ELECTRONIC RECORD AND SIGNATURE DISCLOSURE

From time to time, Professional Risk Management Services, its affiliates and subsidiaries (“PRMS”) may be required by law to provide to you certain written notices or disclosures. Described below are the terms and conditions for providing to you such notices and disclosures electronically through the _____________ electronic signing system. Please read the information below carefully and thoroughly, and if you can access this information electronically to your satisfaction and agree to these terms and conditions, please confirm your agreement by clicking the ‘I agree’ button at the bottom of this document.

Getting paper copies

At any time, you may request from PRMS a paper copy of any record provided or made available electronically to you by PRMS. You may request delivery of such paper copies from PRMS by following the procedure described below.

Withdrawing your consent

If you decide to receive notices and disclosures from PRMS electronically, you may at any time change your mind and tell us that thereafter you want to receive required notices and disclosures only in paper format. How you must inform PRMS of your decision to receive future notices and disclosure in paper format and withdraw your consent to receive notices and disclosures electronically is described below.

Consequences of changing your mind

If you elect to receive required notices and disclosures only in paper format, it will slow the speed at which we can complete certain steps in transactions with you and delivering services to you because PRMS will need first to send the required notices or disclosures to you in paper format, and then wait until PRMS receives back from you your acknowledgment of your receipt of such paper notices or disclosures. To indicate to us that you are changing your mind, you must withdraw your consent using the ________ ‘Withdraw Consent’ form on the signing page of a ____________ envelope instead of signing it. This will indicate to us that you have withdrawn your consent to receive required notices and disclosures electronically from us and you will no longer be able to use the ___________ system to receive required notices and consents electronically from PRMS or to sign electronically documents from us.

All notices and disclosures will be sent to you electronically

Unless you tell PRMS otherwise in accordance with the procedures described herein, we will provide electronically to you through the PRMS Website all required notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to you during the course of our relationship with you. To reduce the chance of you inadvertently not receiving any notice or disclosure, PRMS prefers to provide all of the required notices and disclosures to you by the same method and to the same address that you have given PRMS. Thus, you can receive all the disclosures and notices electronically or in paper format through the paper mail delivery system. If you do not agree with this process, please let us know as described below. Please also see the paragraph immediately above that describes the consequences of your electing not to receive delivery of the notices and disclosures electronically from PRMS.

How to contact PRMS

You may contact us to let us know of your changes as to how we may contact you electronically, to request paper copies of certain information from us, and to withdraw your prior consent to receive notices and disclosures electronically as follows:

By telephone at 703-907-3814, by email at clientservices@prms.com or by writing to PRMS Insurance Services, 4300 Wilson Blvd, Suite 700, Arlington, VA 22203.

Electronic Signature (eSignature): You consent and agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action while using any electronic service we offer; or in accessing or making any transactions regarding any document, agreement, acknowledgement, consent, term, disclosure, or condition constitutes your signature, acceptance and agreement as if actually signed by you in writing. Further, you agree that no certification authority or other third party verification is necessary to validate your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or resulting contract between you and PRMS. You understand and agree that your eSignature executed in conjunction with the electronic submission of your application will be legally binding and such transaction will be considered authorized by you.

Acknowledging your access and consent to receive materials electronically

To confirm to PRMS that you can access this information electronically, which will be similar to other electronic notices and disclosures that we will provide to you, please verify that you were able to read this electronic disclosure and that you also were able to print on paper or electronically save this page for your future reference and access or that you were able to e-mail this disclosure and consent to an address where you will be able to print on paper or save it for your future reference and access. Further, if you consent to receiving notices and disclosures exclusively in electronic format on the terms and conditions described above, please let us know by clicking the ‘I agree’ button below.

By checking the ‘submit’ box, I confirm that:

• I can access and read this Electronic CONSENT TO ELECTRONIC RECEIPT OF ELECTRONIC RECORD AND SIGNATURE DISCLOSURES document; and
• I can print on paper the disclosure or save or send the disclosure to a place where I can print it, for future reference and access; and
• Until or unless I notify PRMS as described above, I consent to receive from exclusively through electronic means all notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to me by HBT Insurance during the course of my relationship with you.