the reimbursedAnnuity plansexpenses were incurred while conducting the business ofValue of store certificates, merchandise, credits or anythe employer, the amount of said expenses is shownsubstitute for money received.separately in the records of the employer and the amountExpense reimbursements to employees to the extent thatof reimbursement approximates the actual expensean employer s records do not confirm that the expenseincurred by the employee in the conduct of his or herwas incurred as a valid business expenseworkPayment for filming of commercials excluding subsequentSick pay paid to an employee by a third party such as anresiduals which are earned by the commercial sinsured’s group insurance carrier that is paying disabilityparticipant(s) each time the commercial appears in printincome benefits to a disabled employee.or is broadcast

MerchandiseValue of meals and lodging received as part of anemployee’s payPayments for salary reduction, employee savings plans,retirement or cafeteria plans (IRC 125) made throughdeductions

Your business is unique! If you have questions about how your specific circumstances affect premium, please contact yourAmerican Family Insurance agent.

Please note that if there is any conflict between the policy and this information, the provisions of the policy will prevail. If you havequestions about how your specific circumstances may affect your premium, please contact your American Family agent.

*May not apply to all states.AMERICAN FAMILY MUTUAL INSURANCE COMPANY

AMERICAN FAMILY INSURANCE COMPANYIncludes copyrighted material

PR-06287 Rev. 2/10 1995, 1997 National Council on Compensation Insurance Inc. Page 2 of 2

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WC 00 00 00 A (Ed. 4-92) Stock No. 05670 Rev. 1/94

Contains copyrighted material of the National Council on Compensation InsuranceCopyright 1991, National Council on Compensation Insurance

Member of American Family Insurance Group

AMERICAN FAMILY MUTUAL INSURANCE COMPANY6000 American Pky

Madison WI 53783-0001(608) 249-2111

Non-assessable policy Issued by

WORKERS COMPENSATION

AND

EMPLOYERS LIABILITY

INSURANCE POLICY

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45555

4

4444444

4

4

33

3

222333333

11111122

i


This Quick Reference is not part of the Workers Compensation and Employers Liability Policy and does notprovide coverage. Refer to the Workers Compensation and Employers Liability Policy itself for actual contractualprovisions.

Information PageGeneral Section

A.B.C.D.E.

PART ONE - WORKERS COMPENSATION INSURANCEA.B.C.D.E.F.G.H.

How This Insurance AppliesWe Will PayWe Will DefendWe Will Also PayOther InsurancePayments You Must MakeRecovery From OthersStatutory Provisions

PART TWO - EMPLOYERS LIABILITY INSURANCEA.B.C.D.E.F.G.H.I.

How This Insurance AppliesWe Will PayExclusionsWe Will DefendWe Will Also PayOther InsuranceLimits of LiabilityRecovery From OthersActions Against Us

PART THREE - OTHER STATES INSURANCEHow This Insurance AppliesNotice

PART FOUR - YOUR DUTIES IF INJURY OCCURS

PART FIVE - PREMIUMA.B.C.D.E.F.G.

Our ManualsClassificationsRemunerationPremium PaymentsFinal PremiumRecordsAudit

PART SIX - CONDITIONSInspectionLong Term PolicyTransfer of Your Rights and DutiesCancelationSole Representative

A.B.C.D.E.

BEGINNING ONPage

1

1

A.B.

IMPORTANT:

11111

The PolicyWho is InsuredWorkers Compensation LawStateLocations

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICYQUICK REFERENCE

PLEASE READ THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CAREFULLY.

2

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AMERICAN FAMILY MUTUAL INSURANCE COMPANY

CUSTOMER BILLING ACCOUNT

05 XE7664-91-0011 0011-BLWC-CO 012-122-894 16

05XE7664910010

140-309 10/13/2011

KEITH D MONTEY JR AGENCY, INC. MIDLAND REGIONAL OFFICETRD 02-123011 W 10TH ST STE 112 4802 MITCHELL AVENUE

GREELEY CO 80634-5300 ST. JOSEPH MO 64507-2500

01

INSUREDWC 00 00 01 A (STANDARD) ED. 5-88 Stock No. 06436 Rev. 07/08

MADISON, WISCONSIN 53783-0001WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

INFORMATION PAGE

COMPANY CODEPOLICY NUMBER

PREVIOUS POLICY NUMBER

Entry Date Branch 001AGENT ISSUING OFFICE

Copyright 1987 National Council on Compensation Insurance Page

15873 FEDERAL EMPLOYER ID NO.CARRIER NUMBER

WEST FORK VILLAGE OWNERS ASSOC 7530857811. NAMEDINSURED

5775 W 29TH ST UNIT 1601GREELEY CO 80634-8340

MAILINGADDRESS

CORPORATIONFORM OF BUSINESS

CO621579008UNEMPLOYMENT ACCOUNT ID NO.

5775 W 29TH ST STE 1601

OTHER WORKPLACES NOT SHOWN ABOVE

GREELEY CO 80634

12/02/2011 12/02/2012 12:01 AM STANDARD TIME AT THE INSURED’S MAILING ADDRESSPOLICY PERIOD

TO2.

FROM

COLORADO

3. COVERAGE

A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION LAW OF THESTATES LISTED HERE:

500,000500,000500,000

EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3.A. THELIMITS OF OUR LIABILITY UNDER PART TWO ARE:

B.

BODILY INJURY BY ACCIDENTBODILY INJURY BY DISEASE $

$ EACH ACCIDENTEACH EMPLOYEEPOLICY LIMIT$BODILY INJURY BY DISEASE

C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY, LISTED HERE:

ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING AND STATES DESIGNATED IN ITEM 3.A. OFTHE INFORMATION PAGE.

WC 00 00 00 A WC 00 04 14 WC 05 04 02 WC 00 04 19 WC 00 04 22 A

D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES:

WC 00 04 21 C WC 05 04 03

PREMIUM4.THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES AND RATINGPLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT.

ESTIMATEDTOTAL ESTIMATEDCODEREMUNERATION

RATE PERNUMBER PREMIUM BASIS $100 PREMIUMCLASSIFICATIONS

COLORADO

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AMERICAN FAMILY MUTUAL INSURANCE COMPANY

CUSTOMER BILLING ACCOUNT

05 XE7664-91-0011 0011-BLWC-CO 012-122-894 16

05XE7664910010

140-309 10/13/2011

KEITH D MONTEY JR AGENCY, INC. MIDLAND REGIONAL OFFICETRD 02-123011 W 10TH ST STE 112 4802 MITCHELL AVENUE

GREELEY CO 80634-5300 ST. JOSEPH MO 64507-2500

02

INSUREDWC 00 00 01 A (STANDARD) ED. 5-88 Stock No. 06436 Rev. 07/08

MADISON, WISCONSIN 53783-0001WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

INFORMATION PAGE

COMPANY CODEPOLICY NUMBER

PREVIOUS POLICY NUMBER

Entry Date Branch 001AGENT ISSUING OFFICE

Copyright 1987 National Council on Compensation Insurance Page

5775 W 29TH ST STE 1601GREELEY CO 80634

000002561110

Number of EmployeesSIC Code

CLERICAL OFFICE EMPLOYEES NOC 8810 $39,224 .26 $102.00

BUILDINGS - OPERATION BY OWNER, LESSEE 9015 $15,000 4.38 $657.00OR REAL ESTATE MANAGEMENT FIRM: ALLOTHER EMPLOYEES

ADDITIONAL PREMIUM FOR EMPLOYERS 9807 $13.00LIABILITY INCREASED LIMITS

EXPENSE CONSTANT 0900 $180.00

ADDITIONAL PREMIUM REQUIRED TO BALANCE 9848 $87.00MIN PREM FOR EMPL LIAB INCREASED LIMITS

DESIGNATED MEDICAL PROVIDER PREMIUM 9874 $21.00-CREDIT

PREMIUM CREDIT FOR EMPLOYEE REHIRE 9899 $0.00

CAT PROVISION FOR TERRORISM 9740 $11.00

CAT PROVISION FOR CATASTROPHE 9741 $11.00

COLORADO $1,040.00TOTAL ESTIMATED PREMIUM FOR

$728.00 $1,040.00POLICY MINIMUM PREMIUM TOTAL ESTIMATED POLICY PREMIUM

AUTHORIZED COUNTERSIGNEDREPRESENTATIVE LICENSED RESIDENT AGENT

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Copyright 1991 National Council on Compensation Insurance.

This policy covers all of your workplaces listed in Items 1 or 4of the Information Page; and it covers all other workplaces inItem 3.A. states unless you have other insurance or areself-insured for such workplaces.

We will not pay more than our share of benefits and costscovered by this insurance and other insurance or self-insurance. Subject to any limits of liability that may apply, allshares will be equal until the loss is paid. If any insurance orself-insurance is exhausted, the shares of all remaining insur-ance will be equal until the loss is paid.

Bodily injury by disease must be caused or aggravated bythe conditions of your employment. The employee’s lastday of last exposure to the conditions causing or aggra-vating such bodily injury by disease must occur during thepolicy period.

PART ONE - WORKERS COMPENSATION INSURANCE

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

ÿ

WC 00 00 00 A (Ed. 4-92)

In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows.

GENERAL SECTION

A.

B. Who Is InsuredYou are insured if you are an employer named in Item 1 of theInformation Page. If that employer is a partnership, and if youare one of its partners, you are insured, but only in yourcapacity as an employer of the partnership’s employees.

C. Workers Compensation LawWorkers Compensation Law means the workers or workmen’scompensation law and occupational disease law of each state

D. StateState means any state of the United States of America, and theDistrict of Columbia.

E. Locations

This policy includes at its effective date the Information Pageand all endorsements and schedules listed there. It is acontract of insurance between you (the employer named inItem 1 of the Information Page) and us (the insurer named onthe Information Page). The only agreements relating to thisinsurance are stated in this policy. The terms of this policy maynot be changed or waived except by endorsement issued by usto be part of this policy.

or territory named in Item 3.A. of the Information Page. Itincludes any amendments to that law which are in effectduring the policy period. It does not include any federal workersor workmen’s compensation law, any federal occupationaldisease law or the provisions of any law that provide non-occupational disability benefits.

A.

The Policy

This workers compensation insurance applies to bodily injuryby accident or bodily injury by disease. Bodily injury includesresulting death.1. Bodily injury by accident must occur during the policy

period.2.

B. We Will PayWe will pay promptly when due the benefits required of you bythe workers compensation law.

We Will DefendWe have the right and duty to defend at our expense anyclaim, proceeding or suit against you for benefits payable bythis insurance. We have the right to investigate and settle theseclaims, proceedings or suits.We have no duty to defend a claim, proceeding or suit that isnot covered by this insurance.

D. We Will Also PayWe will also pay these costs, in addition to other amountspayable under this insurance, as part of any claim, proceedingor suit we defend:1. reasonable expenses incurred at our request, but not loss

of earnings;

2. premiums for bonds to release attachments and for appealbonds in bond amounts up to the amount payable underthis insurance;

3. litigation costs taxed against you;interest on a judgment as required by law until we offer theamount due under this insurance; and

5. expenses we incur.

C.

4.

E. Other Insurance

F. Payments You Must MakeYou are responsible for any payments in excess of the benefitsregularly provided by the workers compensation law includingthose required because:1. of your serious and willful misconduct;

you knowingly employ an employee in violation of law;3. you fail to comply with a health or safety law or regulation;

or4. you discharge, coerce or otherwise discriminate against any

employee in violation of the workers compensation law.

If we make any payments in excess of the benefits regularlyprovided by the workers compensation law on your behalf, youwill reimburse us promptly.

2.

How This Insurance Applies

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Stock No. 04071

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bodily injury to any person in work subject to the FederalEmployers’ Liability Act (45 USC Sections 51-60), anyother federal laws obligating an employer to pay damagesto an employee due to bodily injury arising out of or in thecourse of employment, or any amendments to those laws;


bodily injury to any person in work subject to the Long-shore and Harbor Workers’ Compensation Act (33 USCSections 901-950), the Nonappropriated Fund Instru-mentalities Act (5 USC Sections 8171-8173), the OuterContinental Shelf Lands Act (43 USC Sections 1331-1356),the Defense Base Act (42 USC Sections 1651-1654), theFederal Coal Mine Health and Safety Act of 1969 (30 USCSections 901-942), any other federal workers or workmen’scompensation law or other federal occupational diseaselaw, or any amendments to these laws;

Nothing in these paragraphs relieves you of your duties underthis policy.

Stock No. 04071

Terms of this insurance that conflict with the workers com-pensation law are changed by this statement to conform tothat law.

WC 00 00 00 A (Ed. 4-92)

Bodily injury by disease must be caused or aggravated bythe conditions of your employment. The employee’s lastday of last exposure to the conditions causing or aggra-vating such bodily injury by disease must occur during thepolicy period.

any obligation imposed by a workers compensation, occu-pational disease, unemployment compensation, or disabilitybenefits law, or any similar law;

a.

damages arising out of coercion, criticism, demotion, eval-uation, reassignment, discipline, defamation, harassment,humiliation, discrimination against or termination of anyemployee, or any personnel practices, policies, acts oromissions;

PART TWO - EMPLOYERS LIABILITY INSURANCE

This insurance conforms to the parts of the workers com-pensation law that apply to:

ÿ

G. Recovery From OthersWe have your rights, and the rights of persons entitled to thebenefits of this insurance, to recover our payments fromanyone liable for the injury. You will do everything necessary toprotect those rights for us and to help us enforce them.

H. Statutory ProvisionsThese statements apply where they are required by law.

As between an injured worker and us, we have notice ofthe injury when you have notice.

2. Your default or the bankruptcy or insolvency of you or yourestate will not relieve us of our duties under this insuranceafter an injury occurs.

We are directly and primarily liable to any person entitled tothe benefits payable by this insurance. Those persons mayenforce our duties; so may an agency authorized by law.Enforcement may be against us or against you and us.

4. Jurisdiction over you is jurisdiction over us for purposes ofthe workers compensation law. We are bound by decisionsagainst you under that law, subject to the provisions of thispolicy that are not in conflict with that law.

5.

b. special taxes, payments into security or other specialfunds, and assessments payable by us under that law.

6.

3.

1.

A.This employers liability insurance applies to bodily injury byaccident or bodily injury by disease. Bodily injury includesresulting death.

1. The bodily injury must arise out of and in the course of theinjured employee’s employment by you.

2. The employment must be necessary or incidental to yourwork in a state or territory listed in Item 3.A. of theInformation Page.

Bodily injury by accident must occur during the policyperiod.

4.

5. If you are sued, the original suit and any related legalactions for damages for bodily injury by accident or bydisease must be brought in the United States of America,its territories or possessions, or Canada.

We Will PayWe will pay all sums you legally must pay as damages becauseof bodily injury to your employees, provided the bodily injury iscovered by this Employers Liability Insurance.The damages we will pay, where recovery is permitted by law,include damages:

1. for which you are liable to a third party by reason of aclaim or suit against you by that third party to recover thedamages claimed against such third party as a result ofinjury to your employee;

2. for care and loss of services; and3. for consequential bodily injury to a spouse, child, parent,

brother or sister of the injured employee;

C. ExclusionsThis insurance does not cover:1. liability assumed under a contract. This exclusion does not

apply to a warranty that your work will be done in aworkmanlike manner;

punitive or exemplary damages because of bodily injury toan employee employed in violation of law;

bodily injury to an employee while employed in violation oflaw with your actual knowledge or the actual knowledge ofany of your executive officers;

4.

5. bodily injury intentionally caused or aggravated by you;6. bodily injury occurring outside the United States of

America, its territories or possessions, and Canada. Thisexclusion does not apply to bodily injury to a citizen orresident of the United States of America or Canada who istemporarily outside these countries;

8.

7.

3.

2.

3.

B.

benefits payable by this insurance;

ÿ

because of bodily injury to your employee that arises out ofand in the course of employment, claimed against you in acapacity other than as employer.

4.


9.

10. bodily injury to a master or member of the crew of anyvessel;

Page 2 of 5

provided that these damages are the direct consequence ofbodily injury that arises out of and in the course of the injuredemployee’s employment by you; and

244 05 XE7664-91-0011 001 TRD


We have the right and duty to defend, at our expense, anyclaim, proceeding or suit against you for damages payable bythis insurance. We have the right to investigate and settle theseclaims, proceedings and suits.

Bodily Injury by Disease. The limit shown for "bodily injuryby disease-policy limit" is the most we will pay for alldamages covered by this insurance and arising out ofbodily injury by disease, regardless of the number of em-ployees who sustain bodily injury by disease. The limitshown for "bodily injury by disease-each employee" is themost we will pay for all damages because of bodily injuryby disease to any one employee.

A disease is not bodily injury by accident unless it resultsdirectly from bodily injury by accident.

Bodily Injury by Accident. The limit shown for "bodilyinjury by accident-each accident" is the most we will payfor all damages covered by this insurance because of bodilyinjury to one or more employees in any one accident.

damages payable under the Migrant and SeasonalAgricultural Worker Protection Act (29 USC Sections1801-1872) and under any other federal law awardingdamages for violation of those laws or regulations issuedthereunder, and any amendments to those laws.

Page 3 of 5

Stock No. 04071

We will reimburse you for the benefits required by theworkers compensation law of that state if we are not

The amount you owe has been determined with our con-sent or by actual trial and final judgment.

are shown in Item 3.B. of the Information Page. They apply asexplained below.

If you have work on the effective date of this policy in anystate not listed in Item 3.A. of the Information Page, cover-age will not be afforded for that state unless we are notifiedwithin thirty days.

We will not pay more than our share of damages and costscovered by this insurance and other insurance or self-insurance. Subject to any limits of liability that apply, all shareswill be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insuranceand self-insurance will be equal until the loss is paid.

ÿ

We Will Defend

We have no duty to defend a claim, proceeding or suit that isnot covered by this insurance. We have no duty to defend orcontinue defending after we have paid our applicable limit ofliability under this insurance.

E. We Will Also PayWe will also pay these costs, in addition to other amountspayable under this insurance, as part of any claim, proceedingor suit we defend:

1. reasonable expenses incurred at our request; but not lossof earnings;

2. premiums for bonds to release attachments and for appealbonds in bond amounts up to the limit of our liability underthis insurance;

3. litigation costs taxed against you;4. interest on a judgment as required by law until we offer the

amount due under this insurance; and

5. expenses we incur.

Other InsuranceF.

D.

G. Limits of LiabilityOur liability to pay for damages is limited. Our limits of liability

1.

Bodily injury by disease does not include disease thatresults directly from a bodily injury by accident.

3. We will not pay any claims for damages after we have paidthe applicable limit of our liability under this insurance.

H. Recovery From OthersWe have your rights to recover our payment from anyone liablefor an injury covered by this insurance. You will do everythingnecessary to protect those rights for us and to help us enforcethem.

This insurance does not give anyone the right to add us as adefendant in an action against you to determine your liability.The bankruptcy or insolvency of you or your estate will notrelieve us of our obligations under this Part.

I. Actions Against UsThere will be no right of action against us under insuranceunless:1. You have complied with all the terms of this policy; and2.

This insurance does not give anyone the right to add us as adefendant in an action against you to determine your liability.The bankruptcy or insolvency of you or your estate will notrelieve us of our obligations under this Part.

PART THREE - OTHER STATES INSURANCE

2.

A.1. This other states insurance applies only if one or more

states are shown in Item 3.C. of the Information Page.

2. If you begin work in any one of those states after theeffective date of this policy and are not insured or are notself-insured for such work, all provisions of the policy willapply as though that state were listed in Item 3.A. of theInformation Page.

3.

4.

B. NoticeTell us at once if you begin work in any State listed in Item 3.C. ofthe Information Page.


ÿ

WC 00 00 00 A (Ed. 4-92)

permitted to pay the benefits directly to persons entitled tothem.

fines or penalties imposed for violation of federal or statelaw; and

11.

12.

244 05 XE7664-91-0011 001 TRD


estimated, premium basis and the proper classifications andrates that lawfully apply to the business and work covered bythis policy. If the final premium is more than the premium youpaid to us, you must pay us the balance. If it is less, we willrefund the balance to you. The final premium will not be lessthan the highest minimum premium for the classificationscovered by this policy.

If you cancel, final premium will be more than pro rata; itwill be based on the time this policy was in force, andincreased by our short rate cancellation table and proced-ure. Final premium will not be less than the minimumpremium.

Page 4 of 5

We have the right, but are not obliged to inspect yourworkplaces at any time. Our inspections are not safetyinspections. They relate only to the insurability of the work-places and the premiums to be charged. We may give youreports on the conditions we find. We may also recommendchanges. While they may help reduce losses, we do not

PART SIX - CONDITIONS

Item 4 of the Information Page shows the rate and premiumbasis for certain business or work classifications. These classifi-cations were assigned based on an estimate of the exposuresyou would have during the policy period. If your actualexposures are not properly described by those classifications,we will assign proper classifications, rates and premium basisby endorsement to this policy.

The premium shown on the Information Page, schedules, andendorsements is an estimate. The final premium will be deter-mined after this policy ends by using the actual, not the

PART FIVE - PREMIUM

Cooperate with us and assist us, as we may request, in theinvestigation, settlement or defense of any claim, proceed-ing or suit.

Stock No. 04071WC 00 00 00 A (Ed. 4-92)

Tell us at once if injury occurs that may be covered by this policy.Your other duties are listed here.

5.

4.

Promptly give us all notices, demands and legal papersrelated to the injury, claim, proceeding or suit.

3.

Give us or our agent the names and addresses of theinjured persons and of witnesses, and other information wemay need.

2.

Provide for immediate medical and other services requiredby the workers compensation law.

1.Do nothing after an injury occurs that would interfere withour right to recover from others.

6. Do not voluntarily make payments, assume obligations orincur expenses, except at your own cost.

A. Our ManualsAll premium for this policy will be determined by our manualsof rules, rates, rating plans and classifications. We may changeour manuals and apply the changes to this policy if authorizedby law or a governmental agency regulating this insurance.

B. Classifications

RemunerationC.Premium for each work classification is determined bymultiplying a rate times a premium basis. Remuneration is themost common premium basis. This premium basis includespayroll and all other remuneration paid or payable during thepolicy period for the services of:

1. all your officers and employees engaged in work coveredby this policy; and

2. all other persons engaged in work that could make us liableunder Part One (Workers Compensation Insurance) of thispolicy. If you do not have payroll records for these persons,the contract price for their services and materials may beused as the premium basis. This paragraph 2 will not applyif you give us proof that the employers of these personslawfully secured their workers compensation obligations.

D. Premium PaymentsYou will pay all premium when due. You will pay the premiumeven if part or all of a workers compensation law is not valid.

E. Final Premium

If this policy is canceled, final premium will be determined inthe following way unless our manuals provide otherwise.1. If we cancel, final premium will be calculated pro rata

based on the time this policy was in force. Final premiumwill not be less than the pro rata share of the minimumpremium.

2.

F. RecordsYou will keep records of information needed to computepremium. You will provide us with copies of those recordswhen we ask for them.

G. AuditYou will let us examine and audit all your records that relate tothis policy. These records include ledgers, journals, registers,vouchers, contracts, tax reports, payroll and disbursementrecords, and programs for storing and retrieving data. We mayconduct the audits during regular business hours during thepolicy period and within three years after the policy periodends. Information developed by audit will be used to determinefinal premium. Insurance rate service organizations have thesame rights we have under this provision.

A. Inspection undertake to perform the duty of any person to provide for thehealth or safety of your employees or the public. We do notwarrant that your workplaces are safe or healthful or that theycomply with laws, regulations, codes or standards. Insurancerate service organizations have the same rights we have underthis provision.

ÿ

PART FOUR - YOUR DUTIES IF INJURY OCCURS

244 05 XE7664-91-0011 001 TRD


We may cancel this policy. We must mail or deliver to younot less than ten days advance written notice stating whenthe cancellation is to take effect. Mailing that notice to youat your mailing address shown in item 1 of the InformationPage will be sufficient to prove notice.

Stock No. 04071

Any of these provisions that conflict with a law that con-trols the cancellation of the insurance in this policy ischanged by this statement to comply with that law.

If the policy period is longer than one year and sixteen days, allprovisions of this policy will apply as though a new policy wereissued on each annual anniversary that this policy is in force.

WC 00 00 00 A (Ed. 4-92)

B. Long Term Policy

C. Transfer Of Your Rights And DutiesYour rights or duties under this policy may not be transferredwithout our written consent.If you die and we receive notice within thirty days after yourdeath, we will cover your legal representative as insured.

D. Cancellation1. You may cancel this policy. You must mail or deliver

advance written notice to us stating when the cancellationis to take effect.

2.

3. The policy period will end on the day and hour stated in thecancellation notice.

4.

E. Sole RepresentativeThe insured first named in Item 1 of the Information Page willact on behalf of all insureds to change this policy, receivereturn premium, and give or receive notice of cancellation.

Page 5 of 5

244 05 XE7664-91-0011 001 TRD

2.5% DESIGNATED MEDICAL PROVIDER

12/02/2011 05 XE7664-91-0011

WEST FORK VILLAGE OWNERS ASSOCKEITH D MONTEY JR AGENCY, INC. 140-309

15873 - AMERICAN FAMILY MUTUAL INSURANCE COMPANY

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 05 04 03(Ed. 3-93)

COLORADO PREMIUM CREDIT FOR CERTIFIED RISK MANAGEMENT

PROGRAMS ENDORSEMENT

Schedule

% Premium Credit Certified Risk Management Program/Designated Medical Provider

This endorsement applies to Part One (Workers Compensation Insurance) because Colorado is listed in Item 3.A. of the Information Page.

The Colorado Workers Compensation Cost Containment Board has determined that a premium differential shall be provided on all policieswhen you have selected a designated medical provider.

If you qualify for experience and/or schedule rating and you have implemented a certified workers compensation risk management programor service, we must allow a 5% premium credit if your loss experience has improved since your last renewal date. The Schedule will indicateif you qualify for this credit.

If you do not qualify for experience and/or schedule rating on your workers compensation insurance and you have implemented a certifiedworkers compensation risk management program or service, we must offer premium credits as follows:

Premium Credit Credit Criteria

If you have been loss free for at least the last year immediately preceding the effective date of10%the premium credit.

If you have had one medical loss exceeding $250 in the last year immediately preceding the8%effective date of the premium credit.

If you have had two medical losses, each exceeding $250, within the last year immediately6%preceding the effective date of the premium credit.

If you have had three medical losses, each exceeding $250, within the last year immediately4%preceding the effective date of the premium credit.

If you have had three medical losses, each exceeding $250, and one claim for loss of time in2%the last year immediately preceding the effective date of the premium credit.

If you have had more than three medical losses and one claim for loss of time in the last0%year immediately preceding the effective date of the premium credit.

If you have selected a designated medical provider, we must allow a credit of 2.5%. If you are eligible for schedule rating, the 2.5% creditmust be included in the total schedule credit or debit, subject to the 25% maximum limitation.

If you are not eligible for experience or schedule rating, the 2.5% credit will be applied, in addition to the premium credit applicable. Thecombined premium credit and the 2.5% credit for selection of a designated medical provider shall not exceed 12.5%.

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective Policy No. Endorsement No. Premium $

Insured Countersigned by

Insurance Company

WC 05 04 03Copyright 1993, National Council on Compensation Insurance, Inc.(Ed. 3-93) Stock No. 00385

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NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT

Experience rating is mandatory for all eligible insureds. The experience rating m odification factor, if any, applicable to this policy, may changeif there is a change in your ownership or in that of one or more of the entities eligible to be combined with you for experience ratingpurposes. Change in ownership includes sales, purchases, other transfers, mergers, consolidations, dissolutions, formations of a new entityand other changes provided for in the applicable experience rating plan manual.

You must report any change in ownership to us in writing within 90 days of such change. Failure to report such changes within this periodmay result in revision of the experience rating modification factor used to determine your premium.





Insurance Company

WC 00 04 14Copyright 1990 National Council on Compensation Insurance.(Ed. 7-90) Stock No. 04003

244 05 XE7664-91-0011 001 TRD

12/02/2011 05 XE7664-91-0011




COLORADO CLASSIFICATION ENDORSEMENT

This endorsement applies only to the insurance provided by Part One (Workers Compensation Insurance) because Colorado is shown in Item3.A. of the Information Page.

Section B. Classifications of Part Five (Premium) is amended by adding the foll owing:

The assignment of a proper classification resulting in higher premium is allowed only if the misclassification was caused by your failure toprovide accurate or complete data. If your operation changes during the policy term, you must notify us within ninety days of the change.Failure to notify us will be considered a failure to provide accurate or comp lete data.

Section E. Final Premium of Part Five is amended by adding this sentence at the end of the first paragraph:

Payments to us or to you based on improper classification may be collected or refunded during the term of the policy and for twelve monthsafter the term.





Insurance Company

WC 05 04 02Copyright 1990 National Council on Compensation Insurance.(Ed. 11-90) Stock No. 04005

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12/02/2011 05 XE7664-91-0011




PREMIUM DUE DATE ENDORSEMENT

This endorsement is used to amend:

Section D. of Part Five of the policy is replaced by this provision.

PART FIVE

PREMIUM

D. Premium is amended to read:

You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. The duedate for audit and retrospective premiums is the date of the billing.





Insurance Company

WC 00 04 19Copyright 2000 National Council on Compensation Insurance, Inc.(Ed. 1-01) Stock No. 18700

244 05 XE7664-91-0011 001 TRD

WC 00 04 22 A(Ed. 9-08)

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT

SCHEDULE

State Rate Premium

See Policy Declarations

This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the TerrorismRisk Insurance Program Reauthorization Act of 2007. It serves to notify you of certain limitations under the Act, and that your insurancecarrier is charging premium for losses that may occur in the event of an Act of Terrorism.

Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefitobligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy,and any applicable federal and/or state laws, rules, or regulations.

Definitions

The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases notdefined in this endorsement are defined in the Act, the definitions in the Act will apply.

Act means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto resultingfrom the Terrorism Risk Insurance Program Reauthorization Act of 2007.

Act of Terrorism means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, and theAttorney General of the United States as meeting all of the following requirements:

a. The act is an act of terrorism.b. The act is violent or dangerous to human life, property, or infrastructure.c. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States

missions or certain air carriers or vessels.d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United

States or to influence the policy or affect the conduct of the United States Government by coercion.

Insured Loss means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case ofworkers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in theUnited States or at the premises of United States missions or to certain air carriers or vessels.

Insurer Deductible means, for the period beginning on January 1, 2008, and ending on December 31, 2014, an amount equal to 20% ofour direct earned premiums, over the calendar year immediately preceding the applicable Program Year.

Program Year refers to each calendar year between January 1, 2008 and December 31, 2014, as applicable.

Limitation of LiabilityThe Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a Program Year and if we havemet our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds$100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rata share of such Insured Losses asdetermined by the Secretary of the Treasury.

WC 00 04 22 A Page 1 of 2(Ed. 9-08) Copyright 2008 National Council on Compensation Insurance Inc., All Rights Reserved. Stock No. 26024

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WEST FORK VILLAGE OWNERS ASSOC

KEITH D MONTEY JR AGENCY, INC. 140-309


Policyholder Disclosure Notice

1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses exceed$100,000,000 in a Program Year, the United States Government would pay 85% of our Insured Losses that exceed our InsurerDeductible.

2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of InsuredLosses that exceed $100,000,000,000.

3. The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in Item 4 of theInformation Page or in the Schedule above.

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)



Insurance Company

WC 00 04 22 A Page 2 of 2(Ed. 9-08) Copyright 2008 National Council on Compensation Insurance Inc., All Rights Reserved. Stock No. 26024

244 05 XE7664-91-0011 001 TRD

12/02/2011 05 XE7664-91-0011

WEST FORK VILLAGE OWNERS ASSOC

KEITH D MONTEY JR AGENCY, INC. 140-309


WC 00 04 21 C(Ed. 9-08)

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICYCATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT

SCHEDULE

State PremiumRate

See Policy Declarations

This endorsement is notification that your insurance carrier is charging premium to cover the losses that may occur in the event of aCatastrophe (other than Certified Acts of Terrorism) as that term is defined below. Your policy provides coverage for workers compensationlosses caused by of a Catastrophe (other than Certified Acts of Terrorism). This premium charge does not provide funding for Certified Actsof Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 A),attached to this policy.

For purposes of this endorsement, the following definitions apply:

Catastrophe (other than Certified Acts of Terrorism): Any single event, resulting from an Earthquake, Noncertified Act ofTerrorism, or Catastrophic Industrial Accident, which results in aggregate workers compensation losses in excess of $50 million.Earthquake: The shaking and vibration at the surface of the earth resulting from underground movement along a fault plane orfrom volcanic activity.Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary of Treasury pursuant to theTerrorism Risk Insurance Act of 2002 (as amended) but that meets all of the following criteria:a. It is an act that is violent or dangerous to human life, property, or infrastructure;b. The act results in damage within the United States or outside of the United States in the case of the premises of United

States missions or certain air carriers or vessels as those terms are defined in the Terrorism Risk Insurance Act of 2002 (asamended); and

c. It is an act that has been committed by an individual or individuals as part of an effort to coerce the civilian population of theUnited States or to influence the policy or affect the conduct of the United States Government by coercion.

Catastrophic Industrial Accident: A chemical release, large explosion, or small blast that is localized in nature and affects workersin a small perimeter the size of a building.

The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe (other than CertifiedActs of Terrorism) is shown in Item 4 of the Information Page or in the Schedule above.

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)



Insurance Company

WC 00 04 21 CCopyright 2008 National Council on Compensation Insurance, Inc. All Rights Reserved..(Ed. 9-08) Stock No. 24623

244 05 XE7664-91-0011 001 TRD��

WC 00 00 00 A (Ed. 4-92) Stock No. 05670 Rev. 1/94Contains copyrighted material of the National Council on Compensation Insurance

Copyright 1991, National Council on Compensation Insurance

This policy is signed at Madison, Wisconsin, on our behalf by our President and Secretary. If it is required by law, it iscountersigned on the information page by our authorized representative.

You are a member of the American Family Mutual Insurance Company of Madison, Wisconsin, and are entitled to one voteeither in person or by proxy at its meetings. The Annual Meetings are held at its Home Office in Madison, Wisconsin, on thefirst Tuesday of March at 2:00 P.M.. Notice printed in this policy shall be your notification of the time and place.

This policy is non-assessable. You are not subject to any assessment beyond the premiums we require for each policy period.

If any dividends are distributed, you will share in them according to law and under conditions set by the Board of Directors.

This is not a complete and valid contract without an accompanying INFORMATION PAGE properly executed.

Special Provisions for American Family Mutual Insurance Company Policyholders

244 05 XE7664-91-0011 001 TRD



244 05 XE7664-91-0011 001 TRD��

Please have these certificates available to American Family at audit time. If certificates are not avail-able, you will have to pay additional workers compensation premiums for your sub-contractor’semployees.

NOTICE

HIRING SUB-CONTRACTORS

Thank you for selecting American Family Insurance as your Workers Compensation carrier.

First Time Insured

We have assembled a Claims Kit to help you report a claim to us. This kit will be delivered toyou by mail or one of our claims representatives.

Renewing with Us

If you need any additional forms, please complete the card located in the Claims Kit you previouslyreceived and return it to us.

If you hire sub-contractors, make sure your sub-contractors comply with the workers compensationlaw.

They should furnish you with Certificates of Insurance obtained from their workers compensationinsurance carrier. Certificates are furnished by the sub-contractors’ insurance carriers at no cost toyou.

UBLW-00156 Rev. 11/93

WORKERS COMPENSATION CLAIMS KIT

Documents

AMERICAN FAMILY INSURANCE GROUP