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DEDUCTIBLE NOTICE OF ELECTION TO ACCEPT <br />TEXAS WORKERS COMPENSATION BENEFITS <br />TexaslawpermitsanemployertoobtainWorkers'Compensationinsurancewithadeductible.Thedeductibleappliesto <br />benefitspayableunderTexasWorkers'CompensationLaw.Theinsuranceappliesonlytobenefitsinexcessofthe <br />deductibleamount.Thedeductibleappliesseparatelytoeachaccidentordiseaseregardlessofthenumberofpeople <br />whosustaininjurybysuchaccidentordiseaseorclaimormedical-onlyclaim.Thedeductibleplanshavebeenexplained <br />tome.Premiumreductionsaredeterminedbasedonthedeductibleselected,andthehazardgroup.Thehazardgroupis <br />determined by the classification that produces the largest amount of estimated Texas standard premium. <br />Youarenotrequiredtochooseadeductible.Ifyoudochooseone,yourinsurancecompanywillpaythedeductible <br />amountforyou,butyoumustreimbursetheinsurancecompanywithin30daysaftertheysendyounoticethatpaymentis <br />due.Ifyoufailtoreimbursethecompany,theymaycancelthepolicy,upontendayswrittennotice,andanyresulting <br />premium may be applied to the deductible amount owed. <br />If a deductible amount is desired, please indicate below. <br />()Yes, I want a deductible of:(select only one) <br />1$per accident <br />2.$per claim <br />3.$per medical-only claim <br />appliedtobenefitspayableundertheTexasWorkers'CompensationLaw.Iunderstandthatthecompanywillpay <br />the deductible amount and seek reimbursement <br />(monthly, quarterly or other) <br />()No, I do not want a deductible applied to benefits payable under the Texas Workers' Compensation Law <br />()Yes, I do want a deductible policy, but am unable to obtain for the following reason: <br />Beginners Edge Sports Training <br />Employer Name (print or type)Date <br />76WEGAZ6AMU <br />Signature and TitlePolicy Number <br />WC 66 01 25 APrinted in U.S.A. <br />Process Date:08/17/24Policy Expiration Date:09/26/25 <br />