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					                                                      STATEWIDE INSURANCE CORP.
                                                        P.O. Box 30527, Phoenix, Arizona 85046

                                               ARIZONA, NEVADA, NEW MEXICO & UTAH
                                                      MOTOR TRUCK CARGO
                                                CERTAIN UNDERWRITERS AT LLOYD'S

Insured:                                                                            Policy #:
Effective:                                                                          Agency:


Risk State?                                                                                                       Please Select Risk State
Has this insured had prior insurance coverage?
Is this business a New Venture?
Has this insured been claim free with Statewide for more than one year?
                                                              RATE MODIFIER =                          1.00


Rates effective 6/1/08
                                                   GENERAL LIABILITY CALCULATIONS


Commodity Hauled:
Cargo Value:
# of Power Units to be Covered:
Deductible Requested:                                                 Please Select Deductible


                                                                       Deductible                      Final          Final
                         Commodity Hauled                Rate                          Modifier
                                                                         Factor                        Rate         Premium




                                                                                                               FINAL COMPUTATIONS

    TERRORISM PREMIUM                    $0           Rejected                                        Sub-Total                          $0
                                                                                                  Policy Fee                             $0
         Accept Terrorism?                                                                        Terrorism:          Rejected           $0
                                                                                                  Taxes / Fees:                   Select Risk State
  Please Submit a Signed Terrorism Form                                                           Filing Fee (NV only):                $0.00


                                                                                                      Total                      See Note Below


                                                   Premium Not Offered; Please Select Risk State
                                                                                                                Print Worksheet, then
                                                                                                                Proceed to Page 2 for
                                                                                                                    the TRIA Form




           /85c0851c-cf72-405d-88b7-e01e912fca03.xls/Page 1 - Rating Worksheet                                             Version 05/07
                                                            POLICYHOLDER DISCLOSURE
                                                               OFFER OF TERRORISM
                                                              INSURANCE COVERAGE


You are hereby notified that under the Terrorism Risk Insurance Act of 2002, effective November 26, 2002, that you now have a right to purchase insurance
coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of the Act : The term “act of terrorism” means any act that is certified by the
Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States—to be an act of terrorism; to be a violent
act or an act that is dangerous to human life, property; or infrastructure; to have resulted in damage within the United States, or outside the United States in the
case of an air carrier or vessel or the premises of a United States mission; and to have been committed by an individual or individuals acting on behalf of any
foreign person or foreign interest, as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the
United States Government by coercion.


YOU SHOULD KNOW THAT COVERAGE PROVIDED BY THIS POLICY FOR LOSSES CAUSED BY CERTIFIED ACTS OF TERRORISM IS PARTIALLY
REIMBURSED BY THE UNITED STATES UNDER A FORMULA ESTABLISHED BY FEDERAL LAW. UNDER THIS FORMULA, THE UNITED STATES PAYS
90% OF COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE PAID BY THE INSURANCE COMPANY
PROVIDING THE COVERAGE. THE PREMIUM CHARGED FOR THIS COVERAGE IS PROVIDED BELOW AND DOES NOT INCLUDE ANY CHARGES
FOR THE PORTION OF LOSS COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT.


THERE IS A CAP ON OUR LIABILITY TO PAY FOR SUCH LOSSES IF THE AGGREGATE AMOUNT OF INSURED LOSSES UNDER THE TERRORISM
RISK INSURANCE ACT OF 2002 EXCEEDS $ 100,000,000,000 DURING THE APPLICABLE PERIOD FOR ALL INSUREDS AND ALL INSURERS
COMBINED. IN THAT CASE, WE WILL NOT BE LIABLE FOR THE PAYMENT OF ANY AMOUNT WHICH EXCEEDS THAT AGGREGATE AMOUNT OF
$100,000,000,000.

U.S. TERRORISM RISK INSURANCE ACT PREMIUM


THE CHARGE FOR INCLUDING COVERAGE FOR LOSSES CAUSED BY CERTIFIED ACTS OF TERRORISM IN YOUR INSURANCE COVERAGE IS
$________. THIS CHARGE IS SEPARATE AND IN ADDITION TO THE PREMIUM CHARGED IN RESPECT OF ALL OTHER PERILS COVERED BY THE
POLICY.


THE ABOVE QUOTATION HAS BEEN ISSUED IN ACCORDANCE WITH THE REQUIREMENTS OF THE U.S. TERRORISM RISK INSURANCE ACT OF 2002 AND
ONLY RELATES TO “act of terrorism” AS DEFINED UNDER SAID ACT. THE TERRORISM EXCLUSION THAT IS APPLICABLE TO THE PLACEMENT
REFERENCED ABOVE STILL APPLIES IN FULL FORCE AND EFFECT TO ANY ACTS OR EVENTS THAT ARE NOT INCLUDED IN SAID DEFENITION OF “act of
terrorism”. FURTHERMORE, IT IS EXPLICITLY UNDERSTOOD AND AGREED THAT THIS QUOTATION IS OFFERED IN CONJUNCTION WITH ALL TERMS,
CONDITIONS AND EXCLUSIONS OF THE QUOTED PLACEMENT REFERENCED ABOVE AND DOES NOT CONSTITUTE AN OFFER TO PROVIDE STAND-
ALONE TERRORISM INSURANCE.


PRIOR TO THE BINDING OF COVERAGE FOR YOUR POLICY OR POLICIES, PLEASE INFORM YOUR AGENT OR BROKER IF YOU WOULD LIKE TO
PURCHASE COVERAGE FOR CERTIFIED ACTS OF TERRORISM


                     I hereby elect to purchase Terrorism coverage for a prospective premium of $
                     I hereby elect to have the exclusion for terrorism coverage reinstated. I understand that I will have no
                     coverage for losses arising from acts of terrorism that were previously excluded.


                                                                                    Certain Underwriters at Lloyd's, London
   Policyholder / Applicant's Signature                                                        Name of Insurer


                      Print Name                                                                    Contract Reference


                           Date                                                               Certificate / Policy Number
                                             Nevada Surplus Lines Association
                                                DECLINATION DETAIL

This form is to be used when the policy provides insurance for coverage that cannot be written with admitted insurers.
(Category is not listed on open lines eligible for export.) In pursuant of 685A.215 of NRS, identify three admitted
insurers marketing the class of insurance that declined the risk. Include with this submission form NSLA101.


NAME OF INSURED:


POLICY NUMBER:



                                                             1.
Admitted Insurer:
Address:
Phone Number:                                                     Underwriter
Reason for Declination (enter code from bottom):



                                                             2.
Admitted Insurer:
Address:
Phone Number:                                                     Underwriter
Reason for Declination (enter code from bottom):



                                                             3.
Admitted Insurer:
Address:
Phone Number:                                                     Underwriter
Reason for Declination (enter code from bottom):


                                               Reason for Declination Codes

                1.   Unacceptable Class of Business                             5.   No Market
                2.   Age of Building                                            6.   No Prior Insurance
                3.   Declined to Quote                                          7.   Excessive Claims
                4.   Doesn't Fit Underwriting Requirement                       8.   Other (Please Explain)




SLA AFFIRMATION:                                I hold a Surplus Lines license and will do the SLA filings.
                                                Please do the SLA filings for me. (Must send this form!)




BROKER/AGENT NAME                                              SIGNATURE                                           DATE
                                     EVIDENCE OF GOOD FAITH EFFORT TO PLACE

                                             The Surplus Line Association of Utah

     This form is to be used to document the efforts made by the suplus lines broker (and/or producing agent) to place
     insurance coverage concerned with an admitted insurer before approaching the suplus lines insurer.

     Policy No.                                               Name of Insured:

     List the admitted insurers contacted.

                NAME OF INSURER                              NAME OF UNDERWRITER                        PHONE NUMBER
1.
     Reason for Declining:



2.
     Reason for Declining:



3.
     Reason for Declining:




     If any additional insureds were contracted, attach an additional list.

     Provide any further explanation about the insured and your effort to place the insurance with an admitted insurer
     which would help support the need to place the policy with a surplus lines insurer. Explain why you consider this
     to be reasonable evidence of a good faith effort to place the coverage with an admitted insurer.
     Attach additional sheets if necessary.




     SLA AFFIRMATION:                             I hold a Surplus Lines license and will do the SLA filings.
                                                  Please do the SLA filings for me. (Must send this form!)




     Signature of Producing Producer                                Signature of Surplus Lines Broker

				
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