Electronic Data Submissions Authorization
December 28, 2006

If you wish to send your monthly reports electronically, you must sign the following and fax it to Lydia Bradford at (801)531-0312.

Company Name___________________________________________

Company Control Code(s)___________________________________

I understand that in order to send my monthly submission electronically to Insure-Rite, Inc.â , I must sign this disclaimer.

I understand that my data will be transferred over the Internet. I understand that the Internet may not be secure.

Signature: _______________________________________________________

Print Name: _______________________________________________________