SAMPLE

CANADIAN TIRE ACCIDENT PLUS INSURANCE INSURED INDIVIDUAL John Sample

INSURED INDIVIDUALS DATE OF BIRTH February 2 1918 GROUP POLICY NO 90272

CERTIFICATE NO CT59 1 ORIGINAL EFFECTIVE DATE August 14 2017

REVISION DATE August 14 2017 CURRENT AMOUNT OF INSURANCE $50000

MONTHLY PREMIUM PAYABLE $925

The premium rate shown above includes provincial retail sales taxes where applicable

For the purposes of this Certificate the term You and Your means the Group Member who is the named Insured personon the Schedule We Us and Our means The Canada Life Assurance Company the insurer

We the Canada Life Assurance Company certify that You the Group Member named on the attached Schedule if over age 18 and a resident of Canada when You enroll are covered by Group Policy 90272 that We have issued to Canadian Tire Bank (the Policyholder) If You have chosen the family plan Your Spouse and Eligible Dependent Children are covered too

Your coverage begins on the effective date shown on the Schedule

The Group Policies 90270 90271 90272 90273 90274 74632 and 010401 pay benefits under one Certificate or under one Family Plan per Group Member only If You are the Group Member named under more than one Certificate under Group Policy 90270 90271 90272 90273 90274 74632 and 010401 the Group Member while living may select which Certificate is in effect If the Group Member dies before any selection is made and a benefit is payable We will pay the benefit from the Certificate with the largest benefit Any other Certificate(s) will be voided and all premiums paid for that Certificate refunded If you are a Spouse or Family member is insured under more than one Certificate We will pay the benefit from the Certificate with the largest benefit only and coverage under any other Certificate(s) will be voided

This Certificate forms a part of and is attached to the Group Policy and describes Your coverage Please take a few minutes to read it so You will understand Your rights and obligations We recommend You keep Your Certificate in a safe place with Your other important documents The Group Policy is the contract under which benefits are paid

This Certificate replaces any Certificate which may have been issued to You in the past under the Group Policy

DEFINITIONS Accident means a sudden unforeseen incident causing directly and independently of any other cause bodily injuriesdue exclusively to an external event of a violent nature and does not include sickness or disease

Customer means a natural person who responds to the offer of insurance under the Group Policy and who is a resident of Canada outside Quebec

Eligible Dependent Children means Your unmarried dependent children under age 19 (or under age 23 if a full timestudent) Dependent Children includes stepchildren legallyadopted children foster children children that for a period of at least 12 months You have shown a settled intention to treat as children of Your family and Handicapped Dependents as described here

Eligible Person means a Customer who at time of enrollment are over 18 years of age and are resident in Canada outside of Quebec

Family means You and Your family members whose primaryresidence is the same as Yours This includes Your Spouse andYour Eligible Dependent Children

DEFINITIONS Group Member means the person who is a Customer who iseligible to and has enrolled under this Group Policy and is thenamed Insured Person

Handicapped Dependents are dependent children who havereached the maximum age and whose primary residence is thesame as Yours if they cannot earn their own living due to anintellectual disability or physical handicap We reserve the right to request proof from You before We provide coverage for such an individual

Insured Person means You when single coverage is purchasedor You andor Your Family members when family coverage ispurchased

Schedule means the Schedule page attached to and forming part of this Insurance issued by Canada Life to Group Members upon enrollment

Spouse means the person to whom You are legallymarried or the person with whom You have lived in aconjugal relationship for a period of at least 24 months

SAMPLE

INSURING PROVISIONS WHEN YOUR COVERAGE BEGINS Your coverage begins on the date1 Canada Life receives the Group Members completedapplication at Our Office or

2 The Group Member calls Canada Life or its authorized agentand is enrolled by Canada Life or the authorized agent or

3 The Group Member is contacted by Canada Lifes authorizedagent and is enrolled by Canada Life or the authorized agent

whichever occurs first provided that such application and authorization meets the eligibility requirements of the Group Policy The effective date will be shown on Your Schedule WHEN YOUR COVERAGE ENDS Your Coverage will end 60 days after the earliest of thefollowing dates 1 The date that the Group Policy is terminated or2 You fail to make the required premium contribution for

Your coverageA Family member s coverage will end 1 When Your coverage ends or2 On the date the Family member is no longer eligible

To be and remain eligible for coverage under this CertificateYou must maintain a principal residence in Canada for at least 5months in any 12 month period You may cancel this insurance at any time by providing written notice or a verbal request to Us The cancellation will be effective on the day We receive Your written notice or accept Your verbal request

If Your coverage ends because the premium payment isoutstanding or the Group Policy is terminated Canada Life willoffer You an opportunity to continue the coverage with analternative method of payment if needed You must respond within the 60 day grace period if You wish tocontinue Your coverage Failure to make appropriatearrangements to continue coverage within this period will resultin termination of coverage IF YOU CHANGE YOUR MIND If when You originally apply for this insurance You do not likeYour Certificate for any reason return it to Us within 30 days ofthe original effective date requesting its cancellation We willreturn any premium You have paid and the Certificate will bevoid as if it had never been issued

WHAT IS COVERED This certificate consists of an Accident Coverage

Accident CoverageThe Principal Sum is shown on the Schedule and is the amount of Coverage You have selected and for which You pay a premium

Benefits are based on the Principal Sum shown on the Schedule if You are age 18 to 69 when the Accident occurs This amount is reduced to 50 of the amount shown on the Schedule if You are age 70 to 74 when the Accident occurs and further reduced to 25 of the amount shown on the Schedule if You are age 75 or over when the Accident occurs If You are age 70 or over when You apply for the Coverage benefits are reduced as described Benefits for Your Spouse if insured will be paid in the same manner based on Your Spouse s age Family Plan If You have selected family plan coverage Your spouse is insured for 100 of Your Principal Sum as shown on the Schedule The Principal Sum for each of Your Eligible Dependent Children is 25 of Your Principal Sum and 25 of Your Hospitalization and Home Recovery benefits as shown on the Schedule

COVERAGES We will pay a benefit if an Insured Person suffers one of the Covered Losses listed here as a direct result of an Accident that happens while an Insured Person is covered by the Group Policy and within one year of the Accident

COVERAGES Definition of Terms If an Insured Person suffers a covered loss then Paralysis means total and permanent paralysis from which no recovery is expectedLoss of use means total and permanent loss of useLoss of hearing or sight means total and permanent loss that cannot be correctedLoss of speech means the permanent loss of all ability to communicate by speechLoss of a hand or foot means complete severance through or above the wrist or ankle jointLoss of an arm or leg means complete severance through or above the elbow or knee jointPermanent Total Disability means the inability to perform the activities of any occupation for which the Insured Person is reasonably suited by education training and experience and from which no recovery is expected In the case of an eligible dependent child the Permanent Total Disability must be such that the child is judged by competent medical authorities to be permanently and totally disabledHospital as used here means an acute care facility set up according to law whichbull is mainly for the treatment and care of sick ailing or injured

in-patientsbull has a staff of one or more doctors with patient treatmentprivileges available at all times

bull provides skilled nursing care at all times (24 hours)bull provides organized diagnostic and surgical services either on

the premises or by contract with another qualified facilitybull is not primarily a convalescent chronic care psychiatric

rehabilitation rest or nursing home or a facility for the ageddrug addicts or alcoholics

COVERED LOSSES amp BENEFITS Accidental Death 100 of Principal Sum Dismemberment 100 of Principal SumLoss of one or both hands one or both feet sight in one or both eyes speech one arm or one leg Loss of use of one arm or hand or leg or foot hearing in both ears Accidental Paralysis 100 of Principal SumHemiplegia paraplegia or quadriplegia Accidental Permanent Total Disability

100 of Principal Sum

Permanent Total Disability resulting from a covered loss Only one loss is payable per Insured Person per Accident Hospitalization As shown on the Schedule The daily Hospitalization benefit is paid for each day of Hospitalconfinement if an Insured Person 1 is injured in an Accident which happens while they are

covered for this benefit and2 is admitted to the hospital for treatment as a direct result of the

injuries and from no other cause while they are covered for thisbenefit and

3 is an in-patient in the hospital under the care of a doctorother than themselves for a period of at least 3 days

No benefit is paid for the first 2 days of Hospitalization No benefit is paid for outpatient care and treatment including out-patient surgery received in a hospital We will pay up to a maximum of 180 days Hospitalization benefitfor each Hospitalization or series of Hospitalizations caused by thesame Accident However no benefits are payable 2 years after thedate of the Accident

Home Recovery As shown on the Schedule Two days of Home Recovery benefit are paid for each day a dailyHospitalization benefit is paid to a maximum of 360 days HomeRecovery benefit for each hospitalization or series ofhospitalizations caused by the same Accident

SAMPLE

COVERED LOSSES amp BENEFITS Accidental Death for Automobile Accidents As shown on the Schedule The Accidental Death benefit payable if Coverage is in force will be increased by 50 if the Accident occurs while the Insured Person is driving riding in entering or leaving a Private Passenger Automobile This increase applies ONLY to the Accidental Death benefit other benefit amounts will not be increased

Private Passenger Automobile as used here means a car motorcycle self-propelled mobile home or truck with a factory rated load capacity of 4500 kg or less which is licensed for use on public streets and highways and which is not used as a commercial vehicle A Private Passenger Automobile does not include a car motorcycleself propelled mobile home or truck which is 1) driven for hire or 2) being used in a race speed or endurance test Double Benefit for Common Carrier Accidents The Accidental Death benefits payable will be doubled if the Accident occurs as a result of riding as a fare-paying passenger in or on a public conveyance being operated commercially by a licensed common carrier to transport passengers for hire This increase applies ONLY to Accidental Death other benefit amounts will not be increased

WHAT IS NOT COVERED We will not pay any benefits for loss directly or indirectly

a) caused by sickness or disease medical or surgical treatmentor complications or infections that result from medical orsurgical treatment unless the treatment was required as theresult of an accident

b) caused by suicide attempted suicide or whenever the InsuredPerson injures themselves on purpose whatever their state ofmind and whether or not they are able to understand thenature and consequences of their actions at that time

c) caused by the commission of or attempt to commit a criminaloffense or to which a contributing cause was the InsuredPerson being engaged in a criminal act or illegal occupation

d) caused by war or any act of war whether or not declaredactivities and accidents of war related directly or indirectlyto service in the armed forces of any country riot or civilinsurrection

e) caused by the Insured Person having a blood alcohol level inexcess of 08 or caused by the taking of any drug sedative ornarcotic unless in accordance with a medical prescription

f) caused by the ingestion of poison toxic substances or non-toxicsubstances in such quantity that they become toxic the inhalationof gas voluntarily or otherwise (excluding the occupationalaccidents or accidental smoke inhalation resulting from a fire)

g) caused by participating in a contest of speed or causedbyparticipating in scuba-diving sky-diving parachuting hang-gliding or bungee jumping

h) caused by travel or flight in or getting in or out ofi an aircraft being used for test or experimentii a military aircraft other than on a scheduled transport aircraftiii an aircraft the Insured Person is flying is learning to fly or is

part of the crew of unless the insured is a fare-payingpassenger on a regularly scheduled commercial airline

Aggregate Benefit Canada Lifes liability resulting from a single Accident under a single Certificate is limited to a maximum of onemillion dollars ($100000000) Payment therefore will beprorated among the Certificate Holder and any Insured Familymembers involved in a single common Accident

HOW CLAIMS ARE PAID Notice of Claim In order for benefits to be paid the following conditions must be met 1 We must be notified within 30 days of the loss If it is not possible

to notify Us by that time We must be notified as soon as possiblebut no later than 1 year from the date of the loss

2 We will send a claim form with instructions on how to fill out theform within 15 days of being notified

HOW CLAIMS ARE PAID Notice of Claim

3 The claim forms and any other proof of loss We require must besent back to Us within 90 days or as soon as circumstances willallow

4 If the claim is of a continuing nature We must be sent proof asoften as We require

5 We will pay claims within 60 days of receiving due proof of loss

Proof of Loss To make a claim for benefits under this policy We must receive proofsatisfactory to Us of

a) the happening of the Accident or the commencement of thedisability and

b) the amount of loss andc) Your right to receive payment and Your age andd) satisfactory written proof regarding the cause or nature of

the Accident or disability and the duration of such disabilityYou may reach our claim department at 1-800-663-6622 or at theaddress on this Certificate Who is paidWe will pay Accidental Death benefits to the beneficiary You havechosen We will record Your choice of beneficiary and provide Youwith a written record of Your choice in the Schedule If You have not chosen a beneficiary or if there is no beneficiary alive when You die We will pay the benefit to Your estate You are the beneficiary forfamily members insured under this Certificate Other benefits are payable to You if You are living If You are notliving

a) Spousal benefits are paid to Your spouseb) Eligible Dependent Childrens benefits are paid to Your child

who is claiming if they are of legal age otherwise to theirguardian until they become of legal age

Change of BeneficiaryYou have the right to select or change a revocable beneficiary Anysuch selection or change must be in writing and We must havereceived a signed copy for it to be valid We are not responsible forthe validity or sufficiency of a change in beneficiary

OTHER POLICY PROVISIONS Physical Examinations and AutopsyWe reserve the right to request and examine any medical evidenceof disability when and so often as reasonably required while theclaim is pending We also reserve the right to arrange anindependent medical examination when necessary and to requestan autopsy where it is not forbidden by lawLegal ActionsEvery action or proceeding against an insurer for the recovery ofinsurance money payable under the contract is absolutely barredunless commenced within the time set out in the Insurance Act (for actions or proceedings governed by the laws of Alberta and BritishColumbia) The Insurance Act (for actions or proceedings governed by the laws of Manitoba) the Limitations Act 2002 (for actions or proceedings governed by the laws of Ontario) or other applicablelegislation For those actions or proceedings governed by the laws ofQuebec the prescriptive period is set out in the Quebec Civil Code Access You have the right upon request to obtain a copy of the policyyour application and any written statements or other records youhave provided to Canada Life as evidence of insurability subject tocertain limitations Premium Rate ChangeWe reserve the right to change the premium rates Howeverrates can only be increased if the same increase is made for allCertificate holders insured under the Group Policy We will giveYou at least thirty (30) days notice of such a change CurrencyAll references to dollars in the Certificate refer to Canadian dollars

SAMPLE

FRACTURE BENEFIT IF APPLICABLE

FRACTURE SCHEDULE OF BENEFITS This rider forms a part of and is attached to Group policy issued to Canadian Tire Bank by The Canada Life Assurance Company The following benefit as described here is made available under thisGroup policy effective 1201 am Standard Time on July 1 2010 Allprovisions conditions and exclusions of the Group policy to whichthis rider is attached also apply to this rider For the purposes of this rider only if you have purchased a Family Plan Your Spouse and eligible children are covered according to the Fracture Schedule of Benefits We will pay this benefit if

a) a person is injured in an accident which happens while they arecovered by the policy and

b) they suffer one of the losses listed in the Fracture Schedule ofBenefits as a direct result and from no other causeof the accident

RIDER MONTHLY PREMIUM RATE Single $150 Family $200

FRACTURE BENEFIT IF APPLICABLE

Fracture Schedule of Benefits Loss Fracture Benefit

Spine (two or more vertebrae) $500000 Spine (one vertebrae) $200000 Spine (compression fracture) $100000 Cranium (depressed fracture) $500000 Cranium (other) $200000 Pelvis $300000 Femur $150000 Lower leg $100000 Knee cap $100000 Forearm (compound or comminuted) $75000 Forearm (not compound) $35000 Upper Jaw $75000 Lower Jaw $20000 Arm between Shoulder and Elbow $40000 Shoulder Blade $50000 Ankle (Potts Fracture) $50000 Wrist (Colles Fracture) $50000 Two or more ribs $25000 One rib $10000 Facial bones $20000 Sacrum or Coccyx $25000 Sternum $25000 Collar Bone $25000 Heel Bone $12500 Hand (one or more metacarpals) $10000 Foot (calcaneum andor metatarsal(s)) $10000 Nose $5000 Chip or Hairline Fracture $2500 Any bone not specified $2500

Protecting Your Personal information When coverage is applied for We establish a file that contains personal information that is kept in the offices of Canada Life or the offices of an organization authorized by Canada Life Insured Persons may exercise certain rights of access and rectification with respect to the information in their files by sending a request in writing to Canada Life Canada Life may use service providers located within or outside Canada We limit access to personal information in such files to Canada Life staff or persons authorized by Canada Life who require it to perform their duties to persons to whom the Insured Persons have granted access and to persons authorized by law Insured Persons personal information may be subject to disclosure to those authorized under applicable law within or outside Canada We collect use and disclose the personal information to process applications and if such applications are approved provide and administer the financial product(s) applied for including investigating and assessing claims and creating and maintaining records concerning Our relationship For a copy of our Privacy Guidelines or if You have questions about ourpersonal information policies and practices (including with respect to service providers) write to Canada Lifes Chief Compliance Officer or refer to wwwcanadalifecom

THE CANADA LIFE ASSURANCE COMPANY 140 Fullarton Street 10th Floor London Ontario N6A 5P2

Paul A Mahon President and Chief Executive Officer

SAMPLE

INSURING PROVISIONS WHEN YOUR COVERAGE BEGINS Your coverage begins on the date1 Canada Life receives the Group Members completedapplication at Our Office or

2 The Group Member calls Canada Life or its authorized agentand is enrolled by Canada Life or the authorized agent or

3 The Group Member is contacted by Canada Lifes authorizedagent and is enrolled by Canada Life or the authorized agent

whichever occurs first provided that such application and authorization meets the eligibility requirements of the Group Policy The effective date will be shown on Your Schedule WHEN YOUR COVERAGE ENDS Your Coverage will end 60 days after the earliest of thefollowing dates 1 The date that the Group Policy is terminated or2 You fail to make the required premium contribution for

Your coverageA Family member s coverage will end 1 When Your coverage ends or2 On the date the Family member is no longer eligible

To be and remain eligible for coverage under this CertificateYou must maintain a principal residence in Canada for at least 5months in any 12 month period You may cancel this insurance at any time by providing written notice or a verbal request to Us The cancellation will be effective on the day We receive Your written notice or accept Your verbal request

If Your coverage ends because the premium payment isoutstanding or the Group Policy is terminated Canada Life willoffer You an opportunity to continue the coverage with analternative method of payment if needed You must respond within the 60 day grace period if You wish tocontinue Your coverage Failure to make appropriatearrangements to continue coverage within this period will resultin termination of coverage IF YOU CHANGE YOUR MIND If when You originally apply for this insurance You do not likeYour Certificate for any reason return it to Us within 30 days ofthe original effective date requesting its cancellation We willreturn any premium You have paid and the Certificate will bevoid as if it had never been issued

WHAT IS COVERED This certificate consists of an Accident Coverage

Accident CoverageThe Principal Sum is shown on the Schedule and is the amount of Coverage You have selected and for which You pay a premium

Benefits are based on the Principal Sum shown on the Schedule if You are age 18 to 69 when the Accident occurs This amount is reduced to 50 of the amount shown on the Schedule if You are age 70 to 74 when the Accident occurs and further reduced to 25 of the amount shown on the Schedule if You are age 75 or over when the Accident occurs If You are age 70 or over when You apply for the Coverage benefits are reduced as described Benefits for Your Spouse if insured will be paid in the same manner based on Your Spouse s age Family Plan If You have selected family plan coverage Your spouse is insured for 100 of Your Principal Sum as shown on the Schedule The Principal Sum for each of Your Eligible Dependent Children is 25 of Your Principal Sum and 25 of Your Hospitalization and Home Recovery benefits as shown on the Schedule

COVERAGES We will pay a benefit if an Insured Person suffers one of the Covered Losses listed here as a direct result of an Accident that happens while an Insured Person is covered by the Group Policy and within one year of the Accident

COVERAGES Definition of Terms If an Insured Person suffers a covered loss then Paralysis means total and permanent paralysis from which no recovery is expectedLoss of use means total and permanent loss of useLoss of hearing or sight means total and permanent loss that cannot be correctedLoss of speech means the permanent loss of all ability to communicate by speechLoss of a hand or foot means complete severance through or above the wrist or ankle jointLoss of an arm or leg means complete severance through or above the elbow or knee jointPermanent Total Disability means the inability to perform the activities of any occupation for which the Insured Person is reasonably suited by education training and experience and from which no recovery is expected In the case of an eligible dependent child the Permanent Total Disability must be such that the child is judged by competent medical authorities to be permanently and totally disabledHospital as used here means an acute care facility set up according to law whichbull is mainly for the treatment and care of sick ailing or injured

in-patientsbull has a staff of one or more doctors with patient treatmentprivileges available at all times

bull provides skilled nursing care at all times (24 hours)bull provides organized diagnostic and surgical services either on

the premises or by contract with another qualified facilitybull is not primarily a convalescent chronic care psychiatric

rehabilitation rest or nursing home or a facility for the ageddrug addicts or alcoholics

COVERED LOSSES amp BENEFITS Accidental Death 100 of Principal Sum Dismemberment 100 of Principal SumLoss of one or both hands one or both feet sight in one or both eyes speech one arm or one leg Loss of use of one arm or hand or leg or foot hearing in both ears Accidental Paralysis 100 of Principal SumHemiplegia paraplegia or quadriplegia Accidental Permanent Total Disability

100 of Principal Sum

Permanent Total Disability resulting from a covered loss Only one loss is payable per Insured Person per Accident Hospitalization As shown on the Schedule The daily Hospitalization benefit is paid for each day of Hospitalconfinement if an Insured Person 1 is injured in an Accident which happens while they are

covered for this benefit and2 is admitted to the hospital for treatment as a direct result of the

injuries and from no other cause while they are covered for thisbenefit and

3 is an in-patient in the hospital under the care of a doctorother than themselves for a period of at least 3 days

No benefit is paid for the first 2 days of Hospitalization No benefit is paid for outpatient care and treatment including out-patient surgery received in a hospital We will pay up to a maximum of 180 days Hospitalization benefitfor each Hospitalization or series of Hospitalizations caused by thesame Accident However no benefits are payable 2 years after thedate of the Accident

Home Recovery As shown on the Schedule Two days of Home Recovery benefit are paid for each day a dailyHospitalization benefit is paid to a maximum of 360 days HomeRecovery benefit for each hospitalization or series ofhospitalizations caused by the same Accident

SAMPLE

COVERED LOSSES amp BENEFITS Accidental Death for Automobile Accidents As shown on the Schedule The Accidental Death benefit payable if Coverage is in force will be increased by 50 if the Accident occurs while the Insured Person is driving riding in entering or leaving a Private Passenger Automobile This increase applies ONLY to the Accidental Death benefit other benefit amounts will not be increased

Private Passenger Automobile as used here means a car motorcycle self-propelled mobile home or truck with a factory rated load capacity of 4500 kg or less which is licensed for use on public streets and highways and which is not used as a commercial vehicle A Private Passenger Automobile does not include a car motorcycleself propelled mobile home or truck which is 1) driven for hire or 2) being used in a race speed or endurance test Double Benefit for Common Carrier Accidents The Accidental Death benefits payable will be doubled if the Accident occurs as a result of riding as a fare-paying passenger in or on a public conveyance being operated commercially by a licensed common carrier to transport passengers for hire This increase applies ONLY to Accidental Death other benefit amounts will not be increased

WHAT IS NOT COVERED We will not pay any benefits for loss directly or indirectly

a) caused by sickness or disease medical or surgical treatmentor complications or infections that result from medical orsurgical treatment unless the treatment was required as theresult of an accident

b) caused by suicide attempted suicide or whenever the InsuredPerson injures themselves on purpose whatever their state ofmind and whether or not they are able to understand thenature and consequences of their actions at that time

c) caused by the commission of or attempt to commit a criminaloffense or to which a contributing cause was the InsuredPerson being engaged in a criminal act or illegal occupation

d) caused by war or any act of war whether or not declaredactivities and accidents of war related directly or indirectlyto service in the armed forces of any country riot or civilinsurrection

e) caused by the Insured Person having a blood alcohol level inexcess of 08 or caused by the taking of any drug sedative ornarcotic unless in accordance with a medical prescription

f) caused by the ingestion of poison toxic substances or non-toxicsubstances in such quantity that they become toxic the inhalationof gas voluntarily or otherwise (excluding the occupationalaccidents or accidental smoke inhalation resulting from a fire)

g) caused by participating in a contest of speed or causedbyparticipating in scuba-diving sky-diving parachuting hang-gliding or bungee jumping

h) caused by travel or flight in or getting in or out ofi an aircraft being used for test or experimentii a military aircraft other than on a scheduled transport aircraftiii an aircraft the Insured Person is flying is learning to fly or is

part of the crew of unless the insured is a fare-payingpassenger on a regularly scheduled commercial airline

Aggregate Benefit Canada Lifes liability resulting from a single Accident under a single Certificate is limited to a maximum of onemillion dollars ($100000000) Payment therefore will beprorated among the Certificate Holder and any Insured Familymembers involved in a single common Accident

HOW CLAIMS ARE PAID Notice of Claim In order for benefits to be paid the following conditions must be met 1 We must be notified within 30 days of the loss If it is not possible

to notify Us by that time We must be notified as soon as possiblebut no later than 1 year from the date of the loss

2 We will send a claim form with instructions on how to fill out theform within 15 days of being notified

HOW CLAIMS ARE PAID Notice of Claim

3 The claim forms and any other proof of loss We require must besent back to Us within 90 days or as soon as circumstances willallow

4 If the claim is of a continuing nature We must be sent proof asoften as We require

5 We will pay claims within 60 days of receiving due proof of loss

Proof of Loss To make a claim for benefits under this policy We must receive proofsatisfactory to Us of

a) the happening of the Accident or the commencement of thedisability and

b) the amount of loss andc) Your right to receive payment and Your age andd) satisfactory written proof regarding the cause or nature of

the Accident or disability and the duration of such disabilityYou may reach our claim department at 1-800-663-6622 or at theaddress on this Certificate Who is paidWe will pay Accidental Death benefits to the beneficiary You havechosen We will record Your choice of beneficiary and provide Youwith a written record of Your choice in the Schedule If You have not chosen a beneficiary or if there is no beneficiary alive when You die We will pay the benefit to Your estate You are the beneficiary forfamily members insured under this Certificate Other benefits are payable to You if You are living If You are notliving

a) Spousal benefits are paid to Your spouseb) Eligible Dependent Childrens benefits are paid to Your child

who is claiming if they are of legal age otherwise to theirguardian until they become of legal age

Change of BeneficiaryYou have the right to select or change a revocable beneficiary Anysuch selection or change must be in writing and We must havereceived a signed copy for it to be valid We are not responsible forthe validity or sufficiency of a change in beneficiary

OTHER POLICY PROVISIONS Physical Examinations and AutopsyWe reserve the right to request and examine any medical evidenceof disability when and so often as reasonably required while theclaim is pending We also reserve the right to arrange anindependent medical examination when necessary and to requestan autopsy where it is not forbidden by lawLegal ActionsEvery action or proceeding against an insurer for the recovery ofinsurance money payable under the contract is absolutely barredunless commenced within the time set out in the Insurance Act (for actions or proceedings governed by the laws of Alberta and BritishColumbia) The Insurance Act (for actions or proceedings governed by the laws of Manitoba) the Limitations Act 2002 (for actions or proceedings governed by the laws of Ontario) or other applicablelegislation For those actions or proceedings governed by the laws ofQuebec the prescriptive period is set out in the Quebec Civil Code Access You have the right upon request to obtain a copy of the policyyour application and any written statements or other records youhave provided to Canada Life as evidence of insurability subject tocertain limitations Premium Rate ChangeWe reserve the right to change the premium rates Howeverrates can only be increased if the same increase is made for allCertificate holders insured under the Group Policy We will giveYou at least thirty (30) days notice of such a change CurrencyAll references to dollars in the Certificate refer to Canadian dollars

SAMPLE

FRACTURE BENEFIT IF APPLICABLE

FRACTURE SCHEDULE OF BENEFITS This rider forms a part of and is attached to Group policy issued to Canadian Tire Bank by The Canada Life Assurance Company The following benefit as described here is made available under thisGroup policy effective 1201 am Standard Time on July 1 2010 Allprovisions conditions and exclusions of the Group policy to whichthis rider is attached also apply to this rider For the purposes of this rider only if you have purchased a Family Plan Your Spouse and eligible children are covered according to the Fracture Schedule of Benefits We will pay this benefit if

a) a person is injured in an accident which happens while they arecovered by the policy and

b) they suffer one of the losses listed in the Fracture Schedule ofBenefits as a direct result and from no other causeof the accident

RIDER MONTHLY PREMIUM RATE Single $150 Family $200

FRACTURE BENEFIT IF APPLICABLE

Fracture Schedule of Benefits Loss Fracture Benefit

Spine (two or more vertebrae) $500000 Spine (one vertebrae) $200000 Spine (compression fracture) $100000 Cranium (depressed fracture) $500000 Cranium (other) $200000 Pelvis $300000 Femur $150000 Lower leg $100000 Knee cap $100000 Forearm (compound or comminuted) $75000 Forearm (not compound) $35000 Upper Jaw $75000 Lower Jaw $20000 Arm between Shoulder and Elbow $40000 Shoulder Blade $50000 Ankle (Potts Fracture) $50000 Wrist (Colles Fracture) $50000 Two or more ribs $25000 One rib $10000 Facial bones $20000 Sacrum or Coccyx $25000 Sternum $25000 Collar Bone $25000 Heel Bone $12500 Hand (one or more metacarpals) $10000 Foot (calcaneum andor metatarsal(s)) $10000 Nose $5000 Chip or Hairline Fracture $2500 Any bone not specified $2500

Protecting Your Personal information When coverage is applied for We establish a file that contains personal information that is kept in the offices of Canada Life or the offices of an organization authorized by Canada Life Insured Persons may exercise certain rights of access and rectification with respect to the information in their files by sending a request in writing to Canada Life Canada Life may use service providers located within or outside Canada We limit access to personal information in such files to Canada Life staff or persons authorized by Canada Life who require it to perform their duties to persons to whom the Insured Persons have granted access and to persons authorized by law Insured Persons personal information may be subject to disclosure to those authorized under applicable law within or outside Canada We collect use and disclose the personal information to process applications and if such applications are approved provide and administer the financial product(s) applied for including investigating and assessing claims and creating and maintaining records concerning Our relationship For a copy of our Privacy Guidelines or if You have questions about ourpersonal information policies and practices (including with respect to service providers) write to Canada Lifes Chief Compliance Officer or refer to wwwcanadalifecom

THE CANADA LIFE ASSURANCE COMPANY 140 Fullarton Street 10th Floor London Ontario N6A 5P2

Paul A Mahon President and Chief Executive Officer

SAMPLE

COVERED LOSSES amp BENEFITS Accidental Death for Automobile Accidents As shown on the Schedule The Accidental Death benefit payable if Coverage is in force will be increased by 50 if the Accident occurs while the Insured Person is driving riding in entering or leaving a Private Passenger Automobile This increase applies ONLY to the Accidental Death benefit other benefit amounts will not be increased

Private Passenger Automobile as used here means a car motorcycle self-propelled mobile home or truck with a factory rated load capacity of 4500 kg or less which is licensed for use on public streets and highways and which is not used as a commercial vehicle A Private Passenger Automobile does not include a car motorcycleself propelled mobile home or truck which is 1) driven for hire or 2) being used in a race speed or endurance test Double Benefit for Common Carrier Accidents The Accidental Death benefits payable will be doubled if the Accident occurs as a result of riding as a fare-paying passenger in or on a public conveyance being operated commercially by a licensed common carrier to transport passengers for hire This increase applies ONLY to Accidental Death other benefit amounts will not be increased

WHAT IS NOT COVERED We will not pay any benefits for loss directly or indirectly

a) caused by sickness or disease medical or surgical treatmentor complications or infections that result from medical orsurgical treatment unless the treatment was required as theresult of an accident

b) caused by suicide attempted suicide or whenever the InsuredPerson injures themselves on purpose whatever their state ofmind and whether or not they are able to understand thenature and consequences of their actions at that time

c) caused by the commission of or attempt to commit a criminaloffense or to which a contributing cause was the InsuredPerson being engaged in a criminal act or illegal occupation

d) caused by war or any act of war whether or not declaredactivities and accidents of war related directly or indirectlyto service in the armed forces of any country riot or civilinsurrection

e) caused by the Insured Person having a blood alcohol level inexcess of 08 or caused by the taking of any drug sedative ornarcotic unless in accordance with a medical prescription

f) caused by the ingestion of poison toxic substances or non-toxicsubstances in such quantity that they become toxic the inhalationof gas voluntarily or otherwise (excluding the occupationalaccidents or accidental smoke inhalation resulting from a fire)

g) caused by participating in a contest of speed or causedbyparticipating in scuba-diving sky-diving parachuting hang-gliding or bungee jumping

h) caused by travel or flight in or getting in or out ofi an aircraft being used for test or experimentii a military aircraft other than on a scheduled transport aircraftiii an aircraft the Insured Person is flying is learning to fly or is

part of the crew of unless the insured is a fare-payingpassenger on a regularly scheduled commercial airline

Aggregate Benefit Canada Lifes liability resulting from a single Accident under a single Certificate is limited to a maximum of onemillion dollars ($100000000) Payment therefore will beprorated among the Certificate Holder and any Insured Familymembers involved in a single common Accident

HOW CLAIMS ARE PAID Notice of Claim In order for benefits to be paid the following conditions must be met 1 We must be notified within 30 days of the loss If it is not possible

to notify Us by that time We must be notified as soon as possiblebut no later than 1 year from the date of the loss

2 We will send a claim form with instructions on how to fill out theform within 15 days of being notified

HOW CLAIMS ARE PAID Notice of Claim

3 The claim forms and any other proof of loss We require must besent back to Us within 90 days or as soon as circumstances willallow

4 If the claim is of a continuing nature We must be sent proof asoften as We require

5 We will pay claims within 60 days of receiving due proof of loss

Proof of Loss To make a claim for benefits under this policy We must receive proofsatisfactory to Us of

a) the happening of the Accident or the commencement of thedisability and

b) the amount of loss andc) Your right to receive payment and Your age andd) satisfactory written proof regarding the cause or nature of

the Accident or disability and the duration of such disabilityYou may reach our claim department at 1-800-663-6622 or at theaddress on this Certificate Who is paidWe will pay Accidental Death benefits to the beneficiary You havechosen We will record Your choice of beneficiary and provide Youwith a written record of Your choice in the Schedule If You have not chosen a beneficiary or if there is no beneficiary alive when You die We will pay the benefit to Your estate You are the beneficiary forfamily members insured under this Certificate Other benefits are payable to You if You are living If You are notliving

a) Spousal benefits are paid to Your spouseb) Eligible Dependent Childrens benefits are paid to Your child

who is claiming if they are of legal age otherwise to theirguardian until they become of legal age

Change of BeneficiaryYou have the right to select or change a revocable beneficiary Anysuch selection or change must be in writing and We must havereceived a signed copy for it to be valid We are not responsible forthe validity or sufficiency of a change in beneficiary

OTHER POLICY PROVISIONS Physical Examinations and AutopsyWe reserve the right to request and examine any medical evidenceof disability when and so often as reasonably required while theclaim is pending We also reserve the right to arrange anindependent medical examination when necessary and to requestan autopsy where it is not forbidden by lawLegal ActionsEvery action or proceeding against an insurer for the recovery ofinsurance money payable under the contract is absolutely barredunless commenced within the time set out in the Insurance Act (for actions or proceedings governed by the laws of Alberta and BritishColumbia) The Insurance Act (for actions or proceedings governed by the laws of Manitoba) the Limitations Act 2002 (for actions or proceedings governed by the laws of Ontario) or other applicablelegislation For those actions or proceedings governed by the laws ofQuebec the prescriptive period is set out in the Quebec Civil Code Access You have the right upon request to obtain a copy of the policyyour application and any written statements or other records youhave provided to Canada Life as evidence of insurability subject tocertain limitations Premium Rate ChangeWe reserve the right to change the premium rates Howeverrates can only be increased if the same increase is made for allCertificate holders insured under the Group Policy We will giveYou at least thirty (30) days notice of such a change CurrencyAll references to dollars in the Certificate refer to Canadian dollars

SAMPLE

FRACTURE BENEFIT IF APPLICABLE

FRACTURE SCHEDULE OF BENEFITS This rider forms a part of and is attached to Group policy issued to Canadian Tire Bank by The Canada Life Assurance Company The following benefit as described here is made available under thisGroup policy effective 1201 am Standard Time on July 1 2010 Allprovisions conditions and exclusions of the Group policy to whichthis rider is attached also apply to this rider For the purposes of this rider only if you have purchased a Family Plan Your Spouse and eligible children are covered according to the Fracture Schedule of Benefits We will pay this benefit if

a) a person is injured in an accident which happens while they arecovered by the policy and

b) they suffer one of the losses listed in the Fracture Schedule ofBenefits as a direct result and from no other causeof the accident

RIDER MONTHLY PREMIUM RATE Single $150 Family $200

FRACTURE BENEFIT IF APPLICABLE

Fracture Schedule of Benefits Loss Fracture Benefit

Spine (two or more vertebrae) $500000 Spine (one vertebrae) $200000 Spine (compression fracture) $100000 Cranium (depressed fracture) $500000 Cranium (other) $200000 Pelvis $300000 Femur $150000 Lower leg $100000 Knee cap $100000 Forearm (compound or comminuted) $75000 Forearm (not compound) $35000 Upper Jaw $75000 Lower Jaw $20000 Arm between Shoulder and Elbow $40000 Shoulder Blade $50000 Ankle (Potts Fracture) $50000 Wrist (Colles Fracture) $50000 Two or more ribs $25000 One rib $10000 Facial bones $20000 Sacrum or Coccyx $25000 Sternum $25000 Collar Bone $25000 Heel Bone $12500 Hand (one or more metacarpals) $10000 Foot (calcaneum andor metatarsal(s)) $10000 Nose $5000 Chip or Hairline Fracture $2500 Any bone not specified $2500

Protecting Your Personal information When coverage is applied for We establish a file that contains personal information that is kept in the offices of Canada Life or the offices of an organization authorized by Canada Life Insured Persons may exercise certain rights of access and rectification with respect to the information in their files by sending a request in writing to Canada Life Canada Life may use service providers located within or outside Canada We limit access to personal information in such files to Canada Life staff or persons authorized by Canada Life who require it to perform their duties to persons to whom the Insured Persons have granted access and to persons authorized by law Insured Persons personal information may be subject to disclosure to those authorized under applicable law within or outside Canada We collect use and disclose the personal information to process applications and if such applications are approved provide and administer the financial product(s) applied for including investigating and assessing claims and creating and maintaining records concerning Our relationship For a copy of our Privacy Guidelines or if You have questions about ourpersonal information policies and practices (including with respect to service providers) write to Canada Lifes Chief Compliance Officer or refer to wwwcanadalifecom

THE CANADA LIFE ASSURANCE COMPANY 140 Fullarton Street 10th Floor London Ontario N6A 5P2

Paul A Mahon President and Chief Executive Officer

SAMPLE

FRACTURE BENEFIT IF APPLICABLE

FRACTURE SCHEDULE OF BENEFITS This rider forms a part of and is attached to Group policy issued to Canadian Tire Bank by The Canada Life Assurance Company The following benefit as described here is made available under thisGroup policy effective 1201 am Standard Time on July 1 2010 Allprovisions conditions and exclusions of the Group policy to whichthis rider is attached also apply to this rider For the purposes of this rider only if you have purchased a Family Plan Your Spouse and eligible children are covered according to the Fracture Schedule of Benefits We will pay this benefit if

a) a person is injured in an accident which happens while they arecovered by the policy and

b) they suffer one of the losses listed in the Fracture Schedule ofBenefits as a direct result and from no other causeof the accident

RIDER MONTHLY PREMIUM RATE Single $150 Family $200

FRACTURE BENEFIT IF APPLICABLE

Fracture Schedule of Benefits Loss Fracture Benefit

Spine (two or more vertebrae) $500000 Spine (one vertebrae) $200000 Spine (compression fracture) $100000 Cranium (depressed fracture) $500000 Cranium (other) $200000 Pelvis $300000 Femur $150000 Lower leg $100000 Knee cap $100000 Forearm (compound or comminuted) $75000 Forearm (not compound) $35000 Upper Jaw $75000 Lower Jaw $20000 Arm between Shoulder and Elbow $40000 Shoulder Blade $50000 Ankle (Potts Fracture) $50000 Wrist (Colles Fracture) $50000 Two or more ribs $25000 One rib $10000 Facial bones $20000 Sacrum or Coccyx $25000 Sternum $25000 Collar Bone $25000 Heel Bone $12500 Hand (one or more metacarpals) $10000 Foot (calcaneum andor metatarsal(s)) $10000 Nose $5000 Chip or Hairline Fracture $2500 Any bone not specified $2500

Protecting Your Personal information When coverage is applied for We establish a file that contains personal information that is kept in the offices of Canada Life or the offices of an organization authorized by Canada Life Insured Persons may exercise certain rights of access and rectification with respect to the information in their files by sending a request in writing to Canada Life Canada Life may use service providers located within or outside Canada We limit access to personal information in such files to Canada Life staff or persons authorized by Canada Life who require it to perform their duties to persons to whom the Insured Persons have granted access and to persons authorized by law Insured Persons personal information may be subject to disclosure to those authorized under applicable law within or outside Canada We collect use and disclose the personal information to process applications and if such applications are approved provide and administer the financial product(s) applied for including investigating and assessing claims and creating and maintaining records concerning Our relationship For a copy of our Privacy Guidelines or if You have questions about ourpersonal information policies and practices (including with respect to service providers) write to Canada Lifes Chief Compliance Officer or refer to wwwcanadalifecom

THE CANADA LIFE ASSURANCE COMPANY 140 Fullarton Street 10th Floor London Ontario N6A 5P2

Paul A Mahon President and Chief Executive Officer