**POLICY NUMBER:** HDO G48898919

**CHUBB**

**Chubb Risk Control Services**
**525 W. Monroe Street**
**Chicago, IL 60661**

**Phone:** 1.866.357.3797
**Fax:** 215.640.5084
**www.chubb.com**
**losscontrolreq@chubb.com**

**National Manager, Jurisdictional Services**

**RE: RISK CONTROL SERVICES FOR TEXAS POLICYHOLDERS**
**Commercial Automobile Liability, General Liability, Professional Liability, and Medical Professional Liability**

Chubb is required by Texas law and regulations to maintain or provide accident prevention services for its commercial automobile, general liability, professional liability, and medical professional liability policyholders. Chubb offers 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 e-mail, mail or fax a response to the appropriate address or fax number listed above. 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**
**525 W. Monroe Street**
**Chicago, IL 60661**
**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 policy period.

(Signature) (Phone #) (Date)

Print Name: Policy #
Company Name: Address:
City, State, Zip:

ALL-11559e (07/16)
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