Starr Indemnity & Liability Company Dallas, TX

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1 Starr Indemnity & Liability Company Dallas, TX Occupational Accident Insurance Policy Group Master Application (the Application ) APPLICANT INFORMATION Legal Name ( Employer ) Contact Address Telephone Fax Employer Identification # Year Business Started Website Nature of Business Operations Are any affiliated organizations to be covered? No Yes: complete an additional separate Application Current Workers Compensation ( W/C )/Nonsubscriber status: In W/C Nonsubscriber Date of Nonsubscriber election (historical or anticipated): INSURANCE COVERAGES REQUESTED Policy Effective Date Combined Single Limit per Plan Participant [per Occurrence] Combined Single Limit per Occurrence Annual Policy Aggregate Deductible per Plan Participant per Occurrence Maximum Benefit Amount per Plan Participant Maximum Medical Benefit Period Weeks: Other Maximum Medical Benefit Amount Maximum Accidental Death Benefit lesser of: 10 x Base Annual Earnings or $ Maximum Weekly Wage Replacement Benefit Amount Wage Replacement Maximum Benefit Period Weeks: Other Wage Replacement Percentage of Average Weekly Earnings 75% Wage Replacement Benefit Waiting Period 7 14 Other Is Employer Indemnity Coverage requested? Is Waiver of Subrogation requested? Is Occupational Disease & Cumulative Trauma Coverage requested? Is Owned Aircraft Coverage requested? Is Pilot Crew Members Coverage requested? Attach Census or Texas TEC Report NONSUBSCRIBER NOTICE This is not a policy of workers compensation insurance. The Employer does not become a subscriber to the workers compensation system by purchasing the policy, and if the Employer is a non-subscriber, the Employer loses those benefits which would otherwise accrue under the workers compensation laws. By signing this application you warrant that you will comply with the Workers Compensation Law as it pertains to non-subscribers and that the required notices will be filed and posted. AH R Page 1 of 4

2 ALL LOCATIONS INFORMATION Number of Name(s) Address(es) Employees Are all buildings no more than 1 story? Fully explain No answers (attach additional page(s) as necessary): Total EMPLOYER INFORMATION Are pre-employment physicals required? Does Applicant have any employees subject to the U.S. Longshoreman & Harbor Workers Act, the Jones Act or Federal Employers Liability Act? Are any employees under age 16 or over age 70? Are any employees physically handicapped? Are seasonal employees hired? Do employees have access to group health insurance sponsored by the Employer? If yes, name of insurer and policy # Fully explain all Yes answers (attach additional page(s) as necessary): TRANSPORTATION INFORMATION Do you provide transportation for employees to or from the workplace? Do you require employees to drive their own vehicles for your business? Fully explain all Yes answers (attach additional page(s) as necessary): Do you own, operate lease or charter any vehicles? If No, skip to OPERATIONAL INFORMATION below Are you subject to Liquified Petroleum Gas or Texas Department of Transportation Regulations? Are you required to file with the Railroad Commission? Number of employees who drive or who are passengers of an Employer owned vehicle? Number and type of vehicles owned or operated? Cars Light Trucks Heavy Trucks (greater than 1 ton) Maximum Height exposure Maximum weight of material handling pounds Driving Radius Commodities hauled Percentage of load manually loaded % unloaded % Are state Department of Motor Vehicles Reports reviewed at least annually on all drivers? AH R Page 2 of 4

3 Age of drivers: Minimum Maximum Fully explain all Yes answers (attach additional page(s) as necessary) including types of vehicles and mileage radius of operations: OPERATIONAL INFORMATION Do you own, operate, lease or charter any watercraft or aircraft? Do you use employ any temporary, leased, volunteer, or donated persons? Do you have any operations outside Texas (including temporary assignments)? Do any employees operate a forklift? Do you use/handle any fuels, explosives, asbestos or hazardous material? Is there any exposure to chemicals, drugs, pharmaceuticals or nuclear materials? Is work performed underground (including tunneling and sub-aqueous)? Do you have an alcohol/drug testing program? Do you operate any convenience stores? Fully explain all Yes answers (attach additional page(s) as necessary): NONSUBSCRIBER NOTICE This is not a policy of workers compensation insurance. The Employer does not become a subscriber to the workers compensation system by purchasing the policy, and if the Employer is a non-subscriber, the Employer loses those benefits which would otherwise accrue under the workers compensation laws. By signing this application you warrant that you will comply with the Workers Compensation Law as it pertains to non-subscribers and that the required notices will be filed and posted. APPLICANT STATEMENT By signing this application, I understand, acknowledge and agree on behalf of the Applicant: I have made an application to Starr Indemnity & Liability Company for an Occupational Accident Insurance Policy and no insurance coverage is afforded until this Application is accepted in writing by Starr Indemnity & Liability Company, all information (including all attachments) in the Application is true and complete, I have been provided with and inspected a specimen copy of the insurance policy, I have reviewed and understand the coverages, limits, terms, and exclusions of the insurance policy, the insurance coverage applied for indemnifies or reimburses for Employee Occupational Injury Plan Benefits only to the extent provided in the Employee Occupational Injury Plan and does not insure any casualty or general liability risk of the Applicant, the coverage applied for does not indemnify or reimburse the Applicant for any losses, damages or awards to employees from a finding of negligence or otherwise for accidental injury or death unless the Applicant specifically applies for the Amendment for Employer Indemnity Coverage, this Application will become a part of the insurance policy and as such contains accurate representations as to the risk to be insured, that insurance coverage is also conditioned upon the requirements as set forth in the pricing indication given in response to this Application and any such indication is not an offer to effect coverage, AH R Page 3 of 4

4 the insurance coverage applied for is not a policy of Workers Compensation insurance nor is it a replacement for Workers Compensation insurance, and I have read and understand the NONSUBSCRIBER NOTICE immediately above, certain conditions or disabilities that may be work related and compensable, according to the Texas Workers Compensation statutes, are not covered nor intended to be covered under this insurance policy, and WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT. Authorized Signature of Applicant ( Contact ) Date AGENT INFORMATION Agency Name Address Telephone Fax Producer Agent s Signature Date AH R Page 4 of 4

5 Disclosure and Acknowledgment Concerning Workers Compensation This will acknowledge that in solicitation of my business insurance, the Agent named below (herein referred to as Agent ), explained to me the following facts about the Texas Workers Compensation Act (the Act ). The following facts were discussed, and as an employer I am aware of their importance. To my knowledge, no statements contrary to the following statements were made by the Agent to anyone employed by, or representing, the Named Insured. 1. Workers Compensation Insurance is a No-Fault system that affords coverage for my employees and protections for me which no alternative insurance plan can duplicate. 2. It is my responsibility, should I elect not to purchase workers compensation insurance, to notify the Texas Department of Insurance, Division of Workers Compensation ( DWC ) at the time of such election by filing the appropriate form (currently the DWC Form 5). I must also annually file the appropriate form (currently DWC Form 5) with the DWC on the anniversary date of the original filing or if I have canceled my workers compensation policy, on the anniversary of the cancellation date of the workers compensation policy. I am aware of the penalty for failure to properly file can be as much as $500 per day. I also must notify my workers compensation carrier, in the manner provided by the law, at the time of my election. All notices and elections must be made by certified mail, return receipt requested. 3. Agent has advised me that if I become a non-subscriber under the Act, I should seek the advice of competent legal counsel in meeting the provisions of the Act. Agent has advised me to seek legal advice for the current law as it applies to my situation. 4. I am aware that as a non-subscriber, should I purchase an alternative insurance product that provides Injury medical benefits for my employees, I come under the Employee Retirement Income Security Act of 1974 (ERISA). It is in my best interest to have a written employee injury benefit plan, and to file this plan under ERISA with the U.S. Department of Labor. Such insurance and plan do not preempt a personal injury negligence lawsuit. 5. I understand that an approved safety program could help reduce the frequency and severity of on-the-job injuries and could also help us meet our responsibility to provide a reasonably safe place to work for our employees. Agent has shown me an alternative work place Injury insurance plan. I acknowledge the option I have selected is solely my choice and the alternative plan I have chosen was not represented by Agent to any person as being a substitute for statutory workers compensation insurance. Agent did not induce me or any representative of my company to reject Workers Compensation. THIS IS NOT A POLICY OF WORKERS COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS COMPENSATION SYSTEM BY PURCHASING THIS POLICY, AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED. I read the above and acknowledge the Agent has discussed each of these items with me. Signed this day of _, 20. Insured Officer/Owner Signature Agent Signature Name (please print) Firm Name (please print)

6 MIDLANDS MANAGEMENT ERISA PLAN INFORMATION SHEET 1. Policy Inception Date: 2. Policy Expiration Date: 3. Legal Name of Insured: Physical Address: (Please attach schedule of locations if more than one (1) location.) 4. Street Address: 5. City: 6. State: TX 7. Zip: Mailing Address (if different): 8. P.O. Box or Street Address: 9. City: 10. State: TX 11. Zip: 12. Federal Tax I.D. Number: 13. Contact Name for Employee Questions: 14. Contact Telephone Number: Name and Address of Insured s Company Representative for Agent For Service Of Legal Process: 15. Name: 16. Street Address: 17. City: 18. State: TX 19. Zip: 20. ERISA Plan Number: (3-digit, 500 series number assigned by Insured to this benefit plan) Policy s Combined Single Limits: 21. Per any one person: $ 22. Per any one occurrence: $ 23. Annual aggregate: $ 24. Policy s Combined Coverage Period: weeks Weekly Indemnity Benefits (for ERISA Plan see note below): 25. Elimination Period: days 26. Benefit Percentage: 75% 27. Maximum Per Week: $ Note: The insurance policy has a 5, 7, 14 or 21 day Elimination Period, and indemnifies up to 75% of pay. The Insured has also bound coverage based on a Maximum Per Week Benefit. However, the Insured may elect to self-fund benefits based on a shorter elimination period, a higher percentage of pay, and/or a higher maximum benefit per week. Any benefits paid by the Insured under its ERISA plan that are greater than the benefits specified under the insurance policy will neither count toward satisfaction of the policy s Deductible nor be indemnified under the policy. 28. Was coverage for Occupational Disease and Cumulative Trauma purchased? Yes No

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