HENDRY, SWINTON, MCKENZIE INSURANCE SERVICES INC. CANADIAN RED CROSS

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1 HENDRY, SWINTON, MCKENZIE INSURANCE SERVICES INC. CANADIAN RED CROSS INDIVIDUAL INSTRUCTOR / MASTER TRAINER LIABILITY INSURANCE APPLICATION (Non Aquatics) FOR CANADIAN RED CROSS INSTRUCTORS AND MASTER TRAINERS INCLUDING OPTIONAL COVERAGES EXPIRES ON MAY 31, 2014 NAME OF APPLICANT ** RED CROSS ID # (Individual only) (required before processing) New Renewal CANADIAN ADDRESS City Province Postal Code Phone # Fax # # BASIC COVERAGE AND INCREASED LIMITS ERRORS AND OMISSIONS INSURANCE and COMMERCIAL GENERAL LIABILITY INSURANCE for teaching/ training activities of any Canadian Red Cross Instructors, or Master Trainers who are currently in teaching/training status, EXCLUDING Aquatics Instruction or Training. Coverage is automatically extended to include teaching/ training for Automated External Defibrillation (AED). All limits are subject to a $ deductible. All coverages underwritten by Northbridge Insurance LIMITS / PREMIUMS: $1 MILLION CDN: $ /Annual 5.00/Annual $2 MILLION CDN: $ /Annual We are pleased to inform you that the premiums for the term have been reduced. OPTIONAL COVERAGES: Coverage may be extended to include the teaching / training for the following associations, if qualified: Heart and Stroke Foundation of Canada St. John Ambulance Canada Life Saving Society Extension cost is $25.00 per association please indicate applicable association(s) Return this application with your cheque or money order to: HENDRY, SWINTON, MCKENZIE INSURANCE SERVICES INC., 830 Pandora Avenue - Victoria, BC V8W 1P4 or fax to (250) Or, if you wish to use a Credit Card: Mastercard Visa PREMIUMS (CDN): Card Number Expiry date Instructor / Trainer $ Cardholder Signature Optional Associations: - Heart & Stroke $ Please note: $15.00 charge for all returned cheques (NSF, etc.) - St. John s Ambulance $ Premiums may include administration/finder fees. All premiums are - Life Saving Society $ minimum and retained (no refunds). Provincial Tax Ontario 8% $ I HEREBY DECLARE THAT I HAVE READ, UNDERSTOOD AND ACCEPT ALL CONDITIONS OF THE APPLICATION WHICH FORM A PART OF THE POLICY OF INSURANCE. TOTAL AMOUNT $ * Signature of Applicant Date (Please note: Coverage is not available to residents of Quebec) WARNING - NO COVERAGE IS EFFECTED UNTIL ACCEPTANCE OF THE SIGNED APPLICATION BY HENDRY, SWINTON, MCKENZIE INSURANCE SERVICES INC. 830 Pandora Ave. Victoria, B.C. V8W 1P4 Page 1 of 3 E&OE

2 HENDRY, SWINTON, MCKENZIE INSURANCE SERVICES INC. Attached to and Forming Part of Canadian Red Cross Liability Insurance Application Application Addendum Errors & Omissions Insurance (Required before processing) 1. Name of Applicant: 2. Address: 3. (a) In the past, has the Applicant or any of his/her employees ever been the recipient of any allegations of professional negligence in writing or verbally? YES NO (b) Is the Applicant or any of his/her employees aware of any facts, circumstances or situations which may reasonably give rise to a claim, other than as advised above? YES NO If yes, please attach details. WITHOUT LIMITATION OF ANY OTHER REMEDY AVAILABLE TO THE INSURER, IT IS AGREED THAT IF THERE BE KNOWLEDGE OF ANY SUCH FACT, CIRCUMSTANCE OR SITUATION, ANY CLAIM OR ACTION SUBSEQUENTLY EMANATING THEREFROM IS EXCLUDED FROM COVERAGE UNDER THE PROPOSED INSURANCE. The undersigned Applicant for this insurance declares that, to the best of his/her knowledge and belief, the statements set forth herein are true and correct and that reasonable efforts have been made to obtain sufficient information to facilitate the proper and accurate completion of this Application form. The undersigned further agrees that if any significant change in the condition of the Applicant is discovered between the date of this Application form and the effective date of the policy, which would render this Application form inaccurate or incomplete, notice of such change will be reported immediately in writing to the Insurance Manager. Although the signing of this Application form does not bind the Applicant to purchase the insurance, the undersigned Applicant agrees that this form and the information furnished pursuant hereto shall be the basis of the contract should a policy be issued and this form will become part of the policy. Signature of Applicant (Must be completed /signed and returned with application prior to binding) Date ADDITIONAL CONDITIONS Insurance coverage is only provided if the insurance company is put on notice of a possible claim by immediately contacting Hendry, Swinton, McKenzie Insurance Services Inc. A verbal contact -- use the toll free telephone number along with a written report of the incident containing information as to the name of the injured party, their address, phone number and details of the circumstances surrounding the accident must be included. Policy wordings must be consulted for details of coverages provided and will be paramount in the event of a loss or claim. If you wish more information on the coverages available, please contact Hendry, Swinton, McKenzie Insurance Services Inc. Please note: This insurance applies to one individual member only. Page 2 of 3 NORTHBRIDGE INSURANCE E&OE

3 CANADIAN RED CROSS SUMMARY OF COVERAGE Instructors & Master Trainers Insurance Program (Non-Aquatics) Underwritten by NORTHBRIDGE INSURANCE. A) ERRORS AND OMISSIONS LIABILITY / Claims-Made Form THIS INSURANCE APPLIES TO SERVICES RENDERED WORLDWIDE, PROVIDING SUIT IS FIRST BROUGHT WITHIN CANADA Protection for professional legal liability arising from those services rendered by the INSURED, while acting within the scope of the INSURED S duties in connection with the teaching / instruction / supervision or orientation of non-aquatic first aid / safety courses offered by the Canadian Red Cross Society and other applicable associations when noted on the Certificate of Insurance for the Named Insured; Pays on behalf of the insured, all sums legally incurred for judgements, settlements and defence costs up to the policy limit directly related to the insured operations; subject to a $ deductible; All coverage excludes Aquatic Instruction or Training; Subject to Asbestos Liability Bodily Injury Exclusion; Insured Services; Subject to Absolute Abuse and Sexual Misconduct Exclusion; Subject to all other policy extensions and exclusions. IMPORTANT Coverage period is subject to the Retroactive Date that will be noted on your Certificate of Insurance. The Retroactive Date is the inception i date of which your original application was received, subject to no lapse in your coverage thereafter. Should there have been a lapse in coverage (ie: renewing late), the Retroactive Date will revert to the new effective date of your current application, with coverage only reverting back to that Retroactive Date noted. B) COMMERCIAL GENERAL LIABILITY / Occurrence Form THIS INSURANCE APPLIES TO OCCURRENCES WORLDWIDE BUT ONLY TO CLAIMS, DEMANDS OR PROCEEDINGS FIRST BROUGHT IN CANADA OR THE U.S.A. Legal liability as imposed by law for bodily injury and property damage (damage to property of others) as a result of business operations, as per the *Association standards, including the cost of legal defense, subject to a $ deductible. The coverages provided would include: Personal Injury / Advertising Injury; Premises; Products and Completed Operations; Blanket Contractual Liability; Contingent Employers Liability - where applicable; Broad Form Property Damage Clause; Defined Occurrence Property Damage Clause; Cross Liability Clause; Attached Machinery; Non-owned Automobile, excluding long term lease; Tenants Legal Liability, up to a $500, limit, which pays sums the Insured shall become legally obligated to pay as compensatory damages because of property damage caused by an occurrence to non-owned structures or portions thereof rented to or occupied by the Named Insured, for perils as stated; Medical Payments up to $5, per person / $25, per accident; Specific Terrorism Exclusion; Absolute Abuse and Sexual Misconduct Exclusion; Specific Data Exclusion; All coverage excludes Aquatic Instruction or Training; Subject to all other policy extensions and exclusions. In consideration of the premium charged, it is agreed that the following are added to the policy as Additional Insureds, but only with respect to the liability arising from the operations of the Named Insured: Owners of property that the Insured rents or occupies where the terms of a written agreement require the Insured to provide insurance on behalf of the owner for liability arising out of the Insured s occupancy of such premises. NOTE: The foregoing is a summary of insurance only and policy wordings must be consulted for details of coverages provided and excluded, and will be paramount in the event of a loss. HENDRY, SWINTON, MCKENZIE INSURANCE SERVICES INC. 830 Pandora Avenue - Victoria, BC V8W 1P4 Toll Free: ; Fax: (250) Adrian Stoddart direct line / Lynn York direct line astoddart@hsminsurance.com or lyork@hsminsurance.com Page 3 of 3 EO&E

4 CANADIAN RED CROSS INSTRUCTORS / TRAINERS (FOR INDIVIDUALS) NON AQUATICS INSURANCE PROGRAM for ERRORS & OMISSIONS LIABILITY INSURANCE and COMMERCIAL GENERAL LIABILITY INSURANCE We are pleased to enclose our current Application / Summary of Coverage in regards to the insurance program available until MAY 31, 2014 Each instructor / trainer, etc. must obtain their own policy. ** Please note the Canadian Red Cross Instructors / Trainers Insurance Program is now Underwritten through NORTHBRIDGE INSURANCE ** Please review the Summary of Coverage carefully and do not hesitate to contact us with any concerns or questions you may have. IMPORTANT Coverage period is subject to the Retroactive Date that will be noted on your Certificate of Insurance. The Retroactive Date is the inception date of which your original application was received, subject to no lapse in your coverage thereafter. Should there have been a lapse in coverage (ie: renewing late), the Retroactive Date will revert to the new effective date of your current application, with your coverage only responding subsequent to that date. As you see on the Application, there is an option to extend these coverages to include similar courses taught for the Heart and Stroke Foundation of Canada; St. John Ambulance Canada; and/or Life Saving Society (Canada), for a small additional premium. This extension has been agreed upon with the Canadian Red Cross Society and will remain a privilege, trusting you will continue to support the Canadian Red Cross Society, to ensure this option can continue. No other similar societies can be included on the program. We offer options for a $1,000, limit or a $2,000, limit unfortunately higher limits are not available. A $ deductible applies to each coverage. This insurance includes any defense costs within the limit chosen. Please note, although coverage is worldwide - any lawsuit must be first brought in Canada for the Errors and Omissions section of the coverage. In regards to the Commercial General Liability, again, coverage is worldwide, with any lawsuit first brought in Canada or the USA. The coverage will be issued effective the date the completed, signed application, application addendum and commercial client agreement is received in our office, along with full payment faxes are acceptable. Once the application is received, a Certificate of Insurance will be processed and mailed to you. PLEASE NOTE THERE WILL BE A $20.00 FEE TO RE-ORDER A NEW CERTIFICATE, SO PLEASE KEEP YOUR CERTIFICATE ON FILE. IMPORTANT NOTE: Errors and Omissions insurance is written on a Claims-Made form of coverage. In this connection, nection, insurance must be in place at the time a claim is submitted in order for coverage to respond. It is of utmost importance the insurance continues to be renewed each year without any lapse in the coverage. ** AS IN THE PAST, ALL LATE RENEWALS ARE SUBJECT TO THE FULL ANNUAL PREMIUM**. Also, to comply with the requirements of the insurance policy: Should you have an incident / accident, we must be advised immediately, mediately, by forwarding an Incident Report to us, to include your current contact phone numbers, address, etc. If possible, request any witnesses to write their recollection of the event(s). We would like to take this opportunity to thank you for your continued and anticipated business it is greatly appreciated. We welcome any questions you may have.

5 PERSONAL INFORMATION COMMERCIAL CLIENT AGREEMENT BETWEEN: Hendry, Swinton, McKenzie Insurance Services Inc. (the"broker ) AND (the "Client") The parties acknowledge that the Broker is being retained by the Client to acquire or renew a policy or policies of insurance for the Client, under which certain individuals, including the Client's employees, servants, agents and representatives may be insured (hereinafter called "insured individuals"). Accordingly, each of the parties may need to collect, use and disclose the personal information of such insured individuals. FOR GOOD AND VALUABLE CONSIDERATION, the receipt and sufficiency of which is hereby acknowledged, each of the parties hereto agrees to collect, use and disclose the personal information of such insured individuals in a manner that a reasonable person would consider appropriate in the circumstances. Each of the parties further agrees to safeguard the security of such personal information in a manner appropriate to the sensitivity of that information. FOR THE SAID CONSIDERATION, the Client further covenants and warrants that the Client has obtained the appropriate consent from such insured individuals to disclose their personal information to the Broker. Dated at in the Province of This day of, 20 Witness: Lynn York per: Hendry Swinton McKenzie Insurance Services Inc. (Broker) Print Name: Adrian Stoddart Authorized signing officer Witness: per: (Client) Print Name: Authorized signing officer