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Cover Application - Standard Wording

Application for Cover

(To be drafted on your Corporate Letterhead)

Charles Taylor (Hamilton)
Burnaby Building
16 Burnaby Street
Hamilton, HM 11, Bermuda

Re: The Signal Mutual Indemnity Association Ltd.

Dear Sirs: <Name of Member>
Hereby formally requests cover for themselves under Rule 7.1 effective October 1, 1998.
That the following be accepted and covered as a related employer as that term is defined in The Signal Mutual Indemnity Association Ltd. Bye-laws and Rules of the Association, effective October 1, 1998:

<Related Employer 1>
<Related Employer 2>
<Related Employer 3>

That the following be covered under Rule 5.2:

<Alternate Employer 1> <Address>
<Alternate Employer 2> <Address>
<Alternate Employer 3> <Address>
By jointly executing this application, both «Name» and the above named Related Employers acknowledge receipt of the current Bye-laws and Rules of The Signal Mutual Indemnity Association Ltd. and acknowledge that they have read them. Further, they agree to be bound by each and every one of those Bye-laws and Rules (including, but not without limitation, its joint and several liabilities under Rule 4.4).

Date:______________________

Member Name: ___________________________

_________________________ _________________________ _________________________
(Signature) (Title) (Corporate Name)

Related Employer: <R_Emp_1>

_________________________ _________________________ _________________________
(Signature) (Title) (Corporate Name)

Related Employer: <R_Emp_2>

_________________________ _________________________ _________________________
(Signature) (Title) (Corporate Name)

Related Employer: <R_Emp_3>
(Signature) (Title) (Corporate Name) (To be drafted on Corporate Letterhead)

Mail original letter to:

SIGNAL ADMINISTRATION, INC.
8144 Walnut Hill Lane • Suite 1600 • Dallas, Texas 75231