[Insert name of Insurance Company]

[Insert Address]

Re:      Workers' Compensation Policy No. [insert policy number]

Dear Sir or Madam:

Please be advised that [insert name of client company] (the "Company") has engaged Advanced Insurance Management LLC ("A.I.M.") to conduct an audit of the Company's Workers' Compensation insurance policies and premiums to determine whether there have been errors and/or mistakes in use of classification codes, payroll calculation, Experience Modification Factor computation, and/or other technical factors, thereby entitling the Company to refunds, payments and/or adjustments (collectively "Payments").

In the event it is determined that the Company is entitled to any Payments from [insert name of insurance company], the Company hereby directs that an amount equal to fifty percent (50%) of the total Payments be paid directly to A.I.M. by certified or cashiers' check, wire transfer or such other form of payment as is acceptable to A.I.M.  In the event [insert name of insurance company] is unable to make a payment directly to A.I.M. as provided for above due to insurance company policy or procedures, the Company hereby directs that any and all Payments be made by check and payable jointly to the Company and A.I.M.

This letter of direction is effective as of the date set forth above, and shall terminate only upon joint written notice given to [insert name of insurance company] by the Company and A.I.M.

Sincerely,

[Insert name of client company]

[Insert name of authorized representative]

Please FAX completed letter (on your letterhead and signed by corporate officer) to 800-288-9256

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