Month Day Year. City Province Postal code. Telephone number Fax number Company Web Site (if applicable)

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1 .:Viator Group Out-of-Province/Canada Travel Medical Emergency Insurance & Group Extended Health Benefit Stop-Loss Insurance In the event that the Insurer accepts the present group application, the provisions of this application shall, as applied for, form part of either the Group Out-of-Province/Canada Travel Medical Insurance policy or the Group Extended Health Benefit Stop-Loss Insurance policy, or both, issued by the Insurer. The applicant shall be named Policyholder and the employee and/or member shall be named Participant. 1. SECTION A PLAN INFORMATION Month Day Year Effective date requested (12:01 a.m. on M/D/Y) 2. Month Day Year First renewal date (and every twelve (12) months thereafter) Master Application Do not use this area APP ECA 0313 GRP Policy Number Travel Stop-Loss 3. $ This application is made with the attached binder cheque (Please make cheque payable to RSA) SECTION B APPLICANT INFORMATION 4. Applicant (Full corporate name) Nature of business 5. Address Street Suite City Province Postal code Telephone number Fax number Company Web Site (if applicable) 6. Subsidiary Companies to be included (Full corporate name) - Attach a separate sheet if necessary Name of Subsidiary Address No. of Employees Nature of Business 7. Contacts - Please indicate whom to contact for verification of coverage, premium remittance, etc... Name of company/organization Name of plan administrator Address Street Suite City Province Postal code Telephone number Fax number address Language Contract: c English c French Correspondence: c English c French 1

2 SECTION C PERSONS TO BE INSURED 8. Employees or Member If the applicant is an employer, the employee: a) is an active employee working a minimum of hours per week. (May not be less than 20 hours per week), and b) has satisfied the eligibility period: continuous months of employment with the applicant. If the applicant is other than an employer, the member: a) is in good standing of the applicant, and b) is on the monthly list of members entitled to coverage provided to the Insurer by the applicant. 9. Dependents Spouse (State current extended health care plan cohabitation requirement) Legal spouse or common-law spouse with continuous cohabitation in the last months. Dependent Child (State current extended health care plan age limits, subject to the maximum shown below) a) under years of age, or b) under years of age (26 maximum), if a full-time student at a recognized educational institution. 10. Participation/Class Description Participation is mandatory, that is, 100% of employees or members and their dependents who are currently covered under the applicant s basic group extended health care plan are required. The minimum number of primary lives per applicant is twenty-five (25). Stop-Loss Exception: Employees age seventy (70) or over, retired employees or disabled employees age sixty-five (65) or older are not eligible for Group Extended Health Benefit Stop-Loss insurance. Total number of employees on payroll: Total number of eligible employees/members: Total number of participating employees/members: Is coverage requested for active employees/members age 70 or over? Yes c No c Is coverage requested for retired employees/members?* Yes c No c * If coverage is required, participation for employees/members age 70 or over and retirees must be mandatory for group travel benefits. Class A Class B Class C SECTION D GROUP OUT-OF-PROVINCE/CANADA TRAVEL MEDICAL EMERGENCY INSURANCE: PLAN BENEFITS 11. Overall Maximum per Insured Person - $5 million per Coverage Period per Trip (maximum available) Plan Benefits: Semi-Private Hospital Room, Physician Charges, Diagnostic Services, Paramedical Services, Prescriptions, Ambulance Services, Medical Appliances, Private Duty Nurse, Emergency Air Transportation, Transportation to Bedside, Return of Travelling Companion, Treatment of Dental Accidents, Meals and Accommodation, Vehicle Return, Return of Deceased, Incidental Expenses. Class Overall Maximum Coverage Period 30/60/90/120/180 days Termination Age (as stated below or earlier retirement) Pre-existing Condition Stability Period (mandatory for employees age 70 or over and retirees) Benefit Booklet Quantities English French A B C Certain benefit maximums, limitations and exclusions may apply. If a person entitled to coverage is already on a Trip on the Effective Date of the insurance applied for herein, the Coverage Period for this person will be reduced by the number of days he has been out of the province/canada on the Effective Date of the said insurance. Claims in process for persons outside their province or territory of residence/canada on the Effective Date of the insurance will not be assumed by the Insurer. 2

3 SECTION E GROUP EXTENDED HEALTH HEALTH BENEFIT STOP-LOSS INSURANCE: PLAN BENEFITS 12. Plan Benefits: Annual Review Individual Stop-Loss Initial Review Individual Stop-Loss Aggregate Stop-Loss per Insured Person per Policy Period. per Insured Person per Policy Period. per Policy Period. Coverage protects against large claims from any one individual or dependent. Claims experience is reviewed at inception and at each renewal to set individual Stop- Loss levels for claimants whose most current 12-month experience exceeds 75% of the Stop-Loss level applied for. Coverage protects against large claims from any one individual or dependent. Claims experience is reviewed at inception and at each renewal, but exceptional Stop-Loss levels are set at inception and first renewal for claimants whose most current 12-month experience exceeds 75% of the Stop- Loss level applied for. Coverage protects against the accumulation of expenses on all claimants, as opposed to high expenses for individual claimants, limiting total liability to a certain dollar amount. Claims experience is reviewed annually to assess an aggregate attachment point, in effect, determining the policyholder's liability limit. Stop-Loss Levels Stop-Loss Levels Stop-Loss Levels $5,000 $7,500 $10,000 $15,000 $20,000 $25,000 $5,000 $7,500 $10,000 $15,000 $20,000 $25, %* 115%* 120% 125% 150% of expected claims Plan Options Plan Options Plan Options Stop-Loss Level $ per insured person. Stop-Loss Level $ per insured person. Stop-Loss Level % of expected claims. Certain benefit maximums, limitations and exclusions may apply. * Requires a minimum of 100 primary lives. Stop-Loss coverage is subject to approval by the Insurer s authorized representative. The Insurer s authorized representative reserves the right to insure individuals at specific Stop-Loss levels or to not accept to insure certain individuals. 13. Qualifying for insurance coverage: (i) Available to employees less than age 70. Employees age 70 or over, retired employees or disabled employees age 65 or older are not eligible. (ii) The minimum number of primary lives per group is 25, except for the Aggregate Stop-Loss levels of 110% and 115%, which require a minimum of 100 primary lives; (iii) If at the end of any calendar year there are less than 125 employees covered by the plan, the drug portion of the Stop-Loss does not apply to any employee that is a resident of Quebec. (iv) The applicant must provide the appropriate claims experience on Insurer letterhead to RSA Travel Insurance Inc.: For Annual Review and Initial Review Individual Stop-Loss: a) The most recent 12 months of individual claims experience by benefit line is required; or, if individual claims experience is not available, b) The most recent 24 months of aggregate claims experience by benefit line is required, including the life count for each year of experience. A minimum Stop- Loss level of $10,000 for Drug & Extended Health and $7,500 for Drug Only will apply. Individuals within the group whose claims experience in the most recent 12 months is in excess of 75% of the attachment level applied for, will have their individual Stop-Loss level increased to % of their individual claims amount rounded to the next higher multiple of $5,000. For Aggregate Stop-Loss: a) A minimum of three years of paid claims experience by benefit line with corresponding Individual & Family volumes for each year of experience. SECTION F PREMIUM AND VOLUME Premium for each employee or member covered under either policy is due and payable by the applicant in advance on the first day of each month (the Premium Due Date). The Insurer will suspend the payment of claims while premiums are outstanding. If, at the end of the 31-day grace period allowed for its payment, any premium remains unpaid, the applicable policy shall terminate automatically. Any premium or part thereof which is then due and unpaid must be paid by the applicant nonetheless. No prorated premium is due to the Insurer for the period from the Effective Date of an employee s or a member s coverage under the policy until the first following Premium Due Date, if such Effective Date is other than the Premium Due Date. No prorated premium will be refunded by the Insurer to the applicant if an employee or a member ceases to be insured under either policy on a date other than the Premium Due Date. RSA Travel Insurance Inc. will not issue invoices. It remains the responsibility of the applicant or its administrator to report and remit premiums. 14. Volume Breakdown Class A B C Coverage Type Number of Employees/ Monthly Rates Members Travel Insurance Individual Stop-Loss Aggregate Stop-Loss Rates are guaranteed for no more than 12 months from the Effective Date of the policy. If, at any time, the group falls below 75% of the initial enrolment, the Insurer reserves the right to either adjust the rates accordingly or terminate the policy. 3

4 SECTION G ADDITIONAL REQUESTS (MUST BE APPROVED) 15. SECTION H DECLARATIONS AND SIGNATURES 16. (Original signatures are required) The applicant hereby requests that RSA Travel Insurance Inc. issue (Please check off the coverage applied for): c a non-participating Group Travel Medical Emergency Insurance policy and/or c a non-participating Group Extended Health Benefit Stop-Loss Insurance policy based on the statements and representations stated herein. Furthermore, the applicant hereby declares that, to the best of the applicant s knowledge, the statements and answers contained herein are complete and true as of the date hereof and agrees that such statements and answers shall constitute the application for and form part of the contract(s) and that the insurance applied for herein shall become effective in accordance with and subject to the terms and conditions of the policy(ies) to be issued to the applicant but in no case shall it/they become effective until the application has been approved by the Insurer. The applicant further agrees that no statement in this application shall be binding upon RSA Travel Insurance Inc. nor modify the aforesaid company s rights. In case of errors or omissions discovered by the Insurer in this application, the Insurer is hereby authorized to amend this application by noting the changes in the section entitled CORRECTIONS and MODIFICATIONS and acceptance by the applicant of the policy(ies) accompanied by a copy of this application so amended, shall constitute a ratification of such CORRECTIONS and MODIFICATIONS. The applicant agrees that the insurance will become effective only when the following conditions have been satisfied: 1. RSA Travel Insurance Inc. has approved, at its head office, this application and the Effective Date of the contract(s); 2. the applicant has given a deposit premium of $ with this application (negotiation of the cheque will not, in itself, constitute approval of the application); and 3. as confirmation of initial enrolment, the applicant has provided a copy of the current billing statement from the insurer who currently underwrites the basic group extended health care plan of the applicant. Current coverage should not be cancelled until this application has been approved by RSA Travel Insurance Inc. The applicant consents to any changes being made to the group insurance policy(ies) applied for herein, as required under the applicable laws, regulations and/or guidelines. Signed at on this day of, 20. Name of Applicant (full corporate name) Print Name of applicant s signing officer Title Signature of applicant s signing officer Signature of witness 4

5 SECTION I PRODUCER INFORMATION 17. Name (PLEASE PRINT) Address Signature Month Day Year For Head Office Use Only Corrections and Modifications Effective Date (Month/Day/Year) Authorized by Date (Month/Day/Year) Stop-Loss Determinant Factor Viator Group Extended Health Benefit Stop-Loss Insurance is underwritten by Royal & Sun Alliance Insurance Company of Canada and administered by RSA Travel Insurance Inc., operating as RSA Travel Insurance Agency in British Columbia. RSA and the RSA logo are trademarks owned by RSA Insurance Group plc, licensed for use by Royal & Sun Alliance Insurance Company of Canada. Viator is a trademark of RSA Travel Insurance Inc. 5