Common use of Signed Date Clause in Contracts

Signed Date. The Insured is requested to read this Policy, and if incorrect, return it immediately for alteration. In the event of an occurrence likely to result in a claim under this insurance, immediate notice should be given to the Coverholder whose name and address appears above. All inquiries and disputes are also to be addressed to this Coverholder. For the purpose of the Insurance Companies Act (Canada), this Canadian Policy was issued in the course of Lloyd’s Underwriters’ insurance business in Canada. LSW1548B (amended) 14 December 2011 List of Insurers not of Open Market Insurers Syndicate Coverage(s) Insured Sum(s) Insured or Percentage CNP Syndicate under UMR: B0595PM8277420 Canopius Syndicate*: 4444 Travel Critical Illness, Accident Death, Disability, Dental Treatment, Loss of Limb or Use, Fracture or Dislocation, Medical Treatment & Transportation, and Medical Equipment 21.9375 % *Lead Syndicate HCC Underwriting Agency under UMR: B0595PM8277420 HCC Underwriting Agency Syndicate: 4141 Travel Critical Illness, Accident Death, Disability, Dental Treatment, Loss of Limb or Use, Fracture or Dislocation, Medical Treatment & Transportation, and Medical Equipment 56.250% ▇▇ ▇▇▇▇▇ under UMR: B0595PM8277420 ▇▇ ▇▇▇▇▇ Syndicate: 2001 Travel Critical Illness, Accident Death, Disability, Dental Treatment, Loss of Limb or Use, Fracture or Dislocation, Medical Treatment & Transportation, and Medical Equipment 10.00% Canopius under UMR: B0595PM8277420 AmTrust Syndicate: 1861 Travel Critical Illness, Accident Death, Disability, Dental Treatment, Loss of Limb or Use, Fracture or Dislocation, Medical Treatment & Transportation, and Medical Equipment 11.812% 07/05 LSW1546 At MSH INTERNATIONAL (CANADA) LTD., we recognize and respect every individual’s right to privacy. When You apply for coverage or Benefits, we establish a confidential file of personal information. We use the information to administer the group Benefit plan. This includes many tasks, such as: • Determining an Insured Person’s eligibility for coverage under the plan • Enrolling Insured Persons for coverage • Assessing an Insured Person’s claims and providing them with payment • Managing an Insured Person’s claims • Verifying and auditing eligibility and claims • Underwriting activities, such as determining the cost of the plan, and analyzing the design options of the plan • Providing the applicable Regulatory Forms and Tax Receipts, upon request We limit access to information in the Insured Person’s file to MSH INTERNATIONAL (CANADA) LTD. staff or persons authorized by MSH INTERNATIONAL (CANADA) LTD. who require it to perform their duties, to persons to whom the Insured Person has granted access, and to persons authorized by law. MSH INTERNATIONAL (CANADA) LTD., the Insured Person’s health care provider, other insurance and reinsurance companies, and the plan administrator of the policyholder may also exchange information when the information is needed to administer the group Benefit plan. For questions or concerns regarding the collection, use, disclosure or storage of personal information, please contact the Privacy Officer by mail or email. Concerns will be addressed within 30 days. MSH INTERNATIONAL (CANADA) LTD. ▇/▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇, 999 - 8th Street S.W. Calgary, Alberta, Canada T2R 1N7 Email: ▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇.▇▇▇-▇▇▇▇.▇▇▇ INSURING AGREEMENT 13 SANCTION LIMITATION AND EXCLUSION CLAUSE 13 IMPORTANT NOTICE REGARDING THE PATIENT PROTECTION AND AFFORDABLE CARE ACT ............................................................................................................................................................13 ZONE OF COVERAGE 13 EFFECTIVE DATE AND POLICY TERM 13 TERMINATION OF POLICY 13 ELIGIBILITY 13 REFUNDS 14 DEFINITIONS 15 POLICY EXCLUSIONS 17 NUCLEAR, CHEMICAL, BIOLOGICAL TERRORISM EXCLUSION 18 WAR AND TERRORISM EXCLUSION 18 MEDICAL SCHEDULE OF MAXIMUM BENEFITS 19 CRITICAL ILLNESS 21 MEDICAL EQUIPMENT 22 TRAVEL 22 DENTAL TREATMENT 24 CLAIMS PROCEDURE APPLICABLE TO MEDICAL AND DENTAL BENEFITS 25 ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) 26 STATUTORY CONDITIONS 30

Signed Date. The Insured is requested to read this Policy, and if incorrect, return it immediately for alteration. In the event of an occurrence likely to result in a claim under this insurance, immediate notice should be given to the Coverholder whose name and address appears above. All inquiries and disputes are also to be addressed to this Coverholder. For the purpose of the Insurance Companies Act (Canada), this Canadian Policy was issued in the course of Lloyd’s Underwriters’ insurance business in Canada. LSW1548B (amended) 14 December 2011 List of Insurers not of Open Market Insurers Syndicate Coverage(s) Insured Sum(s) Insured or Percentage CNP Syndicate under UMR: B0595PM8277420 B0595PM8277422 Canopius Syndicate*: 4444 Travel Critical Illness, Accident Death, Disability, Dental Treatment, Loss of Limb or Use, Fracture or Dislocation, Medical Treatment & Transportation, and Medical Equipment 21.9375 40 % *Lead Syndicate HCC Underwriting Agency under UMR: B0595PM8277420 B0595PM8277422 HCC Underwriting Agency Syndicate: 4141 Travel Critical Illness, Accident Death, Disability, Dental Treatment, Loss of Limb or Use, Fracture or Dislocation, Medical Treatment & Transportation, and Medical Equipment 56.25050% ▇▇ ▇▇▇▇▇ under UMR: B0595PM8277420 B0595PM8277422 ▇▇ ▇▇▇▇▇ Syndicate: 2001 Travel Critical Illness, Accident Death, Disability, Dental Treatment, Loss of Limb or Use, Fracture or Dislocation, Medical Treatment & Transportation, and Medical Equipment 10.00% Canopius under UMR: B0595PM8277420 AmTrust Syndicate: 1861 Travel Critical Illness, Accident Death, Disability, Dental Treatment, Loss of Limb or Use, Fracture or Dislocation, Medical Treatment & Transportation, and Medical Equipment 11.812% 07/05 LSW1546 At MSH INTERNATIONAL (CANADA) LTD., we recognize and respect every individual’s right to privacy. When You apply for coverage or Benefits, we establish a confidential file of personal information. We use the information to administer the group Benefit plan. This includes many tasks, such as: • Determining an Insured Person’s eligibility for coverage under the plan • Enrolling Insured Persons for coverage • Assessing an Insured Person’s claims and providing them with payment • Managing an Insured Person’s claims • Verifying and auditing eligibility and claims • Underwriting activities, such as determining the cost of the plan, and analyzing the design options of the plan • Providing the applicable Regulatory Forms and Tax Receipts, upon request We limit access to information in the Insured Person’s file to MSH INTERNATIONAL (CANADA) LTD. staff or persons authorized by MSH INTERNATIONAL (CANADA) LTD. who require it to perform their duties, to persons to whom the Insured Person has granted access, and to persons authorized by law. MSH INTERNATIONAL (CANADA) LTD., the Insured Person’s health care provider, other insurance and reinsurance companies, and the plan administrator of the policyholder may also exchange information when the information is needed to administer the group Benefit plan. For questions or concerns regarding the collection, use, disclosure or storage of personal information, please contact the Privacy Officer by mail or email. Concerns will be addressed within 30 days. MSH INTERNATIONAL (CANADA) LTD. c/o Privacy Officer 2900, ▇/▇▇ - ▇▇▇ ▇▇▇▇▇▇ ▇.▇ ▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇ ▇▇▇, 999 - 8th Street S.W. Calgary, Alberta, Canada T2R 1N7 Email: ▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇.▇▇▇-▇▇▇▇.▇▇▇ INSURING AGREEMENT 13 SANCTION LIMITATION AND EXCLUSION CLAUSE 13 IMPORTANT NOTICE REGARDING THE PATIENT PROTECTION AND AFFORDABLE CARE ACT ............................................................................................................................................................13 ZONE OF COVERAGE 13 EFFECTIVE DATE AND POLICY TERM 13 TERMINATION OF POLICY 13 ELIGIBILITY 13 REFUNDS 14 DEFINITIONS 15 POLICY EXCLUSIONS 17 NUCLEAR, CHEMICAL, BIOLOGICAL TERRORISM EXCLUSION 18 WAR AND TERRORISM EXCLUSION 18 MEDICAL SCHEDULE OF MAXIMUM BENEFITS 19 CRITICAL ILLNESS 21 MEDICAL EQUIPMENT 22 TRAVEL 22 DENTAL TREATMENT 24 CLAIMS PROCEDURE APPLICABLE TO MEDICAL AND DENTAL BENEFITS 25 ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) 26 STATUTORY CONDITIONS 30