This is to verify that the service contract between ____________________________________ (Employer) and _____________________________________________meets the requirements set forth in (Service Company) administrative regulation 803 KAR 25:021 § 3(4) and therefore contains one of the two following provisions: (A) The service organization shall adjust to a final conclusion any and all claims that result from an occurrence during the period for which the contract is effective unless a substitute service organization has been procured; OR (B) The service organization shall adjust any and all claims for a period of sixty (60) days following an order from the Commissioner finding the self- insured employer in default unless a substitute service organization has been procured. _________________________________________________ Signature of authorized Service Company Representative Date ______________________ __________________________________________________ Signature of authorized Self- Insured Employer Representative Date ______________________ American LegalNet, Inc. www.USCourtForms.com