CSIO ALBERTA APPLICATION FOR AUTOMOBILE …

1 insurance COMPANY (Hereinafter called the Insurer)REPLACING POLICY NUMBER1. APPLICANT S FULL NAME AND POSTAL ADDRESS (INCLUDING COUNTY OR DISTRICT) ALBERTA APPLICATION FOR AUTOMOBILE INSURANCEPOLICY NUMBER ASSIGNEDCSIOCEPANEWBROKER S CLIENT IDBROKER / AGENTCODE(S)CONTACT NUMBERAll times are local times at the Applicant s postal address stated :FROMTO12:01 NAMEMIDDLE NAMELAST NAMEEACH DESCRIBED AUTOMOBILE IS AND WILL BE CHIEFLY USED IN THE VICINITY OF THE APPLICANT S ADDRESS ABOVE UNLESS OTHERWISE STATED IN THE REMARKS SECTION POLICY PERIODPREFERRED POLICY LANGUAGEENGLISHFRENCHBROKER/AGENT BILLCOMPANY BILLPAYMENT PLAN POLICY BILLINGCITYPROVINCECOUNTY OR DISTRICTCOMPANY CLIENT IDBRANCH OWNER S FORM PARTICULARS OF THE DESCRIBED AUTOMOBILE (S) NAMEMODEL OR (SERIAL NUMBER)PURCHASED BY APPLICANTYEARMONTHNEW OR USEDPURCHASE PRICEINCLUDING EQUIPMENT1234 VEH.

2 LIENHOLDER INFORMATION FOR SEF 23A OR LEASING COMPANY FOR SEF 5 LIENHOLDERLESSOR1234 MMYYYYMMYYYYMMYYYYMMYYYYYYYYYYYYYYYYYYYY NAMEPOSTAL ADDRESSPOSTAL CODE TRUCK GROSS WEIGHTLIST PRICE NEWVEH. DRIVER( ) OF VEHICLE 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 this item and no other and upon the terms, conditions, provisions, definitions and exclusions of the Insurer s corresponding policy form and for the following specified limit(s) and amount(s).

3 INSURINGAGREEMENTSPERILSLIMITSANDAMOUNTS IN DOLLARSPREMIUMINDOLLARSSECTION ATHIRD PARTY LIABILITYSECTION BACCIDENT BENEFITSSECTION CLOSS OF OR DAMAGE TO INSURED AUTOMOBILE (S)FAMILY PROTECTION ENDORSEMENT N 44 LEGAL LIABILITY FOR BODILY INJURY TO OR DEATH OF ANY PERSON OR DAMAGE TO PROPERTY (EXCLUSIVE OF COSTS AND POST JUDGEMENT INTEREST) FOR LOSS OR DAMAGE RESULTINGFROM BODILY INJURY TO OR THE DEATH OF ONE OR MORE PERSONS, AND FOR LOSS OR DAMAGE TO PROPERTY REGARDLESS OF THE NUMBER OF CLAIMS ARISING FROM ANY ONE FOR DEATHOR BODILY INJURYTHIS POLICY CONTAINS A PARTIAL PAYMENT OF LOSS CLAUSE1.

4 ALL PERILS2. COLLISIONOR UPSET3. COMPREHENSIVE(EXCLUDING COLLISIONOR UPSET)4. SPECIFIED PERILS(EXCLUDING COLLISIONOR UPSET)AMOUNT DEDUCTIBLE ON EACH SEPARATE CLAIM EXCEPT FOR LOSS ORDAMAGE BY FIRE OR LIGHTNING OR THEFT OF THE ENTIRE AUTOMOBILE12341234 ODAS STATEDIN SECTION BOF THE POLICYMINIMUM RETAINED PREMIUMTHE TOTAL ESTIMATED POLICY PREMIUM IS SUBJECT TO ADJUSTMENT TO THE INSURER S MANUAL PREMIUM FOR THE RISK.$TOTAL ESTIMATED POLICY PREMIUM INCLUDES ANY PREMIUM CHARGED FOR OPTIONAL DETAILS OF ANY OPTIONAL COVERAGES, SEE INDUSTRY SECTION.$LIMITS ARE THE SAMEAS SECTION A UNLESSOTHERWISE SPECIFIEDOCCASIONAL DRIVER( ) OF VEHICLE GROUPCOLL/APCOMP/SPGRID GRID STEPYESNOPage 1 of 2 AGENT / BROKER AND COMPANY USE 1 GOVERNMENTCONTACT NUMBERBUSINESSHOMEFAX 2006, Centre for Study of insurance Operations.

5 All rights ALBERTA APPLICATION for AUTOMOBILE insurance - 0306 EALBERTA APPLICATION FOR AUTOMOBILE INSURANCEPOLICY NUMBER ASSIGNEDCSIOCEPAOWNER S FORM Has any driver s licence, vehicle permit or similar authorization issued to the applicant or drivers listed in item 5 above to the knowledge of the applicant been or continued to be suspended, cancelled or lapsed ? 5. LIST ALL DRIVERS OF THE DESCRIBED AUTOMOBILE (S) IN THE HOUSEHOLD OR (as shown on Driver s Licence)6(A).6(B).IS ANY DRIVER SUBJECT TO FAINTING SPELLS, DIZZINESS OR LOSS OF CONSCIOUSNESS?If yes, state particulars in Remarks 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 SAFE OPERATION OF A VEHICLE?

6 If yes, state particulars in Remarks (A).7(B).GIVE PARTICULARS OF ALL CONVICTIONS ARISING FROM THEOPERATION OF ANY AUTOMOBILE DURING THE PAST THREE YEARS.(No convictions indicator all drivers )GIVE PARTICULARS OF ALL ACCIDENTS OR CLAIMS ARISING FROM THE OWNERSHIP OR OPERATION OF ANY AUTOMOBILE DURING THE PAST SIX YEARS.(No claims indicator all drivers )Use Remarks section overleaf if ofClaimAmount Paidor EstimateDESCRIPTIONIf yes, state particulars in Remarks 6. LICENSED** Attach Certificate DriverTraining Course**DRIVER S OCCUPATION1234Y/NY/NY/NY/N7(A).

7 CONVICTIONS DRIVER NUMBERLIST DRIVER NUMBERLIST DRIVER NUMBER1234 Claim Repayment Meets Definition of At-Fault Claim Exemption9(A).9(B).Has any insurer, to the knowledge of the applicant, cancelled, declined or refused to renew or issue AUTOMOBILE insurance to the applicant or drivers shown in item 5 within the THREE years preceding this APPLICATION ? If so, state name of insurer, and policy number if of applicant s most recent AUTOMOBILE DATE YYYY/MM/DDDRIVER (C).Does the applicant owe any money to another insurer related to a policy of auto insurance ?YESNO10(B).IS THE VEHICLE USED TO COMMUTE?

8 (THIS MEANS DRIVING TO WORK, TO SCHOOL OR PART-WAY SUCH AS TO PUBLIC TRANSIT).YESNODISTANCE ONE WAYSTATE THE USUAL DISTANCE DRIVEN ANNUALLY. (ANNUAL DISTANCE)kmkmkmkmkmkmkmkm10(A).THE VEHICLE IS USED FOR:VEH. (C).10(D).IS THE VEHICLE USED OUTSIDE OF CANADA?If Yes, State Particulars In Remarks of monthsNo. of monthsNo. of monthsNo. of monthsY/NY/NY/NY/N10(E).HAVE ANY OF THE FOLLOWING AFTER MARKET MODIFICATIONS BEEN MADE? If yes, state particulars in Remarks RollcageGround (A).Will the AUTOMOBILE be; (B).Will the AUTOMOBILE be used for the transportation of goods for compensation?

9 If so, state class of licence or certificate and radius of otherwise stated, the applicant is both the registered owner and actual owner of the described AUTOMOBILE . If not, state the names of:YYYY/MM/DDYYYY/MM/DDYYYY/MM/DDYYYY/MM /DDYYYY/MM/DDYYYY/MM/DDYYYY/MM/DDYYYY/MM /DDGRIDSTEPSTATE NUMBER OF YEARSLICENSED IN CANADA AND USA*Approx. % of use of vehicleYearsLicensed12341234 Veh. 1 Veh. 2 Veh. 3 Veh. TRAINING CERTIFICATEYY/MM/DDYY/MM/DDYY/MM/DDYY/MM /DDYY/MM/DDYY/MM/DDYY/MM/DDYY/MM/DDYY/MM /DDYY/MM/DDYY/MM/DDYY/MM/DDYY/MM/DDYY/MM /DDYY/MM/DDUsed for carrying passengers for compensation or hire?

10 Rented or Leased?For carrying explosives or radioactive material? (If yes, provide details in Remarks.)Y/NY/NY/NY/NY/NY/NY/NY/NY/NY/NY /NY/NBIRTHDATEDRIVER S LICENCE NUMBERThe registered ownerThe actual of ApplicantPage 2 of 2 PART 1 GOVERNMENT 2006, Centre for Study of insurance Operations. All rights ALBERTA APPLICATION for AUTOMOBILE insurance - 0306 EWhere (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 therein; or (b) the Insured contravenes a term of the contract or commits a fraud; or (c) the Insured willfully 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.