**POLICY NUMBER:** HDO G27865355

**CHUBB**

**Risk Control Services**
436 Walnut Street
Philadelphia, PA 19106-3703
Phone: 1.866.357.3797
Fax: 215.640.5084
www.chubb.com

**National Manager, Jurisdictional Services**

**RE:** **RISK CONTROL SERVICES FOR TEXAS POLICYHOLDERS**
Commercial Automobile Liability, General Liability, Professional Liability, and Medical Professional Liability (other than Hospitals)

The Chubb Companies are required by Texas law and regulations to maintain or provide accident prevention services for its commercial automobile, general liability and professional liability policyholders. The Chubb Companies offer an array of accident prevention services in Texas at no additional charge. These services are intended to help prevent and/or minimize loss.

These services include but are not limited to: individual risk surveys; improvement recommendations; loss investigation; specific loss problem identification and recommended improvement actions.

Chubb may recommend one or more of these services based upon hazard, experience, and size of your Texas operations. You have the choice of receiving or declining any of the services offered. If you wish to decline all of the services or wish to receive only selected risk control service, please indicate that by signing and dating this letter in the space provided below. Please mail or fax to the captioned address or fax number. If you decline all of Chubb's risk control services or choose only a support service, such as ergonomics survey, driving training, or other services and not a complete risk survey, we still have a responsibility under Texas law and regulation to monitor your losses. In the event you start to have a loss problem and a trend is established, and/or adverse loss ratio is developed, we will contact you and offer to assist you in addressing the situation.

Sincerely,

**National Manager, Jurisdictional & Regulatory Services**
**Chubb Risk Control Services**
436 Walnut Street, Philadelphia, PA 19106-3703
or call toll free at: 1-866-357-3797

- I am aware of the loss control services offered and decline them. I have made other arrangements for these services.
- I wish to obtain the following offered accident prevention services:
- I have no risk control services needs now. I reserve the right to request loss control services within the period.

(Signature) ________________ (Phone #) ________________ (Date) ________________

Print Name: __________________________ Policy #: ___________________________

Company Name: __________________________

Address: ___________________________

City, State, Zip: ___________________________

One of the Chubb Group of Insurance Companies
This Company has undertaken a survey of your premises, equipment, or operations (whichever is pertinent to the type of insurance applied for or provided) for the purpose of supporting the functions of risk underwriting. Any recommendations or information provided is not intended as a substitute for advice from a safety expert or legal counsel you may retain for your own purposes. It is not intended to supplant any legal duty you may have to provide a safe premises, workplace, product or operation.

ALL-11559d (10/07)
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