March 16, 2007



ARROWHEAD Workers’ Compensation Program

Small Workers’ Compensation Accounts (under $15,000) Questionnaire

|Insured Name: |      |

|Total Annual Payrolls |Total Annual Premium |

|Current Year:       |Current Year:       |

|Prior Year:       |Prior Year:       |

|Prior Year:       |Prior Year:       |

|New Venture: No Yes If yes, owner resume required. |

|Operations and Benefits |

|Hours of Operation:      to       |# of Shifts:       |Driving exposure No Yes Delivery No Yes |

|Group Med. or Employer Contribution No Yes |Radius of operations |

|% Enrolled:       % paid by employer:       |1-4 1-5 1-6 ................
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