Please Send the Completed form to: SIU Marketing Department Attn: Meagan Pind

Georgia Southern Insurance Underwriters Inc. appreciates your interest in contracting with us. Please review the Producer agreement and complete the attached forms and checklist before submitting. Please note: We will be unable to process your application if information is missing / omitted. We look forward to working with you and your agency in the future. Producer Questionnaire Producer Agreement Signed by Principal & Witness Copy of Principal s Insurance License Copy of Agency License issued by the state of Georgia Agency in-force E&O Declarations Page (min. of $1 million in coverage claim and aggregate) Subagent Certificate of Authority (section 3) W-9 Form Volume Commitment on Agency Letterhead of $25,000/year Please provide one designated e-mail address to receive all SIU policy documents electronically: o E-mail Please Send the Completed form to: SIU Marketing Department Attn: Meagan Pind Mail: Fax: E-Mail: P.O. Box 105609 678.498.4610 mpind@siuins.com Atlanta, GA 30348-5609 Questions? Please contact Meagan Pind, Marketing Assistant: (PH) 678.498.4619 (FX) 678.498.4610 (TF) 800.568.1700 ext: 4619 (Email) mpind@siuins.com * Notification of Southern Insurance Underwriters, Inc. intent to obtain a credit report as part of the appointment process. Southern Insurance Underwriters, Inc. P.O. Box 105609 Atlanta, GA 30348-5609 (PH) 678.498.4500 (FX) 678.498.4600 (TF) 800.568.1700

Confidential Producer Questionnaire Agency Legal Name Agency d/b/a Office Address Mailing Address ( ) ( ) Phone number Fax Number Please Provide the Percentage of Business you write in Each Class: Individual Date Agency Opened Partnership Corporation / / Federal Tax ID Number or Social Security Number % of Volume that comes from E&S business % Number of Employees: Annual Agency Premium $1 mil to $3 mil $10 mil to $20 mil $3 mil to $5 mil $20 mil to $30 mil $5 mil to $10 mil $30 + Commercial P&C Commercial Transportation Homeowners Boats/ Yachts Professional Liability Personal Auto Other Lines Associations: Big I PIA Other: With whom do you Finance your E&S book: Please List Agency s Standard Carriers P& C Volume Loss Ratio Length of Contract With what other wholesalers / General Agents are you contracted? Volume Length of Contract Why do you want to be an SIU Producer? Does your Agency Carry Errors & Omissions Insurance? No Yes - Please Attach a copy of your E&O Dec Page. Has your Agency ever been sued in as a result of placing or non-placing of insurance? No Yes Complete below Date of Lawsuit Nature of Lawsuit Legal Results Remarks

Principals, Officers, Producers Owner(s) Name Title DOB Social Security Number Insurance License Number Years associated with the Agency Residential Address City State Zip Previous Business Experience (Last 7 Years) Name of Firm / Address Position Date of Tenure Reason for Leaving Owner(s) Name Title DOB Social Security Number Insurance License Number Years associated with the Agency Residential Address City State Zip Previous Business Experience (Last 7 Years) Name of Firm / Address Position Date of Tenure Reason for Leaving Please Provide an email Address Producer Name Line of Business Email License # Licensed Agents List any former agency names, Producer numbers or previous addresses or agency affiliations with SIU. Website: Additional Locations, emails, etc? - Please attach.

Southern Insurance Underwriters, inc. PRODUCER AGREEMENT Agreement effective the day of, 20, between (Principal s Name) (Hereinafter called Producer) of (Agency s Name) and Southern Insurance Underwriters, Inc. or Wesley C. Duesenberg, Jr. (hereinafter called SIU ), as agent of record for SIU, if required by law. WHEREAS, Producer desires to procure for his clients, from time to time, various coverage s through the facilities of SIU, and WHEREAS, SIU desires to make its facilities available to the Producer upon terms which are mutually agreeable. NOW, therefore, the parties hereto agree as follows: A. Licensing WHEREAS Producer is a duly licensed insurance agent to procure insurance in the State of, pursuant to law, and holds a current insurance agent license No., (Principal s License Number) and current licensing residence address located at (Principal s Home Address) and Producer wishes to be granted a Certificate of Authority in accordance with applicable law to procure insurance through SIU. B. Limited Authority 1. Pursuant to law, Producer shall have no binding authority on business transacted through SIU, or an insurance carrier represented by SIU, nor does Producer have the authority to countersign policies, binders, certificates of insurance or any other insurance documents on behalf of SIU or any insurer represented by SIU, unless otherwise expressly qualified and agreed in writing and signed by all required parties. 2. In the event of unauthorized binding, Producer shall reimburse SIU for all expenses incurred because of unauthorized binding, including attorneys fees and including those incurred by SIU by collecting such reimbursements or in denying liability. C. Indemnification Producer agrees to maintain an insurance policy for errors and omissions with a minimum limit of $1,000,000/$1Mill insuring against any acts or omissions of Producer. Attached hereto and incorporated herein by reference is a Certificate of Insurance issued to SIU, expressly giving SIU advance notice of cancellation of the policy. Producer expressly agrees and understands that in the event of cancellation of this policy or the failure of Producer to give SIU evidence of annual renewal of the policy prior to the expiration date, the Producer s Certificate of Authority granted to Producer pursuant to this Agreement, may be cancelled without notice to Producer. Producer agrees to save and hold harmless SIU and any insurance carrier represented by SIU, from any negligence, errors, acts, or omissions of Producer, his employees, agents or subagents. Without, in any manner, limiting or diminishing Agency s right to make claim, SIU shall indemnify and hold harmless Agency and its officers, directors, agents, representatives, contractors and employees from any liability, damage, claims or causes of action with regard to any and all losses, claims, damages, fees and expenses, reasonably incurred or paid by Agency as a result of any negligent or willful misconduct of SIU in the performance of any duty set forth in this Agreement; provided, however, that SIU shall not be obligated hereunder if Agency or its employees caused or contributed to such claim, cause of action, liability or damage. D. Commissions 1. SIU will allow Producer commissions at such rates as are agreed upon from time to time by the parties hereto. 2. In the event of return premiums becoming due for any reason whatsoever, Producer shall refund commission to SIU at the same rate at which commission was originally allowed. 3. Policies financed through premium finance companies other than those affiliated with either SIU or the particular writing insurance company, may result in reduction of normal commission to Producer. 4. It is agreed there will be no commission paid on any policy fees added to policy and in the event of cancellation the policy fee will be fully earned.

E. Premiums Held in Trust 1. All premiums received by Producer for the benefit of SIU or the insurers represented by SIU, shall be held in trust for SIU until delivered to SIU. Producer further agrees not to commingle personal or company funds with those funds representing premiums owed to SIU. In the event Producer fails to properly account for all such funds, this Producer agreement shall be terminated without notice to Producer. 2. Producer agrees to maintain all records required by law, and make same available at Producer s place of business during normal office hours for inspection and review by SIU or insurers represented by SIU. F. Payment of Premium 1. Producer agrees to pay SIU all premiums per SIU statement submitted on insurance written, no later than ten days after the end of the month in which the business is written. The Producer shall not be entitled to credit for any cancellations until proof of such cancellations, satisfactory to SIU, shall have been furnished to SIU and appear on the SIU statement to Producer. 2. Producer may be subject to a monthly service charge of 1.5% of the statement balance on all payments received after the tenth of the month. 3. Producer specifically agrees that any extension of credit by Producer to Producer s client or to any other person is solely at Producer s own risk, and Producer shall pay SIU all sums due SIU when due, whether or not such moneys are collected from whom may owe Producer. The Producer is responsible for all additional premiums due as a result of audits and / or endorsements. Furthermore, Producer recognizes that in agreeing to pay SIU, Producer does so as an original undertaking on his own part, and not as guarantor or surety of another s obligation. 4. Producer agrees to use SIU affiliated finance company when possible or the particular writing insurance company for all policies financed by the insured. G. Cancellation 1. No policy, binder or cover note will be cancelled flat. 2. Notwithstanding the return of an original policy for cancellation, cancellation will not be effective until sufficient time has elapsed for proper notice to mortgagees, loss payees, certificate holders, public utility regulatory bodies, etc., in cases where such notice is required. 3. Cancellation, unless requested by SIU or otherwise specifically agreed, will be computed on Standard Short Rate Table. H. Notice of Expiration SIU shall be under no obligation to give Producer advance notice of expiration of any policies of insurance which Producer from time to time procures through the facilities of SIU. As a courtesy, SIU may give the Producer advance notice of the expiration of said policies, but the failure of SIU to provide such notice shall not render SIU liable to Producer, and SIU shall in no way be responsible for failure to notify Producer of the expiration date of any policy of insurance. I. Ownership 1. Producer, as agent for an insured, agrees that this agreement expressly recognizes the independent ownership by the Producer of the insurance policies covered by this agreement. In the event it is necessary for SIU to cancel this agreement, or directly service Producer business written through SIU, the Producer relinquishes all rights or claims to subsequent renewals, additional premium, or commission thereon, insofar as they may be necessary to satisfy the interest of SIU. 2. SIU shall not be responsible for Producers expenses of any kind or description. J. Limitations of Producer 1. Producer has no authority to handle claims other than notify SIU of their occurrence which Producer undertakes to do immediately upon his knowledge of same. 2.No act or statement of Producer shall in any way be binding on SIU or any insurer(s) represented by SIU. Producer has no binding authority unless Producer shall have first qualified and received prior written approval from SIU to so act or state, unless SIU has expressly extended such binding authority to Producer in writing. 3. Notice to Producer of change in risk does not constitute notice to SIU or the insurer (s). Producer must immediately notify SIU or the applicable insurer of any change known to Producer. 4. Producer is not the employee or authorized representative of SIU or of any insurer (s) represented by SIU. At all times mentioned herein, subagent s relationship with SIU, and any insurer (s) represented by SIU, is that of an independent contractor. 5. Producer is not authorized to issue Binders to any insured in lieu of binders issued by SIU or any of the insurers represented by SIU without the express written approval of SIU.

K. Producer s Warranty 1. Producer warrants that he is properly licensed for the classes of business and the coverages of insurance to be procured through the facilities of SIU, and further understands and warrants that such license shall be renewed (and shall notify SIU of that renewal) and continued in force as long as he continues to insure risks through SIU or any of its facilities. L. Guarantee 1. As an inducement to SIU to grant Producer a certificate of authority through which Producer can place insurance policies, from which Producer will personally benefit, Producer personally guarantees the performance of all obligations pursuant to this Producer s Agreement and further warrants and represents that in the event of failure of Producer to perform the conditions of this agreement, that Producer shall be personally liable to SIU or the insurers represented by SIU for any and all acts, errors and omissions under this agreement. 2. In the event the Producer under this agreement is a corporation, it is further understood, agreed and guaranteed by the undersigned individual(s), that all conditions of this agreement shall be binding upon them severally and jointly in the same manner as upon the corporation named as producer. 3. As part of the producer appointment, an investigation may be made which will provide pertinent information as the financial character, credit worthiness and general reputation of the producer and/ or producer s principles. 4. Producer understands that the conditions of this Agreement are binding upon Producer s heirs, executors, administrators and assigns. M. Cancellation This agreement may be cancelled at any time by either of the parties hereto, by giving written notice to the other at the mailing address shown in this agreement. N. Collection Expenses Producer agrees to pay all reasonable collection expenses including attorney fees incurred to enforce this agreement. O. E-Commerce SIU may, during the term of this Agreement, provide to Producer who needs to access the SIU web site to perform functions of daily business activity, a password to access and logon to the SIU web site. Producer shall permit only its authorized agency employees to obtain and use password and to access and use the content solely for the purpose of performing functions of daily business activity with SIU. Producer shall immediately notify SIU of any threatened or actual damage, hacking, security breach, or other unauthorized or illegal intrusion or use of the SIU web site by any former or existing employee of Producer. Producer shall hold password in strict confidence and shall not permit any authorized agency employees to use, disclose, or distribute such information to any person or entity, including without limitation any competitor of SIU or any of its affiliates, except as expressly permitted under this Agreement. IN WITNESS WHEREOF, the parties hereto have herein affixed their hands and seals effective the date first written above. Agency Signature (Must be signed by Owner or Officer) Please Print Name Name of Agency Southern Insurance Underwriters, Inc. (Title, SIU) (Witness for SIU) Witness for Producer

1. GENERAL INSTRUCTIONS COMMISSIONER OF INSURANCE, RALPH T. HUDGENS STATE OF GEORGIA REQUEST FOR NEW & TERMINATED SUBAGENT CERTIFICATE OF AUTHORITY All questions should be directed to Pearson VUE at 1-888-204-6204 between the hours of 7AM and 6PM Monday through Friday, EST. A. This request for New/Terminated Subagent Certificate of Authority should only be submitted by the sponsoring agent. If you are requesting a New Certificate of Authority, enclose a check or money order for $5.00, payable to Pearson VUE. There are no fees for Certificate of Authority Termination. B. A Certificate of Authority will cover all classes of insurance HELD IN COMMON BETWEEN THE SPONSORING AGENT AND THE APPOINTED LICENSEE. C. Certificates of Authority may not be processed for temporary licenses. D. This form may be photocopied for future use. E. Forward request, along with payment, if applicable, to: GEORGIA INSURANCE DEPARTMENT/Pearson VUE, PO Box 281137, Atlanta, GA 30384-1137. 2. NEW & TERMINATED CERTIFICATE OF AUTHORITY INFORMATION Indicate whether this request is for a new certificate of authority or certificate of authority termination by placing an X in the appropriate box and, if applicable, completing the related section. ADD A NEW CERTIFICATE OF AUTHORITY If adding a New Certificate of Authority, enclose a $5.00 check or money order, payable to Pearson VUE. A Certificate of Authority will cover all classes held in common between the sponsoring agent and the appointed licensee. TERMINATE AN EXISTING CERTIFICATE OF AUTHORITY Amount Enclosed: Complete the information below. Requests for termination must be submitted within 30 days of the termination date. There is no fee for a Certificate of Authority Termination. If terminating a Limited Subagent, one must submit the Limited Subagent s license with this form. Termination Effective Date: Reason for Termination: Is this a Termination for cause? NO YES If yes, please attach all supporting documentation with this form. 3. SUBAGENT INFORMATION GID-122SA/122TSA Version 2.0 020 Print the subagent s name as it appears on the subagent s Georgia insurance license in the boxes provided. Select the subagent s license prefix by placing an X in the appropriate box and print the subagent s six-digit license number and SSN on the lines provided. The subagent must sign and date the document. Last Name First Name MI Suffix (Jr., etc.) SUBAGENT LICENSE PREFIX (select one): AGR - Agent Resident LSR - Limited Subagent Resident WCN - Workers Compensation Non-resident AGN - Agent Non-resident LSB - Limited Subagent Borderline WCB - Workers Compensation Borderline BLB - Agent Borderline WCR - Workers Compensation Resident SUBAGENT LICENSE NUMBER SUBAGENT SOCIAL SECURITY NUMBER I, the undersigned agent, certify that I am properly licensed in the state of Georgia for the Certificate of Authority for which I am applying. SUBAGENT SIGNATURE DATE 4. SPONSORING AGENT INFORMATION Print the sponsoring agent s name as it appears on the sponsoring agent s Georgia insurance license in the boxes provided. Select the sponsoring agent s license prefix by placing an X in the appropriate box and print the six-digit license number on the line provided. Print the subagent s SSN in the boxes provided. Print the name of the sponsoring agent s agency in the space provided. The sponsoring agent must sign and date the document. Last Name First Name MI Suffix (Jr., etc.) SPONSORING AGENT LICENSE PREFIX (select one): AGR - Agent Resident AGN - Agent Non-resident SPONSORING AGENT LICENSE NUMBER SPONSORING AGENT SOCIAL SECURITY NUMBER SPONSORING AGENT S AGENCY NAME We, the undersigned, have made a diligent inquiry and investigation relative to this applicant s identity, residence and experience or instruction as to the classes of insurance to be transacted and are satisfied that the applicant is trustworthy and qualified to act as our subagent and to hold himself out in good faith to the general public as such subagent. We desire that he/she represent us in your state. I, the undersigned Agent, certify that I have possession of a copy (or the original where required by Georgia Insurance Department Regulation 120-2-3) of this applicant s current and valid license for the above line(s) of insurance and that the applicant has received a copy of this request for certificate of authority. Further, we understand that it is a violation of the Georgia Insurance Statutes for any agent to accept applications for insurance from an applicant if the applicant is not properly licensed. SPONSORING AGENT SIGNATURE DATE Clerk s Initials: Date: Forward request along with payment, if applicable, to: GEORGIA INSURANCE DEPARTMENT/Pearson VUE, PO Box 281137, Atlanta, GA 30384-1137. Checks must be made payable to: Pearson VUE. Copyright 2010 Pearson Education, Inc., or its affiliates. All Rights Reserved. Stock #6011-09 12/10