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EFEVDUJCMF!OPUJDF!PG!FMFDUJPO!UP!BDDFQU <br />UFYBT!XPSLFST!DPNQFOTBUJPO!CFOFGJUT <br />TeaslawpermitsanemployertootainWorersCompensationinsrancewitadedctile.Tededctileappliesto <br />enefitspayalenderTeasWorersCompensationLaw.Teinsranceappliesonlytoenefitsinecessofte <br />dedctileamont.Tededctileappliesseparatelytoeacaccidentordiseaseregardlessoftenmerofpeople <br />wosstaininryyscaccidentordiseaseorclaimormedical-onlyclaim.Tededctileplansaeeeneplained <br />tome.Premimredctionsaredeterminedasedontededctileselected,andteaardgrop.Teaardgropis <br />determined y te classification tat prodces te largest amont of estimated Teas standard premim. <br />Yoarenotreiredtocooseadedctile.Ifyodocooseone,yorinsrancecompanywillpaytededctile <br />amontforyo,tyomstreimrseteinsrancecompanywitin30daysafterteysendyonoticetatpaymentis <br />de.Ifyofailtoreimrsetecompany,teymaycanceltepolicy,pontendayswrittennotice,andanyreslting <br />premim may e applied to te dedctile amont owed. <br />If a dedctile amont is desired, please indicate elow. <br />Yes, I want a dedctile ofselect only one <br />1per accident <br />2.per claim <br />3.per medical-only claim <br />appliedtoenefitspayalenderteTeasWorersCompensationLaw.Inderstandtattecompanywillpay <br />te dedctile amont and see reimrsement <br />montly, arterly or oter <br />o, I do not want a dedctile applied to enefits payale nder te Teas Worers Compensation Law <br />Yes, I do want a dedctile policy, t am nale to otain for te following reason <br />Beginners Edge Sports Training <br />Employer ame print or typeDate <br />6WEGB3P <br />Signatre and TitlePolicy mer <br />XD!77!12!36!B Printed in .S.A. <br />Qspdftt!Ebuf;11/04/2Qpmjdz!Fyqjsbujpo!Ebuf;11/04/26 <br /> <br />