Workers' Compensation Policy Forms and Endorsements

Transcription

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:

29 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 07/14 WC100601B GEORGIA CANCELLATION, NONRENEWAL, AND CHANGE WC /99 WC GEORGIA EMPLOYEE LEASING WC /13 WC GEORGIA NON-COOPERATION WITH PREMIUM AUDIT WC A 01/15 WC100501A GEORGIA RETROSPECTIVE RATING PLAN PREMIUM ONE- YEAR PLAN WC A 01/15 WC100504A GEORGIA RETROSPECTIVE RATING PLAN PREMIUM ONE- YEAR PLAN MULTIPLE LINES WC A 01/15 WC100502A GEORGIA RETROSPECTIVE RATING PLAN PREMIUM THREE- YEAR PLAN WC A 01/15 WC100505A GEORGIA RETROSPECTIVE RATING PLAN PREMIUM THREE- YEAR PLAN MULTIPLE LINES WC A 01/15 WC100503A GEORGIA RETROSPECTIVE RATING PLAN PREMIUM WRAP- UP CONSTRUCTION PROJECT WC A 01/15 WC100506A GEORGIA RETROSPECTIVE RATING PLAN PREMIUM WRAP UP CONSTRUCTION PROJECT MULTIPLE LINES 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 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 WC536 01/94 WC MERIT RATING END [GA] WC448 07/92 WC MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE PAGE WC 29 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

30 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) 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 PAGE WC 30 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

31 WAIVER OF RIGHT TO RECOVER FROM OTHERS Hawaii WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC112 04/84 WC 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 ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC583 01/96 WC CONT CLSFCTN PREM WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR 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 /08 WC HAWAII TERRORISM RISK INSURANCE PROGRAM REQUATHORIZATION ACT ENDORSMENET 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 WC449 06/92 WC PAGE WC 31 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

32 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 WC329 A 10/89 WC520601A MED BEN DED END (HI) WC341 03/87 WC MERIT RATING (HI) 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 WC587 01/96 WC NOTIFICATION END (HI) 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 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 WC597 02/97 WC RESIDUAL MARKET LIMITED OTHER STATES INSURANCE 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 PAGE WC 32 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

33 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 WC VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC /84 WC VOLUNTARY COMPENSATION MARITIME COVERAGE WC140 04/84 WC VOLUNTR WRKRS END (HI) WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS Idaho WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC ANNIVERSARY RATING DATE WC458 09/92 WC ASSGN RISK PREM END [ID] 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 WC391 04/91 WC EMPLOYEE LEASING CLIENT WC A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE PAGE WC 33 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

34 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 A 07/11 WC110402A IDAHO ALCOHOL-AND DRUG-FREE WORKPLACE PREMIUM CREDIT WC /99 WC IDAHO COMPENSATION REIMBURSEMENT OPTION 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 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 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 /01 WC PREMIUM DUE DATE WC A 01/06 WC000321A PAGE WC 34 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

35 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 Illinois WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC E 01/15 WC120601E AMENDATORY END (IL) 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 WC464 09/92 WC CONTRACTING CLASS PREM ADJ [IL WC644 12/03 FORM121CCPAP CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM PAGE WC 35 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

36 (ILCCPAP) CONFIDENTIAL WORKERS COMPENSATION PREMIUM CREDIT APPLICATION 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 WC391 04/91 WC EMPLOYEE LEASING CLIENT WC A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC A 06/03 WC120303A0603 EMPLOYEE LEASING ENDT (IL) 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 /99 WC IL EMPLOYEE LEASING CLIENT EXCLUSION WC /99 WC IL LABOR CONTRACTOR EXCLUSION WC /15 WC ILLINOIS SOLE PROPRIETORS, PARTNERS, OFFICERS, MEMBERS OF LIMITED LIABILITY COMPANIES, AND OTHER EXCLUDED EMPLOYEES AND EMPLOYMENTS EXCLUSION WC A 07/11 WC120306A ILLINOIS WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY EXCLUSION 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 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 WC150 A 08/92 WC120602A0892 MED DEDUCT END [IL] WC448 07/92 WC MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC A 01/06 WC000323A PAGE WC 36 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

37 MULTIPLE COORDINATED POLICY FORM635 L 11/11 635L NEW YORK WORKERS COMPENSATION PREMIUM CREDIT APPLICATION 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 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 /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 Indiana PAGE WC 37 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

38 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 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 WC430 01/92 WC BENE DED END [IN] WC403 02/91 WC BENEFITS DEDUCTIBLE WC432 01/92 WC COINSURANCE END (IN) WC431 01/92 WC COINSURANCE/DED END(IN) 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 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 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 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 PAGE WC 38 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

39 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 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 PAGE WC 39 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

40 WC /84 WC VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS Iowa 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 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 WC /02 WC IOWA EXECUTIVE OFFICERS, SOLE PROPRIETORS, PARTNERS, MEMBERS AND MANAGERS OF LIMITED LIABILITY COMPANIES AND OTHERS, BENEFIT LEVEL SELECTION WC /11 WC PAGE WC 40 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

41 IOWA MEDICAL DEDUCTIBLE PROGRAM CARRIER REIMBURSED DEDUCTIBLE 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 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 /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 WC597 02/97 WC RESIDUAL MARKET LIMITED OTHER STATES INSURANCE WC581 06/96 WC RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC RETRO PREMIUM AVIATION PAGE WC 41 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

42 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 WC141 04/84 WC RETROSPECTIVE PREMIUM - RATING OPTIONS V - LONG TERM CONSTRUCTION PROJECT 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 Kansas 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 F 01/15 WC150403F ASSIGNED RISK RESTRO (KS) WC /17 WC AUDIT NONCOMPLIANCE CHARGE WC403 02/91 WC BENEFITS DEDUCTIBLE WC152 A 01/87 WC150601A CANC NONRENEW END 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 WC312 03/85 WC DOMESTIC/AG WRKS [KS] WC391 04/91 WC EMPLOYEE LEASING CLIENT PAGE WC 42 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

43 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 WC622 01/98 WC KANSAS ASSIGNED RISK WC621 03/98 WC150407A0198 KANSAS ASSIGNED RISK WC /05 WC KANSAS HOME AND COMMUNITY BASED SERVICES WAIVER PROGRAM WC /06 WC KANSAS PER CLAIMANT BENEFITS DEDUCTIBLE WC /06 WC KANSAS PER OCCURRENCE BENEFITS DEDUCTIBLE WC A 09/14 WC150303A KANSAS PROFESSIONAL EMPLOYER ORGANIZATION (PEO) MULTIPLE COORDINATED POLICY FOR POLICY COVERING THE PEO 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 WC586 03/96 WC LOSS COST CHG END (KS) 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 PAGE WC 43 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

44 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 WC585 03/96 WC PENDING LOSS COST (KS) 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 WC597 02/97 WC RESIDUAL MARKET LIMITED OTHER STATES INSURANCE 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 Kentucky WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER PAGE WC 44 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

45 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 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 WC610 05/97 WC EMPLOYEE LEASING (KY) WC391 04/91 WC EMPLOYEE LEASING CLIENT WC A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC A 12/99 WC160302A1299 EMPLOYEE LEASING END'T (KY) WC B 05/17 WC160302B EMPLOYEE LEASING END'T (KY) 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 WC618 12/97 WC KENTUCKY CANC/NONREN END WC /99 WC KENTUCKY NOTICE OF APPEAL RIGHTS WC /07 WC KENTUCKY PART ONE WORKERS COMPENSATION INSURANCE WC611 05/97 WC LABOR CONT EXCL END(KY) WC449 06/92 WC LIMITED MARITIME COVERAGE WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE PAGE WC 45 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

46 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 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 WC292 10/84 NOTICE TO INSUREDS TAX AND ASSESSMENT CHARGE 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 WC549 05/97 WC REJ OF COV END (KY) 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 PAGE WC 46 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

47 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 Louisiana WC126 04/84 WC AIRCRAFT PREMIUM 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 ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC537 A 02/96 WC170602A COST CONT ACT END (LA) 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 PAGE WC 47 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

48 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 F 08/15 WC170601F LOUISIANA AMENDATORY WC /04 WC LOUISIANA ANNIVERSARY RATING DATE WC /00 WC LOUISIANA DUTY TO DEFEND WC /03 WC LOUISIANA PROFESSIONAL EMPLOYER ORGANIZATION WC /03 WC LOUISIANA PROFESSIONAL EMPLOYER ORGANIZATION EXCLUSION ENDOREMENT WC B 01/15 WC170501B LOUISIANA RETROSPECTIVE RATING PLAN PREMIUM ONE- YEAR PLAN WC B 01/15 WC170504B LOUISIANA RETROSPECTIVE RATING PLAN PREMIUM ONE- YEAR PLAN MULTIPLE LINES WC B 01/15 WC170502B LOUISIANA RETROSPECTIVE RATING PLAN PREMIUM THREE- YEAR PLAN WC B 01/15 WC170505B LOUISIANA RETROSPECTIVE RATING PLAN PREMIUM THREE- YEAR PLAN - MULTIPLE LINES WC B 01/15 WC170503B LOUISIANA RETROSPECTIVE RATING PLAN PREMIUM WRAP- UP CONSTRUCTION PROJECT WC B 01/15 WC170506B LOUISIANA RETROSPECTIVE RATING PLAN PREMIUM WRAP- UP CONSTRUCTION PROJECT - MULTIPLE LINES 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 PAGE WC 48 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

49 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 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 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 PAGE WC 49 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

50 WAIVER OF RIGHT TO RECOVER FROM OTHERS Maine WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC599 09/96 WC ANNIV MODIFICATION (ME) 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 WC360 A 06/95 WC180603A CANC & NONREN END (ME) 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 WC395 05/88 WC FINAL PREM AUD END (ME) WC B 01/15 WC B FOREIGN TERRORISM PREMIUM WC A 05/98 WC000001A INFORMATION PAGE WC B 01/15 WC000001B INFORMATION PAGE NOTES WC153 04/84 WC INSPEC IMUNTY END [ME] 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 PAGE WC 50 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

51 WC419 04/92 WC000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE WC237 04/84 WC LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC357 D 12/97 WC180602D1297 MAINE BENEFITS DED END WC /99 WC MAINE NOTICE OF FILING OF FIRST REPORTS OF INJURY WC A 07/11 WC180607A MAINE SUPPLEMENTAL BENEFITS FUND WC B 01/15 WC000201B MARITIME COVERAGE WC356 11/87 WC180402A MERIT RAT ENDT [ME] 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 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 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 PAGE WC 51 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

52 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 Maryland 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 WC F 01/16 WC F CANCELLATION (MD) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC476 07/93 WC CONST CLASS PREM [MD] 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 52 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

53 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 WC /14 WC MARYLAND NOTIFICATION OF 45-DAY UNDERWRITING PERIOD 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 PAGE WC 53 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

54 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 SOLEPROP 01/10 WCC FORM IC-02 SOLE PROPRIETOR'S STATUS AS A COVERED EMPLOYEE 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 Massachusetts WC126 04/84 WC AIRCRAFT PREMIUM 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 WC403 02/91 WC BENEFITS DEDUCTIBLE WC474 01/93 WC BENEFITS DET END [MA] ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC386 01/91 WC CONSTRUCTION CLASSIFICTN (MA) 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 WC391 04/91 WC EMPLOYEE LEASING CLIENT WC A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION PAGE WC 54 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

55 WC C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC443 03/92 WC EXC OF COV LSD [MA] 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 WC449 06/92 WC LIMITED MARITIME COVERAGE WC B 06/13 WC200306B LIMITED OTHER STATES BENEFIT WC242 04/84 WC LMTS OF LIAB END (MA) 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 WC444 B 12/97 WC200304B1297 MASS EMPLY LEASING END WC /02 WC MASSACHUSETTS ASSIGNED RISK POOL ELIGIBILITY WC A 04/15 WC200603A MASSACHUSETTS BENEFITS CLAIM AND AGGREGATE DEDUCTIBLE WC /08 WC200601A MASSACHUSETTS CANCELATION WC652 B 11/11 MASSACHUSETTS CONSTRUCTION CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC /14 WC MASSACHUSETTS NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 WC /02 WC MASSACHUSETTS POLICY DEFINITION WC /01 WC MASSACHUSETTS PREMIUM DUE DATE WC /08 WC /08 MASSACHUSETTS TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT WC A 09/08 WC200302A MASSACHUSETTS-ASSESSMENT CHARGE WC448 07/92 WC PAGE WC 55 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

56 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 D 08/10 WC200303D NOTICE TO POLICYHOLDER 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 WC380 11/90 WC PNDNG REM CHG END (MA) 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 WC A 01/06 WC000321A PROFESSIONAL EMPLOYER WC B 01/06 WC000320B PROFESSIONAL EMPLOYER WC418 B 01/94 WC QUAL LOSS MGMT [MA] WC132 04/84 WC RATE CHANGE WC581 06/96 WC RESIDUAL MARKET MULTIPLE COMPANY WC571 04/95 WC RETRO PREM END [MA] 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 PAGE WC 56 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

57 VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS Michigan WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC112 04/84 WC ALTERNATE EMPLOYER WC WC AMENDMENT TO MICHIGAN LAW - EXCLUSION OF DESIGNATED CONSTRUCTION SITE WC168 04/84 WC AMENDMENT TO MICHIGAN LAW (COVERAGE LIMITED TO DESIGNATED CONSTRUCTION SITE) 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 WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC509 04/84 WC DESGNTD CONST SITE [MI] WC113 04/84 WC DESIGNATED WORKPLACE EXCLUSION WC510 04/84 WC DESIGNTD CONST SIT [MI] WC236 09/85 WC DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC170 04/84 WC DUAL OR JOINT EMPLY END WC516 04/84 WC DUAL/JOINT EMP END [MI] 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 WC103 04/84 WC FEDERAL EMPLOYERS' LIABILITY ACT COVERAGE WC A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC115 04/84 WC INSURANCE COMPANY AS INSURED WC116 04/84 WC JOINT VENTURE AS INSURED WC491 04/84 WC LAW ENDORSMNT [MI] WC449 06/92 WC LIMITED MARITIME COVERAGE WC419 04/92 WC000106A PAGE WC 57 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

58 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 A 06/97 WC210503A0697 MICHIGAN RETRO PREM END 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 WC171 A 01/87 WC A NON-RATABLE SPECIFIC DISEASE ELEMENT (SUPPLEMENT TO RETROSPECTIVE PREMIUM ) WC A 06/97 WC210303A0697 NOTICE TO POLCHLDR ENDT (MI) 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 WC130 04/84 WC POLICY PERIOD WC514 04/84 WC PREM DETERMNT END [MI] WC267 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 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 WC172 04/84 WC RETRO PREM END [MI] WC142 04/84 WC RETRO PREMIUM AVIATION WC340 04/87 WC000509A PAGE WC 58 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

59 RETRO PREMIUM CHANGES WC145 04/84 WC RETRO PREMIUM SHORT FORM WC144 04/84 WC RETROSPECTIVE PREMIUM - NON RATABLE CATASTROPHE ELEMENT OR SURCHARGE WC141 04/84 WC RETROSPECTIVE PREMIUM - RATING OPTIONS V - LONG TERM CONSTRUCTION PROJECT WC137 04/84 WC RETROSPECTIVE PREMIUM - RATING OPTIONS V - ONE YEAR PLAN WC650 04/84 WC RETROSPECTIVE PREMIUM CHANGES WC /84 WC RETROSPECTIVE-1 YR PLAN-OPTION I,II,III & IV WC /84 WC RETROSPECTIVE-3YR PLAN-OPTION I,II,III & IV WC121 04/84 WC SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC B 01/15 WC210402B TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE WC530 04/84 WC VOL COMP FED EMP [MI] 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 WC320 10/85 WC WAIVER/COORD BEN [MI] WC511 04/84 WC WC PLAMNT FAC END [MI] WC512 01/85 WC WC PLANT FAC (MI) Minnesota WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC A 11/03 WC220000A1103 AMENDATORY (MN) WC580 09/95 WC ANNIV RATING DATE ENDT (MN) 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 WC D 08/06 WC220601D0806 CANCELL & NONREN ENDT (MN) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC438 10/92 WC CONTRACT PREM ADJ [MN] WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC DESIGNATED WORKPLACE EXCLUSION PAGE WC 59 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

60 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 A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC B 01/15 WC B FOREIGN TERRORISM PREMIUM 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 WC448 07/92 WC MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC /09 WC MINNESOTA ALTERNATE EMPLOYER [EXCLUDING EMPLOYERS LIABILITY COVERAGE] WC /05 WC MINNESOTA COMPLIANCE WITH APPLICABLE TRADE SANCTION LAWS WC /06 WC MINNESOTA EMPLOYEE LEASING WC /05 WC MINNESOTA ENTITY ADDRESS SCHEDULE WC /06 WC MINNESOTA EXCLUSION OF COVERAGE FOR LEASED EMPLOYEES WC /02 WC MINNESOTA INFORMATION PAGE AND NOTES WC /06 WC MINNESOTA THIRD DEGREE OF KINDRED FAMILY MEMBER EXCLUSION WC /05 WC MINNESTOA INDEPENDENT CONTRACTORS 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 PAGE WC 60 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

61 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 /02 WC POLICY CHANGE WC A 10/07 WC220616A POLICY CHANGE WC /02 WC POLICY INFORMATION PAGE - ADD STATES WC /02 WC POLICY INFORMATION PAGE - CARRIER NUMBER WC /02 WC POLICY INFORMATION PAGE - CARRIER SERVICING OFFICE WC /02 WC POLICY INFORMATION PAGE - CHANGE IN STATE WC /02 WC POLICY INFORMATION PAGE - CHANGE IN WORKPLACE OF INSURED WC A 10/07 WC220615A POLICY INFORMATION PAGE - CLASS, RATE, OTHER CHANGE WC /02 WC POLICY INFORMATION PAGE - EFFECTIVE DATE WC /02 WC POLICY INFORMATION PAGE - EMPLOYER LIMITS WC /02 WC POLICY INFORMATION PAGE - NUMBERS WC /02 WC POLICY INFORMATION PAGE - EXPERIENCE MODIFICATION WC /02 WC POLICY INFORMATION PAGE - EXPIRATION DATE WC /02 WC POLICY INFORMATION PAGE - INSURED'S LEGAL STATUS WC /02 WC POLICY INFORMATION PAGE - INSURED'S MAILING ADDRESS WC /02 WC POLICY INFORMATION PAGE - INSURED'S NAME WC /02 WC POLICY INFORMATION PAGE - INTERSTATE / INTRASTATE RISK I.D. NUMBER WC /02 WC POLICY INFORMATION PAGE - POLICY NUMBER WC /02 WC POLICY INFORMATION PAGE - PRODUCER'S NAME WC130 04/84 WC POLICY PERIOD WC266 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 1 PAGE WC 61 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

62 WC267 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 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) WC547 02/94 WC000309A 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 Mississippi 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 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 PAGE WC 62 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

63 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 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 WC /99 WC MISSISSIPPI-SMALL EMPLOYER LOSS- FREE POLICY PREM C 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 PAGE WC 63 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

64 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) 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 Missouri WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC112 04/84 WC ALTERNATE EMPLOYER WC127 04/84 WC ANNIVERSARY RATING DATE WC439 09/91 WC ASSGND RISK PREM [MO] WC505 07/90 WC ASSIGNED RISK ADJUSTMENT PROGRAM PAGE WC 64 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

65 WC504 01/90 WC ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC ASSIGNED RISK PREMIUM SURCHARGE WC /17 WC AUDIT NONCOMPLIANCE CHARGE WC579 10/95 WC BENEFITS DED END (MO) WC403 02/91 WC BENEFITS DEDUCTIBLE WC158 B 01/96 WC240601B CANC & NONREN END (MO) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC368 01/90 WC CONT CLASS PREM AS [MO] WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR 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 08/05 WC240406C0805 EMPLOYER PAID MEDICAL END (MO) 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 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 PAGE WC 65 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

66 MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC B 01/17 WC240604B MISSOURI AMENDATORY FORM24-1 A 01/14 FORM MISSOURI CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM WORKERS COMPENSATION - PREMIUM CREDIT APPLICATION WC A 01/14 WC MISSOURI EXCLUSION OF ADDITIONAL MESOTHELIOMA BENEFITS WC A 01/14 WC MISSOURI NOTIFICATION OF ADDITIONAL MESOTHELIOMA BENEFITS 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 B 07/06 WC240602B0706 P&C GUAR ASSOC NOTIFIC END(MO) WC C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC119 04/84 WC PARTNERS, OFFICERS AND OTHERS EXCLUSION WC B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC POLICY PERIOD 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 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 WC157 A 12/91 WC240501A1291 RETROSP PREM SUP [MO] WC C 01/15 WC000504C PAGE WC 66 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

67 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 Montana 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 WC403 02/91 WC BENEFITS DEDUCTIBLE WC A 10/03 WC250601A1003 CANCEL & NONRENEWAL ENDT (MT) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR 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 PAGE WC 67 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

68 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 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 WC448 07/92 WC MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC /99 WC MONTANA EMPLOYEE LEASING/ PROFESSIONAL EMPLOYER CLIENT EXCLUSION WC /99 WC MONTANA EMPLOYEE LEASING/ PROFESSIONAL EMPLOYER WC /02 WC MONTANA INTENTIONAL INJURY EXCLUSION WC /99 WC MONTANA LABOR CONTRACTOR/ PROFESSIONAL EMPLOYER ORGANIZATION EXCLUSION WC /12 WC MONTANA NON-COOPERATION WITH PREMIUM AUDIT SURCHARGE 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 PAGE WC 68 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

69 WC B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC POLICY PERIOD 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 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 WC542 01/94 WC SAFETY END (MT) 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 Nebraska 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 WC337 C 07/96 WC260601C CANC & NONREN END(NE) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION PAGE WC 69 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

70 WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR NC5000 A 07/11 FORM NC-5000A CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC304 01/95 WC CONTRACTION CLASS [NE] 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 WC381 05/89 WC EXP RATY MOD END [NE] 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 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 WC393 07/90 WC MED BENEFITS END [NE] WC448 07/92 WC MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC A 01/06 WC000323A MULTIPLE COORDINATED POLICY (New) WC A 05/17 WC260401A NEBRASKA EXPERIENCE RATING MODIFICATION WC /13 WC NEBRASKA PROFESSIONAL EMPLOYER ORGANIZATION (PEO) CLIENT EXCLUSION ENDORSMENT WC /13 WC PAGE WC 70 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

71 NEBRASKA PROFESSIONAL EMPLOYER WC /13 WC NEBRASKA PROFESSIONAL EMPLOYER ORGANIZATION (PEO) MULTIPLE COORDINATED POLICY FOR POLICY COVERING THE CLIENT (New) WC A 05/17 WC260302A NEBRASKA PROFESSIONAL EMPLOYER ORGANIZATION (PEO) MULTIPLE COORDINATED POLICY FOR POLICY COVERING THE CLIENT WC /13 WC NEBRASKA PROFESSIONAL EMPLOYER ORGANIZATION (PEO) MULTIPLE COORDINATED POLICY FOR POLICY COVERING THE PEO WC A 05/17 WC260301A NEBRASKA PROFESSIONAL EMPLOYER ORGANIZATION (PEO) MULTIPLE COORDINATED POLICY FOR POLICY COVERING THE PEO 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 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 PAGE WC 71 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

72 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 Nevada 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 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 PAGE WC 72 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

73 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 WC C 10/08 WC270601C NEVADA CANCEL/NONRENEWAL ENDT WC A 06/12 WC270302A NEVADA EMPLOYEE LEASING CLIENT EXCLUSION WC A 06/12 WC270303A NEVADA EMPLOYEE LEASING EXCLUSION WC /12 WC NEVADA EMPLOYEE LEASING MASTER POLICY BASIS WC A 06/12 WC270301A NEVADA EMPLOYEE LEASING MULTIPLE COORDINATED POLICIES BASIS WC B 05/17 WC270301B NEVADA EMPLOYEE LEASING MULTIPLE COORDINATED POLICIES BASIS WC /15 WC NEVADA RETROSPECTIVE RATING PLAN PREMIUM WRAP-UP CONSTRUCTION PROJECT WC /15 WC NEVADA RETROSPECTIVE RATING PLAN PREMIUM WRAP-UP CONSTRUCTION PROJECT MULTIPLE LINES 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 PAGE WC 73 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

74 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 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 New Hampshire WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC447 04/92 WC AMENDAROTY END (NH) WC127 04/84 WC ANNIVERSARY RATING DATE WC477 12/92 WC ASSIGN RISK SUR [NH] 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 PAGE WC 74 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

75 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 WC A 07/03 WC280402A0703 CERTIFIED MANAGED CARE (NH) 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 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 PAGE WC 75 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

76 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 WC /08 WC PENDING RATE CHANGE WC446 03/92 WC PER ACCID PER DIS (NH) WC445 03/92 WC PER CLAIM BENE END (NH) WC B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC POLICY PERIOD 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 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 WC365 A 01/96 WC280403A SAFETY INC PROG (NH) WC200 04/84 WC SDE REPRESENTV [NH] PAGE WC 76 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

77 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 WC B 01/09 WC280301B WC/EMPLYRS LIAB COV RES [NH] New Jersey WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC ANNIVERSARY RATING DATE WC531 A 01/96 WC290409A APP MNGD CARE PGRM (NJ) 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 WC577 04/96 WC CONSTRUCTION CLASIF(NJ) WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC113 04/84 WC DESIGNATED WORKPLACE EXCLUSION WC D 01/15 WC D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC470 01/93 WC EMP LEAS CL EX END [NJ] WC471 01/93 WC EMP LEAS CONT END [NJ] WC469 01/93 WC EMP LEAS CONT EQ [NJ] 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 WC115 04/84 WC INSURANCE COMPANY AS INSURED WC116 04/84 WC JOINT VENTURE AS INSURED NJLRLD 07/06 FORMNJLRLD LARGE RISK - LARGE DEDUCTIBLE PROGRAM NOTICE OF ELECTION WC497 A 01/94 WC290601A LG RISK DED END [NJ] WC A 07/05 WC290309A0705 LIMIT OTHER STATE INS ENDT(NJ) PAGE WC 77 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

78 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 WC /05 WC NEW JERSEY LARGE RISK - LARGE DEDUCTIBLE PER PERSON BASIS WC /13 WC NEW JERSEY PREMIUM DISCOUNT SCHEDULE X WC /00 WC NEW JERSEY SOLE PROPRIETORS AND PARTNERS COVERAGE WC203 A 01/99 WC290302A NEW JERSEY WC EMP LIAB RESID. WC /04 WC NEW JERSEY WORKERS' COMPENSATION INSURANCE PLAN ELIGIBILITY WC /03 WC NJ LARGE RISK - LARGE DEDUCTIBLE AGGREGATE LIMIT ENDORSMENT WC614 01/98 WC NJ PARTICIPATING PROV END WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC106 01/89 NOTICE FORMPP1 B 07/07 FORMPP1B NOTICE OF ELECTION - PROPRIETORS AND PARTNERS WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE NJRR2 01/14 NJRR-2 (1/14) NOTICE OF ELECTION OF RETROSPECTIVE RATING (MUST BE FILED WITH NJCRIB) 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 B 07/07 WC290306B0707 PART 2 EMPLYRS LIAB ENDT (NJ) 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 WC205 A 01/86 WC PREM DIXC END SCHD (NJ) WC267 07/91 WC PAGE WC 78 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

79 PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC B 01/15 WC290411B PREMIUM DISCOUNT - SCHEDULE Y WC Y 01/12 WC290406Y PREMIUM DISCOUNT SCHEDULE Y 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 WC C 07/00 WC290509C RETRO PREM ENDT PRT2 EXC (NJ) WC142 04/84 WC RETRO PREMIUM AVIATION WC145 04/84 WC RETRO PREMIUM SHORT FORM WC B 01/05 WC290602B0105 RETROSPECTIVE ADJMNT ENDT (NJ) WC C 01/05 WC290513C0105 RETROSPECTIVE PREM 1 YEAR (NJ) WC144 04/84 WC RETROSPECTIVE PREMIUM - NON RATABLE CATASTROPHE ELEMENT OR SURCHARGE WC C 01/15 WC000504C RETROSPECTIVE PREMIUM - RATING OPTION V THREE YEAR PLAN WC137 04/84 WC RETROSPECTIVE PREMIUM - RATING OPTIONS V - ONE YEAR PLAN WC650 04/84 WC RETROSPECTIVE PREMIUM CHANGES WC /10 WC RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC C 01/05 WC290514C0105 RETROSPECTOVE PREM 3 YR (NJ) WC C 01/05 WC290515C0105 RETROSPECTOVE PREM ENDT (NJ) WC B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC201 04/84 WC VOL COMP FED [NJ] 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 New Mexico WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC505 07/90 WC ASSIGNED RISK ADJUSTMENT PROGRAM WC B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC PAGE WC 79 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

80 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 /07 WC CONSUMER DIRECTED PROGRAM WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR NC /11 FORM NC-5001 CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM APPLICATION FOR NON-ARD STATES 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 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 PAGE WC 80 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

81 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 WC /05 WC NEW MEXICO ASSIGNED RISK SURCHARGE WC A 03/15 WC300601A NEW MEXICO CANCELLATION AND NONRENEWAL 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 /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 PAGE WC 81 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

82 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC159 04/84 WC SAFETY DEVICE CURG (NM) WC160 04/84 WC SFTY DEVICE EX [NM] 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 WC161 04/84 WC VOLUNTEER WRKR END (NM) WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS WC459 A 07/93 WC300401A WC PREM ADJ PROG [NM] New York WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC485 01/89 WC AMBULANCE DIST LB [NY] WC488 01/89 WC AMBULANCE/FIRE D [NY] 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 WC402 A 04/94 WC310315A BENEFITS DED END (NY) WC403 02/91 WC BENEFITS DEDUCTIBLE ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC473 04/93 WC CONS CLASS PREM AD [NY] WC G 10/13 WC310319G CONSTRUCTION CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM EXPLANATORY WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC218 04/84 WC COV FOR ELECTED (NY) WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC DESIGNATED WORKPLACE EXCLUSION WC219 04/84 WC DESIGNATED WORKPLCE(NY) WC D 01/15 WC D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC220 04/84 WC DOMESTIC WORKERS (NY) WC391 04/91 WC EMPLOYEE LEASING CLIENT WC A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC423 04/92 WC000303B EMPLOYERS LIABILITY COVERAGE WC487 01/89 WC EXC FOR DESGNTD [NY] PAGE WC 82 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

83 WC221 04/84 WC EXCESS MEDICAL [NY] WC223 B 01/94 WC310305B EXCL OF EXEC OFF (NY) WC222 04/84 WC EXCLUSION DES [NY] WC224 01/86 WC EXEC OFF EXCL [NY] WC225 04/84 WC EXECUTIVE OFFCRS [NY] WC128 04/84 WC EXPERIENCE RATING MODIFICATION FACTOR WC174 04/84 EXTENSION OF INFORMATION PAGE (ITEM 4. PREMIUM) WC A 10/04 WC000104A FEDERAL EMPLOYERS LIABILITY ACT COVERAGE WC226 A 01/89 WC FIRE DIST LIAB EC [NY] WC B 01/15 WC B FOREIGN TERRORISM PREMIUM WC A 08/00 WC310314A INCLUSION OF AUXILIARY POLICY WC227 A 01/87 WC310306A0187 INCLUSION OF EXEC (NY) WC A 05/98 WC000001A INFORMATION PAGE WC A 10/08 WC310003A INFORMATION PAGE NEW YORK VOLUNTEER AMBULANCE WORKERS BENEFIT POLICY WC /15 WC000001C INFORMATION PAGE NOTES WC115 04/84 WC INSURANCE COMPANY AS INSURED WC116 04/84 WC JOINT VENTURE AS INSURED WC479 07/93 WC LABOR CONT END [NY] WC480 07/93 WC LABOR CONT EXC END [NY] WC228 04/84 WC LIAB OF MUNIC (NY) WC230 04/84 WC LIMIT OF LIAB END [NY] 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 WC231 04/84 WC MED BEN REIMBURS (NY) WC554 10/94 WC MERIT RATNG END [NY] WC448 07/92 WC MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC A 10/08 WC310617A NEW YORK FOREIGN VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC /00 WC NEW YORK LIMIT OF LIABILITY WC /99 WC NEW YORK PEND PAYROLL LIMIT & PREM DIFFERERENTIAL WC B 02/15 WC310316B NEW YORK SOLE PROPRIETORS, PARTNERS AND MEMBERS OF LLC S, PSLC S, RLLP S, ETC. EXCLUSION WC A 10/08 WC310001A NEW YORK VOLUNTEER FIREFIGHTERS BENEFIT FORM PAGE WC 83 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

84 WC232 04/84 WC NON/SUBJ EMP END [NY] WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC233 04/84 WC NON-SUBJECT EXEC [NY] RR50 10/10 RR-50 NOTICE OF ELECTION OF RETROSPECTIVE RATING PLAN NYLR1 10/10 NYLR-1 NOTICE OF ELECTION OF RETROSPECTIVE RATING PLAN - NEW YORK LARGE RISK RATING OPTION WC369 07/90 WC NOTIFICATION OF CHANGE IN OWNERSHIP RR1 10/10 RR-1 NOTIFICATION OF COVERAGE - MULTI- STATE RETROSPECTIVE RATING PLAN WC633 01/99 WC NY OPT CLIENT EXCL ENDT WC631 01/99 WC NY OPT LABOR CONTRACTR ENDT WC632 01/99 WC NY OPT LABOR CONTRCTR EXCL END WC615 A 01/99 WC310616A NY PREF PROV ORG END WC616 A 01/99 WC310403A NY PREF PROV ORG PREM END 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 WC130 04/84 WC POLICY PERIOD WC /15 WC POLICYHOLDER NOTICE OF RIGHT TO APPEAL WC267 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 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 PAGE WC 84 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

85 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 WC /10 WC RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC120 04/84 WC RURAL ELECTRIFICATION ADMINISTRATION WC B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC466 10/92 WC SOLE PROPRIETORS [NY] WC /02 WC TERRORISM RISK INSURANCE ACT WC407 04/91 WC VOL AMB BEND [NY] WC319 11/85 WC VOL FIREFT (NY) WC234 04/84 WC VOL FIREMENS [NY] WC636 01/84 WC VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC /84 WC VOLUNTARY COMPENSATION MARITIME COVERAGE WC486 01/89 WC VOLUNTEER AMB W [NY] WC484 01/89 WC VOLUNTEER AMB W PR [NY] WC139 01/93 WC310002A0193 VOLUNTEER AMB WK [NY] WC235 04/84 WC VOLUNTEER FIREMEN'S(NY WC114 01/93 WC310000A0193 VOLUNTEER FIRFT [NY] WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS North Carolina WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC /09 WC ALTERNATE EMPLOYER (EXCLUDING EMPLOYERS LIABILITY COVERAGE) 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 PAGE WC 85 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

86 ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC ASSIGNED RISK PREMIUM SURCHARGE WC403 02/91 WC BENEFITS DEDUCTIBLE WC A 07/10 WC320601A CANCELLATION/NON-RENEWAL ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC /08 WC CONTROL INS PROG W/LARGE DEDUCTIBLE 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 WC103 04/84 WC FEDERAL EMPLOYERS' LIABILITY 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 WC B 01/15 WC000201B MARITIME COVERAGE WC117 04/84 WC MEDICAL BENEFITS EXCLUSION WC448 07/92 WC MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE PAGE WC 86 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

87 WC437 02/92 WC MULTIPLE COORDINATED POLICY WC A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC /15 WC NEVADA RETROSPECTIVE RATING PLAN PREMIUM WRAP-UP CONSTRUCTION PROJECT WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE WC C 01/14 WC320301C NORTH CAROLINA AMENDED COVERAGE WC /08 WC NORTH CAROLINA CONTROLLED INSURANCE PROGRAM - AMENDATORY 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 NCDISC2 02/15 DISCLOSURE NO.2 POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE NCDISC1 02/15 DISCLOSURE NO.1 POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE WC267 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 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 WC /10 WC PRO-RATA CANCELLATION 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 WC414 12/91 WC000505A1291 RETROSPECTIVE PREMIUM - LONG TERM CONSTRUCTION PROJECT WC C 01/15 WC000504C PAGE WC 87 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

88 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 North Dakota 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 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 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 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 PAGE WC 88 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

89 LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE 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 WC369 07/90 WC NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE 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 WC267 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 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 WC137 04/84 WC RETROSPECTIVE PREMIUM - RATING OPTIONS V - ONE YEAR PLAN WC /84 WC RETROSPECTIVE-1 YR PLAN-OPTION I,II,III & IV WC636 01/84 WC VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS Ohio 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 PAGE WC 89 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

90 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 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) 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 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 WC369 07/90 WC NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC119 04/84 WC PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC PENDING RATE CHANGE WC130 04/84 WC POLICY PERIOD WC267 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 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 PAGE WC 90 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

91 RETRO PREMIUM AVIATION WC145 04/84 WC RETRO PREMIUM SHORT FORM WC636 01/84 WC VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS Oklahoma WC112 04/84 WC ALTERNATE EMPLOYER WC /17 WC AUDIT NONCOMPLIANCE CHARGE WC C 07/06 WC350602C0706 BENEFITS DED ENDT (OK) WC F 02/14 WC350601F CANCELTN/NONREN/CHANGE (OK) WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC590 07/96 WC CONTR CLSFCTN PREM (OK) NC5000 A 07/11 FORM NC-5000A CONTRACTING CLASSIFICATION PREMIUM ADJUSTMENT PROGRAM WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC236 09/85 WC DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC D 01/15 WC D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM WC336 01/87 WC EMPLOYERS LIAB AM [OK] WC B 01/15 WC000102B FEDERAL COAL MINE HEALTH AND SAFETY ACT COVERAGE WC B 01/15 WC B FOREIGN TERRORISM PREMIUM WC534 12/93 WC FRAUD WARNING END [OK] WC A 05/98 WC000001A INFORMATION PAGE WC B 01/15 WC000001B INFORMATION PAGE NOTES WC237 04/84 WC LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT RATE CHANGE WC B 01/15 WC000201B MARITIME COVERAGE WC B 11/01 WC350403B1101 MERIT RATING END (OK) WC525 11/85 FORM351 NOTICE TO POLICYHOLDERS 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 WC /99 WC OKLAHOMA ELECTION OF COV NOTIFICATION WC /11 WC OKLAHOMA EMPLOYERS LIABILITY INTENTIONAL TORT EXCLUSION WC C 01/15 WC000000C PART TWO EMPLOYERS LIABILITY INSURANCE WC A 01/01 WC350402A0101 PREM REDCT PROG(WCPR)ENDT (OK) WC131 08/84 WC PREMIUM DISCOUNT WC A 07/95 WC000406A PREMIUM DISCOUNT WC142 04/84 WC RETRO PREMIUM AVIATION PAGE WC 91 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

92 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 WC /84 WC VOLUNTARY COMPENSATION MARITIME COVERAGE FORM35-4 A 07/06 FORM354A0706 WORKERS COMPENSATION DEDUCTIBLE ACCEPTANCE/REJECTION FORM FORM35-3 B 04/97 FORM353B0497 WORKERS COMPENSATION MEDICAL DEDUCTIBLE ACCEPTANCE/REJECTION FORM WC526 11/85 FORM352 WORKERS COMPENSATION PREMIUM CHANGE NOTICE Oregon WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC ANNIVERSARY RATING DATE WC478 01/93 WC ASSIGNED RISK ADJUSTMENT PROGRAM 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 WC403 02/91 WC BENEFITS DEDUCTIBLE WC E 01/08 WC360601E0108 CANCELATION END (OR) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC405 01/91 WC CONT CLASS PRE ADJ (OR) WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR 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 PAGE WC 92 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

93 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 WC532 10/93 WC GROUP SUPPL EXP [OR] 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 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 WC353 01/88 WC MERIT RATING ENDT (OR) 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 WC /11 WC OREGON CONFIDENTIALITY WC /11 WC OREGON EMPLOYER PAID MEDICAL CLAIMS (New) WC A 05/17 WC360404A OREGON GROUP SUPPLEMENTAL EXPERIENCE RATING PLAN WC /02 WC OREGON LIMITS OF LIABILITY WC /01 WC OREGON PREMIUM DUE DATE WC421 04/92 WC000109A PAGE WC 93 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

94 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 WC541 01/94 WC PILOT PROG MED BEN (OR) WC B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC POLICY PERIOD WC267 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC PREMIUM DISCOUNT 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 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 WC162 04/84 WC UNSAFE EQUIP EXCL [OR] 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 Pennsylvania WC190 04/84 WC (PA)CHURCH END 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 PAGE WC 94 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

95 WC383 01/90 WC ASSIGNED RISK PREMIUM SURCHARGE WC403 02/91 WC BENEFITS DEDUCTIBLE WC B 12/02 WC370404B1202 CERT SAFETY COM END(PA) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC279 01/91 WC CONST CLASS PREM (PA) WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC498 08/93 WC DEDUCTIBLE ENDT [PA] 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 WC192 04/84 WC EXCLUSION OF EMP (PA) WC128 04/84 WC EXPERIENCE RATING MODIFICATION FACTOR 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 WC595 08/96 WC MERIT RATING PLAN(PA) 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 WC346 A 08/95 WC370603A NOT OF INC OF PREM (PA) WC434 04/84 WC NOTICE (PA) WC /14 WC PAGE WC 95 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

96 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 WC193 04/84 WC PARINCIPALS AS ADD (PA) 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 /05 WC PENNSYLVANIA - NOTIFICATION OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE ACT OF 2002 WC /05 WC PENNSYLVANIA - TERRORISM RISK INSURANCE ACT WC /99 WC PENNSYLVANIA EMPLOYER ASSISSMENT WC /13 WC PENNSYLVANIA MULTIPLE COORDINATED POLICY WC649 E 06/15 PA CCPAP (PA) PENNSYLVANIA WORKERS COMPENSATION PREMIUM CREDIT APPLICATION WC191 04/84 WC POLICE/FIRE EN [PA] WC130 04/84 WC POLICY PERIOD WC267 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC A 07/95 WC000406A PREMIUM DISCOUNT WC /01 WC PREMIUM DUE DATE WC194 04/84 WC PROF ASSOC ACT EN [PA] WC A 01/06 WC000321A PROFESSIONAL EMPLOYER WC B 01/06 WC000320B PROFESSIONAL EMPLOYER WC132 04/84 WC RATE CHANGE WC195 04/84 WC REAL ESTATE MGMT END (PA) WC196 04/84 WC RELIGIOUS INS [PA] 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 WC414 12/91 WC000505A1291 RETROSPECTIVE PREMIUM - LONG TERM CONSTRUCTION PROJECT WC417 12/91 WC000514A1291 RETROSPECTIVE PREMIUM - LONG-TERM CONSTRUCTION PROJECT - MULTIPLE LINES PAGE WC 96 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

97 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 WC189 04/84 WC SPECIAL END (PA) WC197 04/84 WC SPOUSE OF INS END (PA) WC198 B 03/86 WC STATUTORY EMPLOYER (PA) WC /02 WC TERRORISM RISK INSURANCE ACT 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 Rhode Island 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 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 WC163 04/84 WC DIRECT LIAB ST [RI] WC236 09/85 WC DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC D 01/15 WC D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM PAGE WC 97 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

98 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 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 PAGE WC 98 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

99 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 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 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 WC496 06/93 WC SAFETY INSP END [RI] WC B 01/15 WC380401B SHORT RATE CANCELLATION 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 South Carolina WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC ANNIVERSARY RATING DATE FORM39-1 A 09/14 FORM39-1A APPLICATION FOR DRUG - AND ALCOHOL-FREE WORKPLACE PREMIUM CREDIT PROGRAM WC505 07/90 WC ASSIGNED RISK ADJUSTMENT PROGRAM WC B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM PAGE WC 99 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

100 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 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 WC117 04/84 WC PAGE WC 100 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

101 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 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 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 101 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

102 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 South Dakota 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 WC /90 WC BENEFITS DEDUCTIBLE WC B 04/06 WC400605B0406 CANCELLATION AND NONRENEWAL 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 PAGE WC 102 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

103 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 WC568 01/94 WC MANAGED CARE END [SD] WC B 01/15 WC000201B MARITIME COVERAGE WC600 09/96 WC MED BEN DED END (SD) WC117 04/84 WC MEDICAL BENEFITS EXCLUSION WC118 04/84 WC MEDICAL BENEFITS REIMBURSEMENT WC457 A 01/96 WC400401A MERIT RATING END (SD) 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 WC267 07/91 WC PAGE WC 103 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

104 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 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 Tennessee WC /12 WC (TWCIP) LARGE ACCOUNT INCURRED LOSS PREMIUM ADJUSTMENT PLAN (TAIL PLAN) - AND NOTICE WC /12 WC (TWCIP) LARGE ACCOUNT INCURRED LOSS PREMIUM ADJUSTMENT PLAN (TAIL PLAN) - RATING WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC ANNIVERSARY RATING DATE WC A 01/08 ASSIGND RISK PREM SURCHRG [TN] 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 PAGE WC 104 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

105 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 JOINT VENTURE AS INSURED WC435 02/92 WC LABOR CONTRACTOR EXCLUSION WC449 06/92 WC LIMITED MARITIME COVERAGE WC /09 WC LIMITED OTHER STATES 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 PAGE WC 105 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

106 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 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 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 WC /03 WC TENNESSEE PENDING LOSS COST AND ASSIGNED RISK RATE WC /15 WC TENNESSEE SMALL EMPLOYER PLAN WC /15 WC TENNESSEE SPECIAL RISK PLAN WC /15 WC TENNESSEE TABULAR SURCHARGE WC A 09/12 WC410601A TENNESSEE WORKERS COMPENSATION INSURANCE PLAN (TWCIP) REHABILITATION AND TABULAR SURCHARGE REDUCTION INCENTIVE PROGRAM PREMIUM PAGE WC 106 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

107 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 FORM /07 FORM WORKERS' COMPENSATION INSURANCE PLAN - COST REDUCTION SEMINAR INCENTIVE PLAN PREMIUM CREDIT FORM FORM /07 FORM WORKERS COMPENSATION INSURANCE PLAN - SMALL EMPLOYER PLAN FORM FORM /07 FORM WORKERS' COMPENSATION INSURANCE PLAN - SPECIAL RISK PLAN FORM Texas WC B 01/00 WC420604B0100 ACC/AGGREG DED ENDT (TX) WC548 A 01/02 ERM411 ACCIDENTS INVOLVING TWO OR MORE PERSONS WC B 01/00 WC420603B0100 AGGREGATE DED END (TX) WC126 04/84 WC AIRCRAFT PREMIUM WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC112 04/84 WC ALTERNATE EMPLOYER WC G 06/14 WC420301G AMENDATORY END (TX) WC564 A 03/97 WC420402A0397 ANNIV RATING DATE (TX) WC505 07/90 WC ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC ASSIGNED RISK PREMIUM DIFFERENTIAL WC383 01/90 WC ASSIGNED RISK PREMIUM SURCHARGE WC527 04/90 FORM421 ASSIGNED RISK RATING PROGRAM REPORT 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 DNE1 A 06/14 DNE-1A DEDUCTIBLE NOTICE OF ELECTION 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 WC D 06/14 WC420406D EMPL PROV CLIENT CO END (TX) WC391 04/91 WC EMPLOYEE LEASING CLIENT WC A 01/06 WC000322A EMPLOYEE LEASING CLIENT EXCLUSION WC C 10/04 WC000303C EMPLOYERS LIABILITY COVERAGE WC A 01/00 WC420305A0100 EXEMPT EMPL COV END(TX) WC275 A 03/97 WC420403A0397 EXPERIENCE RATING (TX) WC551 05/94 ERM12 EXPERIENCE RATING FORM WC128 04/84 WC PAGE WC 107 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

108 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 WC103 04/84 WC FEDERAL EMPLOYERS' LIABILITY ACT COVERAGE WC B 01/15 WC B FOREIGN TERRORISM PREMIUM 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 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 WC528 04/90 FORM NOTICE TO WORKERS COMPENSATION ASSIGNED RISK POLICYHOLDERS 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 WC267 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 WC131 08/84 WC PREMIUM DISCOUNT WC A 07/95 WC000406A PREMIUM DISCOUNT WC A 01/06 WC000321A PROFESSIONAL EMPLOYER WC B 01/06 WC000320B PROFESSIONAL EMPLOYER WC601 01/97 WC PRTNRS,OFFCRS & OTHER WC581 06/96 WC RESIDUAL MARKET MULTIPLE COMPANY WC142 04/84 WC RETRO PREMIUM AVIATION WC340 04/87 WC000509A RETRO PREMIUM CHANGES WC /10 WC PAGE WC 108 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

109 RETROSPECTIVE RATING PLAN PREMIUM LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC120 04/84 WC RURAL ELECTRIFICATION ADMINISTRATION WC602 01/97 WC SOLE PROPRIETORS WC /02 WC TEXAS - AUDIT PREMIUM AND RETROSPECTIVE PREMIUM WC A 06/14 WC420602A TEXAS ACCIDENT DEDUCTIBLE WC /15 WC TEXAS ADVANCE NOTICE OF CANCELLATION TO THE PROFESSIONAL EMPLOYER ORGANIZATION (PEO) WC /14 WC TEXAS CLAIM DEDUCTIBLE WC /15 WC TEXAS COVERED EMPLOYEE EXCLUSION FOR POLICY COVERING DIRECT EMPLOYEES OF A CLIENT WC A 06/14 WC420404A TEXAS GROUP PURCHASE OF WORKERS COMPENSATION INSURANCE WC A 06/14 WC420408A TEXAS HEALTH CARE NETWORK WC /14 WC TEXAS MEDICAL BENEFITS DEDUCTIBLE WC /94 WC TEXAS NOTICE OF MATERIAL CHANGE WC /15 WC TEXAS PROFESSIONAL EMPLOYER ORGANIZATION (PEO) CLIENT WC /15 WC TEXAS PROFESSIONAL EMPLOYER ORGANIZATION (PEO) WC /15 WC TEXAS PROFESSIONAL EMPLOYER ORGANIZATION (PEO) EXECUTIVE EMPLOYEE EXCLUSION WC /15 WC TEXAS PROFESSIONAL EMPLOYER ORGANIZATION (PEO) EXECUTIVE EMPLOYEE INCLUSION WC /11 WC TEXAS RETROSPECTIVE PREMIUM SHORT FORM WC B 01/15 WC420505B TEXAS RETROSPECTIVE RATING PLAN PREMIUM LONG-TERM CONSTRUCTION PROJECT WC B 01/15 WC420514B TEXAS RETROSPECTIVE RATING PLAN PREMIUM LONG-TERM CONSTRUCTION PROJECT - MULTIPLE LINES WC B 01/15 WC420510B TEXAS RETROSPECTIVE RATING PLAN PREMIUM NONRATABLE CATASTROPHE ELEMENT OR SURCHARGE WC B 01/00 WC420303B0100 VOL WORKERS COV ENDT (TX) WC636 01/84 WC VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC WC PAGE WC 109 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

110 VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC /84 WC VOLUNTARY COMPENSATION MARITIME COVERAGE WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS WC B 06/14 WC420304B WAIVER OF RIGHT TO RECOVR [TX] Utah 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 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 WC449 06/92 WC LIMITED MARITIME COVERAGE WC419 04/92 WC000106A PAGE WC 110 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

111 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 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 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 PAGE WC 111 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

112 RURAL UTILITIES SERVICE WC121 04/84 WC SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE WC /02 WC UTAH CANCELLATION WC /00 WC UTAH EMPLOYEE LEASING CLIENT EXCLUSION WC /00 WC UTAH EMPLOYEE LEASING COMPANY EXCLUSION WC /00 WC UTAH EMPLOYEE LEASING WC A 05/17 WC430302A UTAH EMPLOYEE LEASING WC /00 WC UTAH WAIVER OF SUBROGATION 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 WC490 01/93 WC WKPLACE SFTY PROG [UT] Vermont WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC127 04/84 WC ANNIVERSARY RATING DATE 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 WC /08 WC BENEFITS DEDUCT 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 PAGE WC 112 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

113 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 WC165 04/84 WC LAW END [VT] 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 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 PAGE WC 113 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

114 WC B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC POLICY PERIOD 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 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 WC B 07/14 WC440602B VERMONT CANCELLATION AND NONRENEWAL WC /03 WC VERMONT WORKERS COMPENSATION INSURANCE PLAN MERIT RATING 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 Virginia WC173 A 10/85 WC ADDTL BENE [VA] WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC489 07/93 WC AMENDTRY END [VA] WC127 04/84 WC ANNIVERSARY RATING DATE WC505 07/90 WC ASSIGNED RISK ADJUSTMENT PROGRAM WC B 01/10 WC000415B ASSIGNED RISK ADJUSTMENT PROGRAM WC504 01/90 WC ASSIGNED RISK PREMIUM DIFFERENTIAL PAGE WC 114 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

115 WC383 01/90 WC ASSIGNED RISK PREMIUM SURCHARGE WC /17 WC AUDIT NONCOMPLIANCE CHARGE WC593 05/96 WC BENEFITS DED END (VA) 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 WC /97 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 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 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 WC448 07/92 WC MIGRANT AND SEASONAL AGRICULTURAL WORKER PROTECTION ACT COVERAGE WC A 01/06 WC000323A PAGE WC 115 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

116 MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE FORM /89 FORM45-1 NOTICE TO VIRGINIA POLICYHOLDERS 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 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 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 WC /01 WC VIRGINIA CLIENT COMPANY WC /01 WC VIRGINIA CLIENT COMPANY EXCLUSION WC /01 WC VIRGINIA PEO PAGE WC 116 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

117 WC /01 WC VIRGINIA PEO EXCLUSION FORM /89 FORM45-2 VIRGINIA WORKERS COMPENSATION RATE CHANGE NOTICE 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 Washington 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 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 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) 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 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 PAGE WC 117 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

118 WC369 07/90 WC NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC119 04/84 WC PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC PENDING RATE CHANGE WC130 04/84 WC POLICY PERIOD WC267 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 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 B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC636 01/84 WC VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS West Virginia 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 WC /06 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 PAGE WC 118 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

119 WC236 09/85 WC DOMESTIC AND AGRICULTUREAL WORKERS EXCLUSION WC D 01/15 WC D DOMESTIC TERRORISM, EARTHQUAKES, AND CATASTROPHIC INDUSTRIAL ACCIDENTS PREMIUM 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 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 /09 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 PAGE WC 119 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

120 WC130 04/84 WC POLICY PERIOD WC267 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 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 WC /09 WC PROFESSIONAL EMPLOYER ORGANIZATION CLIENT COMPANY EXCLUSION WC /09 WC PROFESSIONAL EMPLOYER ORGANIZATION EXCLUSION WC /09 WC PROFESSIONAL EMPLOYER ORGANIZATION EXTENSION 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 WC A 07/08 WC470301A WEST VIRGINIA EMPLOYERS LIABILITY INSURANCE DELIBERATE INTENTION EXCLUSION WC B 07/11 WC470314B WEST VIRGINIA WORKERS COMPENSATION AND EMPLOYERS LIABILITY COVERAGE FOR DOMESTIC SERVICE EMPLOYEES WC /06 WC WEST VIRGINIA WORKERS COMPENSATION INSURANCE RECOVERY FROM OTHERS Wisconsin PAGE WC 120 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

121 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 WC403 02/91 WC BENEFITS DEDUCTIBLE WC B 01/02 WC480606B0102 CANCELL/NONRENEWL ENDT (WI) ERM-14 12/03 NC790 CONFIDENTIAL REQUEST FOR OWNERSHIP INFORMATION WC362 01/90 WC CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC607 07/97 WC CONTRA PREM ADJ PRG(WI) 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 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 01/01 WC480603B0101 FOREIGN COVERAGE END [WI] 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 WC C 04/01 WC480601C0401 LAW (WI) WC449 06/92 WC LIMITED MARITIME COVERAGE WC C 12/07 WC480301C LIMITED OTHER STATES INSURANCE 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 PAGE WC 121 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

122 WC A 01/06 WC000323A MULTIPLE COORDINATED POLICY WC420 04/92 WC000108A NON-APPROPRIATED FUND INSTRUMENTALITY'S ACT COVERAGE 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 WC B 07/01 WC890600B POLICY INFORMATION PAGE WC130 04/84 WC POLICY PERIOD WC267 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 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 A 01/15 WC480507A RETROSPECTIVE PREMIUM LARGE RISK ALTERNATIVE RATING OPTION WC /11 WC RETROSPECTIVE RATING PLAN PREMIUM - LARGE RISK ALTERNATIVE RATING OPTION WC /12 WC RETROSPECTIVE RATING PLAN PREMIUM - LARGE RISK ALTERNATIVE RATING OPTION - PLAN TYPE WC /12 WC RETROSPECTIVE RATING PLAN PREMIUM - LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC /11 WC RETROSPECTIVE RATING PLAN PREMIUM - LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC /11 WC PAGE WC 122 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

123 RETROSPECTIVE RATING PLAN PREMIUM - LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC /11 WC RETROSPECTIVE RATING PLAN PREMIUM - WISCONSIN LARGE RISK ALTERNATIVE RATING OPTION (LRARO) WC178 04/84 WC RURAL ELECT COOP (WI) WC B 01/06 WC000309B0106 RURAL UTILITIES SERVICE WC653 05/11 WC SCHEDULE OF VARIABILITY TO WC WC654 09/11 WC SCHEDULE OF VARIABILITY TO WC WC655 07/11 WC SCHEDULE OF VARIABILITY TO WC 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 WC /01 WC WISCONSIN CHANGE OF INSURANCE CARRIER NAME WC /08 WC WISCONSIN EMPLOYEE LEASING COMPANY CLIENT TERMINATION MASTER POLICY WC /08 WC WISCONSIN EMPLOYEE LEASING COMPANY MASTER POLICY WC /08 WC WISCONSIN EMPLOYEE LEASING COMPANY MULTIPLE COORDINATED POLICY (MCP) WC /12 WC WISCONSIN RETROSPECTIVE RATING PLAN PREMIUM - LARGE RISK ALTERNATIVE RATING OPTION WC623 11/96 WC WISCONSIN WAIVER OF SOVEREIGN WC A 01/13 WC480302A WISCONSIN WORK-STUDY COVERAGE WC606 03/97 WC WORKSTUDY COV END (WI) Wyoming WC331 05/86 WC000401A AIRCRAFT PREMIUM WC269 02/89 WC000301A ALTERNATE EMPLOYER WC467 07/92 WC AMENDATORY END [WY] 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 WC362 01/90 WC PAGE WC 123 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

124 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR WC217 04/92 WC000101A DEFENSE BASE ACT COVERAGE WC113 04/84 WC DESIGNATED WORKPLACE EXCLUSION 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) 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 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 WC369 07/90 WC NOTIFICATION OF CHANGE IN OWNERSHIP WC421 04/92 WC000109A OUTER CONTINENTAL SHELF LANDS ACT COVERAGE WC119 04/84 WC PARTNERS, OFFICERS AND OTHERS EXCLUSION WC129 04/84 WC PENDING RATE CHANGE WC130 04/84 WC POLICY PERIOD WC267 07/91 WC PREMIUM DETERMINATION - FORMER SELF- INSURERS 2 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 PAGE WC 124 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

125 RETRO PREMIUM CHANGES WC145 04/84 WC RETRO PREMIUM SHORT FORM WC636 01/84 WC VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE WC124 04/84 WC WAIVER OF RIGHT TO RECOVER FROM OTHERS PAGE WC 125 of 125 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: