CSIO ALBERTA APPLICATION FOR AUTOMOBILE

ResetALBERTA APPLICATION FOR AUTOMOBILE INSURANCECSIOCEPAPOLICY NO. ASSIGNED:OWNER’S FORM S.A.F.1INSURANCE COMPANY (HEREINAFTER CALLED THE INSURER)REPLACING POLICY NO.NEWPOLICY LANGUAGE:ENGLISHFRENCH1. APPLICANT’S FULL NAME AND POSTAL ADDRESS (INCLUDING COUNTY OR DISTRICT)COMPANY CLIENT IDBROKER’S CLIENT IDBROKERCODE(S)BRANCHPOSTALCODECONTACT NUMBERPOLICY BILLINGCONTACT NUMBERBUSINESSHOMEFAXBROKER BILLCOMPANY BILLBUSINESSHOMEFAXPAYMENT PLANEACH DESCRIBED AUTOMOBILE IS AND WILL BE CHIEFLY USED IN THE VICINITY OF THE APPLICANT’S ADDRESS ABOVE UNLESS OTHERWISE STATED IN THE REMARKS SECTION OVERLEAF.2. POLICY PERIODTIMEP.M.A.M.DATEDATE:FROMTO 12:01 A.M.ALL TIMES ARE LOCAL TIMES AT THE APPLICANT'S POSTAL ADDRESS STATED HEREIN.3. PARTICULARS OF THE DESCRIBED AUTOMOBILE(S)VEH. MODELNO. YEARMODEL OR C.C.TRADE NAMEPURCHASE PRICEPURCHASED BY APPLICANTYEAR MONTH NEW OR USED INCLUDING EQUIPMENTV.I.N. (SERIAL NO.)BODY TYPE1234VEH. NO. IF APPLICABLE, INDICATE WHICH AND STATE NAME, POSTAL ADDRESS AND POSTAL CODE OF:1LIENHOLDERLESSOR234BROKER AND COMPANY USE ONLYVEH.NO.TRUCK GROSS WEIGHT LIST PRICE NEWGRIDYESGRID STEPVEH. CODELOC.TERR.D.R.T.P.L.CLASSD.R.COLL/A.P.RATE GROUPCOLL/A.P.COMP/S.P.NO1234OCCASIONAL DRIVER(O.D.) OF VEHICLE NO.OCCASIONAL DRIVER(O.D.) OF VEHICLE NO.4.THIS APPLICATION IS MADE FOR INSURANCE AGAINST ONE OR MORE OF THE PERILS MENTIONED IN THIS ITEM, BUT FOR INSURANCE UNDER THE SECTION(S) FOR WHICH A PREMIUM IS SPECIFIED IN THISITEM AND NO OTHER AND UPON THE TERMS, CONDITIONS, DEFINITIONS AND EXCLUSIONS OF THE INSURER'S CORRESPONDING STANDARD POLICY FORM AND FOR THE SPECIFIED LIMIT(S) AND AMOUNT(S).SECTION AINSURINGAGREEMENTSPERILSTHIRD PARTY LIABILITYLEGAL LIABILITY FOR BODILY INJURY TO OR DEATH OF ANY PERSON OR DAMAGETO PROPERTY (EXCLUSIVE OF COSTS AND POST JUDGEMENTINTEREST) FOR LOSS OR DAMAGE RESULTINGFROM BODILY INJURY TOOR THE DEATH OF ONE OR MORE PERSONS, AND FOR LOSS ORDAMAGE TO PROPERTY REGARDLESS OF THE NUMBER OF CLAIMS ARISINGFROM ANY ONE ACCIDENT.SECTION BSECTION CLOSS OF OR DAMAGE TO INSURED AUTOMOBILE(S)ACCIDENT BENEFITSTHIS POLICY CONTAINS A PARTIAL PAYMENT OF LOSS CLAUSEPAYMENTS FOR DEATHOR BODILY INJURY1. ALL PERILS2. COLLISIONOR UPSET3. COMPREHENSIVE(EXCLUDING COLLISIONOR UPSET)ENDORSEMENTSVEH. NO.S.E.F. NO.S.E.F. PREMIUMVEHICLEPREMIUM4. SPECIFIED PERILS(EXCLUDING COLLISIONOR UPSET)AMOUNT DEDUCTIBLE ON EACH SEPARATE CLAIM EXCEPT FOR LOSS ORDAMAGE BY FIRE OR LIGHTNING OR THEFT OF THE ENTIRE AUTOMOBILE1LIMITSANDAMOUNTSIN DOLLARS2AS STATEDIN SECTION BOF THE POLICY341PREMIUMINDOLLARS234ODODMINIMUM RETAINED PREMIUM THE TOTAL ESTIMATED POLICY PREMIUM IS SUBJECT TO ADJUSTMENT TO THE INSURER’S MANUAL PREMIUM FOR THE RISK.CSIO - Alberta Application for Automobile Insurance AB1001e 201401PART 1 GOVERNMENTPage 1 of 2TOTAL ESTIMATED POLICY PREMIUMINCLUDES ANY PREMIUM CHARGED FOR OPTIONAL COVERAGES. FORDETAILS OF ANY OPTIONAL COVERAGES, SEE INDUSTRY SECTION. 2013, Centre for Study of Insurance Operations. All rights reserved.

CSIOCEPAALBERTA APPLICATION FOR AUTOMOBILE INSURANCEPOLICY NO. ASSIGNED:OWNER’S FORMLIST ALL DRIVERS OF THE DESCRIBED AUTOMOBILE(S) IN THE HOUSEHOLD ORS.A.F.1BUSINESS5.DriverNo.OPERATOR LICENCE NUMBERNAME(as shown on Driver’s Licence)DATE OF BIRTH1234STATE NUMBER OF YEARS LICENCEDIN CANADA OR UNITED STATES6.DriverLIC. CLASSDATE LIC.No.GRID STEPAPPROX. % USE OF VEHICLE/RELEVANT DR.Veh. 1Veh. 2Veh. 3DRIVER TRAINING CERTIFICATEDRIVER’S OCCUPATION** Attach Certificate DriverTraining Course**Veh. 412346(A). IS ANY DRIVER SUBJECT TO FAINTING SPELLS, DIZZINESS OR LOSS OF CONSCIOUSNESS?YESIF YES, STATE PARTICULARS IN THE REMARKS SECTION.NO6(B). HAS ANY DRIVER EVER SUFFERED FROM A HEART DISORDER, EPILEPSY, DIABETES, DEFECTIVE VISION OR HEARING, OR ANY OTHER PHYSICAL OR MENTAL DISABILITY WHICH MIGHT AFFECT THE SAFEOPERATION OF A VEHICLE?YESNO IF YES, STATE PARTICULARS IN THE REMARKS SECTION.7(A). GIVE PARTICULARS OF ALL CONVICTIONS ARISING FROM THE OPERATION OF ANY AUTOMOBILE DURING THE PAST THREE YEARS.DRIVERNO.7(B).DATEYY/MM/DDGIVE PARTICULARS OF ALLVEHICLE YY/MM/DDDESCRIPTIONACCIDENTS OR CLAIMS ARISING FROM THE OWNERSHIP OR OPERATION OF ANY AUTOMOBILE DURING THE PAST SIX YEARS.TYPE OF AMOUNT PAIDCLAIM OR ESTIMATECLAIM AMOUNT REPAID TOINSURERDESCRIPTIONHAS ANY DRIVER'S LICENCE, VEHICLE PERMIT OR SIMILAR AUTHORIZATION ISSUED TO THE APPLICANT ORDRIVERS LISTED IN ITEM 5 ABOVE TO THE KNOWLEDGE OF THE APPLICANT BEEN OR CONTINUED TO BESUSPENDED, CANCELLED OR LAPSED?YESNOIF YES, STATE PARTICULARS IN THE REMARKS SECTION.9(A). HAS ANY INSURER, TO THE KNOWLEDGE OF THE APPLICANT, CANCELLED, DECLINED OR REFUSED TO RENEW 9(B). DETAILS OF APPLICANT'S MOST RECENTOR ISSUE AUTOMOBILE INSURANCE TO THE APPLICANT OR DRIVERS SHOWN IN ITEM 5 WITHIN THE THREEYEARS PRECEDING THIS APPLICATION? IF SO, STATE NAME OF INSURER, AND POLICY NUMBER IF AVAILABLE.INSURERVEH.NO.POLICY NO.10(A). STATE THE USUAL 10(B). IS THE VEHICLEDISTANCE DRIVENANNUALLY.kmkmkm1234USED TOCOMMUTE?YES NO(DRIVING TO WORK,SCHOOL OR PARTWAY SUCH AS TOPUBLIC TRANSIT.)VEH.NO.AUTOMOBILE INSURANCEINSURERPOLICY NO.10(C). STATE THE USUAL %OF ANNUALDISTANCEKILOMETERS DRIVENONE WAYFOR BUSINESS USE.kmENTER 0 IF NOkmBUSINESS USE.kmkmkm11(A). WILL THE AUTOMOBILE BE RENTED OR LEASED, OR USED FORCARRYING PASSENGERS OR HIRE, OR FOR CARRYING EXPLOSIVESOR RADIOACTIVE MATERIAL? IF SO, PROVIDE DETAILSUSE REMARKS SECTION OVERLEAF IF NECESSARYEXPIRYDATE10(D). IS THE VEHICLE USEDOUTSIDE OFCANADA?YES NONO. OF MONTHS9(C). DOES THE APPLICANT OWE ANY MONEY TOANOTHER INSURER RELATED TO A POLICYOF AUTO INSURANCE?YESNO10(E). HAVE ANY OF THE FOLLOWING AFTERMARKET MODIFICATIONS BEEN MADE?IF YES, STATE PARTICULARS IN REMARKS SECTION.ENGINE%%%%GROUNDCLEARANCEINTERIORROLL CAGETIRES11(B). WILL THE AUTOMOBILE BE USED FOR THE TRANSPORTATION OF GOODS FOR COMPENSATION? IF SO, STATE CLASS OF LICENCE ORCERTIFICATE AND RADIUS OF OPERATIONS.123412. UNLESS OTHERWISE STATED, THE APPLICANT IS BOTH THE REGISTERED OWNER AND ACTUAL OWNER OF THE DESCRIBED AUTOMOBILE. IF NOT, STATE THE NAMES OF:THE REGISTERED OWNERTHE ACTUAL OWNER13.DATEIf (a) an applicant for a contract (i) gives false particulars of the described automobile to be insured to the prejudice of the insurer, or (ii) knowingly misrepresents or fails to disclose in the application any fact required to be stated in the application, (b) the insured contravenes a term of the contract or commits afraud, or (c) the insured wilfully makes a false statement in respect of a claim under the contract, a claim by the insured is invalid and the right of the insured to recover indemnity is forfeited.The applicant acknowledges that: all of the information given by the applicant in items 1 through 13 and any particulars in the Remarks section relating thereto are true and the applicant hereby applies for a contract of automobile insurance to be based on the truth of the said information.The personal information collected on this application is needed to issue the policy. We are required to provide this information to the Underwriting Information Tracking System, which is a data bank operated on behalf of the automobile insurance industry for the purpose of statistical analysis, identification ofeligible risks and the proper rating of those risks. The information in the data bank is available to all insurance companies and insurance agents providing automobile insurance in Canada.Consent: I am applying for automobile insurance based on the information provided in this application. I authorize you to collect, use and disclose information on this form and any additional information about my driving record, automobile insurance policy and claims history and that of the listed drivers fromwhom I declare I have obtained consent for these purposes. I understand that this personal information is necessary to assess the risk, issue the insurance contract, renewal or change, detect and prevent fraud and investigate and settle any claims. If I apply for a premium payment plan, I authorize you toobtain and use my credit report.SIGNATURE OF APPLICANTxCSIO - Alberta Application for Automobile Insurance AB1001e 201401PART 1 GOVERNMENTPage 2 of 2 2013, Centre for Study of Insurance Operations. All rights reserved.

OPTIONAL ADDITIONAL COVERAGEALBERTA APPLICATION FOR AUTOMOBILE INSURANCEPOLICY NO. ASSIGNED:OWNER’S FORM S.A.F.14. ENDORSEMENTSVEHICLE 1DESCRIPTIONSEF N .4. ENDORSEMENTSVEHICLE 2VEHICLE 3SEF N .VEHICLE 4LIMIT 2DEDUCTIBLE%PREMIUMLIMIT 2DEDUCTIBLE%PREMIUMLIMIT 2DEDUCTIBLE%PREMIUMLIMIT 2DEDUCTIBLE%PREMIUMADDITIONAL COVERAGES INCLUDING DISCOUNTS AND SURCHARGESLIMIT 1ADDITIONAL COVERAGES INCLUDING DISCOUNTS AND SURCHARGESDESCRIPTIONSEF N .4. ENDORSEMENTSLIMIT 1DESCRIPTIONSEF N .4. ENDORSEMENTSADDITIONAL COVERAGES INCLUDING DISCOUNTS AND SURCHARGESLIMIT 1ADDITIONAL COVERAGES INCLUDING DISCOUNTS AND SURCHARGESDESCRIPTIONLIMIT 1*PREMIUMS ARE INCLUDED IN TOTAL ESTIMATED ON PAGE 1CSIO - Alberta Application for Automobile Insurance AB1001e 201401PART 2 INDUSTRY - PAGE 1 2013, Centre for Study of Insurance Operations. All rights reserved.

CSIOCEPA14.ALBERTA APPLICATION FOR AUTOMOBILE INSURANCEPOLICY NO. ASSIGNED:PART 2ADDITIONAL INFORMATION FOR DRIVERS SHOWN IN ITEM 5.DriverNo.DRIVER TRAININGDATE COMPLETED TYPENAME (as shown on Driver’s Licence)MARITALSTATUSSEXRELATIONSHIPTO APPLICANT1234DriverNo.DATE OF MVRCODECONVICTIONS/C %DESCRIPTION%CODEAT FAULTCLAIM %DESCRIPTION%CODEDISCOUNT %APPLIEDDESCRIPTION%123415.DATE HIREDNAME AND ADDRESS OF EMPLOYERDriverNo.1NAMEADDRESS23416 (B). NON-LICENSEDRESIDENT?16 (A). LIST ALL RESIDENTS OF HOUSEHOLD OR EMPLOYEES IN THE BUSINESS NOT ALREADY LISTED IN ITEMS 5 AND 14 (PROVIDING ALL APPLICABLE DATA).DriverNo.FULL NAMEBIRTHDATEDRIVER’S LICENCE NUMBER(if applicable)OWN A VEHICLE?123417. IS VEHICLE USED FOR CAR POOLSOR SHARE-THE-RIDE ARRANGEMENTS?VehicleNo.Yes/NoNo. ofPassengers18.Frequency# of timesper19.FUEL IF NOT POWEREDBY GAS OR DIESELENGINEIS THERE ANY UNREPAIREDDAMAGE INCLUDING DAMAGETO GLASS?20.DESCRIBE AND GIVE VALUE FOR ANY SPECIAL EQUIPMENTAND/OR CUSTOM PAINT FINISHValueDescribe123422. IF APPLICANT HAS CHANGED ADDRESS WITHIN THE LAST THREE YEARS,PROVIDE PREVIOUS ADDRESS21. PROVIDE DETAILS OF VEHICLE ANTI-THEFT DEVICE. (IF peProductCode1223. TOTAL NUMBER OF PRIVATE PASSENGER VEHICLES IN HOUSEHOLD INCLUDING THOSEALREADY LISTED #3424.REMARKS25.REPORT OF BROKER/AGENTHave you bound this risk?How long have you knownYESNOIs this business new to your office?(a) the applicant?YESDriver N Motor vehicle liability insurance card issued?NO(b) the principal operator(s)TEMPORARYPERMANENTNONEDriver N Provide Applicant’s email address if applicable.Does your client have other insurance with this company?YESNOPolicy N Policy N If yes, give particularsAre there any special circumstances concerning this application which the company should know?YESNOIs this risk eligible for the residual market, but being placed in the regular market under the take-all-comers rule?Was the Supplementary Market Availability Plan (SMAP) accessed to place this risk?26.YESNOIf yes, give particularsYESNOIf yes, give particularsIf yes, provide “map” reference number:BROKER/AGENT DECLARATIONI CONFIRM THAT I HAVE READ TO THE APPLICANT THE CONSENT PROVISION IN ITEM 13 OF THE APPLICATION FORM AND THE APPLICANT HAS DECLARED THEIR CONSENT AND FURTHER DECLARES THAT THEY HAVE OBTAINEDTHE CONSENT OF THE LISTED DRIVERS FOR THIS PURPOSE.BROKER/AGENT NAMECSIO - Alberta Application for Automobile Insurance AB1001e 201401BROKER/AGENT SIGNATUREPART 2 INDUSTRY - PAGE 2DATE 2013, Centre for Study of Insurance Operations. All rights reserved.