Page 11 *0010954700306—" ~ DISCLOSURE PURSUANT TO TERRORISM RISK INSURANCE ACT Terrorism Coverage and Premium |In accordance with the federal Terrorism Risk Insurance Act (as amended “TRIA”™), we are required to make coverage available under your policy for “certified acts of terrorism.” The actual coverage provided by your policy(ies) will be limited by the terms, conditions, exclusions, limits, and other provisions of your policy(ies), as well as any applicable rules of law The portion of your premium attributable to this terronsm coverage is shown in the premium section(s) of this quote proposal or binder. Definition of Certified Act of Terrorism A “certified act of terrorism” means an act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State and the Attomey General of the United States, to be an act of terrorism under TRIA. The criteria contained in TRIA for a “certified act of terrorism” include the following ] The act results in insured losses in excess of $5 million in the aggregate, attributable to all types of insurance subject to TRIA; and The act results in damage within the United States, or outside the United States in the case of certain air carriers or vessels or the premises of an United States mission; and The act is a violent act or an act that is dangerous to human life, property or infrastructure and is committed by an individual or individuals acting as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. i) Disclosure of Federal Share of Terrorism Losses The United States Department of the Treasury will reimburse insurers for 85% of that portion of insured losses attributabic to certified acts of terrorism that exceeds the applicable msurer deductible. However, if aggregate industry insured losses under TRIA | exceed $100 Billion in a Program Year (January | through December 31), the Treasury shall not make any payment for any portion of the amount of such losses that exceeds $100 billion. The United States government has not charged any premium for their participation in covering terrorism losses Cap on Insurer Liability for Terrorism Losses If aggregate industry insured losses attributable o “certified acts of terronsm” under TRIA exceed $/00 Billion in a Program Year (January | through December 31), and we have met, or will meet, our insurer deductible under TRIA, we shall not be liable for the payment of any portion of the amount of such losses that exceed $100 billion. In such case, your coverage for terrorism losses may be reduced on a pro-rata basis in accordance with procedures established by the Treasury, based on its estimates of aggregate industry losses and our estimate that we will exceed our insurer deductible. In accordance with the Treasury's procedures, amounts paid for losses may be subject to further adjustments based on differences between actual losses and estimates | Note to Producer on TRIA: The premium for terrorism coverage and the TRIA disclosures above must be provided to the insured OT prospect at the time of quoting. If you are not using this quote proposal, you can usc Hartford's stand-alone TRIA disclosure form for quotes and binders, which is available on EBC or from the company —— — — — Reference Number: 76WEG9743MF - 003 Total Estimated Annual Premium for Workers' Compensation: § 290 *0010954700306--* EFTA00523631

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*0010954711701-—* AD? Automatic Data Processing Insurance Agency, Inc. Workers' Compensation Loss History Affidavit l, , do hereby certify and swear that (name of owner or officer) (Company name:dba) has incurred x f : injuries within the last 36 months. (Number of Injuries) . Amount a Open or Rs QO Se QO a Rs es RS eS ( Re SR Rs Re S(O SR Rs Note: if there have been no injuries, write (None) in the table above. Explanation if an individual claim amount exceeds $15,000.00. Company Name: Signed By: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files, statement of claim, or an application containing any false, incomplete, or misleading information with the purpose of avoiding or reducing the amount of premiums for workers compensation coverage or conceal information pertinent to the computation and application of an experience rating modification factor, is guilty of a felony of the third degree or as otherwise punishable as provided under the law. *0010954711701--" Page 12 EFTA00523632

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TOA > Automatic Data Processing Insurance Agency, Inc. 10065 Veorstn Business: eas Individual [~ Corporation [~ Partnership Total Employees : I~ Subchapter S Corp. VW uc I Seasonal Client [~ INS ASOCampaign [~ Is construction company PRIMARY CONTACT PAYROLL INFO Est Payroll Start: 09/18/2012 PAYMENT INFO Payment Method: _ Direct Bill Pay by Pay Price: _ $13 Per Payroll - Run, EasyPay, AutoPay BUSINESS DESCRIPTION ee does office work, design services for furniture. no store front or website, works on word of mouth. any furniture the client wants to purchase the client can buy through the vendor Tax Branch / Client code : REFERRAL INFO Lead Source: —_ Self Generated - Cold Call DM Name: SC Region: Carrier Name: (Regular) Hartford Date : 10/15/2012 Policy Number : Policy Effective Date: 10/15/2012 Est. Annual Premium: 290 Policy Expiration Date: 10/15/2013 Comments : *0010854704501-—" Page 13 EFTA00523633

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STL LULU Mare Automatic Data Processing Insurance Agency, Inc. Lo] . CLIENT LOCATION 301 66th St Apt Mie I] PRIMARY CONTACT NAME OMPANY NAM Officer Signature: ¢ ’ AO/Z_ Page 14 EFTA00523634