Date: 20170721 . . DO NOT WRITE, STAMP OR SIGH BELOW THIS LIBE RESEW/ED FOR.FIUMSCIAL IUSTITUTIOn USE * • • • - • OS.-S2 (Rev. Ay: . • I: Tit& security features ltit:d below, as well a; those not listed. exceed industryquid:gime. I Brew Ay Features' elesulto ;A document alter:non: W.:tr.

he government Insurance Euzu4 the Employer's &port to the Commissioner of 'Finance and paid the required premium in accordance with the provision of Tit& 24 Chapter 11, Section 273, of the `Virgin Islands Code, and accordingly is entitled to the rights And benefits cf the insurance coverage establish