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SENDER:
<br /> ■ Complete items 1,2,and 3. A. Signature
<br /> ❑Agent
<br /> ■ Print your name and address on the reverse X , , 'f� I ®'Addresse
<br /> so that we can return the card to you. —
<br /> ■ Attach this card to the back of the mailpiece, B. eceived (Printed Name) C. Date of Deliver
<br /> or on the front if space permits. % ✓ : �`
<br /> 1. Article Addressed to: D. Is delivery address different from item 1? ❑Yes
<br /> If YES,enter delivery address below: ❑ No
<br /> Jean Johnson
<br /> Great American Insurance Company
<br /> 424-E-ast South Temple, Suite 330
<br /> Salt Lake City, LT 84111
<br /> 3. Service Type ❑priority Mail Express)
<br /> ❑Adult Signature ❑Registered Ma
<br /> 0 Adult Signature Restricted Delivery ❑Registered Mailil Restne
<br /> +4Certihed Maile Delivery
<br /> 9590 9402 l,a 88 r 2/5 7581 03 ❑Certified Mail Restricted Delivery O Return Receipt for
<br /> ❑Collect on Delivery Merchandise
<br /> n i ni, o,rrranefar from service label) ❑Collect on Delivery Restricted Delivery ❑Signature Confirmation
<br /> ❑Insured Mad ❑Signature Confirmation
<br /> 7 016 2710 0000 0 9 6 5 4080 ❑Insured Mail Restricted Delivery Restricted Delivery
<br /> (over$500)
<br /> PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receif
<br /> Certified Mail service provides the following benefits: U.S. Postal
<br /> ■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail CERTIFIED MAIVHECEIPT
<br /> ■A unique identifier for your mail iece. associate for assistance.To receive a duplicate
<br /> ■Electronic vedf of delivery or a @Flpl. return receipt for no additional fee,present this r� ■
<br /> deliver C. (� USPS®-postmarked Certified Mail receipt to the O
<br /> ■A record delivery me u mg a recipieM's a il'associate. 121
<br /> signatu that is retained by the Postal Service" Restneted delivery service,which provides _
<br /> for a s Hill iftriod. 1111,110 v delivery to the addressee specified by name,or u_1 —— �— — E
<br /> Importan eminders: ire addressee's authorized agent _C ,; .: •• S 3.
<br /> CJL6✓c9C�� Adult signature service,which requiresthe c
<br /> ■You may purc rtifiedMailservicewith "f Certified Fee: S2��
<br /> signee to be at least 21 years of age(not +-s
<br /> First-Class Mad®,First- available at retaio. Return R e C e l Pt Fee:
<br /> or Priority Mad®service. Adult signature restricted delivery service,which
<br /> ■Certified Mail service is notavailable for requires the signee to be at least 21 years of age L= $S,fi7
<br /> � T
<br /> international mail. and provides delivery to the addressee specified ota I P o Sta ge & Fees:
<br /> ■Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent O
<br /> with Certified Mail service.However,the purchase (not available at retail). C n 17
<br /> of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is C)^ t n^e
<br /> insurance coverage automatically included with _z r1 1 +^ n ^'
<br /> certain Priority Mail items. accepted as legal proof of mailing,it should bear a
<br /> USPS postmark If you would like a postmark on■For an additional fee,and with a proper this Certified Mad receipt,please present your r� T,,Pnsragra-ird c.?,
<br /> endorsement on the mailpiece,you may request Certified Mad item at a Post Offce'"for �
<br /> the following services: postmarking.If you don't need a postmark on this M — Jean Johnson
<br /> -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion
<br /> of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply CD _ great MCnca11 Insurance C ompan•
<br /> You can request a hardcopy return receipt or an appropriate postage,and deposit the mail iece.
<br /> celectromploni 1q P Vi Room 215,Denver,CO 80�03 4?0 East South Temple, Suite »0
<br /> complete nn 3 1 , omes c etum
<br /> Receipt attach PS Form 3811 to your mailpiece; IMPO9TAff.save this recelptfor your records, t Salt Lake City, UT 84111
<br /> PS Fom 3800,April 2o15(Reverse)PSN 7530-02-000-9047
<br /> USPS TRACKING#
<br /> 101
<br /> ram': First-Class Mail
<br /> Postage&Fees PaidUSPS
<br /> Permit No.G-10
<br /> 9590 940� 4$8 7275 7581 03
<br /> United States I • Sender:Please print your name,address,and ZIP+4®in this box*
<br /> Postal Service State of Colorado
<br /> Department of Natural Resources
<br /> Division of Reclamation,Mining& Safety
<br /> 1313 Sherman Street, Suite 215
<br /> Denver, CO 80203 Spec yam 4-
<br /> File rim I�I7�l L�is
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