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A11v H R LLC Loss Histo Affidavit A►'�' R <br />Y neSoy rce <br />A Vensure Employer Services Company= <br />This affidavit shall be utilized to validate and acknowledge a prospective company's workers' compensation loss <br />experience, or the lack thereof, when Carrier, PEO and/or Payroll Company generated loss runs or declarations are <br />not being presented. <br />This affidavit must be completed by an owner/officer. <br />COMPANY INFORMATION <br />1, Jason Gutman _ 1 (Print Owner/Officer Name) certify that Vairose Investment Group I LC (Company LegalName) and any related business entities through common ownership/ interest, as well as any predecessor companies <br />listed below, if any: (Common Ownership/Related Entities), <br />LOSS HISTORY ACKNOWLEDGEMENT <br />has not experienced any work related injuries and/or reported any workers' compensation claims and certifythat <br />no current or former employees have reported an injury in the prior 3 years from the date this form is signed. <br />0 has experienced work related injuries and/or reported workers' compensation claims in the prior 3 years. <br />PRESENT ALL(**) INJURIES AND DETAILS BELOW: <br />**If more claims exists, within the prior 3 year period, please present on another sheet of paper using the same format. <br />It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers' compensation <br />transaction for the purpose of committing fraud. Penalties include imprisonment, fines, and denial of insurance benefits. <br />Any person who knowingly, and with intent to defraud any insurance company or another person, files an application <br />for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading <br />information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the <br />person to criminal and civil p nalties. <br />Owner/Officer Signature: Title/Position: Owner Date: 03/0212022 <br />PEO REPRESENTATIVE ACKNOWLEDGEMENT <br />I attest that I have counseled the aforementioned business owner/ officer regarding the presentation of loss data for underwriting. <br />Owner/Officer Signature: MatrixOneSource Date: 03/02/2022 <br />PEO Representative Name: Thomas A Deming Signature: <br />MOSFORM-FULLPEOENROLLMENTPACK 17 92020 MatrixOneSoure <br />