(To be drafted on your Corporate Letterhead)

Application for Membership

Charles Taylor Consulting (Hamilton)
Dallas Building
7 Victoria Street
Hamilton, Bermuda HMGX

Dear Sirs:

(Name of Member) hereby formally applies for Membership in The Signal Mutual Indemnity Association Ltd., to be effective (month/day/year) and, if accepted by its Managers, do hereby constitute and appoint The Signal Mutual Indemnity Association Ltd. and its Managers to act as our agent in all matters relating to the Longshore and Harbor Workers' Compensation Act.

We acknowledge receipt of the current Bye-laws and Rules of The Signal Mutual Indemnity Association and acknowledge that we have read them. Further, we agree to be bound by each and every one of those Bye-laws and Rules.

Date:
Corporate Name
By
(Title)
[to be signed by corporate officer]

Mail original letter to:

SIGNAL ADMINISTRATION, INC.
12700 Park Central Dr. • Ste. 1705 • Dallas, TX 75251