BEGINNERS EDGE SPORTS TRAINING, LLC (3)

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The Hartford DEDUCTIBLE NOTICE OF ELECTION TO ACCEPT TEXAS WORKERS COMPENSATION BENEFITS Teas law permits an employer to o❑tain WoriEors:Compensation ins0rance wit❑ a ded❑ctiiJe. T❑e ded❑cti:le applies to Denefits paya:]e Ender Te::8s Wor!Eors❑Compensation Law. T❑e ins0rance applies only to iDenefits in e::(,ess of tip ded❑cti:le amoEnt. T❑e ded❑ctii1e applies separately to eac❑ accident or disease regardless of t:le nErn:ler of people wig s::8tain inny ❑y s:j,,❑accident or disease or claim or medical -only claim. T❑e ded❑ctii1e plans !1a::o iDeen eEplained to me. Premi::n red:jrtions are determined iOased on tFle ded❑cti:le selected, and tip iOal:8rd groom. T❑e :a!:ard groi-p is determined ❑y t:le classification t0at prod❑ces tie largest amoFlnt of estimated Terms standard premiiErn. Yo❑ are not re❑fired to ci-oose a ded❑cti:le. If yo❑ do ciEoose one, yoi-ir instance company will pay tElb ded❑ctiFle amoi�t for yoq ❑ t yo❑ m::8t reim❑use tEib instance company witi-lin 30 days after t❑ ey send yo❑ notice tFlat payment is dF8. If yo❑ fail to reim❑i-irse tip company, tidy may cancel tEie policy, iEpon ten days written notice, and any resifting premi:in may De applied to t❑e dedEti:le amoEnt owed. If a ded❑cti:le amoEnt is desired, please indicate Mow. ❑ ❑ Yes, I want a dedi-Ptii-le of❑ -Select only one❑ 1 ❑ per accident 2. ❑ per claim 3. ❑ per medical -only claim applied to :10nefits payaiJe Ender tEib Tei-:8s Wori�ers❑Compensation Law. I iEnderstand tit t❑e company will pay tLie dedEctiLle amoEnt and see❑reim❑:Irsement inonti-ly, ❑❑erterly or ot❑ er❑ ❑ ❑ ❑o, I do not want a ded❑ctiiFle applied to ❑enefits pays[le Ender tip Te!-:8s Wor!_:Ors!FCompensation Law ❑ ❑ Yes, I do want a ded❑cti:le policy, ❑!A am iEna!Fle to oEtain for t❑e following reason:] Beginners Edge Sports Training Employer Flame [print or type[] Signatie and Title Date 6 WEG B❑3❑P❑ Policy ❑iEM-lar WC 66 01 25 A Printed in D.S.A. Process Date: 11/04/2❑ Policy Expiration Date: 11/04/26