NOTICE TO APPLICANT, PROXY AND POWER TO VOTE

BY MY SIGNATURE I HEREBY APPLY TO COLONIAL COUNTY MUTUAL INSURANCE COMPANY FOR THE ABOVE SPECIFIED INSURANCE ON THE BASIS OF STATEMENTS
CONTAINED HEREIN.  I AGREE THAT SUCH POLICY WILL BE SUBJECT TO ADJUSTMENT IN THE PREMIUM DUE, THE POLICY PERIOD SHOWN HEREIN, AS A
RESULT OF MY MOTOR VEHICLE DRIVING RECORD OR OTHER UNDERWRITING FACTORS.  I ALSO AGREE  THAT IF MY PREMIUM REMITTANCE IS NOT HONORED
BY THE BANK NO COVERAGE WILL BE BOUND, AND THAT FRAUDULENT INFORMATION COULD JEOPARDIZE SOME OR ALL OF MY COVERAGES.

I ALSO HEREBY APPOINT THE LONE STAR GENERAL AGENCY, INC., WITH FULL POWER OF SUBSTITUTION, TO BE MY LAWFUL ATTORNEY IN FACT, AND IN MY
ABSENCE IT IS AUTHORIZED AND EMPOWERED TO VOTE FOR ME AT ANY MEMBERSHIP MEETING OF THE COMPANY, UNLESS I GIVE WRITTEN NOTICE
OTHERWISE.  THIS PROXY SHALL CONTINUE IN FORCE FOR THE FULL PERIOD OF THE POLICY AND ANY RENEWAL THEREOF, UNLESS SOONER REVOKED IN
WRITING AND SHALL BE IRREVOCABLE FOR THE FULL PERIOD PERMITTED BY LAW.  I AGREE TO BE GOVERNED BY THE PROVISIONS OF CHAPTER 17, OF THE
TEXAS INSURANCE CODE.

Signature of Applicant X_____________________________________________  Date: ________  TIME: ________ A.M.  P.M.
Signature of Parent or Legal Guardian X______________________________  Date: ________  TIME: ________ A.M.  P.M.
(If Applicant is under 18 years of age)
Signature of Agent X_________________________________________________  Date: ________  TIME: ________ A.M.  P.M.