ISP Application Proprietary and Confidential Road America Motor Club v1 5/3/2019

ISP Application Proprietary and Confidential Road America Motor Club v1 5/3/2019

Dear Future Road America Provider,

Thank you for your interest in joining our network of elite service providers. We feel fortunate that you

have taken the initial step in the contracting process and hope to soon have you onboard servicing our

clients and their valued customers.

Please, do not hesitate to contact us if you need any assistance completing or delivering any forms in the

application package. According to your convenience, you can submit them via fax, email or through Road

America’s dedicated provider network web portal (www.road-america.com). We encourage you to

become familiarized with our portal, which will be a very useful account management tool.

Soon after your application is approved, you will receive a Welcome Package containing very important

information that will help you learn who we are, how to reach us, how to submit your invoices for

payment, etc.

We recommend that you review and complete thoroughly all the forms enclosed and deliver it to us

promptly so that we can activate your account with Road America and begin accepting request for

services.

We look forward to the opportunity of beginning a long, rewarding relationship with you and your

company!

Sincerely,

Jason Jones

Jason Jones

Deputy Director of Provider Network

ISP Application Proprietary and Confidential Road America Motor Club v1 5/3/2019

Completing the Road America

Independent Service Provider Application All the information requested must be completed and submitted to Road America (RAMC) for initial review. Please review the following checklist of items that must be completed to insure your prompt consideration. Checklist (Required Items)

Completed Application Completed Servicer Provider Agreement Copy of Current Insurance Certificate W-9, Request for Taxpayer Identification Number and Certificate Service Territory Agreement ACH Direct Deposit Form (highly recommended)

Insurance Requirements In order to keep you on our dispatch system, Road America must have on file at all times, a copy of your current certificate of insurance. Please ask your insurance agent to list Road America as a certificate holder, with certificates to be sent to via fax 1-877-324-8916, or by email at recruiter@road-america.com or to this address:

Please be certain that Road America receives a copy of your new certificate of insurance upon expiration to avoid inactivation of your account. The minimum requirements for Road America services are as follows:

a) Worker’s Compensation and Occupational /LFHQVH Insurance as required by applicable law.

b) Comprehensive General and Automobile Liability Insurance with minimum limits of a. $100,000 each person and $300,000 each occurrence for bodily injury and $100,000 for each occurrence for property damage or a minimum combined single limit for bodily injury and property damage of $500,000 per occurrence.

c) Garage Keeper’s Legal Liability Insurance (including, but not limited to, “On-Hook” a. Liability Insurance) with a minimum limit of $ 50,000 and any additional coverage or

limits as may be required by applicable law.

d) Any additional coverage or limits as may be required by applicable law. ISP shall provide RA a certificate of insurance evidencing ISP’s compliance with these insurance requirement.

Road America Motor Club Att: Provider Relations Department

7300 Corporate Center Drive, Suite 601 Miami, FL 33126

ISP Application Proprietary and Confidential Road America Motor Club v1 5/3/2019

Service Provider Application Form Legal Business Name Date

Legal Business Address City State Zip

Physical Business Address (if different) City State Zip

Owner’s Name Email address

Dispatch Phone Number Alternate Phone Number Primary Fax Number

Does your Operation Digitally Dispatch Calls? Yes / No Beacon Towbook Tracker Specify other:

e)

TOW SERVICES

Light Duty Motorcycle Medium Duty Heavy Duty Super Duty

Towing Accident/ Towing Secondary Towing Transport Services Winching

ROAD SERVICES

Light Duty Motorcycle Medium Duty Heavy Duty Super Duty

Jumpstart Fuel / Fluid Delivery Lockout Locksmith Tire Change Battery Delivery & Inst

f)

REPAIRS

Mechanical Repair In Shop: Mobile (Roadside): Body Repair In Shop: Mobile (Roadside): Transmission Repair In Shop: Mobile (Roadside):

g)

HOURS OF OPERATION

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Open 24/7 Open on Holidays Storage Lot Details

Yes No Yes No Storage Lot Fenced Lighted Yes No Yes No Yes No

h)

EQUIPMENT

Please indicate how many of the following you have:

Tow Trucks Roadside Service Vehicles Motorcycle Equipment Vehicle Carriers Other Equipment

Wheel Lifts Light Duty Carriers/Haul 2-Car Landolls

Flatbeds Fleet Adapters 3-Car Dollies

Low Clearance Low Clearance Enclosed > 3-Car Other

Medium Duty Mobile e-Chargers Soft Straps

Heavy Duty

Total: Total: Total: Total: Total: i)

You can submit this form via: Fax 1-877-324-8916, or by email at recruiter@road-america.com

ISP Application Proprietary and Confidential Road America Motor Club v1 5/3/2019

Service Territory Agreement ISP Name ISP Number (if available)

Contact Name

j)

SELECT RADIUS

5 miles 10 miles 15 miles 20 miles 25 miles k)

INDICATE SPECIFIC ZIP CODES

Zip Code Corresponding City / Town Miles from Base

l)

Coverage area should include only those zip codes where the service provider can guarantee that required service Performance standards will be satisfactorily met under normal conditions.

Independent Service Provider (ISP) - Signature Effective Date

Road America Provider Relations Rep (RAMC) - Signature Effective Date

m)

ISP Application Proprietary and Confidential Road America Motor Club v1 5/3/2019

ACH Direct Deposit Form

Dear Service Provider,

We would like to encourage all of our Service Providers to participate in our ACH Direct Deposit payment program. All payments will be automatically deposited to your specified account. This process will help reduce the amount of time needed to receive your payment and it will also eliminate delays due to postal system errors.

Please complete the following information and follow the instructions below: ISP Name ISP Number (if available)

a)

b)

ACCOUNT INFORMATION

Routing Number:

Account Number:

Account Type:

Checking Savings Credit Union

Independent Service Provider (ISP) - Signature Effective Date

c)

BANK INFORMATION

Bank Name:

Address: Contact Person:

Phone Number: Fax Number:

PLACE A COPY OF A VOID CHECK HERE

Please complete this form and attach a copy of a voided check. You may email it to providerpayables@road-america.com or fax it to Provider Payables Department at (877) 377- 8441. Please allow

7 to 10 business days for processing.

1 | P a g e v. 11-8-17

ISP#: _________________________ City & State: __________________

INDEPENDENT SERVICE PROVIDER AGREEMENT

THIS INDEPENDENT SERVICE PROVIDER AGREEMENT (the "Agreement") made and entered into as of the ____ day of ___________________________________, 20____ (the “Effective Date”) by and between Brickell Financial Services-Motor Club, Inc. d/b/a Road America Motor Club and Road America Motor Club, Inc., Florida corporations with their principal place of business located at 7300 Corporate Center Drive, Suite 601, Miami, Florida 33126 (collectively “RA”), and

___________________________________________________________________________________________________________ Company Name

___________________________________________________________________________________________________________ d/b/a

___________________________________________________________________________________________________________ Street Address

___________________________________________________________________________________________________________ City State Zip

(Hereinafter, the “Independent Service Provider” or “ISP”) (“RA” and “ISP” to also be referred to, individually, as a “Party” and, collectively, as the “Parties”).

In consideration of the mutual covenants contained herein, and other good and valuable consideration, the receipt and legal

sufficiency of which are hereby acknowledged, the Parties, intending to be legally bound, agree as follows: 1. Dispatch: RA will assign coverage areas to ISP utilizing Global Positioning Data (Longitude/Latitude) in accordance to the

information supplied by ISP in the Service Provider Application which is incorporated herein by referenced and as it may be amended from time to time. ISP hereby agrees to provide Services to Members and/or Customers in the assigned coverage areas. If ISP is unable to provide a proper level and quality of Service in the area of coverage indicated on the Service Provider Application, RA may, at its sole discretion, reduce ISP’s area of coverage. RA shall contact and dispatch ISP to perform service calls for Members with disabled vehicles who are in need of Services in the assigned coverage areas. The ISP agrees to make itself available to accept RA’s dispatches and to promptly respond to RA’s request for Services on behalf of its Members within the hours of operation as set forth in the Service Provider Application. ISP shall provide RA with an estimated time of arrival (“ETA”) to the location of the Member in need of Services. ISP shall use its best efforts to arrive at the Member location within the ETA provided. If there are any changes to the ETA, the ISP is required to update RA with the change.

2. Services: ISP shall be responsible for providing the Services as further set forth in the Service Provider Application which

is incorporated herein by referenced and as it may be amended from time to time. ISP is solely responsible and shall promptly report to RA of any changes in the Service Provider Application, including, but not limited to, contact information, hours of operation, service capability, and equipment. In providing said Services, ISP shall do so in a safe and professional manner, being solely responsible for determining the proper equipment and methods. Drivers must be skilled in the tasks to which they are assigned, uniformed and must maintain a clean and neat appearance. Drivers should always arrive to render a service well prepared and equipped, possessing all required tools and equipment that shall be needed if any difficulties or unpreventable event occurs. RA reserves the right to require ISP to reassign any employee with history of discrimination, harassment or abusive conduct, or that is otherwise deemed, in RA’s sole discretion, incompetent, careless, insubordinate, or otherwise objectionable to work with under the Agreement. ISP’s drivers will not be accompanied by another person when rendering the Services unless such other person is an employee of ISP and is in training and/or is necessary to perform the Services. ISP’s drivers will not suggest and/or deviate a customer to an alternative destination location unless previously authorized to do so by a RA agent. ISP understands that steering and/or interfering with and/or influencing the sale of a Member’s vehicle in any way, will result in suspension of the Services and/or termination of the Agreement. ISP trucks must be maintained in a good, clean, and operable condition, displaying ISP’s name, meet the necessary safety standards, comply with all Department of Transportation Regulations, and prevent damages of vehicles, property and/or injuries to others. ISP shall be solely responsible for maintaining its own equipment as listed in the Service Provider Application, and shall promptly inform RA of any changes in the equipment that ISP has available for RA’s work. ISP shall be solely responsible for any personal injury or property damage resulting from the ISP’s failure to perform the Services in a safe and professional manner.

3. Rate Schedule: ISP will charge RA for Services rendered to RA’s Members in accordance with the rates including those

that may be incorporated to a specific pilot program, as set forth in the Rate schedule which is incorporated herein by referenced and as it may be amended from time to time. RA rates include any and all applicable Taxes. All charges in excess of those shown in the most current Rate Schedule shall be charged back to ISP. The Rate Schedule may be amended at any time by RA, in its sole discretion, and RA will provide notice of such changes to ISP. RA shall reimburse ISP for Services rendered to Members if such services are preauthorized by RA or in instances where such Services are permitted under the applicable membership manual. ISP agrees to charge RA’s Members that are designated by RA as “Cash Call” Members their same contracted rates as per the current Rate Schedule on file.

2 | P a g e v. 11-8-17

ISP#: _________________________ City & State: __________________

4. Invoicing: ISP will invoice RA for Services no later than 90 days from the date that Services were rendered. RA shall not be obligated to pay ISP for any invoices submitted in excess of 90 days after the Service has been rendered. Payments by RA to ISP for Service rendered to Members shall not include reimbursement for any parts, repairs, or merchandise, nor for any matter other than that specifically authorized by RA at time of service in accordance to the respective program’s benefits’ structures & limitations. ISP shall be accountable for any charges made to RA for unauthorized parts or Services.

5. Damages: ISP shall report to RA of any damages or accidents that may occur in the course of providing Services as soon

as practicable. ISP further agrees to cooperate with RA in the resolution of any claims, including, but not limited to, the provision of supporting documentation and evidence of any accident and/or damages resulting thereof. In the event that a Member alleges that ISP damaged a Member’s vehicle in the course of providing Services, or a Member otherwise alleges any damages as the result of ISP’s action or omissions, RA may withhold any monies due to ISP for Services under this Agreement pending resolution of the dispute with the Member. If ISP fails to reach a resolution with such Member and RA in its reasonable discretion believes that the Member’s complaint is valid, RA may reimburse Member and deduct such reimbursement from any monies due to ISP.

6. Non-exclusivity: It is expressly understood by the Parties that this Agreement is not exclusive in any respect. RA shall

have the right to contract with others to provide Services within said area of coverage. The area has been established for the sole purpose of providing prompt and reliable Service to Members and/or Customers. It is further understood that this Agreement does not guarantee ISP any amount of business, revenue or profit, and RA is not obligated to refer any amount of business to ISP. ISP expressly waives any claim for lost profits under this Agreement.

7. Independent Contractor: It is expressly agreed that the Parties shall be independent contractors and that the relationship

between the Parties shall not constitute a partnership, joint venture or agency. Neither Party shall have the authority to make any statements, representations or commitments of any kind, or to take any action, which shall be binding on the other Party, without the prior consent of such other Party. It is further agreed and understood that ISP shall not subcontract any part of its performance required under this Agreement to any third party without prior written consent of RA. If the use of a specific subcontractor has expressly been permitted by RA: (a) ISP shall act as an independent contractor and not act as RA’s agent; (b) ISP shall not act on behalf of RA and not act in the name of or on the account of RA; (c) ISP shall not receive the authority to directly or indirectly bind or commit RA; (d) ISP shall act as a general contractor assuming total control for the ISP’s and/or subcontractor’s performance and deliverables; (e) ISP shall be responsible to RA for each subcontractor as set forth herein; and, (f) all services provided by subcontractors will be provided on behalf of ISP under the terms and conditions of this Agreement. A permitted subcontracting shall not reduce ISP's obligations under this Agreement. Furthermore, ISP shall not charge to RA any surcharge for ISP’s fees or expenses.

8. Insurance: During the term of this Agreement, ISP shall maintain at its own expense: (a) Worker’s compensation and

occupational license insurance as request by an applicable law; (b) Comprehensive General and Automotive Liability Insurance, including, but not limited to, Contractual Liability Insurance specifically insuring ISP against the liabilities assumed under this Agreement, with minimum limits of $100,000 each person and $300,000 each occurrence for bodily injury and $100,000 each occurrence for property damage, or a minimum combined single limit for bodily injury and property damage of $500,000 per occurrence; (c) Garage Keeper’s Legal Liability Insurance (including, but not limited to “On-Hook” Liability Insurance) with a minimum limit of $50,000; and (d) any additional coverage or limits as may be required by applicable law. ISP shall provide RA a certificate of insurance evidencing ISP’s compliance with these insurance requirements (the “Certificate”) and, with respect to liability coverage, naming Brickell Financial Services-Motor Club, Inc. d/b/a Road America Motor Club as an “Additional Insured” on those policies where allowable. It is the responsibility of ISP to submit a copy of the current Certificate to be enclosed with the signed Agreement, as well as to keep such Certificate current. At the time this Agreement is signed and annually thereafter, each Party will provide to the other with a certificate of insurance evidencing the foregoing insurance coverages

9. Indemnity: ISP hereby agrees to defend, indemnify, and hold harmless at its own expense RA as well as their respective

directors, officers, agents, employees, attorneys in fact and shareholders (the “Indemnitees”) from and against any and all third party claims, debts, losses, liabilities, demands, obligations, costs, expenses, fines, penalties, actions and causes of action, judgment, judgment for damages, alleged claims or litigation to the extent arising out of or resulting from: (a) the negligent provision of services or products by ISP under this Agreement, including, but not limited to, any claim, judgment or determination resulting from the action of any person or entity providing services hereunder negligently on behalf of RA; (b) any breach of the terms of this Agreement by ISP; (c) any willful misconduct, or negligent error, omission, or any other negligent act by ISP, its respective employees, agents, subcontractors or franchisees in connection with the Services rendered in furtherance of this Agreement; (d) any claim, judgment or determination against RA and/or RA’s affiliates that ISP, its respective employees, agents, subcontractors or franchisees are deemed or considered employees of ISP; or (e) any claim that any Service or product provided by ISP provided hereunder infringes, violates or misappropriates any copyright, patent, trade secret or any other intellectual property right of a third party.

3 | P a g e v. 11-8-17

ISP#: _________________________ City & State: __________________

10. Trademarks and Trade Names: ISP must obtain prior written consent from RA for all advertising, displays or promotions using RA’s names, symbols or other intellectual property, including any advertising in the Yellow Pages or other local telephone directories. Except as otherwise agreed in writing, all approved advertising utilizing RA’s name, symbols, and other intellectual property shall be done solely at ISP’s expense. ISP may display at its place of business and on its service equipment decals, signs and other materials provided by RA. Upon termination of this Agreement, ISP agrees that is will immediately cease using RA’s names, symbols and other intellectual property and will remove all such items at ISP’s sole expense from its advertising, place of business and service equipment.

11. Compliance with the Law: ISP must adhere to and follow all laws, rules and regulations of the State(s) within the area of

coverage in regard to the operation of their towing business, operation of motor vehicles and employment of personnel. ISP must also adhere to all city ordinances within the area of coverage, including, but not limited to, those concerning the operation of motor vehicles and business licensing requirements. ISP is required to have and hold permits as required by the State(s) within the area of coverage and, if required, the city(ies) within the area of coverage for the removal of vehicles as required for law enforcement purposes. ISP shall maintain in current status all federal, state and local licenses and permits required for the operation of the business conducted by ISP, including any and all licenses and permits required under the applicable statutes of the State(s) within the area of coverage, as well as by any regulatory agency. ISP will provide copies of all licenses, permits, etc., required to conduct business as an emergency road or tow operator upon request by RA. In addition, ISP agrees to notify RAMC within twenty-four (24) hours if a required statutory or regulatory business license application is denied, or if any required statutory or regulatory business licenses is revoked, suspended, rescinded, terminated or limited, which would affect the ISP's performance under this Agreement.

12. Confidentiality: Any information that ISP is exposed by virtue of its relationship with RA under this Agreement – including

that of RA’s Members, which information is not available to the general public, shall be considered to be “Confidential Information”. ISP agrees that it will not sell, copy or transfer any Confidential Information to any third party without RA’s express written approval and that it shall not, without the express permission of the Member, use information acquired in the provision of Services pursuant to this Agreement for any purpose whatsoever except as necessary to perform such Services. ISP agrees that the terms and conditions of this Agreement, including the Service Provider Application and Rate Schedule also represent RA’s Confidential Information and ISP shall not divulge the contents of this Agreement to any third party without RA’s express written approval or except as required by law. ISP shall apply to such Confidential Company Information administrative, technical and physical safeguards at least as stringent as those required for customer information under applicable industry standards. ISP understands that that any breach of this provision is likely to result in irreparable injury to RA and that the remedy at law alone likely will be an inadequate remedy for such breach, and that in addition to any other remedy it may have, RA shall be entitled to enforce the specific performance of this Agreement by ISP in a court of competent jurisdiction, including, but not limited to, temporary and permanent injunctive relief, to the extent permitted by law, without the necessity of posting a bond or proving actual damages.

13. Term & Termination: This Agreement shall be effective as of the Effective Date and may be terminated at any time with or

without cause by either Party.

14. Assignment; Change of Ownership: ISP may not assign this Agreement or any of its rights or obligations under this agreement without RA's prior written consent. Change of ownership will result in the termination of this Agreement, and the new owner will have to file for a new agreement with RA.

15. Change of Ownership: Before ISP sells, conveys or otherwise disposes of ISP’s interest in his business as related to this

Agreement and the services provided hereunder, ISP shall provide RA 30 days’ advance written notice by certified mail of the intended action, giving a full and accurate description of the terms and conditions of such intended transfer of interest. Upon receipt of such notice, whether before or after the transfer of interest, RA reserves the right in its sole discretion to terminate this Agreement.

16. No Third Party Beneficiaries: Except as provided in Section 8 (“Indemnity”) and as to any indemnified party, the provisions of this Agreement are and shall be for the exclusive benefit of and shall be enforceable solely by each of the Parties. No provision of this Agreement shall be enforceable by or is intended by any Party to inure to the benefit of any other person or entity.

17. Notices: All notices required to be issued to RA by this Agreement shall be in writing and deemed to have been given: (a) when personally delivered; (b) 1 business day after being sent by a nationally recognized overnight courier with guaranteed next day delivery; or (c) 5 days after being mailed by United States Certified Mail, return receipt requested, postage prepaid, addressed as follows: Brickell Financial Services-Motor Club, Inc. d/b/a Road America Motor Club and Road America Motor Club, Inc. 7300 Corporate Center Drive, Suite 601, Miami, Florida 33126, Attn: Director of Provider Network, cc: Legal & Compliance Department. All notices will be sent to ISP by RA to the contact information on file with RA. It is the ISP’s responsibility to keep this information current.

4 | P a g e v. 11-8-17

ISP#: _________________________ City & State: __________________

18. Governing Law; Venue: This agreement shall be governed, construed, and enforced in accordance with the laws of the State of Florida, without regard to its conflict of laws rules. The parties agree that any litigation in any way relating to this Agreement shall be brought and venued exclusively in federal or state court in Miami-Dade, Florida, and ISP hereby consents to the personal jurisdiction of these courts and waives any objection that such venue is inconvenient or improper. EACH PARTY HEREBY IRREVOCABLY WAIVES ITS RIGHTS TO TRIAL BY JURY IN ANY ACTION OR PROCEEDING ARISING OUT OF THIS AGREEMENT OR THE TRANSACTIONS RELATING TO ITS SUBJECT MATTER.

19. Entire Agreement; Severability: This Agreement compromises the entire agreement between the Parties. All modifications and amendments, except amendments to the applicable Rate Schedule(s) made in the manner otherwise provided herein, must be made in writing and signed by both Parties. If any one or more of the provisions contained in this Agreement shall be or become invalid, illegal or unenforceable in any respect under any applicable law, the validity, legality and enforceability of the remaining provisions contained herein shall not in any way be affected or impaired.

20. Counterparts: This Agreement may be executed in any number of counterparts, and each such counterpart shall be deemed to be an original instrument, but all such counterparts. RA may accept an executed Agreement returned by facsimile as an original executed Agreement and such executed facsimile shall be binding upon ISP. RA may accept an electronic acknowledgment or signature of this Agreement as an original executed Agreement and such electronic acknowledgment or signature shall be binding upon ISP.

21. Drug Screening: RA shall not permit any employee or contractor to perform or assist in providing roadside services, towing of any vehicle or otherwise have contact with a Member or other individual pursuant to this Agreement if: (a) the employee has not consented to and passed periodic drug screening procedures conducted by a reputable, licensed provider. This requirement will be waived if the ISP provider proof that such testing violates applicable law in the state or locality wherein the Services will be provided; or (b) the employee has been convicted of any crime bearing upon the individual’s fitness to have responsibility for the tasks being assigned to the individual or for which the ISP’s owner(s) or manager(s) know or reasonably know, any other information, including, but not limited to, evidence of current violent or physically abusive behavior, indicating that the individual poses a significant risk to the health or safety to others that cannot be eliminated by reasonable accommodations.

IN WITNESS HEREOF, the Parties hereto have caused their authorized representatives to execute this Independent Services

Agreement as of the date first written above. Independent Service Provider Brickell Financial Services-Motor Club, Inc. d/b/a Road America Motor Club and Road America Motor Club, Inc. __________________________________________ __________________________________________ Signature Signature __________________________________________ __________________________________________ Title Title __________________________________________ __________________________________________ Date Date

Form W-9 (Rev. October 2018) Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

a Go to www.irs.gov/FormW9 for instructions and the latest information.

Give Form to the

requester. Do not

send to the IRS.

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.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.

Individual/sole proprietor or C Corporation S Corporation Partnership Trust/estate

single-member LLC

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) a

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.

Other (see instructions) a

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting

code (if any)

(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.) See instructions. Requester’s name and address (optional)

Road America Motor Club Inc.

7300 Corporate Center Drive Suite 601

Miami, Florida 33126 USA

6 City, state, and ZIP code

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Social security number

–

–

Employer identification number

–

Part II Certification

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. or

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

Sign Here

Signature of

U.S. person a Date a

General Instructions Section references are to the Internal Revenue Code unless otherwise noted.

Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9.

Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following.

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutual funds)

• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)

• Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later.

Cat. No. 10231X Form W-9 (Rev. 10-2018)

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:CONTACT

(A/C, No):FAX

E-MAILADDRESS:

PRODUCER

(A/C, No, Ext):PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement onthis certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEDREPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

OTHER:

(Per accident)

(Ea accident)

$

$

N / A

SUBRWVD

ADDLINSD

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

$

$

$

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS ONLY

AUTOSAUTOS ONLYNON-OWNED

SCHEDULEDOWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?(Mandatory in NH)

DESCRIPTION OF OPERATIONS belowIf yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

$

$

$

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

EROTH-

STATUTEPER

LIMITS(MM/DD/YYYY)POLICY EXP

(MM/DD/YYYY)POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTRINSR

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

$

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCEDAMAGE TO RENTED

$PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICYPRO-JECT LOC

CERTIFICATE OF LIABILITY INSURANCEDATE (MM/DD/YYYY)

CANCELLATION

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

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