Workers' Compensation Policy Forms and Endorsements

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1 ALPHABETICAL INDEX Forms are listed alphabetically by form title. The forms included in this section, which WOLTERS KLUWER FINANCIAL SERVICES makes available as stock items, are as follows: 1. Standard and Advisory General Use and State Endorsements based on National Council on Compensation Insurance (NCCI) text. 2. Endorsements containing Tables of Rating Values (used in conjunction with Retrospective Premium Endorsements ). Based on NCCI text. 3. Specific state endorsements in text provided by local Workers Compensation Boards or Bureaus with corresponding Identification Numbers when designated. Monopolistic Jurisdiction:None of the forms listed herein are for use in the following jurisdictions having a "monopolistic" Workers' Compensation program, except where specifically listed: Ohio, North Dakota, Washington, and Wyoming. Certain Employers Liability forms may, of course, be used even though Workers' Compensation is not used. PAGE WC 1 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

2 GENERAL USE/STATE SPECIFIC Alabama WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC ANNIVERSARY RATING DATE WC598 11/96 WC ANNIVERSARY RATING DATE WC505 07/90 WC ASSIGNED RISK ADJUSTMENT PROGRAM WC B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC ASSIGNED RISK PREMIUM SURCHARGE WC /17 WC AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC D 01/15 WC D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC EMPLOYEE LEASING CLIENT WC436 02/92 WC EMPLOYEE LEASING CLIENT EXCLUSION WC A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC B 01/15 WC B FOREIGN TERRORISM PREMIUM WC A 05/98 WC000001A INFORMATION PAGE WC B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC INSURANCE COMPANY AS INSURED WC116 04/84 WC PAGE WC 2 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

3 JOINT VENTURE AS INSURED WC435 02/92 WC LABOR CONTRACTOR EXCLUSION WC449 06/92 WC LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC B 01/15 WC000201B MARITIME COVERAGE WC463 11/92 WC MERIT RATING WC448 07/92 WC MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC MULTIPLE COORDINATED POLICY WC A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC /14 WC NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC PENDING RATE CHANGE WC B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC POLICY PERIOD WC266 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC131 08/84 WC PREMIUM DISCOUNT WC A 07/95 WC000406A PREMIUM DISCOUNT WC /01 WC PREMIUM DUE DATE WC A 01/06 WC000321A PROFESSIONAL EMPLOYER WC B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC RATE CHANGE WC581 06/96 WC RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES PAGE WC 3 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

4 WC145 04/84 WC RETRO PREMIUM SHORT FORM WC C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC /10 WC RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC /84 WC VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS Alaska WC331 05/86 WC000401A AIRCRAFT PREMIUM WC /13 WC ALASKA NOTICE OF INSTALLMENT OPTION FORM542 03/13 FORM 54-2 ALASKA POLICYHOLDER NOTICE - ACCESS TO MANUAL INFORMATION WC /99 WC ALASKA RESIDUAL MARKET SAFE WORKPLACE INCENTIVE WC A 01/15 WC540501A ALASKA RETROSPECTIVE RATING PLAN PREMIUM ONE-YEAR PLAN WC A 01/15 WC540504A ALASKA RETROSPECTIVE RATING PLAN PREMIUM ONE-YEAR PLAN MULTIPLE LINES WC A 01/15 WC540502A ALASKA RETROSPECTIVE RATING PLAN PREMIUM THREE-YEAR PLAN WC /15 WC540505A ALASKA RETROSPECTIVE RATING PLAN PREMIUM THREE-YEAR PLAN MULTIPLE LINES WC /10 WC ALASKA RETROSPECTIVE RATING PLAN PREMIUM WRAP-UP CONSTRUCTION PROJECT WC A 01/15 WC540503A ALASKA RETROSPECTIVE RATING PLAN PREMIUM WRAP-UP CONSTRUCTION PROJECT WC A 01/15 WC540506A ALASKA RETROSPECTIVE RATING PLAN PREMIUM WRAP-UP CONSTRUCTION PROJECT MULTIPLE LINES WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC ANNIVERSARY RATING DATE WC505 07/90 WC ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC ASSIGNED RISK PREMIUM DIFFERENTIAL WC465 09/92 WC ASSIGNED RISK PREMIUM SURCHARGE WC383 01/90 WC ASSIGNED RISK PREMIUM SURCHARGE PAGE WC 4 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

5 WC403 02/91 WC BENEFITS DEDUCTIBLE WC573 05/95 WC CANCELLATION AND NONRENEWAL ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC584 01/96 WC CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT WC646 12/03 FORM541CCPAP CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC D 01/15 WC D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC EMPLOYEE LEASING CLIENT WC A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC B 01/15 WC B FOREIGN TERRORISM PREMIUM WC A 05/98 WC000001A INFORMATION PAGE WC B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC INSURANCE COMPANY AS INSURED WC116 04/84 WC JOINT VENTURE AS INSURED WC572 05/95 WC LIMIT OF LIABILITY WC449 06/92 WC LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A PAGE WC 5 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

6 NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC424 08/91 WC NOTICE OF INSTALLMENT OPTION WC /14 WC NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC PENDING RATE CHANGE WC130 04/84 WC POLICY PERIOD WC266 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC /01 WC PREMIUM DUE DATE WC A 01/06 WC000321A PROFESSIONAL EMPLOYER WC B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC RATE CHANGE WC581 06/96 WC RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC RETRO PREMIUM SHORT FORM WC C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC /84 WC VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS Arizona WC331 05/86 WC000401A AIRCRAFT PREMIUM WC C 02/10 WC020401C ALCOHOL/DRUG-FREE WORKPLACE PREMIUM CREDIT WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC ANNIVERSARY RATING DATE PAGE WC 6 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

7 WC /02 WC ARIZONA BENEFITS DEDUCTIBLE WC A 09/15 WC020601A ARIZONA CANCELLATION AND NONRENEWAL WC A 05/17 WC020301A ARIZONA EMPLOYEE LEASING WC /02 WC ARIZONA RETROSPECTIVE PREMIUM LARGE RISK ALTERNATIVE RATING OPTIOIN WC505 07/90 WC ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC ASSIGNED RISK PREMIUM SURCHARGE WC /17 WC AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC BENEFITS DEDUCTIBLE WC330 05/86 WC CANCELLATION ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC D 01/15 WC D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC EMPLOYEE LEASING CLIENT WC604 01/97 WC EMPLOYEE LEASING CLIENT EXCLUSION WC A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC603 01/97 WC EMPLOYEE LEASING WC C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC B 01/15 WC B FOREIGN TERRORISM PREMIUM WC A 05/98 WC000001A INFORMATION PAGE WC B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC INSURANCE COMPANY AS INSURED WC116 04/84 WC JOINT VENTURE AS INSURED WC605 01/97 WC LABOR CONTRACTOR EXCLUSION WC449 06/92 WC PAGE WC 7 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

8 LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC /14 WC NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC PENDING RATE CHANGE WC B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC POLICY PERIOD WC266 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC A 01/06 WC000321A PROFESSIONAL EMPLOYER WC B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC RATE CHANGE WC581 06/96 WC RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC RETRO PREMIUM SHORT FORM WC C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC /10 WC RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC B 01/06 WC000309B0106 RURAL UTILITIES SERVICE PAGE WC 8 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

9 WC121 04/84 WC SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC /84 WC VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS Arkansas WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC262 A 04/92 WC030601A AMENDATORY WC127 04/84 WC ANNIVERSARY RATING DATE WC A 07/11 WC030603A ARKANSAS CONTRACT HAULING WARRANTY WC505 07/90 WC ASSIGNED RISK ADJUSTMENT PROGRAM WC552 01/94 WC ASSIGNED RISK ASSOCIATED OR SPONSORED POLICY COVERAGE WC553 01/94 WC ASSIGNED RISK MULTIPLE COORDINATED POLICY COVERAGE WC504 01/90 WC ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC ASSIGNED RISK PREMIUM SURCHARGE WC /17 WC AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC BENEFITS DEDUCTIBLE WC556 A 10/96 WC030602A1096 BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC D 01/15 WC D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC EMPLOYEE LEASING CLIENT WC436 02/92 WC EMPLOYEE LEASING CLIENT EXCLUSION WC A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE PAGE WC 9 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

10 WC A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC B 01/15 WC B FOREIGN TERRORISM PREMIUM WC A 05/98 WC000001A INFORMATION PAGE WC B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC INSURANCE COMPANY AS INSURED WC116 04/84 WC JOINT VENTURE AS INSURED WC435 02/92 WC LABOR CONTRACTOR EXCLUSION WC449 06/92 WC LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC617 10/97 WC MANAGED CARE WC B 01/15 WC000201B MARITIME COVERAGE WC117 04/84 WC MEDICAL BENEFITS EXCLUSION WC118 04/84 WC MEDICAL BENEFITS REIMBURSEMENT WC448 07/92 WC MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC MULTIPLE COORDINATED POLICY WC A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC /14 WC NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC PENDING RATE CHANGE WC B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC POLICY PERIOD WC266 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC131 08/84 WC PREMIUM DISCOUNT WC A 07/95 WC000406A PREMIUM DISCOUNT WC /01 WC PREMIUM DUE DATE WC A 01/06 WC000321A PAGE WC 10 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

11 PROFESSIONAL EMPLOYER WC B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC RATE CHANGE WC581 06/96 WC RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC RETRO PREMIUM SHORT FORM WC C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC /84 WC VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS WC540 03/94 WC WORKERS COMPENSATION INSURANCE PLAN ALTERNATE PREFERRED PLAN PREMIUM WC538 03/94 WC WORKERS COMPENSATION INSURANCE PLAN ASSIGNED RISK TABULAR ADJUSTMENT PROGRAM PREMIUM WC539 03/94 WC WORKERS COMPENSATION INSURANCE PLAN MERIT RATING California WC /02 WC PREMIUM INCREASE ENDORSMENT - CALIFORNIA WC /02 WC PREMIUM INCREASE ENDORSMENT - CALIFORNIA WC /02 WC PREMIUM INCREASE ENDORSMENT - CALIFORNIA WC /02 WC PREMIUM INCREASE ENDORSMENT - CALIFORNIA WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC ANNIVERSARY RATING DATE WC256 04/84 WC ANNIVERSARY RATING DATE WC505 07/90 WC ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC ASSIGNED RISK PREMIUM SURCHARGE PAGE WC 11 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

12 WC403 02/91 WC BENEFITS DEDUCTIBLE WC /12 WC CALIFORNIA SHORT-RATE CANCELATION WC535 12/93 WC040601A CANCELLATION ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC DESIGNATED WORKPLACE EXCLUSION WC D 01/15 WC D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC565 01/95 WC DUTY TO DEFEND WC391 04/91 WC EMPLOYEE LEASING CLIENT WC A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC387 A 10/98 WC040307A1098 EMPLOYEE LEASING WC626 A 10/98 WC040312A1098 EMPLOYEE LEASING (FOR LEASING ARRANGEMENTS THAT DO NOT FALL WITHIN THE SCOPE OF THE EMPLOYEE) WC388 A 10/98 WC040308A1098 EMPLOYEE LEASING SHORT FORM WC625 A 10/98 WC040311A1098 EMPLOYEE LEASING SHORT FORM (FOR LEASING ARRANGEMENTS THAT DO NOT FALL WITHIN THE SCOPE OF THE EMPLOYEE LEASING RULE) WC C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC B 01/15 WC040360B EMPLOYERS LIABILITY COVERAGE AMENDATORY - CALIFORNIA WC253 04/84 WC AGREEMENT [CA] WC /93 NO14 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE (LIABILITY NOT INSURED) WC /93 NO13 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE (LIABILITY NOT INSURED) WC7956 F 08/99 FORM 11 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE WC7606 K 08/99 FORM 10 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE WC /93 FORM 4 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE (RELATIVES NOT INSURED) WC7967 H 01/84 FORM 7 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE - MEDICAL BENEFITS NOT INSURED WC /06 WC AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE (EMPLOYEE INSURED BY GENERAL EMPLOYER EXCLUDED) WC /05 WC AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE PAGE WC 12 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

13 (LABOR CONTRACTOR AS NAMED INSURED - EXCLUSION OF LEASED EMPLOYEES) WC /05 WC AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE (LABOR CONTRACTOR AS NAMED INSURED WITH LCF DESIGNATION RESTRICTION OF COVERAGE TO CLIENT WORKERS) WC /05 WC AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE (LABOR CONTRACTOR AS NAMED INSURED EXCLUSION OF CLIENT'S EMPLOYEES) WC /05 WC AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE (LABOR CONTRACTOR AS NAMED INSURED RESTRICTION OF COVERAGE TO CLIENT WORKERS) WC /94 AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE/ WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY AMENDATORY WC255 04/84 WC AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE- JOINT VENTURE WC354 01/88 WC ESTIMATED ANNUAL PREMIUM WC128 04/84 WC EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC /98 WC EXTENSION OF INFORMATION PAGE CLASSIFICATIONS WC /98 WC EXTENSION OF INFORMATION PAGE SCHEDULE OF FORMS WC /98 WC EXTENSION OF INFORMATION PAGE SCHEDULE OF LOCATIONS WC /98 WC EXTENSION OF INFORMATION PAGE SCHEDULE OF NAMED INSURED WC C 01/09 WC C FARM SCHED ENDORSE-CALIFORNIA WC A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC B 01/15 WC B FOREIGN TERRORISM PREMIUM WC B 10/14 WC040001B INFORMATION PAGE WC /04 WC (CA) INSOLVENT RATING ADJUSTMENT PLAN WC115 04/84 WC INSURANCE COMPANY AS INSURED PN A 07/15 PN049907A JANUARY 1, 2014 AUDIT REQUIREMENTS FOR POLICIES WITH FINAL PREMIUM OF LESS THAN $10,000 THAT DEVELOP PAYROLL IN HIGH WAGE DUAL WAGE CONSTRUCTION OR ERECTION CLASSIFICATIONS WC116 04/84 WC JOINT VENTURE AS INSURED PAGE WC 13 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

14 WC B 01/15 WC040603B LARGE RISK DEDUCTIBLE WC /13 WC LIMITED LIABILITY COMPANY COVERAGE / EXCLUSION -CALIFORNIA WC449 06/92 WC LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC247 A 04/92 WC040101A0492 LONGSHOREMEN S AND HARBOR WORKERS COMPENSATION ACT COVERAGE WC B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE PN /99 PN NOTICE REQUIRED BY LAW WC369 07/90 WC NOTIFICATION OF CHANGE IN OWNERSHIP WC249 A 01/85 WC OFFICER & DIRECTOR (CA) WC /08 WC OPTIONAL PREMIUM INCREASE - CA WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC PARTNERS, OFFICERS AND OTHERS EXCLUSION WC248 B 10/86 WC040302A PARTNERSHIP COVERAGE/EXCLUSION WC129 04/84 WC PENDING RATE CHANGE WC166 B 03/98 WC040301A0398 POLICY AMENDATORY END WC C 10/14 WC040301C POLICY AMENDATORY - CALIFORNIA PN /01 PN POLICY HOLDER NOTICE - CALIFORNIA INSURANCE GUARANTEE ASSOCIAITON (CIGA) SURCHARGE PN /03 PN POLICY HOLDER NOTICE - DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE NEW AND RENEWAL POLICIES WC130 04/84 WC POLICY PERIOD PN C 07/15 PN049906C POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE PN B 05/02 PN049902B0502 POLICYHOLDER NOTICE (INSURANCE RATING LAWS) PN F 03/15 PN049901F POLICYHOLDER NOTICE (YOUR RIGHT TO RATING AND DIVIDEND INFORMATION) WC /99 WC PREMIUM ADJUSTMENT WC /05 WC PREMIUM CHANGE EFFECTIVE JULY 1, 2005 WC266 07/91 WC PAGE WC 14 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

15 PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC A 07/95 WC000406A PREMIUM DISCOUNT WC A 01/06 WC000321A PROFESSIONAL EMPLOYER WC B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC RATE CHANGE WC581 06/96 WC RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC561 01/95 WC RETRO PREMIUM SHORT FORM WC145 04/84 WC RETRO PREMIUM SHORT FORM WC E 01/15 WC040501E RETROSPECTIVE PREM END [CA] WC B 12/06 WC040602B1206 SMALL DEDUCTIBLE WC250 A 01/85 WC SOLE PROPRIETOR COVERAGE WC636 01/84 WC VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC251 A 01/85 WC VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC /84 WC VOLUNTARY COMPENSATION MARITIME COVERAGE WC252 04/84 WC WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS Colorado WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC ANNIVERSARY RATING DATE WC505 07/90 WC ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC ASSIGNED RISK PREMIUM SURCHARGE WC /17 WC AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC BENEFITS DEDUCTIBLE WC385 11/90 WC CLASSIFICATION WC A 01/12 WC COLORADO NON-COOPERATION WITH PREMIUM AUDIT SURCHARGE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A PAGE WC 15 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

16 DEFENSE BASE ACT COVERAGE WC113 04/84 WC DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC D 01/15 WC D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC EMPLOYEE LEASING CLIENT WC436 02/92 WC EMPLOYEE LEASING CLIENT EXCLUSION WC A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC B 01/15 WC B FOREIGN TERRORISM PREMIUM WC A 05/98 WC000001A INFORMATION PAGE WC B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC INSURANCE COMPANY AS INSURED WC116 04/84 WC JOINT VENTURE AS INSURED WC435 02/92 WC LABOR CONTRACTOR EXCLUSION WC449 06/92 WC LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC437 02/92 WC MULTIPLE COORDINATED POLICY WC A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC /14 WC NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC NOTIFICATION OF CHANGE IN OWNERSHIP PAGE WC 16 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

17 WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC PENDING RATE CHANGE WC B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC POLICY PERIOD WC567 03/93 WC PREMIUM CREDIT FOR CERTIFIED RISK MANAGEMENT PROGRAMS WC266 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC131 08/84 WC PREMIUM DISCOUNT WC A 07/95 WC000406A PREMIUM DISCOUNT WC /01 WC PREMIUM DUE DATE WC A 01/06 WC000321A PROFESSIONAL EMPLOYER WC B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC RATE CHANGE WC581 06/96 WC RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC RETRO PREMIUM SHORT FORM WC C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC /10 WC RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC /84 WC VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS Connecticut WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC ANNIVERSARY RATING DATE WC199 04/84 WC APPLICATION OF WORKERS COMPENSATION INSURANCE PAGE WC 17 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

18 WC505 07/90 WC ASSIGNED RISK ADJUSTMENT PROGRAM WC B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC ASSIGNED RISK PREMIUM SURCHARGE WC /17 WC AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC /14 WC CONNECTICUT FOREIGN VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC /03 WC CONNECTICUT WORKERS' COMPENSATION FUNDS WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC588 07/96 WC CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT NC5000 A 07/11 FORM NC-5000A CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC D 01/15 WC D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC EMPLOYEE LEASING CLIENT WC A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC B 01/15 WC B FOREIGN TERRORISM PREMIUM WC A 05/98 WC000001A INFORMATION PAGE WC B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC INSURANCE COMPANY AS INSURED WC116 04/84 WC PAGE WC 18 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

19 JOINT VENTURE AS INSURED WC392 04/91 WC LABOR CONTRACTOR WC449 06/92 WC LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC /08 WC MANDATORY ARBITRATION WC B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC /14 WC NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC PENDING RATE CHANGE WC B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC POLICY PERIOD WC266 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC267 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC PREMIUM DISCOUNT WC A 07/95 WC000406A PREMIUM DISCOUNT WC /01 WC PREMIUM DUE DATE WC A 01/06 WC000321A PROFESSIONAL EMPLOYER WC B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC RATE CHANGE WC581 06/96 WC RESIDUAL MARKET MULTIPLE COMPANY WC146 04/84 WC RETRO PREM SUPP (CT) WC142 04/84 WC RETRO PREMIUM AVIATION PAGE WC 19 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

20 WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC RETRO PREMIUM SHORT FORM WC C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC /10 WC RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC121 04/84 WC SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC /84 WC VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS Delaware FORM /04 FORM AGREEMENT BY EXCECUTIVE OFFICE NOTICE FORMDCRB- EX 12/09 DCRB-EXCL AGREEMENT BY EXECUTIVE OFFICER(S)/ LLC MEMBER(S) NOT TO BE SUBJECT TO THE DELAWARE WORKERS' COMPENSATION LAW WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC184 04/84 WC AMENDATORY FARMING OPERATIONS WC127 04/84 WC ANNIVERSARY RATING DATE WC505 07/90 WC ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC ASSIGNED RISK PREMIUM SURCHARGE WC403 02/91 WC BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC375 07/90 WC CONSTRUCTION CLASSIFICATION PREMIUM ADJUSTMENT WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC181 04/84 WC DEDUCTIBLE WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC651 D 06/14 DCCPAP DELAWARE WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC113 04/84 WC DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC D 01/15 WC D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC PAGE WC 20 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

21 EMPLOYEE LEASING CLIENT WC A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC B 01/15 WC B FOREIGN TERRORISM PREMIUM WC B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC INSURANCE COMPANY AS INSURED WC116 04/84 WC JOINT VENTURE AS INSURED WC449 06/92 WC LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC B 01/15 WC000201B MARITIME COVERAGE WC117 04/84 WC MEDICAL BENEFITS EXCLUSION WC118 04/84 WC MEDICAL BENEFITS REIMBURSEMENT WC /99 WC MERIT RATING PLAN WC448 07/92 WC MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC358 07/88 WC NONRENEW WC /14 WC NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC PENDING RATE CHANGE WC WC POLICY INFORMATION PAGE PAGE WC 21 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

22 WC130 04/84 WC POLICY PERIOD WC266 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC A 07/95 WC000406A PREMIUM DISCOUNT WC /01 WC PREMIUM DUE DATE WC A 01/06 WC000321A PROFESSIONAL EMPLOYER WC B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC RATE CHANGE WC581 06/96 WC RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC RETRO PREMIUM SHORT FORM WC481 10/93 WC RETROSPECTIVE PREMIUM - FLEXIBILITY OPTIONS WC414 12/91 WC000505A1291 RETROSPECTIVE PREMIUM - LONG TERM CONSTRUCTION PROJECT WC417 12/91 WC000514A1291 RETROSPECTIVE PREMIUM - LONG-TERM CONSTRUCTION PROJECT - MULTIPLE LINES WC144 04/84 WC RETROSPECTIVE PREMIUM - NON RATABLE CATASTROPHE ELEMENT OR SURCHARGE WC412 12/91 WC000503A1291 RETROSPECTIVE PREMIUM - ONE YEAR PLAN WC415 12/91 WC000512A1291 RETROSPECTIVE PREMIUM - ONE YEAR PLAN - MULTIPLE LINES WC413 12/91 WC000504A1291 RETROSPECTIVE PREMIUM - THREE YEAR PLAN WC416 12/91 WC000513A1291 RETROSPECTIVE PREMIUM - THREE YEAR PLAN - MULTIPLE LINES WC650 04/84 WC RETROSPECTIVE PREMIUM CHANGES WC120 04/84 WC RURAL ELECTRIFICATION ADMINISTRATION WC121 04/84 WC SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC /84 WC VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS District of Columbia PAGE WC 22 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

23 WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC ANNIVERSARY RATING DATE WC505 07/90 WC ASSIGNED RISK ADJUSTMENT PROGRAM WC B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC ASSIGNED RISK PREMIUM SURCHARGE WC /17 WC AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC BENEFITS DEDUCTIBLE WC263 04/84 WC CANCELLATION ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC D 01/15 WC D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC EMPLOYEE LEASING CLIENT WC A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC128 04/84 WC EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC B 01/15 WC B FOREIGN TERRORISM PREMIUM WC A 05/98 WC000001A INFORMATION PAGE WC B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC INSURANCE COMPANY AS INSURED WC116 04/84 WC JOINT VENTURE AS INSURED WC392 04/91 WC LABOR CONTRACTOR WC449 06/92 WC LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE PAGE WC 23 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

24 WC237 04/84 WC LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC B 01/15 WC000201B MARITIME COVERAGE WC117 04/84 WC MEDICAL BENEFITS EXCLUSION WC118 04/84 WC MEDICAL BENEFITS REIMBURSEMENT WC448 07/92 WC MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC /14 WC NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC PENDING RATE CHANGE WC B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC POLICY PERIOD WC266 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 WC131 08/84 WC PREMIUM DISCOUNT WC A 07/95 WC000406A PREMIUM DISCOUNT WC /01 WC PREMIUM DUE DATE WC A 01/06 WC000321A PROFESSIONAL EMPLOYER WC B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC RATE CHANGE WC581 06/96 WC RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC RETRO PREMIUM SHORT FORM WC C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC /10 WC RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) PAGE WC 24 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

25 WC B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC A 09/01 WC080401A0901 SAFE WORKPLACE PRGR ENDT (DC) WC121 04/84 WC SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC636 01/84 WC VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC /84 WC VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS Florida WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC ANNIVERSARY RATING DATE WC8093 C 07/04 FORM APPLICATION FOR DRUG-FREE WORKPLACE PREMIUM CREDIT PROGRAM WC505 07/90 WC ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC ASSIGNED RISK PREMIUM SURCHARGE WC /17 WC AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC BENEFITS DEDUCTIBLE WC401 07/90 WC BENEFITS DEDUCTIBLE NC /06 FORMSAFETY93 CERTIFICATION EMPLOYER WORKPLACE SAFETY PROGRAM PREMIUM CREDIT FORM /06 FORM CERTIFICATION OF EMPLOYER WORKPLACE SAFETY PROGRAM PREMIUM CREDIT WC399 07/90 WC COINSURANCE AND DEDUCTIBLE WC400 07/90 WC COINSURANCE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR FORM094 C 01/10 CONTRACTING CLASS PREM ADJ(FL) WC483 06/87 WC CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC DESIGNATED WORKPLACE EXCLUSION WC236 09/85 WC DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC D 01/15 WC D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC EMPLOYEE LEASING CLIENT WC A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC /05 WC PAGE WC 25 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

26 EMPLOYERS LIABILITY COVERAGE WC C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC359 10/88 WC EXPER RAT MOD END (FL) WC128 04/84 WC EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC /07 WC FLORIDA EMPLOYEE LEASING COMPANY CLIENT COMPANY DIRECT WORKERS INCLUSION WC /07 WC FLORIDA EMPLOYEE LEASING COMPANY CLIENT COMPANY EXCLUSION WC /07 WC FLORIDA EMPLOYEE LEASING COMPANY EXCLUSION WC /07 WC FLORIDA EMPLOYEE LEASING COMPANY EXTENSION WC /98 WC FLORIDA EMPLOYMENT AND WAGE INFORMATION RELEASE WC A 07/14 WC FLORIDA FOREIGN VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC /15 WC FLORIDA MARITIME COVERAGE WC /07 WC FLORIDA MULTIPLE COORDINATED POLICY WC /13 WC FLORIDA NON-COOPERATION WITH PREMIUM AUDIT FORM09 A 01/14 FORM 09-NOTICE FLORIDA NOTICE OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC /15 WC FLORIDA RETROSPECTIVE RATING PLAN PREMIUM - LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC A 01/15 WC090503A FLORIDA RETROSPECTIVE RATING PLAN PREMIUM ONE-YEAR PLAN WC A 01/15 WC090504A FLORIDA RETROSPECTIVE RATING PLAN PREMIUM ONE-YEAR PLAN - MULTIPLE LINES WC B 01/15 WC B FOREIGN TERRORISM PREMIUM WC A 05/98 WC000001A INFORMATION PAGE WC B 01/15 WC000001B INFORMATION PAGE NOTES WC115 04/84 WC INSURANCE COMPANY AS INSURED WC116 04/84 WC JOINT VENTURE AS INSURED WC392 04/91 WC LABOR CONTRACTOR WC449 06/92 WC LIMITED MARITIME COVERAGE WC419 04/92 WC000106A PAGE WC 26 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

27 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC B 01/15 WC000201B MARITIME COVERAGE WC448 07/92 WC MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC /14 WC NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC369 07/90 WC NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC PENDING RATE CHANGE WC B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC POLICY PERIOD WC /01 WC PREMIUM DUE DATE WC A 01/06 WC000321A PROFESSIONAL EMPLOYER WC B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC RATE CHANGE WC581 06/96 WC RESIDUAL MARKET MULTIPLE COMPANY WC589 05/95 WC RETRO PREMIUM END (FL) WC142 04/84 WC RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC145 04/84 WC RETRO PREMIUM SHORT FORM WC414 12/91 WC000505A1291 RETROSPECTIVE PREMIUM - LONG TERM CONSTRUCTION PROJECT WC417 12/91 WC000514A1291 RETROSPECTIVE PREMIUM - LONG-TERM CONSTRUCTION PROJECT - MULTIPLE LINES WC144 04/84 WC RETROSPECTIVE PREMIUM - NON RATABLE CATASTROPHE ELEMENT OR SURCHARGE PAGE WC 27 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

28 WC412 12/91 WC000503A1291 RETROSPECTIVE PREMIUM - ONE YEAR PLAN WC415 12/91 WC000512A1291 RETROSPECTIVE PREMIUM - ONE YEAR PLAN - MULTIPLE LINES WC C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC A 01/08 WC090502A0108 RETROSPECTIVE PREMIUM FOR NON-RATABLE CATASTROPHE ELEMENT OR SURCHARGE WC /06 WC RURAL UTILITIES SERVICE WC121 04/84 WC SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC B 01/15 WC090403B TERRORISM RISK INSURANCE WC636 01/84 WC VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC /84 WC VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS Georgia WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC505 07/90 WC ASSIGNED RISK ADJUSTMENT PROGRAM WC F 01/11 WC000418F ASSIGNED RISK LOSS SENSITIVE RATING PLAN WC B 01/11 WC000417A ASSIGNED RISK LOSS SENSITIVE RATING PLAN NOTIFICATION WC504 01/90 WC ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC ASSIGNED RISK PREMIUM SURCHARGE WC /17 WC AUDIT NONCOMPLIANCE CHARGE WC370 07/90 WC BENEFITS DED END [GA] WC403 02/91 WC BENEFITS DEDUCTIBLE WC379 A 04/93 WC100601A CANCLTN/NONR/CHG [GA] ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC DESIGNATED WORKPLACE EXCLUSION WC /94 FORMGID63 DISCLOSURE STATEMENT (FOR USE WITH EXPERIENCE RATED INSUREDS) WC236 09/85 WC DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC D 01/15 WC D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC391 04/91 WC EMPLOYEE LEASING CLIENT PAGE WC 28 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

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