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INN/,tCOt <br />ASSURANCE <br />750t E Lowry Blvd <br />Denver, CO 80230.7006 <br />www.pinneeol.oom <br />NCCI °: WC890406 <br />Policy ~: 3489398 <br />I\SL'RED: AGENT: <br />ROCKY iv10UNTAIN STEEL INC COhfhiUNITY FIRST INS AGENCIES, INC./ <br />P O BOX 486 PO BOX 695 <br />OLATHE CO 81425 GUNNISON, CO 81230 <br />(970) 641-0614 <br />E~iDORSE~IENT: Debit/Credit Contingent/ Exp. 1\fod. Factor <br />Risk Id: 050034089 <br />In accordance with the provisions of the policy to which this endorsement is attached, and as a <br />result of the application of the experience rating plan approved by Colorado's Commissioner of ' <br />Insurance, the premium, as mentioned in I[em 4 of the Declarations (classifications of apes[ions), <br />or in any audit statement or quarterly adjustment statement forming a part of said policy, shall be <br />adjusted by the experience modification set forth, and paid in accordance with the provisions of [he <br />said policy. <br />ROCKY MOUNTAIN STEEL INC <br />EXPERIENCE PREMILiM MODTFICATTON <br />Experience h4odification Factor of 0.70 or 30 Percent CREDIT <br />Nothing herein contained shall be held to vary, waive, alter or extend any of the provisions or <br />conditions of said policy except as above stated. <br />Effective Date : October 1, 2003 TO October 1, 2004 <br />Pinnacol Assurance has issued [his endorsement JUNE 2, 2003 <br />Stephanie Willox <br />Underwriter <br />i• <br />ttii E+~aN E\R GvN OoI>' P..I~LC.]Ob!Ir _Lp VTN EMW N) <br />