Election Form

EX-10.10 6 c83745exv10w10.txt ELECTION FORM EXHIBIT 10.10 2004 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, 2004 - December 31, 2004 RETENTION LIMIT: $360,000 (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 December 24, 2002. 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: December 26, 2003 Workers' Compensation Reinsurance Association(R) Suite 1700, 400 Robert Street North, Saint Paul, MN 55101 Phone: 651 ###-###-#### Fax: 651 ###-###-#### www.wcra.biz