Election Form for 2005 Minnesota Workers' Compensation Reinsurance Association

EX-10.10 4 c93685exv10w10.txt ELECTION FORM FOR 2005 MINNESOTA WORKERS' COMPENSATION REINSURANCE ASSOCIATION EXHIBIT 10.10 (WCRA LOGO) 2005 CERTIFICATE OF REINSURANCE for the AGREEMENT OF REINSURANCE between the WORKERS' COMPENSATION REINSURANCE ASSOCIATION and RTW INC American Compensation Insurance Company 0030392 COVERAGE PERIOD: January 1, 2005 - December 31, 2005 RETENTION LIMIT: $380,000 (12:01 a.m. Standard Time) This certifies that the entities named above are Members of the Workers' Compensation Reinsurance Association (WCRA), and that the WCRA reinsures the Members' liability during the indicated coverage period for benefits pursuant to Minn. Stat. Ch. 176 in excess of the Members' retention limit for the period indicated above. This certificate provides for coverage in accordance with the terms and conditions of the Reinsurance Agreement approved by the Commissioner of the Minnesota Department of Labor and Industry on January 4, 2005. This certificate shall not be valid for any portion of the indicated period during which an entity is not a Member of the Association. /s/ CARL W. CUMMINS III Carl W. Cummins III President and Chief Executive Officer Dated: January 5, 2005 Workers' Compensation Reinsurance Association(R) Suite 1700, 400 Robert Street North, Saint Paul, MN 55101 Phone: 651 ###-###-#### Fax: 651 ###-###-#### www.wcra.biz