BEGINNERS EDGE SPORTS TRAINING, LLC. (2)

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IkThe Hartford DEDUCTIBLE NOTICE OF ELECTION TO ACCEPT TEXAS WORKERS COMPENSATION BENEFITS Texas law permits an employer to obtain Workers' Compensation insurance with a deductible. The deductible applies to benefits payable under Texas Workers' Compensation Law. The insurance applies only to benefits in excess of the deductible amount. The deductible applies separately to each accident or disease regardless of the number of people who sustain injury by such accident or disease or claim or medical-only claim. The deductible plans have been explained to me. Premium reductions are determined based on the deductible selected, and the hazard group. The hazard group is determined by the classification that produces the largest amount of estimated Texas standard premium. You are not required to choose a deductible. If you do choose one, your insurance company will pay the deductible amount for you, but you must reimburse the insurance company within 30 days after they send you notice that payment is due. If you fail to reimburse the company, they may cancel the policy, upon ten days written notice, and any resulting premium may be applied to the deductible amount owed. If a deductible amount is desired, please indicate below. ( ) Yes, I want a deductible of: (select only one) 1 $ per accident 2. $ per claim 3. $ per medical-only claim applied to benefits payable under the Texas Workers' Compensation Law. I understand that the company will pay the deductible amount and seek reimbursement (monthly, quarterly or other) ( ) No, I do not want a deductible applied to benefits payable under the Texas Workers' Compensation Law ( ) Yes, I do want a deductible policy, but am unable to obtain for the following reason: Beginners Edge Sports Training Employer Name (print or type) Date 76 WEG BX3ZPJ Signature and Title Policy Number WC 66 01 25 A Printed in U.S.A. Process Date: 11/04/25 Policy Expiration Date: 11/04/26