Signature Form Clause Samples

Signature Form. Print name(s) of Optionholder: (Must appear exactly as the name(s) appear(s) on the Options) Signature(s) of Optionholder: Date: , 2014 Daytime telephone number: ( ) E-mail address: July 14, 2014 Health Insurance Innovations, Inc. ▇▇▇ ▇▇▇▇▇▇ ▇▇▇., Suite 325 Tampa, Florida 33613 Attention: ▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇, ▇▇., General Counsel Ladies and Gentlemen: This letter agreement (this “Agreement”) is delivered to you pursuant to the Agreement and Plan of Merger, dated July 14, 2014 (the “Merger Agreement”), among the Company, HealthPocket, Inc. (the “Acquired Company”), SV Merger Sub, Inc. (the “Merger Subsidiary”), ▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇, and the other parties thereto. Capitalized terms used and not otherwise defined herein shall have the meanings ascribed thereto in the Merger Agreement. In consideration of the Merger upon the terms and conditions set forth in the Merger Agreement, the former stockholders and certain option and warrant holders of the Acquired Company will receive a combination of cash and Parent Shares. The undersigned acknowledges and agrees that the execution and delivery of this Agreement by the undersigned is a material inducement to, and condition of, the Company’s consummation of the Merger. In consideration of the Company’s obligations under the Merger Agreement, the undersigned hereby agrees that during the period beginning on the Closing Date and continuing through the third (3rd) anniversary of the Closing Date, the undersigned will not offer, sell, contract to sell, pledge, transfer, or otherwise dispose of, directly or indirectly, any of the Parent Shares issued to the undersigned pursuant to the Merger (the “Lock-Up Shares”), enter into a transaction that would have the same effect, or enter into any swap, hedge or other arrangement that transfers, in whole or in part, any of the economic consequences of ownership of the Lock-Up Shares, without, in each case, the prior written consent of the Company. The restrictions set forth in this paragraph shall lapse as to five percent (5%) of the aggregate number of Lock-Up Shares on each of the following dates: (i) January 14, 2016, (ii) April 14, 2016, (iii) July 14, 2016, (iv) October 14, 2016, (v) January 16, 2017, and (vi) April 14, 2017. The restrictions shall lapse as to all other Lock-Up Shares on July 14, 2017. The restrictions set forth in this paragraph shall not apply to Lock-Up Shares disposed of (i) as bona fide gifts in transactions not involving a disposition for value,...

Signature Form pdf Reference Form Reference Form JOC (Parts 1 & 2).xls

Signature Form pdf Reference Form Reference Form JOC (Parts 1 & 2) Legacy updated.xls Required Confidentiality Claim Form Claim Form.pdf Conflict of Interest Questionnaire - Form CIQ No response Disclosure of Lobbying Activities - Standard Form - LLL No response Current Form W-9 W9 Legacy Signs.pdf Certificates & Licenses (Supplemental Vendor Information Only)

Signature Form. By signing the below, the student and his/her parent/guardian agree to follow and accept:

Signature Form pdf Pricing Spreadsheet #1 Region 8 TIPS Medical Equipment, Supplies and Services 200804_Pricing_Form_1.xlsx Pricing Spreadsheet #2 UNIPAK CORP. 200804_Pricing_Form_2.xlsx References Region 8 TIPS Reference_Form.xls Proposed Goods and Services D/M/WBE Certification OPTIONAL No response Supplementary Unipak Corp Catalog for Liners - 24% Discount DP.pdf All Other Certificates No response Logo and Other Company Marks company-logo.gif Conflict of Interest Form CIQ- ONLY REQUIRED IF A CONFLICT EXISTS PER THE INSTRUCTIONS Certificate of Corporate Offerer - COMPLETE ONLY IF OFFERER IS A CORPORATION Disclosure of Lobbying Activities Standard Form LLL Unipak Corp. Disclosure of Lobbying Activities.pdf ONLY IF you answered "I HAVE Lobbied per above" to attribute #66, please download and complete and upload the

Signature Form. Print name(s) of registered holder(s): Signature(s) of authorized representative(s): Title of authorized representative(s): Date: , 2014 Daytime telephone number: ( ) E-mail address: Under federal income tax law, a Holder whose Warrants are surrendered is required to provide the Company with such Holder’s correct Taxpayer Identification Number (“TIN”) on IRS Form W-9 or on the applicable Form W-8 (in the case of non-U.S. persons). If such Holder is an individual, the TIN is his or her social security number. If the Company is not provided with the proper TIN, the Holder may be subject to a penalty imposed by the Internal Revenue Service (the “IRS”). In addition, failure to timely provide a properly completed, signed, and dated IRS Form W-9 may subject a Holder to federal income tax backup withholding (currently at a rate of 28%) on any payments made in connection with the Merger (including in connection with the Escrow Agreement) to such Holder and may subject such Holder to penalties imposed by the IRS. Certain Holders (including, among others, certain corporations and certain foreign individuals) may not subject to these backup withholding and reporting requirements. See the enclosed instructions on IRS Form W-9 for additional information. If backup withholding applies, Parent and/or the Company is required to withhold a percentage (currently at a rate of 28%) of any payments made to the Holder pursuant to the Merger Agreement. Any amount withheld is non-refundable by Parent, Merger Sub, the Company, the Surviving Corporation, Representative, the Paying Agent and/or the Escrow Agent. To prevent federal income tax backup withholding with respect to payments made to a Holder with respect to Warrants in connection with the Merger Agreement, a Holder should provide the Paying Agent with his, her or its correct TIN by completing the IRS Form W-9 and certifying that the TIN provided on IRS Form W-9 is correct (or that such holder is awaiting a TIN), that such Holder is a U.S. citizen or other U.S. person (as defined) and that such Holder is not subject to backup withholding because: (i) such holder is exempt from federal backup withholding, or (ii) such holder has not been notified by the IRS that such holder is subject to federal backup withholding as a result of a failure to report all interest or dividends, or (iii) the IRS has notified such holder that such holder is no longer subject to federal backup withholding (see Part 2 of IRS Form W-9).

Signature Form. NextEra Energy Solutions, LLC (▇▇▇▇) is submitting this proposal to qualify for Performance Contracting. Because the boilerplate “Vendor Agreement” contained in the RFP does not specifically apply to all services that we will provide through the TIPS cooperative, upon selection, we are prepared to negotiate the appropriate vendor contract with the TIPS cooperative to the mutual agreement of both parties. • The unsigned vendor agreement form has been uploaded separately.

Signature Form