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WILLIS TOWERS WATSON <br /> 26 CENTURY BLVD. <br /> 6TH FL <br /> NASHVILLE, TN 37214 <br /> 263 1 AB 0.409 <br /> COLORADO DIVISION OF MINING&SAFETY 263 <br /> 1313 N SHERMAN ST STE 215 <br /> DENVER, CO 80203-2243 <br /> ****NOTICE**** <br /> In order to expedite distribution of certificates to Certificate Holders, we would like to begin using electronic <br /> distribution for future issuances.Also, we would like to remove any certificates that are no longer needed. <br /> If you would like to receive electronic copies in the future or no longer require a certificate for this Insured, <br /> please note as such below. <br /> Please complete this form and submit with a copy of your current certificate to the contact <br /> information below: <br /> Do you wish to receive renewal certificates: Yes [ ] No [ ] <br /> Require a hard copy be mailed: Yes [ ] No [ ] <br /> Email Address or Fax Number: <br /> SR ID: 18287549 <br /> If you require additional information or have further questions, please feel free to contact: <br /> Willis Towers Watson Global Certificate Center <br /> Email: EDPCERTS@willistowerswatson.com <br /> Fax: 888-467-2378 <br /> Phone: 877-945-7378 <br /> Please note that it is your responsibility to provide up-to-date contact information to assure correct <br /> distribution of any future renewal certificates. <br /> 1 of 2 263 <br />