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I agree that I am the applicant or an authorized representative of the applicant and represents that reasonable inquiry has been made to obtain the answers to questions on this application. I agree that I fully read and understand the terms of this application. I certify and represent that the answers are true, correct and complete to the best of my knowledge.

If you cancel the policy, the premium earned prior to cancellation will be increased (multiplied by a factor to determine the short rate penalty premium). The maximum factor that can be applied to your earned premium is 18.24. This factor applies if you cancel the first day of your policy period. The final premium will not be less than the full highest minimum premium for the classifications covered by this policy.

Recurring Direct Draft Program:
A Recurring Direct Draft Program ('Direct Draft') may be offered to certain customers. If you select to enroll in Direct Draft, you must agree that the following Direct Draft terms apply. After enrolling in Direct Draft, we will automatically deduct payment when it is due. We will continue to send you Billing Statements as a courtesy, but cannot guarantee that you will receive any specific notice, or that notices will arrive prior to the date that the direct draft is made. Enrollment in Direct Draft does not change your obligations to make payments under the policy terms. By enrolling in Direct Draft, you also agree that Direct Draft will renew automatically if you renew your policy. You may rescind Direct Draft at any time by calling 877-528-7878 Monday through Thursday between 8:00 AM – 8:00 PM EST and Friday between 8:00 AM – 7:00 PM EST.

Online Payments:
AmTrust offers that flexibility with 24/7 online payment for insurance premiums. Signing up is simple. Click on "Register" in the AmTrust Online log-in box. All of the information needed to register can be found on your invoice. Once registered, payments can be made by paying the minimum payment, full balance or anything in between with a credit card or electronic check. You may contact AmTrust for assistance at: 877-528-7878 Monday through Thursday between 8:00 AM – 8:00 PM EST and Friday between 8:00 AM – 7:00 PM EST.

AutoPay - Recurring Credit Card Program:
By enrolling in AutoPay by clicking the Purchase button on the payment page, you agree to allow AmTrust to automatically debit future insurance payments from your account. You also agree to allow your financial institution to debit your account for these payments, and you understand changes to your policy or premium may change the amount debited. You can discontinue automatic insurance payments at any time by contacting AmTrust at 877-528-7878 Monday through Thursday between 8:00 AM – 8:00 PM EST and Friday between 8:00 AM – 7:00 PM EST. To sign-up, log into AmTrust Online and click 'Register'. Once registered, navigate to the menu item to sign-up forDirect Debit. Complete the needed information and payments will begin being automatically deducted each month. AmTrust AutoPay requires a minimum premium of $600.

Additional Ways to Pay:
If these payment options do not fit your needs, you can also pay by check, phone (credit card or electronic check). To pay by phone, call our Customer Service Department at 877-528-7878 Monday through Thursday, between 8:00 AM – 8:00 PM EST and Friday between 8:00 AM – 7:00 PM EST.

For payments regarding direct bill installments, down payments, quotes, audits or claims:
AmTrust North America
P.O. Box 6939
Cleveland, OH 44101-1939

For overnight payments:
AmTrust North America
Attention: Accounts Receivable
800 Superior Avenue E., 21st Floor
Cleveland, OH 44114

Personal information about you, including information from a credit or other investigative report, may be collected from persons other than you in connection with this application for insurance and subsequent amendments and renewals. Such information as well as other personal and privileged information collected by us or our agents may in certain circumstances be disclosed to third parties without your authorization. Credit scoring information may be used to help determine either your eligibility for insurance or the premium you will be charged. We may use a third party in connection with the development of your score. You may have the right to review your personal information in our files and request correction of any inaccuracies. You may also have the right to request in writing that we consider extraordinary life circumstances in connection with the development of your credit score. These rights may be limited in some states. Please contact your Granite to learn how these rights may apply in your state or for instructions on how to submit a request to us for a more detailed description of your rights and our practices regarding personal information. (Not applicable in AZ, CA, DE, KS, MA, MN, ND, NY, or, VA, or WV.) In California, $150 that's calculated to cover our costs of issuing policies will be non-refundable once your policy has been in effect for one day.

Applicable in Arizona:
As described in Arizona revised statute 20-2104(d), a credit report or other investigative report about you may be requested in connection with this application for insurance. Any information which we have or may obtain about you or other individuals listed as policyholders on our policy will be treated confidentially. However, this information, as well as other personal or privileged information subsequently collected, may under certain circumstances, be disclosed without prior authorization to non-affiliated third parties. We may also share such information with affiliated companies for such purposes as claims handling, servicing, underwriting and insurance marketing. You have the right to see personal information collected about you, and you have the right to correct any information which may be wrong. Also, pursuant to Arizona revised statute 20-2104(c), if you are interested in obtaining a complete description of information practices, and your rights regarding information we collect, please write us at the address provided with your policy.

Applicable in California:
This authorization shall expire one year from the date you signed the authorization.

Applicable in Massachusetts:
Credit scoring information may be used to determine your eligibility for insurance but not for rating purposes.

Applicable in Minnesota:
I, the undersigned, hereby authorize my agent named in this application, if any, and/or the underwriting department of the insurance company named in this application to collect credit-related and other information about me from the following types of organizations: credit bureaus and other organizations providing personal or privileged information. I understand this information will be used for the purpose of making underwriting decisions in connection with the insurance for which I have applied, sought reinstatement or requested a change in benefits. These decisions may include determinations to grant or deny me coverage and/or the rates I will be charged. I also understand that I have the right to request in writing that extraordinary life circumstances be considered in connection with the development of my credit score.

Applicable in Oregon:
In connection with my application for insurance to the company shown above, I hereby authorized you to collect and disclose personal, privileged information, about me, by and to consumer reporting agencies, your authorized representatives, assignees, agents and affiliates. The information collected and disclosed extends to my credit standing, credit worthiness, credit capacity, personal characteristics and mode of living. I understand that credit scoring information may be used to either determine my eligibility for insurance or the premium I will be charged. Credit scoring cannot be used for renewals unless requested by the insured. I understand that I am entitled to receive a copy of this authorization and, upon request, a record of any subsequent disclosures of personal or privileged information that must include the name, mailing address ad institutional affiliation of the party to which the information was disclosed as well as the date of the disclosure, and to the extent practicable, a description of the information being disclosed.

Applicable in AL, AR, DC, LA, MD, NM, RI and WV:
Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

*Applies in MD Only

Applicable in CO:

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Applicable in FL and OK :
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (of the third degree)*.

*Applies in FL Only

Applicable in KS:
Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

Applicable in KY, NY, OH and PA:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties (not to exceed five thousand dollars and the stated value of the claim for each such violation)*.

*Applies in NY Only

Applicable in ME, TN, VA and WA:
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits.

*Applies in ME Only.

Applicable in NJ:
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Applicable in OR:
Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.

Applicable in UT:
Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.

I hereby authorize, Granite Insurance Brokers DBA E-COMP, and their agents to initiate electronic withdrawals and/or deposits to the bank account shown below for the purpose of making payments on my behalf including payments of premiums, fees, audit amounts, taxes and miscellaneous costs and charges. I understand that adjustment and/or reversing entries may be made to this account to insure an accurate and balanced accounting of all transactions. This authorization will remain in effect until: (a) I notify my Bank and E-COMP in writing to terminate this agreement and give the Bank and E- COMP reasonable time to terminate this agreement, (b) the Bank, third party/employer, and/or E-COMP have sent me five (5) business days advance written notice of the Bank's and/or E-COMP's termination of this Agreement.

I understand that any cancellation in writing will become effective no earlier than five (5) business days after the day the last transaction has cleared and there are no outstanding balances to the account.

IN THE EVENT THE FUNDING FOR A TRANSFER IS RETURNED FOR ANY REASON OR E-COMP HAS BEEN PROVIDED INCORRECT INFORMATION AND/OR HAS ERRONEOUSLY TRANSFERRED FUNDS TO MY ACCOUNT, I AUTHORIZE E-COMP TO WITHDRAW/REVERSE FROM MY ACCOUNT THE AMOUNT OF FUNDS TRANSFERRED IN ERROR. REMEDY FOR ANY ERRONEOUS TRANSFERS IS SOLELY AGAINST THE PROCESSOR AND/OR MY EMPLOYER AND THAT I WILL HOLD HARMLESS E-COMP FROM ANY LIABILITY AND DAMAGES RESULTING THEREFROM.

Electronic Funds Transfer (15 U.S.C. § 1693): I hereby acknowledge receipt of notice by the financial institution described herein of the undersigned's liability for any unauthorized electronic fund transfers, duty to promptly report such unauthorized transfers or any disputes by contacting customer service at (888) 493-2667, 6600 Koll Center Pkwy, Suite 100, Pleasanton, CA 94566, charges for electronic fund transfers, the right to stop payment of pre-authorized electronic fund transfers, procedure to initiate such stop payment orders, the right to receive documentation of electronic fund transfers, and the Bank's liability pursuant to the Electronic Funds Transfer Act found at 15 U.S.C. § 1693h,

Electronic Collection of Insufficient Funds Fees: If your payment is returned due to insufficient funds in your account you authorize us to make a one-time electronic fund transfer from your account to collect a fee. The fee will not exceed the maximum amount permitted by applicable law. Fees are as follows: First Time NSF Fee $45.00, Second Time NSF Fee $100.00. After Second NSF fee your policy will be transferred to direct bill.

Procedure for Notification and Limitation of Action: The undersigned acknowledges that it has 60 days from the date of a withdrawal or deposit to the undersigned's account to dispute the withdrawal or deposit by the undersigned contacting my employer and E-COMP by telephone and later supplemented in writing, or in writing of any discrepancies, errors or disputes concerning any transfer of funds to or from any account processed. This will include but not limited to, errors in amounts, erroneous transactions, or other transactions processed. All written notices must include the following information:

1. The name of the company with whom the undersigned authorized the transaction, i.e., employer and/or third party;
2. Federal Taxpayer ID number of the company authorized to make the transaction;
3. Federal Taxpayer ID number of the undersigned;
4. The name of the undersigned;
5. The name, account number and ABA number on the transaction in question
6. The dollar amount of the transaction in question; and
7. Description of the error and explanation of the error.

E-COMP will investigate and respond to any dispute within 10 business days and correct any error within 1 business day or at its election, provisionally refund the disputed amount within 10 business days, and investigate the matter and report its findings at the end of 45 days.

Please note that you will be receiving an email from E-COMP within the next 7 days asking you to complete your banking information through our secure portal. Please complete this step as soon as possible to avoid any delay or cancellation of your policy.

License #0C41366