The provisions of this application shall, as applied for, form part of Canadian Benefit Providers Inc. application and will be subject to acceptance by the carriers who underwrite the products. Our 60 Day Travel Plan Out of Province/Country Emergency Medical supplied by AIG Insurance Company of Canada or the Group Extended Health Benefit Stop-Loss Insurance policy issued by the Lions Gate Underwriting Agency. SECTION A - PLAN INFORMATION OUT-OF-CANADA AND STOP LOSS EFFECTIVE DATE REQUESTED (12:01 A.M.) FIRST RENEWAL DATE (AND EVERY 12 MONTHS THEREAFTER) OCC FOR OFFICE USE ONLY POLICY NUMBER STOP LOSS This application is made with the attached binder Cheque. Please make Cheque payable to Canadian Benefit Providers Inc. SECTION B - CLIENT INFORMATION APPLICANT (FULL CORPORATE NAME) NATURE OF BUSINESS MAILING ADDRESS CITY PROVINCE POSTAL CODE AUTHORIZED ADMINISTRATOR(S) PHONE NUMBER FAX NUMBER EMAIL SUBSIDIARY COMPANIES TO BE INCLUDED - FULL CORPORATE NAME (ATTACH A SEPARATE SHEET IF REQUIRED) # OF NAME OF SUBSIDIARY ADDRESS EMPLOYEES NATURE OF BUSINESS SECTION C - PERSONS TO BE INSURED EMPLOYEE OR MEMBER A) is an active employee working a minimum of hours per week. (May not be less then 20 hrs/wk), and B) has satisfied the eligibility requirements set forth by the applicant. DEPENDANTS: 1. Spouse Legal spouse or common-law spouse with continuous cohabitation as defined by the jurisdiction of the member. 2. Dependant Child a) Under years of age, as defined by the jurisdiction of the member (maximum of 21). b) Under years of age (26 maximum), if a full-time student at a recognized educational institution. Page 1 of 12
PARTICIPATION/CLASS DESCRIPTION Total number of employees on payroll: Total number of eligible employees/members: Total number of participation employees/members: CLASS A CLASS B CLASS C DESCRIPTION DESCRIPTION DESCRIPTION PARTICIPATION PARTICIPATION PARTICIPATION MANDATORY VOLUNTARY MANDATORY VOLUNTARY MANDATORY VOLUNTARY SECTION D - 60 DAY TRAVEL PLAN OUT OF PROVINCE/COUNTRY EMERGENCY MEDICAL OVERALL MAXIMUM PER INSURED PERSON: 2 MILLION LIFETIME MAXIMUM PER ELIGIBLE INDIVIDUAL Trip Coverage of 60 days includes Semi-Private Hospital Room, Diagnostic Services, Paramedical Services, Prescriptions, Ambulance Services, Medical Appliances, Private Duty Nursing, Emergency Air Transportation, Transportation to Bedside, Return of Traveling Companion, Treatment of Dental Accidents, Meals and Accommodation, Vehicle Return, Return of Deceased, Incidental Expenses. CERTAIN BENEFIT MAXIMUMS, LIMITATIONS AND EXCLUSIONS MAY APPLY. Initial here It is understood and agreed that this Travel Medical Emergency plan will be effective on the 1st of the month for which approval has been granted. Initial here 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. Initial here 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. Initial here The minimum number of primary lives per group is five (5) for Travel Medical Emergency coverage. SECTION E - STOP-LOSS INSURANCE: PLAN BENEFITS OVERALL MAXIMUM PER INSURED PERSON: 1 MILLION PER ANNUM (MAXIMUM AVAILABLE) STOP-LOSS LEVEL PER INSURED PERSON STOP-LOSS LEVEL PER INSURED PERSON 3500 5000 10 000 DRUG LIMITATION PER INSURED PERSON 50,000 OTHER CERTAIN BENEFIT MAXIMUMS, LIMITATIONS AND EXCLUSIONS MAY APPLY. Initial here Stop-Loss insurance is not available to participants age 70 or over, retired participants or disabled employees age 65 or older. Initial here It is understood and agreed that this Stop-Loss contract will be effective on the 1st of the month for which approval has been granted. Initial here Subsequent policy periods will renew every twelve (12) months thereafter. QUALIFYING FOR INSURANCE COVERAGE: A) The minimum number of primary lives per group is five (5) for Stop-loss coverage. B) For individuals within the group whose claims experience in the twelve (12) months prior to the Effective Date Requested is in excess of seventy-five percent (75%) of the Stop-Loss level being applied for: i) the applicant will provide the appropriate claims experience to Canadian Benefits Provider Inc. ii) the individual will have their individual Stop-Loss level increased to 133% of their individual claims amount rounded to the next higher multiple of 5,000. C) The insurer reserves the right to insure individuals at specific Stop-Loss levels. Page 2 of 12
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 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. It remains the responsibility of the administrator to issue invoices to the applicant and to report and remit premiums. VOLUME BREAKDOWN CLASS A COVERAGE TYPE INDIVIDUAL FAMILY NUMBER OF EMPLOYEES OUT OF PROVINCE/CANADA MONTHLY RATES STOP-LOSS INSURANCE MONTHLY RATES CLASS B COVERAGE TYPE INDIVIDUAL FAMILY NUMBER OF EMPLOYEES OUT OF PROVINCE/CANADA MONTHLY RATES STOP-LOSS INSURANCE MONTHLY RATES CLASS C COVERAGE TYPE INDIVIDUAL FAMILY NUMBER OF EMPLOYEES OUT OF PROVINCE/CANADA MONTHLY RATES STOP-LOSS INSURANCE MONTHLY RATES 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 adjust the rates accordingly or terminate the policy. SECTION G - ADDITIONAL REQUESTS (MUST BE APPROVED) Page 3 of 12
SECTION H - DECLARATIONS AND SIGNATURES (ORIGINAL SIGNATURES ARE REQUIRED) THE APPLICANT HEREBY REQUESTS THAT CANADIAN BENEFIT PROVIDERS INC. ISSUE (PLEASE CHECK OFF COVERAGE) a non-participating 60 Day Emergency Medical Insurance Out of Province/Country Travel Plan underwritten by AIG Insurance Company of Canada a non-participating Group Extended Health Benefit Stop Loss Insurance Policy issued by Lions Gate Underwriting Agency Based on the statements and representations stated herein. Further more, the applicant herby 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 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 Canadian Benefit Providers Inc. nor modify the aforesaid company's rights. In case of errors or ommissions discovered by the Insurer in the 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. CBP 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. CBP has confirmation of initial enrolment. Current coverage should not be cancelled until this application has been approved by CBP. 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. NAME OF APPLICANT (FULL CORPORATE NAME) APPLICANT S AUTHORIZED SIGNING OFFICER (Please Print) SIGNATURE SIGNED AT (CITY AND PROVINCE) DATE Page 4 of 12
SECTION I - STOP LOSS COVERAGE. PLAN SPONSOR'S DECLARATION I hereby acknowledge that I am entering into an agreement with the Insurers and for Stop Loss coverage. I agree to all the exceptions, limitations and provisions within this stop-loss insurance and I acknowledge that Appendix A (Stop Loss Pricing) and Appendix B (Employee Enrolment Application) form part of this policy of insurance, as stated in the policy wording, and I agree to adhere to the Terms within this stop-loss insurance. PARTICIPATING EMPLOYER SIGNATURE AUTHORIZED OFFICER (PRINT NAME) DATE PLAN SPONSOR SIGNATURE LICENSED BROKER (PRINT NAME) DATE Page 5 of 12
SECTION J - PRODUCER INFORMATION (COMPLETED BY PLAN ADVISOR) NAME (PLEASE PRINT) ADDRESS CITY PROVINCE POSTAL CODE SIGNATURE DATE SECTION K - FOR CBP APPROVAL NAME (PLEASE PRINT) SIGNATURE DATE FOR HEAD OFFICE USE ONLY Correction and Modifications POLICY NUMBER EFFECTIVE DATE AUTHORIZED BY DATE TRAVEL STOP-LOSS Page 6 of 12
APPENDIX A - STOP LOSS PRICING PROVINCE 3,500 SINGLE 3,500 FAMILY 5,000 SINGLE 5,000 FAMILY 10,000 SINGLE 10,000 FAMILY ALBERTA 4.14 10.75 3.00 7.79 2.11 5.51 BC 3.61 9.36 2.61 6.80 1.84 4.78 MANITOBA 3.19 8.30 2.33 6.04 1.62 4.23 NEW BRUNSWICK 5.10 13.21 3.70 9.60 2.60 6.75 NEWFOUNDLAND 6.56 17.04 4.77 12.39 3.36 8.72 NOVA SCOTIA 4.70 12.24 3.43 8.88 2.40 6.26 ONTARIO 5.29 13.74 3.85 10.00 2.71 7.04 PEI 4.29 11.15 3.12 8.12 2.20 5.71 QUEBEC 5.33 13.86 3.88 10.10 2.73 7.10 SASKATCHEWAN 3.76 9.76 2.73 7.11 1.92 5.00 TERRITORIES 2.77 7.20 2.02 5.23 1.41 3.68 Page 7 of 12
APPENDIX B - REQUEST TO BIND STOP LOSS COVERAGE POL. 10139 PLAN SPONSOR BROKER CLIENT ID EFFECTIVE DATE POLICYHOLDER NAME ADDRESS CITY PROVINCE POSTAL CODE NATURE OF BUSINESS PROVINCE OF POLICYHOLDER HEAD OFFICE (IF DIFFERENT) ADDITIONAL DIVISIONS NEW BUSINESS COVERAGE CHANGE EMPLOYEE SPLIT: ACTIVE EMPLOYEES UNDER AGE 70, AND DISABLED EMPLOYEES UNDER AGE 65 COVERAGE PROVIDED: MAXIMUM LIMIT: MONTHLY PREMIUM: EXISTING PLAN DEDUCTIBLE 3,500 5,000 10,000 DEDUCTIBLE APPLIED FOR 3,500 5,000 10,000 # SINGLE: #FAMILY: #DEPENDENT: MEDICAL EXPENSES AS PROVIDED FOR AS ELIGIBLE EXPENSES UNDER THE PARTICIPATING EMPLOYER S HEALTH BENEFITS PLAN AND THIS STOP LOSS INSURANCE POLICY, IN EXCESS OF THE STOP LOSS DEDUCTIBLE LEVEL WHICH APPLIES. 1,000,000 MINUS THE INDIVIDUAL STOP LOSS DEDUCTIBLE LEVEL APPLICABLE # SINGLE X = # FAMILY X = TOTAL MONTHLY PREMIUM: CLAIMS EXPERIENCE AVAILABLE: NO - 10,000 STOP LOSS DEDUCTIBLE APPLIES YES - PLEASE PROVIDE CLAIMS HISTORY FOR THE PAST 3 YEARS YEAR # OF CLAIMS TOTAL CLAIMS EXPENSES DATE SUBMITTED: OFFICE USE ONLY DATE APPROVED: SUBMITTED BY: APPROVED BY: Page 8 of 12
APPENDIX C - PLAN MEMBER ENROLMENT FORM PLAN SPONSOR SECTION (to be completed by the Plan Administrator) PLAN SPONSOR/GROUP NAME GROUP NO. DIVISION NO. BENEFIT CLASS ID # DATE OF FULL-TIME EMPLOYMENT DATE ELIGIBLE OCCUPATION ANNUAL EARNINGS PLAN MEMBER S RESIDENCE PROVINCE PLAN ADMINISTRATOR S SIGNATURE NO. OF HOURS PER WEEK PLAN MEMBER S PROVINCE OF EMPLOYMENT WAIVE WAIT PERIOD (Y/N) PLAN MEMBER SECTION (to be completed by the Plan Member) LAST NAME DATE OF BIRTH FIRST NAME GENDER: (M/F) MARITAL STATUS MIDDLE INITIAL MAILING ADDRESS CITY PROVINCE POSTAL CODE PHONE NUMBER EMAIL (REQUIRED FOR ONLINE SERVICES & DIRECT CLAIM PAYMENT) APPLICATION FOR COVERAGE If provided by the policy, I elect the following coverage: Single Family Waived Health Dental Health and/or Dental coverage may only be removed if you have DUPLICATE group benefits through your spouse s employer. If you lose spousal coverage you must apply for coverage within 31 days of loss of such coverage. If you do not apply within 31 days you may be required to provide acceptable proof of your insurability to be covered. If you are approved, dental benefits, if applicable, may be restricted. Please see your plan administrator for details. COORDINATION OF BENEFITS SPOUSAL INSURANCE COMPANY NAME POLICY NO. EFFECTIVE DATE OF PLAN (IF KNOWN) What Group Benefits coverage does your spouse/common-law spouse have through an employer? Health Dental Single Family Page 9 of 12
DEPENDANT INFORMATION LAST NAME FIRST NAME RELATIONSHIP (SPOUSE/CHILD) DATE OF BIRTH GENDER (M/F) FULL-TIME STUDENT (Y/N) * DISABLED DEPENDANT (Y/N)** *Please include proof of post-secondary school enrolment, if older than 21 years of age. **Please complete disabled dependant form. BANKING INFORMATION For Direct Claim Payment. Attach void cheque or a completed direct deposit from your bank. Plese note that a valid Email Required ( See page 1) PERSONAL INFORMATION RELEASE Please list any individuals that you would like to have access to your personal information under your Group Benefit Plan. Personal information includes, but is not limited to: ID number, dependant information, beneficiary information and claim information. NAME OF INDIVIDUAL RELATIONSHIP TO YOU We will continue to allow the individuals listed above access to your personal information until such time as you advise us not to. AUTHORIZATION & DECLARATIONS Whereas the Company refers to Canadian Benefit Providers Inc., I certify that the information in this form is true and complete to the best of my knowledge. I acknowledge and agree that this Coverage or any portion of this Coverage, and future claims thereunder may be denied or terminated as a result of the provision of false, incomplete, or misleading information. I authorize the collection, use, maintenance and disclosure of personal information relevant to this application ( Information ) for the purposes of Group Benefits plan administration, audit, assessment, investigation, claim management, underwriting and for determining plan eligibility ( Purposes ). I authorize any person or organization with Information, including any medical and health professionals, facilities or providers, professional regulatory bodies, any employer, group plan administrator, insurer, investigative agency, and any administrators of other benefits programs to collect, use, maintain and exchange this information with each other and with my Plan Advisor, its re insurers and/or its service providers, for the Purposes. I understand that any Information provided to or collected in accordance with this authorization, will be kept in a Group Benefits life, health or disability file. Access to my Information will be limited to: Plan Advisor employees, representatives, re insurers, and service providers in the performance of their jobs; Persons to whom I have granted access; and Persons authorized by law. I authorize all future claims payments to be sent via electronic funds transfer to the bank account listed here. I agree that I will access my Explanation of Benefits via the secured employee web portal and that I will maintain a current email address to receive notification of payments as they occur. I recognize that it is my responsibility to ensure that my file is kept up-to-date with my preferred bank account information and personal information. I agree that the Company will not be responsible for any payments that are lost or misdirected due to incorrect banking information. I authorize the deduction from my pay of any contributions I must make towards the cost of these benefits. I agree that a photocopy or electronic version of this authorization is valid. PLAN MEMBER S SIGNATURE DATE Forward completed form to: Canadian Benefits Providers Inc., #202, 10235-124th Street NW, Edmonton, Alberta, T5N 1P9, Canada TEL: 780.944.9166, FAX: 780.944.9168, TOLL FREE: 855.944.9166, www.cbproviders.ca Page 10 of 12
APPENDIX D - BENEFICIARY FORM PART 1 YOUR INFORMATION PLAN SPONSOR/GROUP NAME PLAN MEMBER NAME (Last Name, First Name) DATE OF BIRTH GROUP # MEMBER ID # MAILING ADDRESS CITY PROVINCE PRIMARY PHONE POSTAL CODE EMAIL PART 2 BENEFICIARY DESIGNATION Do not scratch-out or white-out FIRST NAME LAST NAME MIDDLE INITIAL DATE OF BIRTH PERCENT ALLOCATED * RELATIONSHIP TO PLAN MEMBER LAST NAME MIDDLE INITIAL DATE OF BIRTH PERCENT ALLOCATED * RELATIONSHIP TO PLAN MEMBER * The above percentages must total 100% to be valid FIRST NAME PART 3 TRUSTEE DESIGNATION (not available in Quebec): Page 11 of 12
PART 4 AUTHORIZATION AND DECLARATIONS Whereas the Company refers to Canadian Benefits Providers Inc., I certify that the information in this form is true and complete to the best of my knowledge. I acknowledge and agree that this Coverage or any portion of this Coverage, and future claims thereunder may be denied or terminated as a result of the provision of false, incomplete, or misleading information. I authorize the collection, use, maintenance and disclosure of personal information relevant to this application ( Information ) for the purposes of Group Benefits plan administration, audit, assessment, investigation, claim management, underwriting and for determining plan eligibility ( Purposes ). I authorize any person or organization with Information, including any medical and health professionals, facilities or providers, professional regulatory bodies, any employer, group plan administrator, insurer, investigative agency, and any administrators of other benefits programs to collect, use, maintain and exchange this information with each other and with my Plan Advisor, its reinsurers and/or its service providers, for the Purposes. I understand that any Information provided to or collected in accordance with this authorization, will be kept in a Group Benefits life, health or disability file. Access to my Information will be limited to: Plan Advisor employees, representatives, reinsurers, and service providers in the performance of their jobs; Persons to whom I have granted access; and Persons authorized by law. I designate the person(s) named under the Beneficiary Designation as my beneficiary. The person(s) designated on this form will replace all previous designations for my beneficiary. I agree that a photocopy or electronic version of this authorization is valid. PLAN MEMBER S SIGNATURE DATE SIGNED Send Questions? Call us at 780.944.9166 ext 280, or toll free at 855.944.9166 ext 280 Mail Canadian Benefit Providers, #202, 10235-124th Street NW, Edmonton, Alberta, T5N 1P9, Page 12 of 12