Sample proposal

Workers' Compensation Insurance Premium Quote AMERICAN INTERSTATE INSURANCE COMPANY - 24759 2301 HWY 190 WEST DERIDDER, LA 70634Insured AgentHibernia Enterprises, Inc. RISK ALTERNATIVES & MANAGEMENT2266 Tayside Crossing (KENNESAW)KENNESAW, GA 30152 3104 CREEKSIDE VILLAGE DRIVE, SUITE 501 KENNESAW, GA 30144Submission No. Effective0000781635 12/31/2014 - 12/31/2015Alabama Basis Exposure Rate 10.640000 =5445 Wallboard,Sheetrock,Drywall,Plasterboard,Cement PAYROLL 0* 12.840000 = 0 Board Instal PAYROLL 0* 0.020000 = 05473 Asbestos Contractor NOC &Drivers 0.014000 = 0Total Manual Premium 0*0930 Waiver of subrogation 0* 0.820000 = 2509812 1000/1000/1000 E.L. Limits 0Total Subject Premium 250 * 0.100000 = 2509898 Experience ModificationTotal Modified Premium 205 * 0.015000 = -45Total Standard Premium 0.015000 = 2050063 Premium Discount 0* 205Subtotal 0*9740 Terrorism -219741 Catastrophe (other than Certified Acts of Terrorism 184Estimated Annual Premium for AL 0 0 184 12/4/2014 3:48 PM

Workers' Compensation Insurance Premium Quote AMERICAN INTERSTATE INSURANCE COMPANY - 24759 2301 HWY 190 WEST DERIDDER, LA 70634Insured AgentHibernia Enterprises, Inc. RISK ALTERNATIVES & MANAGEMENT2266 Tayside Crossing (KENNESAW)KENNESAW, GA 30152 3104 CREEKSIDE VILLAGE DRIVE, SUITE 501 KENNESAW, GA 30144Submission No. Effective0000781635 12/31/2014 - 12/31/2015Mississippi Basis Exposure Rate 10.660000 =5445 Wallboard,Sheetrock,Drywall,Plasterboard,Cement PAYROLL 0* 10.680000 = 0 Board Instal PAYROLL 0* 0.020000 = 05473 Asbestos Contractor NOC &Drivers 0.011000 = 0Total Manual Premium 0*0930 Waiver of subrogation 0* 0.820000 = 2509812 1000/1000/1000 E.L. Limits 0Total Subject Premium 250 * 0.100000 = 2509898 Experience ModificationTotal Modified Premium 205 * 0.015500 = -45Total Standard Premium 0.015500 = 2050063 Premium Discount 0* 205Subtotal 0*9740 Terrorism -219741 Catastrophe (other than Certified Acts of Terrorism) 184Estimated Annual Premium for MS 0 0 184 12/4/2014 3:48 PM

Workers' Compensation Insurance Premium Quote AMERICAN INTERSTATE INSURANCE COMPANY - 24759 2301 HWY 190 WEST DERIDDER, LA 70634Insured AgentHibernia Enterprises, Inc. RISK ALTERNATIVES & MANAGEMENT2266 Tayside Crossing (KENNESAW)KENNESAW, GA 30152 3104 CREEKSIDE VILLAGE DRIVE, SUITE 501 KENNESAW, GA 30144Submission No. Effective0000781635 12/31/2014 - 12/31/2015South Carolina Basis Exposure Rate 9.950000 =5445 Wallboard,Sheetrock,Drywall,Plasterboard,Cement PAYROLL 0* 13.380000 = 0 Board Instal PAYROLL 0* 0.020000 = 05473 Asbestos Contractor NOC &Drivers 0.011000 = 0Total Manual Premium 0*0930 Waiver of subrogation 0* 0.820000 = 2509812 1000/1000/1000 E.L. Limits 0Total Subject Premium 250 * 0.100000 = 2509898 Experience ModificationTotal Modified Premium 205 * 0.016500 = -45Total Standard Premium 0.016500 = 2050063 Premium Discount 0* 205Subtotal 0*9740 Terrorism -219741 Catastrophe (other than Certified Acts of Terrorism) 184Estimated Annual Premium for SC 0 0 184 12/4/2014 3:48 PM

Workers' Compensation Insurance Premium Quote AMERICAN INTERSTATE INSURANCE COMPANY - 24759 2301 HWY 190 WEST DERIDDER, LA 70634Insured AgentHibernia Enterprises, Inc. RISK ALTERNATIVES & MANAGEMENT2266 Tayside Crossing (KENNESAW)KENNESAW, GA 30152 3104 CREEKSIDE VILLAGE DRIVE, SUITE 501 KENNESAW, GA 30144Submission No. Effective0000781635 12/31/2014 - 12/31/2015Tennessee Basis Exposure Rate 10.290000 =5445 Wallboard,Sheetrock,Drywall,Plasterboard,Cement PAYROLL 0* 11.500000 = 0 Board Instal PAYROLL 0* 0.000000 = 05473 Asbestos Contractor NOC &Drivers 0.014000 = 0Total Manual Premium 0*0930 Waiver of subrogation 0* 0.820000 = 09812 1000/1000/1000 E.L. Limits 0Total Subject Premium 0* 0.100000 =9898 Experience Modification 0Total Modified Premium 0* 0.015500 = 0Total Standard Premium 0.031000 =0063 Premium Discount 0* 0Subtotal 0* 09740 Terrorism 09741 Catastrophe (other than Certified Acts of Terrorism) 0Estimated Annual Premium for TN 0 0 0 12/4/2014 3:48 PM

Workers' Compensation Insurance Premium Quote AMERICAN INTERSTATE INSURANCE COMPANY - 24759 2301 HWY 190 WEST DERIDDER, LA 70634Insured AgentHibernia Enterprises, Inc. RISK ALTERNATIVES & MANAGEMENT2266 Tayside Crossing (KENNESAW)KENNESAW, GA 30152 3104 CREEKSIDE VILLAGE DRIVE, SUITE 501 KENNESAW, GA 30144Submission No. Effective0000781635 12/31/2014 - 12/31/2015Georgia Basis Exposure Rate5445 Wallboard,Sheetrock,Drywall,Plasterboard,Cement PAYROLL 0 * 14.990000 = 0 Board Instal PAYROLL 500,000 * 13.790000 = 68,9505473 Asbestos Contractor NOC &Drivers PAYROLL 44,000 * 0.430000 = 1898742 Salespersons, Collectors or Messengers-Outside PAYROLL 28,000 * 0.230000 = 648810 Clerical Office Employees NOCTotal Manual Premium 69,203 * 0.020000 = 1,384 69,2030930 Waiver of subrogation 69,203 * 0.011000 = 7619812 1000/1000/1000 E.L. Limits 71,348Total Subject Premium 71,348 * 0.820000 = -12,843 58,5059898 Experience Modification 58,505Total Modified Premium 58,505 * 0.100000 = -5,851Total Standard Premium 0 * 150.000000 = 150 52,8040063 Premium Discount0900 Expense Constant 572,000 * 0.016400 = 94 52,992Subtotal 572,000 * 0.016400 = 949740 Terrorism9741 Catastrophe (other than Certified Acts of TerrorismEstimated Annual Premium for GA 12/4/2014 3:48 PM

Workers' Compensation Insurance Quote Summary AMERICAN INTERSTATE INSURANCE COMPANY - 24759 2301 HWY 190 WEST DERIDDER, LA 70634Insured Agent Hibernia Enterprises, Inc. RISK ALTERNATIVES & MANAGEMENT 2266 Tayside Crossing (KENNESAW) KENNESAW,GA 30152 3104 CREEKSIDE VILLAGE DRIVE, SUITE 501 KENNESAW, GA 30144Submission No. Effective0000781635 12/31/2014 - 12/31/2015 State Estimated Taxes/ Estimated Premium Surcharges (If Any)Total For : AlabamaTotal For : Georgia $0 $184Total For : Mississippi $0 $52,992Total For : South Carolina $0 $184Total For : Tennessee $0 $184 $0 $0 $0 Total Estimated Premium and Taxes $53,544 The Down Payment Will Be $0States of Coverage: • Those states shown under ITEM 3A of declaration page. • Part 3C coverage will EXCLUDE monopolistic states. There will be no coverage in states that insuring company subsidiaries of AMERISAFE, Inc. are not licensed to write business. • Other States Insurance - All states except those listed in ITEM 3A and Connecticut, Hawaii, New Jersey, New York, North Dakota, Ohio, Washington, Wyoming. • Policy Provisions, Part Three - other states insurance; A2& A4 will apply to other states insurance. • Amerisafe subsidiaries do not offer an \"All States Endorsement\".Audit Information: • Per Diem Allowance - when verifiable receipts ARE maintained, the total amount is excluded from payroll. If receipts are NOT maintained, Amerisafe will allow $30 per day as an exclusion {NCCI Rule 2, B2h}. Example - if $150/per day is paid as per diem, Amerisafe will use $120/per day as payroll for premium calculation purpose. • Any Florida exposure - traveling through, working in, resident employees, load delivery or pick ups, etc. must be reported to insuring company subsidiary of Amerisafe and will be added to Item 3A of the policy per the Florida WC Bureau. • Kansas risks with owner operators are not acceptable. Such policies may be cancelled, subject to applicable state law. • Insuring company subsidiaries of AMERISAFE, Inc. do not recognize Occupational/Accident policies whether with or without contingent Workers Compensation as proof of coverage. • Risk should report and pay premium on any uninsured subcontractor or owner/operator exposure to avoid additional premium due upon final audit. • TEXAS SUBCONTRACTORS: A signed copy of any subcontractor DWC Waiver will be required PRIOR to binding or as soon as it is executed during the policy period. ***Please note we do not accept the DWC waivers for trucking operations; payroll for such operations is required to be reported based on actual or 1/3 of the total contract cost. • Roofing exposure risks may split the salesman and/or estimator payroll separate from the roofing class code provided proper records are maintained. Insuring company subsidiary of Amerisafe will require time spent on the roof by these employees to be assigned to the roofing class code. • Rates are subject to approval by the Insurance Commissioner. Quoted rates may be pending for states shown and subject to revision. • Reporting basis to be monthly based on actual payroll and subject to an interim audit unless otherwise noted. If annual pay, an interim audit will be performed. Rates shown on the quote rating page are \"base\". Reporting form rates shown are \"net\".Binding:• Agent has NO binding authority. Coverage will be bound upon receipt prior to the effective date for new and renewal business.• Confirmation of binding will be returned with a policy number. 9• If bound, coverage will be provided through the insurance company subsidiaries of AMERISAFE, Inc, rated A by A.M. Best Co.• This quotation is subject to all underwriting requirements and is valid for 60 days after date issue.• Binding is subject to favorable loss control and compliance with recommendations, if applicable.Deposit: • Must be received in our office within 10 days of binding. • May be returned when the relationship is concluded and upon completion of final audit.• Will be rolled upon renewal.• Premium discount: refer to monthly reporting form - \"Premium Discount Given\" or blank (premium discount not given up front).Please visit our website at www.amerisafe.com 12/4/2014 3:48 PM

AMERICAN INTERSTATE INSURANCE COMPANY REPORTING FORMInsured's Report for the Period from 12/31/2014 to 12/31/2015 Policy Period : 12/31/2014 - 12/31/2015 Submission ID : 0000781635Policy Holder: Hibernia Enterprises, Inc. Account # : 01257349 2266 Tayside Crossing KENNESAW,GA 30152Mail to: AMERICAN INTERSTATE INSURANCE COMPANY 2301 HWY 190 WEST DERIDDER, LA 70634Agent: RISK ALTERNATIVES & MANAGEMENT (KENNESAW)Workers' Compensation Unit Basis Payroll Net Rate Premium PAYROLLClass Code Description PAYROLLAlabama PAYROLL PAYROLL5445 Wallboard,Sheetrock,Drywall,Plasterboard,Cement Board PAYROLL ÷ 100 X 9.021443 = Instal PAYROLL ÷ 100 X 10.886779 =5473 Asbestos Contractor NOC &Drivers PAYROLL PAYROLLGeorgia PAYROLL5445 Wallboard,Sheetrock,Drywall,Plasterboard,Cement Board PAYROLL ÷ 100 X 12.672846 = Instal5473 Asbestos Contractor NOC &Drivers 500000 ÷ 100 X 11.658342 = 44000 ÷ 100 X 0.363531 =8742 Salespersons, Collectors or Messengers-Outside 28000 ÷ 100 X 0.194447 =8810 Clerical Office Employees NOCMississippi5445 Wallboard,Sheetrock,Drywall,Plasterboard,Cement Board ÷ 100 X 9.012177 = Instal ÷ 100 X 9.029086 =5473 Asbestos Contractor NOC &DriversSouth Carolina5445 Wallboard,Sheetrock,Drywall,Plasterboard,Cement Board ÷ 100 X 8.411929 = Instal ÷ 100 X 11.311720 =5473 Asbestos Contractor NOC &Drivers Total Premium :F REMEMBER TO REPORT PAYROLL / PREMIUM FOR INCLUDED OWNER / OFFICERS.SIGNED BY: NOTE: THIS REPORT ALONG WITH YOUR REMITTANCE SHOULD BE RECEIVED BY TITLE: AMERICAN INTERSTATE INSURANCE COMPANYMail Remittance To: BY THE 10TH OF EACH MONTH.AMERICAN INTERSTATE INSURANCE COMPANY - 24759P.O. DRAWER 1570 PLEASE MAKE CHECK PAYABLE TOAttention Treasury Department AMERICAN INTERSTATE INSURANCE COMPANY2301 HWY 190 WESTDERIDDER, LA 70634 or Pay Online at www.Amerisafe.com 12/4/2014 3:48 PM* QUOTE *

AMERICAN INTERSTATE INSURANCE COMPANY REPORTING FORMInsured's Report for the Period from 12/31/2014 to 12/31/2015 Policy Period : 12/31/2014 - 12/31/2015 Submission ID : 0000781635Policy Holder: Hibernia Enterprises, Inc. Account # : 01257349 2266 Tayside Crossing KENNESAW,GA 30152Mail to: AMERICAN INTERSTATE INSURANCE COMPANY 2301 HWY 190 WEST DERIDDER, LA 70634Agent: RISK ALTERNATIVES & MANAGEMENT (KENNESAW) =Tennessee ÷ 100 X 8.555929 = ÷ 100 X 9.562020 =5445 Wallboard,Sheetrock,Drywall,Plasterboard,Cement Board PAYROLL Instal PAYROLL5473 Asbestos Contractor NOC &Drivers Total Premium :F REMEMBER TO REPORT PAYROLL / PREMIUM FOR INCLUDED OWNER / OFFICERS.SIGNED BY: NOTE: THIS REPORT ALONG WITH YOUR REMITTANCE SHOULD BE RECEIVED BY TITLE: AMERICAN INTERSTATE INSURANCE COMPANYMail Remittance To: BY THE 10TH OF EACH MONTH.AMERICAN INTERSTATE INSURANCE COMPANY - 24759P.O. DRAWER 1570 PLEASE MAKE CHECK PAYABLE TOAttention Treasury Department AMERICAN INTERSTATE INSURANCE COMPANY2301 HWY 190 WESTDERIDDER, LA 70634 or Pay Online at www.Amerisafe.com 12/4/2014 3:48 PM* QUOTE *

AMERICAN INTERSTATE INSURANCE COMPANY 2301 Hwy. 190 West DeRidder, LA 70634 SOUTH CAROLINA WORKERS' COMPENSATION TELEPHONE: (337)463-9052 DEDUCTIBLE ACCEPTANCE FORM WATS: (800)256-9052 FAX: (337)463-8870 MEDICAL AND INDEMNITYINSURED Hibernia Enterprises, Inc.South Carolina law requires insurers to offer a deductible on all South Carolina Workers Compensationpolicies. You are not required to select a deductible, but if you choose to exercise this option, you may chooseonly \"one\" deductible amount as outlined below.The claim shall be paid by the insurer, which shall then be reimbursed by the employer for any deductibleamounts paid by the insurer. The employer shall be liable for reimbursement up to the limit of the deductiblechosen.The policyholder's Acceptance or Rejection of a deductible program option must be made prior to the effectivedate of the policy, and shall apply to the entire policy period. AMERICAN INTERSTATE INSURANCE COMPANYwill accept election only by receipt of this written form within Ten (10) days of the effective date of the policy.Failure to return this form within (10) days of the effective date of the policy will be deemed byAMERICAN INTERSTATE INSURANCE COMPANY as rejection of the deductible program options andthese options will no longer be available to the policyholder within the policy period.Note ACCEPTANCE or REJECTION Yes, I have read the deductible information outlined above and want the following deductible amount to apply to claims under South Carolina Workers' Compensation Law. I understand that this amount applies separately to each claim for bodily injury by accident or disease. The hazard group is determined by the classification that produces the largest amount of estimated South Carolina premium, which is subject to change for any endorsement or audit event. Your selection of a deductible may have an effect on your experience modification. Choosing a Deductible may change the value of expected losses used by your rating bureau in calculating your mod. (select only one) Check One Deductible Hazard Amount Amount Group: F $100 0.2% $200 0.4% $300 0.5% $400 0.7% $500 0.8% $1,000 1.3% $1,500 1.8% $2,000 2.1% $2,500 2.4% No, I do not want a deductible.Hibernia Enterprises, Inc. Signature & Title Date2266 Tayside CrossingKENNESAW, GA 30152 0000781635 12/31/2014 Submission/Policy No. Policy Effective Date

AMERICAN INTERSTATE INSURANCE COMPANY 2301 Hwy. 190 West DeRidder, LA 70634 TELEPHONE (337) 463-9052 WATS (800) 256-9052 FAX (337) 463-8870 ALABAMA WORKERS' COMPENSATION ACCEPTANCE/REJECTION FORMINSURED Hibernia Enterprises, Inc.Alabama law requires insurers to offer a deductible on all Alabama workers compensation policies. You are notrequired to select a deductible, but if you choose to exercise this option, you may choose only \"one\" deductibleamount as outlined below.The claim shall be paid by the insurer, which shall then be reimbursed by the employer for any deductibleamounts paid by the insurer. The employer shall be liable for reimbursement up to the limit of the deductiblechosen. The payment or nonpayment of deductible amounts by the insured employer to the insurer shall betreated under the policy insuring the liability for workers compensation in the same manner as payment ornonpayment of premiums.The policyholder's Acceptance or Rejection of a deductible program option must be made prior tothe effective date of the policy, and shall apply to the entire policy period. American InterstateInsurance Company will accept election only by receipt of this written form within Ten (10) daysof the effective date of the policy. Failure to return this form within (10) days of the effective dateof the policy will be deemed by American Interstate Insurance Company as rejection of the deductibleprogram options and these options will no longer be available to the policyholder within this policyperiod.Check One Deductible Hazard Amount Amount Group: F $100 0.2% $200 0.5% $300 0.7% $400 0.9% $500 1.1% $1,000 1.8% $1,500 2.3% $2,000 2.7% $2,500 3.1%Yes, I have read the deductible information outlined above and want the following deductibleamount to apply to claims under Alabama Workers Compensation Law. I understand that thisdeductible amount is available for medical and indemnity benefits. The deductible shall applyseparately for each claim for bodily injury by accident or disease.The hazard group is determined by the classification, subject to any deductible amount, thatproduces the largest amount of estimated Alabama premium, which is subject to change forany endorsement or audit event. Signature & Title DateHibernia Enterprises, Inc. 0000781635 12/31/20142266 Tayside CrossingKENNESAW,GA 30152 Submission/Policy No. Effective Date

AMERICAN INTERSTATE INSURANCE COMPANY 2301 Hwy. 190 West DeRidder, LA 70634 TELEPHONE (337)463-9052 TENNESSEE WORKERS' COMPENSATION WATS: (800)256-9052 ACCEPTANCE/REJECTION FORM FAX (337)463-8870INSURED: Hibernia Enterprises, Inc.Tennessee law does not require insurers to offer a deductible. The deductible option is however, available.You are not required to select a deductible, but if you choose to exercise this option, you may choose only\"one\" deductible amount as outlined below. Deductible coverage is effected by attaching the BenefitsDeductible Endorsement (WC 00 06 03) to the policy.The deductible shall apply on a per claim basis and apply to a claim's total indemnity and medical loss,excluding any adjustment expenses.The caim shall be paid by the insurer, which shall then be reimbursed by the employer for any deductibleamounts paid by the insurer. The employer shall be liable for reimbursement up to the limit of the deductiblechosen. The payment or nonpayment of deductible amounts by the insured employer to the insurer shall betreated under the policy insuring the liability for workers compensation in the same manner as payment ornonpayment of premiums.The policyholder's Acceptance or Rejection of a deductible program option must be made prior tothe effective date of the policy, and shall apply to the entire policy period. American InterstateInsurance Company will accept election only by receipt of this written form within Ten (10) days ofthe effective date of the policy. Failure to return this form within (10) days of the effective date ofthe policy will deemed by American Interstate Insurance Company as rejection of the deductibleprogram options and these options will no longer be available to the policyholder within thispolicy period. (select only one) Check One Deductible Hazard Amount Amount Group: F $100 0.3% $200 0.5% $300 0.7% $400 0.9% $500 1.1% $1,000 1.9% $1,500 2.5% $2,000 3.0% $2,500 3.5%ACCEPTANCE or REJECTIONYes, I have read the deductible information outlined above and want the following deductibleamount to apply on a per claim basis under Tennessee's Workers' Compensation Law. Thehazard group is determined by the classification that produces the largest amount ofestimated Tennessee premium, which is subject to change for any endorsement or auditevent.No, I do not want a deductible. Signature & Title DateHibernia Enterprises, Inc. 0000781635 12/31/20142266 Tayside CrossingKENNESAW, GA 30152 Submission/Policy No. Effective Date

AMERICAN INTERSTATE INSURANCE COMPANY 2301 Hwy. 190 West MISSISSIPPI WORKERS' DeRidder, LA 70634 COMPENSATION TELEPHONE: (337)463-9052LOSS REIMBURSEMENT PLAN WATS: (800)256-9052 FAX: (337)463-8870INSURED: Hibernia Enterprises, Inc.You are not required to select a loss reimbursement plan, but if you choose to exercise this option, you maychoose only \"one\" loss reimbursement amount as outlined below.All claims shall be paid by the insurer, which shall then be reimbursed by the employer for any lossreimbursement amounts paid by the insurer. The employer shall be liable for reimbursement up to the limit ofthe loss reimbursement option chosen below. Failure of the employer to reimburse American InterstateInsurance Company shall not, in any way, affect the benefits due the employee. The Loss ReimbursementPlan is offered soley at the discretion of American Interstate Insurance Company.The policyholder's Acceptance or Rejection of a loss reimbursement plan option may be made prior to theeffective date of the policy, and shall apply to the entire policy period. American Interstate Insurance Company willaccept election only by receipt of this written form within Ten (10) days of the effective date of the policy. Failureto return this form within ten (10) days of the effective date of the policy will be deemed by American InterstateInsurance Company as rejection of the loss reimbursement plan options and these options will no longer beavailable to the policyholder within this policy period.**Note: Your selection of a Loss Reimbursement may have an effect on your experience modificaton.Choosing a Loss Reimbursement may change the expected losses used by your rating bureau in calculating yourexperience modification. (select only one)Check One Loss Hazard Amount Reimbursement Group: F $100 0.2% $200 0.4% $300 0.6% $400 0.8% $500 0.9% $1,000 1.7% $1,500 2.3% $2,000 2.8% $2,500 3.3% $5,000 5.4% $7,500 7.3% $10,000 8.9%Yes, I have read the loss reimbursement information outlined above and agree to have the above loss reimbursementamount to apply to claims under Mississippi Workers' Compensation Law. I understand that this loss reimbursementamount applies separately to each claim for bodily injury by accident or disease. The hazard group is determined bythe classification, subject to any deductible amount, that produces the largest amount of estimated standard premiumfor Mississippi, which is subject to change for any endorsement or audit event.No, I do not want a deductible. Signature & Title DateHibernia Enterprises, Inc. 0000781635 12/31/20142266 Tayside CrossingKENNESAW, GA 30152 Submission/Policy No. Effective Date

AMERICAN INTERSTATE INSURANCE COMPANY 2301 Hwy. 190 West DeRidder, LA 70634GEORGIA WORKERS' COMPENSATION TELEPHONE (337)463-9052 ACCEPTANCE/REJECTION FORM WATS: (800)256-9052 FAX (337)463-8870INSURED: Hibernia Enterprises, Inc.Georgia law requires insurers to offer a claims deductible on all Georgia Workers Compensation policies. Ninedeductible options are available. You are not required to select a deductible, but if you choose to exercise thisoption, you may choose only \"one\" deductible amount as outlined below. Please carefully review therequirements for the deductible option outlined below. DEDUCTIBLE OPTIONSThe claims deductible options are one hundred dollars ($100), two hundred dollars ($200), three hundreddollars ($300), four hundred dollars ($400), five hundred dollars ($500), one thousand dollars ($1000), onethousand five hundred dollars ($1500), two thousand dollars ($2000), two thousand five hundred dollars($2500).The claim shall be paid by the insurer, which shall then be reimbursed by the employer for any deductibleamounts paid by the insurer. The employer shall be liable for reimbursement up to the limit of the deductiblechosen.Please indicate if you wish to ELECTor REJECT the deductible and return it to our office within 10 days. Yes, I have read the deductible information outlined above and want the following deductible amount to apply to claims under Georgia Workers Compensation Law. I understand that this deductible amount applies to every claim for bodily injury by accident or disease filed by an injured employee. The hazard group is determined by the classification, subject to any deductible amount, that produces the largest amount of estimated Georgia premium, which is subject to change for any endorsement or audit event. No, I do not want a deductible. (select only one)Check One Deductible Hazard Amount Amount Group: G $100 0.1% $200 0.3% $300 0.4% $400 0.5% $500 0.7% $1,000 1.1% $1,500 1.5% $2,000 1.8% $2,500 2.0% Signature & Title DateHibernia Enterprises, Inc. 0000781635 12/31/20142266 Tayside CrossingKENNESAW, GA 30152 Submission/Policy No. Effective Date