10. Does the Applicant manufacture, store, distribute, sell, handle or transport any of the following?

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1 INDEPENDENCE AMERICAN INSURANCE COMPANY a Delaware Insurance Company Administrative Office: 485 Madison Avenue, 14 th Floor, New York, NY Contractual Liability and Employers Liability Application Application is hereby made for the coverage specified to become effective on at 12:01 A.M. Central Standard Time at the address described below and provided that the initial premium is paid in full and Independence American Insurance Company (the Company ) approves this application. This application will become part of the policy. 1. Legal Name of Applicant: DBA: Federal Tax ID Number: 2. Contact Person: Title: 3. Physical Address: City: State: Zip: 4. Mailing Address: City: State: Zip: 5. Address: Business Phone: 6. Nature of Organization: Corporation LLC Sole Proprietorship Other (explain): 7. How long has the organization been in business? What are the hours of operation? 8. What date was the Worker s Compensation Act rejected? 9. Has insurance of this type (Occupational Accident and/ or Employer Liability) been canceled, refused or nonrenewed by any company during the past three (3) years? Yes No If Yes, please provide details: 10. Does the Applicant manufacture, store, distribute, sell, handle or transport any of the following? Chemicals Yes No Details: Pharmaceuticals Yes No Details: Fuel Oils Yes No Details: Hazardous Materials Yes No Details: Nuclear Materials Yes No Details: Asbestos Materials Yes No Details: 11. Does the Applicant currently have an ERISA Plan they wish to continue? Yes No If Yes, please provide a copy of the complete plan document, including the Summary Plan Description. It must be approved in writing by the Company prior to use. 12. Are employees required to drive their own vehicles for business purposes? Yes No If Yes, please provide details: 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-SUSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER 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. IAIC CL APP 0314 Page 1 of 5 AIS 0414

2 13. Are owners, officers or partners to be covered? Yes No If Yes, do they appear on the State Employment Commission Report? Yes No Please list the owners, officers or partners that are to be excluded from coverage: 14. Are any affiliated entities to be covered? Yes No If Yes, please provide Legal Names and Addresses: 15. Specify the number of employees at the applicant s address and each affiliate location, if any: Designate employee status: W-2 Employees: Yes No 1099 Labor: Yes No 16. Policy Elections: Combined Single Limit (per covered employee per occurrence): Indicate amount: $1 mill Other, please list ($100,000 min/ $5 mill max): $ Self-Insured Retention: per covered employee per occurrence OR per occurrence Indicate amount: $ ($500 min/ $5 mill max) Combined Benefit Period (weeks): Weekly Indemnity: - Elimination Period (days): 5 7 Other, please list (0 days min/ 28 days max): - Benefit Amount (% of weekly wage): 75% Other, please list (50% min/ 90% max): % - Maximum Weekly Indemnity: $900 Other, please list ($200 min/ $1,000 max): $ - Maximum Weeks Duration (weeks): Accidental Death, Dismemberment and Loss of Use: $150,000 Other, please list ($100,000 min/ $500,000 max): $ Exclude Cumulative Trauma and Occupational Disease: Yes No Include Waiver of Subrogation: Yes No Include Alternate Employer Endorsement: Yes No 17. Premium Calculation and Payment Method: Monthly NCCI Code Payroll Payroll Rate Total for Class Total Payroll Composite Rate Premium Subtotal: Monthly Admin Fee: Annual Policy Fee: ERISA Fee: Initial Payment: (Please make premium check payable to Independence American Insurance Company) IAIC CL APP 0314 Page 2 of 5 AIS 0414

3 As per the policy provisions, we have the right to audit your payroll records at any time. If it is determined that premiums have been unpaid, we shall be entitled to recover such underpayments. 1. The applicant requests coverage for a policy of insurance as described above. The applicant also agrees to be bound by all of the terms, conditions and exclusions of the policy applied for. The applicant further understands and agrees that: a. Neither the Request for Coverage, nor the payment of any monies to be applied, shall guarantee insurance to become effective. In order for insurance to take effect on the date specified, the Company must accept and issue a policy. b. The Insured/Employer will agree to pay the required premiums to the Company when due. 2. Acceptance of this request/application is subject to all of the following: (a) Company s requirements; (b) Terms of the policy; (c) Company verification of the quoted premium. 3. The Company will notify the Insured/Employer of any approval or disapproval of this request. Any notice/binder of approval will specify the policy effective date and schedule of coverage. 4. The undersigned Insured/Employer understands that he/she may be subject to on-site loss control/safety inspections. Periodic loss control/safety inspections may be required as a contingency for continuation of coverage. The Insured/Employer also understands and agrees that he/she will be required to comply with any/all loss control/safety recommendations as a contingency for continuation of coverage. 5. The undersigned Insured/Employer has reviewed with his agent (who signs below) and understands the coverage, limits, terms, conditions and exclusion of this application and the policy. This application shall become a part of the policy. 6. The Employer shall make modified duty available for employees approved for rehabilitation and able to return to some form of work as agreed to by the employee s treating physician. 7. The undersigned Insured/Employer understands coverage is written on a Combined Single Limit basis. All coverage afforded under this policy shall not exceed the coverage amount specified for any one person or occurrence per the policy terms and conditions. 8. This is not Workers Compensation Insurance, nor is it a replacement for Workers Compensation Insurance. Independence American Insurance Company does not sell, nor is it authorized to sell, Workers Compensation Insurance with this application. Applicant Signature (Officer): Title: Date: The undersigned agent warrants he/she has not represented the above coverage as anything other than an Occupational Accident policy for on-the-job employee-related injuries. Agent of Record: Date: Agency/Recording Agent Printed Name: Address: City: State: Zip: Phone: Fax: License I.D. Number: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance Policy containing any false, incomplete or misleading information may be guilty of a felony. IAIC CL APP 0314 Page 3 of 5 AIS 0414

4 Disclosure and Acknowledgement Concerning Workers Compensation This will acknowledge that in solicitation of the Independence American Insurance Company Contractual Liability and Employer s Liability Insurance Policy, 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 me. 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 $25,000 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 occupational injury benefits for my employees, I may come under the Employee Retirement Income Security Act of 1974 (ERISA). I understand that it may be in my best interest to have a written occupational 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 a safety program could help reduce the frequency and severity of on-the-job injuries and could also help me meet my responsibility to provide a reasonably safe place to work for our employees. 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. I have sought, or been given the opportunity to seek, competent legal counsel to advise me on this decision. 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 Agent has discussed each of these items with me. Signed this day of, 20. Agent Signature Employer Name (please print) Agent Name (please print) Signature Officer/Owner Witness Name and Title (please print) IAIC CL APP 0314 Page 4 of 5 AIS 0414

5 ERISA Plan Worksheet 1. Company Legal Name: 2. Street Address: 3. Federal Tax ID#: 4. Mailing Address: 5. Contact Person/Title: 6. Phone Number: Fax Number: 7. Company is: Corporation Sole Proprietorship Other State of Incorporation: Company Fiscal Year End? Other specify: 8. Company is Interstate Motor Carrier for Hire? (Yes or No) Company is required to comply with TxDOT limits? (Yes or No) 9. Number of covered employees: Do you need SPD s in Spanish (Yes or No) Union employees covered? (Yes or No) # of Spanish SPD's needed 10. Are affiliated or subsidiary companies covered? (Yes or No) % Common Ownership (Attach additional sheets showing all above information for each, with % of common ownership.) 11. Name/Address of person to be named Plan Administrator. (A position of Trust) Administrator Name: Street Address: 12. Do you currently have any employee welfare benefit plan in place which is governed by ERISA. (I.E. Group Health Insurance)? (Yes/No) If Yes, Plan I.D. Number(s): Describe plan(s): IAIC CL APP 0314 Page 5 of 5 AIS 0414