| LMI HOLDINGS, INC. STOCK ORDERFORM INSTRUCTIONS Sections (1) and (2) — Number of Shares and Total Payment Due. Indicate the Number of Shares that you wish to subscribe for and the Total Payment Due. Calculate the Total Payment Due by multiplying the number of shares by the $10.00 price per share. The minimum purchase is 25 shares ($250). The maximum allowable purchase for any person or entity, together with associates, affi liates or persons acting in concert with such person or entity, is 50,000 shares ($500,000). Please see the Prospectus section entitled “The Conversion — Limitations on Purchases of Common Stock,” beginning on page ___of the Prospectus. By signing this form, you are certifying that your order does not confl ict with these purchase limitations. Section (3) — Payment by Check or Money Order. Payment must be made by including with this form a personal check, bank check or money order made payable to Christiana Bank & Trust Company, escrow agent. These will be cashed upon receipt; the funds remitted by personal check must be available within the account when your Stock Order Form is received. Indicate the amount remitted. Please do not remit cash, wire transfers or third party checks for this purchase. Section (4) — Purchaser Information (Subscription Offering). Please check the box that refl ects the highest eligibility priority of the purchasers listed in Section 9 of the Stock Order Form. If you checked box (a) please list all names and policy numbers that the purchaser(s) had at December 19, 2007. Include all policies held individually or jointly. If purchasing shares for a minor, list only the minor’s eligible policies. If purchasing shares for a corporation or partnership, list only the entity’s eligible policies. Attach a separate page, if necessary. Box (b) refers to any director, offi cer or employee of Lebanon Mutual who was not an Eligible Policyholder as of December 19, 2007. Failure to complete this section, or providing incorrect or incomplete information, could result in a loss of part or all of our share allocation in the event of an oversubscription. Orders placed in the Subscription Offering will take preference over orders placed in the Community Offering. See “The Conversion” section of the Prospectus for further details about the Subscription Offering and Community Offering, and the method for allocating shares in the event of an oversubscription. Section (5) Purchaser Information (Community Offering). If boxes (a) and (b) do not apply, please check one box (c), (d), (e) or (f), applicable to the purchaser(s) in Section 9. Orders placed in the Subscription Offering will take preference over orders placed in the Community Offering. See “The Conversion” section of the Prospectus for further details about the Subscription Offering and Community Offering, and the method for allocating shares in the event of an oversubscription. Section (6) — Management and Employees. Check the box if you are a Lebanon Mutual director, offi cer or employee, or a member of their immediate family. Immediate family includes spouse, parents, siblings and children who reside in the same house as the director, offi cer or employee. Section (7) — Maximum Purchaser Identifi cation. Check the box, if applicable. If you check the box but have not subscribed for 50,000 shares and did not complete Section 8, you may not have an opportunity to purchase more shares. Section (8) — Associates/Affi liates/Acting in Concert. Check the box, if applicable, and provide the requested information. Attach a separate page, if necessary. Please see the Prospectus section entitled “The Conversion — Limitations on Purchases of Common Stock” for the defi nition of “associate,” “affi liate” and “acting in concert.” Section (9) — Stock Registration. Clearly PRINT the name( s) in which you want the shares registered and the mailing address for all correspondence related to your order, including a stock certifi cate. Each Stock Order Form will generate one stock certifi cate, subject to the stock allocation provisions described in the Prospectus. IMPORTANT: Subscription rights are non-transferable. If placing an order in the Subscription Offering, you may include the names of one or more named insureds on the eligible policy, but you may not add the names of persons who are not named insureds on your eligible policy. NOTE FOR FINRA MEMBERS (Formerly NASD): If you are a member of the Financial Industry Regulatory Authority (“FINRA”), formerly the National Association of Securities Dealers (“NASD”), or a person affi liated or associated with a FINRA member, you may have additional reporting requirements. Please report this subscription in writing to the applicable FINRA member within one day of payment thereof. Section (10) — Form of Stock Ownership. For reasons of clarity and standardization, the stock transfer industry has developed uniform stockholder registrations for issuance of stock certifi cates. Benefi ciaries may not be named on stock registrations. If you have any questions on wills, estates, benefi ciaries, etc., please consult your legal advisor. When registering stock, do not use two initials — use the full fi rst name, middle initial and last name. Omit words that do not affect ownership such as “Dr.” or “Mrs.” Check the one box that applies. Buying Stock Individually — Used when shares are registered in the name of only one owner. To qualify in the Subscription Offering, the purchaser named in Section 9 of the Stock Order Form must have been a named insured on an eligible policy at Lebanon Mutual on December 19, 2007, or be a director, offi cer or employee of Lebanon Mutual. Buying Stock Jointly — To qualify in the Subscription Offering, the persons named in Section 9 of the Stock Order Form must have been a named insured on an eligible policy at Lebanon Mutual on December 19, 2007, or be a director, offi cer or employee of Lebanon Mutual. Joint Tenants — Joint Tenancy (with Right of Survivorship) may be specifi ed to identify two or more owners where ownership is intended to pass automatically to the surviving tenant(s). All owners must agree to the sale of shares. Tenants in Common — May be specifi ed to identify two or more owners where, upon the death of one co-tenant, ownership of the stock will be held by the surviving co-tenant(s) and by the heirs of the deceased co-tenant. All owners must agree to the sale of shares. Buying Stock for a Minor — Shares may be held in the name of a custodian for a minor under the Uniform Transfer to Minors Act. To qualify in the Subscription Offering, the minor (not the custodian) named in Section 9 of the Stock Order Form must have been a named insured on an eligible policy at Lebanon Mutual on December 19, 2007. The standard abbreviation for custodian is “CUST.” The Uniform Transfer to Minors Act is “UTMA.” Include the state abbreviation. For example, stock held by John Smith as custodian for Susan Smith under the PA Uniform Transfer to Minors Act, should be registered as John Smith CUST Susan Smith UTMA-PA (list only the minor’s social security number). Buying Stock for a Corporation/Partnership — On the fi rst name line, indicate the name of the corporation or partnership and indicate that entity’s Tax ID Number for reporting purposes. To qualify in the Subscription Offering, the corporation or partnership named in Section 9 of the Stock Order Form must have been a named insured on an eligible policy at Lebanon Mutual on December 19, 2007. Buying Stock in a Trust/Fiduciary Capacity — Indicate the name of the fi duciary and the capacity under which they are acting (for example, “Executor”), or name of the trust, the trustees and the date of the trust. Indicate the Tax ID Number to be used for reporting purposes. To qualify in the Subscription Offering, the entity named in Section 9 of the Stock Order Form must have had an eligible policy at Lebanon Mutual on December 19, 2007. Buying Stock in a Self-Directed IRA (for trustee/broker use only) — The opportunity to purchase common stock through individual retirement accounts is allowable only in the Community Offering (see Section 5). Stock may be purchased using self-directed individual retirement accounts which have the ability to hold the securities, such as at a brokerage fi rm. The purchase of shares using such funds can only be made through a self-directed retirement account, not through retirement accounts which are not self-directed. Registration should refl ect the custodian or trustee fi rm’s registration requirements. For example, on the fi rst name line indicate the name of the brokerage fi rm, followed by CUST or TRUSTEE. On the second name line, indicate the name of the benefi cial owner (for example, “FBO JOHN SMITH IRA”). You can indicate an account number or other underlying information, and the custodian or trustee fi rm’s address and department to which all correspondence should be mailed related to this order, including a stock certifi cate. Indicate the Tax ID Number under which the IRA account should be reported for tax purposes. Section (11) — Acknowledgment and Signature(s). Sign and date the Stock Order Form where indicated. All persons listed in Section 9 of the Stock Order Form must sign the form. If signing on behalf of a company registering common stock in Section 9, or otherwise signing in a fi duciary capacity, you must be legally authorized to do so. Before you sign, please carefully review the information you provided and read the acknowledgment. Verify that you have printed clearly, and completed all applicable shaded areas on the Stock Order Form. Please review the Prospectus carefully before making an investment decision. Deliver your completed Stock Order Form, with full payment, so that it is received (not postmarked) by Lebanon Mutual by 12:00 noon, Eastern Time, on , 2008. Stock Order Forms can be delivered by using the enclosed postage paid Order Reply Envelope, or by hand or overnight delivery to the Stock Information Center address on the front of the Stock Order Form. Stock Order Forms will only be accepted at this address. We are not required to accept Stock Order Forms that ar |
