THE EMPIRE LIFE INSURANCE COMPANY APPLICATION FOR GROUP INSURANCE

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THE EMPIRE LIFE INSURANCE COMPANY

APPLICATION FOR GROUP INSURANCE

Please print; do not use pencil.

1. Policyowner (Full Legal Name):

2. Address: Street/Suite

City Province Postal Code

Telephone Fax Internet E-Mail Address

( ) ( )

Policy Administrator: (Give Name and title of person to whom correspondence and billings should be directed):

3. Nature of Business (Goods or services provided):

4. Ownership (check one): Sole Proprietorship Partnership Corporation Name(s) of Owner(s), if Sole Proprietorship or Partnership:

5. Billing Type: Head Office Self Administered Third Party Administered (must be an approved Empire Life TPA) Employees to be listed in: Certificate Number Order or Alpha (by Surname) Order

6. Policy Effective Date: 12:01 a.m. on - Day / Month / Year 7. Renewal Date: Day / Month

8. Subsidiary Companies to be Included (Print full legal name(s). If more than 2, complete, initial and attach “Subsidiary Company Appendix”). #1 Name

Street/Suite City Province Postal Code

Telephone Fax

( ) ( )

Policy Administrator (Give Name and Title of Person to whom correspondence and billings should be directed).

Business relationship to Policyowner: Common Ownership (Yes) Number of Employees on Payroll: Nature of Business:

Is a separate Billing required (for mailing to the Subsidiary Address)? Yes No If Yes, Division Number:

If No, is a subtotalling by subsidiary company within Division 001 desired? If Yes, see “9. Billing Subtotalling” .

Head Office Use

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8. Subsidiary Companies to be Included (Continued). #2 Name

Street/Suite City Province Postal Code

Telephone Fax

( ) ( )

Policy Administrator (Give Name and Title of Person to whom correspondence and billings should be directed).

Business relationship to Policyowner: Common Ownership ■■ (Yes) Number of Employees on Payroll: Nature of Business:

Is a separate Billing required (for mailing to the Subsidiary Address)? ■■ Yes ■■ No If Yes, Division Number:

If No, is a subtotalling by subsidiary company within Division 001 desired? If Yes, see “9. Billing Subtotalling” . 9. Billing Subtotalling

Is a subtotalling (by department or by subsidiary company) of the billing required? ■■ Yes ■■ No If Yes, indicate desired Department Code (alpha/numeric, 5 character maximum):

Code: Description:

Note that all enrolment cards must indicate their respective Department Code if billing subtotals are desired.

10. Present Coverage Will the insurance applied for replace similar insurance? ■■ Yes ■■ No. If Yes, complete this section.

Benefit Name of Insurer & Policy Number Date of Termination

Life A.D. & D.

Weekly Indemnity Long Term Disability Extended Health Dental

Attach a list of employees who have wholly or partly satisfied their deductibles, if applicable.

11. Eligible Employees ■

■ Employees who are active, full time, who reside in Canada, employed on a permanent basis in Canada, and working a minimum of 20 hours per week.

or ■■ Employees who are active, full time, who reside in Canada, employed on a permanent basis in Canada, and working a minimum of hours per week, subject to a minimum of 20 hours per week.

Coverage also being extended to: ■

■ Retirees ■ ■ Early Retirees (age to 65) ■■ Part-time Employees ( hours per week). Total Number of Employees to be insured as of the Policy Effective Date:

Total Number of Employees on payroll as of the Policy Effective Date: If different, please explain:

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12. Definition of Salary ■

■ Base salary only, or inclusive of ■■ commissions

If commissions are to be included, salary to be based on: ■

■ the previous calendar year T-4, or ■■ the average of the previous 2 year’s T-4s.

15. Premium Contributions (Indicate the percentage of the cost to be paid by thePolicyowner for each Benefit) Division ➞ Class ➞ a) Employee Life b) Employee AD&D c) Dependant Life d) *Weekly Indemnity e) *Long Term Disability f) Extended Health g) Dental

* Disability benefits (Weekly Indemnity or Long Term Disability) are taxable if the Employer pays any portion of the premium for the benefit. 13. Division and Class Structure

Division # Class Class Description

14. Waiting Period (length of time employees must be employed by the Policyowner to be eligible for coverage) Division ➞

Class ➞ Benefit (note “all” if same for all Benefits) a) Number (e.g. 3)

b) Timeframe (e.g. months)

c) Of continuous employment (Y or N) d) If not continuous employment, describe e) Applies to present and future employees? f) Applies to future employees only?

Note: check only one of “e” or “f” for each Class.

001 A

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SCHEDULE OF BENEFITS

17. Employee Life Benefit ■■ Yes ■■ No Employee A.D.& D. Benefit ■ ■ Yes ■■ No Note “All” in the Class row if coverage applies to all classes, and coverage details are the same for all classes.

Division ➞

Class ➞

a) Life Schedule

b) Life Maximum Amount c) AD&D Schedule

d) AD&D Maximum Amount e) Reduction Schedule f) Termination Age

No Evidence Limit $ . Any Employee Life Insurance and/or A.D. & D. in excess of the No Evidence Limit will be granted only subject to evidence of insurability satisfactory to the Company for plan enrolees under age 65. Age 65 and over, any Employee Life Insurance and/or A.D. & D. in excess of one half of the No Evidence Limit will be granted only subject to evidence of insurability satisfactory to the Company.

A.D. & D. includes Loss of Use of Extremities.

A.D. & D. to include Waiver of Premium? ■■ Yes ■ ■ No

18. Employee Optional Life Benefit ■■ Yes ■■ No Employee Optional A.D.& D. Benefit ■ ■ Yes ■ ■ No Note “All” in the Class row if coverage applies to all classes, and coverage details are the same for all classes.

Division ➞

Class ➞

a) Optional Life Schedule - Units of b) Optional Life Maximum Amount c) Optional AD&D Schedule - Units of d) Optional AD&D Max Amount e) Reduction Schedule f) Termination Age (65 or 70)

Employee Optional A.D. & D. to include coverage for Loss of Use of Extremities? ■■ Yes ■ ■ No Evidence of insurability is required for all amounts of Employee Optional Insurance benefits.

16. Participation

Participation under this Plan is ■■ Mandatory* ■■ Non-mandatory**

* If participation is Mandatory, 100% of all eligible employees who are actively at work must be insured for all benefits for which they are eligible. If the plan is 100% employer paid, it is a Mandatory plan.

** If participation is Non-mandatory, an eligible employee is allowed to refuse all coverage under the Policy, subject to the minimum participation requirements of the Policy. An employee refusing coverage under the Policy must refuse all coverage. Refusal of some, but not all coverage, is not permitted.

If the Policy includes Extended Health and/or Dental Benefits, an eligible employee may waive coverage for these benefits if insured for similar coverage under their spouse’s plan. Such waivers will not affect the participation level.

001 A

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20. Spousal Optional Life Benefit ■■ Yes ■■ No Spousal Optional A.D.& D. Benefit ■ ■ Yes ■ ■ No Note “All” in the Class row if coverage applies to all classes, and coverage details are the same for all classes.

Division ➞ Class ➞ a) Optional Life Schedule - Units of b) Optional Life Maximum Amount c) Optional AD&D Schedule - Units of d) Optional AD&D Maximum Amount e) Reduction Schedule

f) Termination Age (65 or 70)*

Spousal Optional A.D. & D. to include coverage for Loss of Use of Extremities? ■■ Yes ■ ■ No

* The termination age for Spousal Optional Insurance benefits is the earlier of the termination of the Insured Employee’s participation in the Policy, or the spouse’s attainment of age 65 or 70, as indicated above.

Evidence of insurability is required for all amounts of Spousal Optional Insurance benefits.

21. Weekly Indemnity Benefit ■■ Yes ■■ No

Note “All” in the Class row if coverage applies to all classes, and coverage details are the same for all classes. Division ➞

Class ➞ a) Percentage of Weekly Salary b) Maximum Weekly Benefit c) Injury Elimination Period (days) d) Sickness Elimination Period (days) e) Incl. 1st Day Hospitalization (Y or N) f) Maximum Benefit Period (weeks) g) Termination Age

No Evidence Limit $ Taxable Benefit? ■■ Yes ■ ■ No

Are these benefits to be registered under the Employment Insurance (E.I.) Premium Reduction Plan or any Government Sponsored Plan? ■■ Yes ■■ No

Occupational (24 hour) coverage? ■■ Yes ■■ No (If “No”, the benefit is not eligible for E.I. premium reduction.)

Carve Out Plan? (No benefit is payable during the 15 week Employment Insurance disability benefit period.) ■ ■ Yes ■■ No 19. Dependant Life Benefit ■■ Yes ■■ No

Class ➞

a) Spouse Amount b) Child Amount

c) Include Dep. A. D. & D. (Y or N)? d) Termination Age*

*Termination Age is based on the age of the employee. Dependant Life Benefit includes Spousal Conversion privilege.

Coverage for dependant children commences upon the attainment of the age of 24 hours. Dependant Life to include Waiver of Premium? ■■ Yes ■ ■ No

001 A 001 A 001 A

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23. Extended Health Benefit ■■ Yes ■■ No

Class ➞ a) Annual EHB Single Deductible (indicate amount)

b) Annual EHB Family Deductible (indicate amount) DRUG BENEFIT nn Yes nn No c) Include Infertility Treatments (Y or N)

d) Include Smoking Cessation Treatments (Y or N) e) Include Erectile Dysfunction Treatments (Y or N)

Pay Direct Drug Card: nn Yes nn No f) Indicate Type: Prescription (RxA), Prescription Generic

(RxAG), Prescribed (RxB), or Prescribed Generic (RxBG) g) Deductible Amount per Prescription (indicate amount) h) Coinsurance (indicate percentage)

i) Deductible Equal to Dispensing Fee (Y or N)

j) Annual Single/Family Deductible on Drug Card (indicate amounts) k) Dispensing Fee Maximum (indicate amount) Note: in the

absence of a maximum, a reasonable & customary provincial maximum will be administered.

l) Preferred Provider Arrangement? (attach specifications) m) Drug Benefit, Benefit Period Maximum (unlimited, or indicate

amount)

Empire Reimbursement: nn Yes nn No n) Annual EHB Deductibles Applicable? (Y or N) o) Coinsurance (indicate percentage)

22. Long Term Disability Benefit ■■ Yes ■■ No

Class ➞ a) Percentage of Monthly Salary?, or

Graded Scale? Please indicate scale below. b) Maximum Monthly Benefit

c) Injury Elimination Period (days) d) Sickness Elimination Period (days) e) Maximum Benefit Period

f) Own Occupation Period (indicate period) or Any Occupation (indicate “Any”) g) CPP/QPP Integration

(Primary, Secondary or None)? h) Termination Age

Graded Scale (if applicable)

% of the first $ . % of the next $ . % of the next $ , and % of the excess. No Evidence Limit $ Taxable Benefit? ■■ Yes ■ ■ No

Survivor Benefit? ■■ Yes ■■ No If “Yes”, number of months: ■■ 3 months ■■ 6 months Cost of Living Adjustment (COLA) Clause? ■■ Yes ■■ No If “Yes”, the percentage is %.

The all source maximum benefit is 85% of pre-disability Take Home Pay when benefits are Non-Taxable, or 85% of pre-disability Monthly Earnings when benefits are Taxable.

DRUG BENEFIT Yes No

Empire Reimbursement: Yes No Pay Direct Drug Card: Yes No 001 A

001 A

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23. Extended Health Benefit (continued)

Division ➞ Class ➞

HOSPITALIZATION BENEFIT ■■ Yes ■■ No p) Semi-Private Hospitalization (Y or N)

q) Private Hospitalization (Y or N)

r) Annual EHB Deductibles Applicable? (Y or N) s) Hospitalization Coinsurance (indicate percentage)

MAJOR MEDICAL BENEFIT ■■ Yes ■■ No t) Major Medical Coinsurance

u) Major Medical subject to the EHB deductible? (Y or N) v) Vision Care? Indicate maximum amount (every 2 years) w) Vision Care benefit period for children under age 18 (1 or 2 years) x) Vision Coinsurance equal to Major Med Coinsurance? (If No,

indicate %)

y) Vision Care to be subject to EHB Deductible? (Y or N) z) Convalescent Hospital; $20/day

(Indicate maximum # of days: 120 or 180)

aa) Convalescent Hospital Coinsurance equal to Major Med Coinsurance? (If No, indicate %)

bb) Convalescent Hosp. subject to the EHB Deductible? (Y or N) cc) Private Duty Nursing (PDN) Maximum (indicate amount) dd) PDN Maximum amount - over a period of 1, 2, or 3 years? ee) Hearing Aid Maximum (indicate amount)

ff) Hearing Aid Maximum over a period of 4 or 5 years? PARAMEDICAL SERVICES(Maximum is per Benefit Period) gg) Per Practitioner Benefit Period Max (indicate amount not to exceed $1,000) Doctor’s referral required on Masseur only hh) Reduce Paramedical max by the Coinsurance. (Y or N) ii) Include first dollar Paramedical coverage (Y or N)

(See Representative for availability)

OUT OF PROVINCE OF RESIDENCE BENEFIT jj) Out of Province of Residence Referral (Y or N) kk) Out of Province of Residence Emergency (Y or N)

ll) Out of Province of Residence MEDeMERG Travel Assistance (Y or N)

GENERAL INFORMATION mm) Termination Age (indicate age)

nn) Overall Lifetime EHB Max per Person Insured (indicate unlimited, or indicate amount)

oo) Survivor Benefit (If Yes, indicate 1 or 2 years)

pp) Benefit Period - indicate “Cal” for Calendar Year, or “Pol” for Policy Year

qq) Are claim forms to be authorized by the Policyowner? (Y or N) rr) Are claim payments to be sent directly to the employees? (Y or N)

Cost Plus Addendum is included for EHB, if EHB is insured under the Policy.

The Termination Age for Insured Dependant Children is the attainment of age 22; 26 if full-time student at an accredited educational institute. Notes:

HOSPITALIZATION BENEFIT Yes No

MAJOR MEDICAL BENEFIT Yes No

001 A

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24. Dental Benefit ■■ Yes ■■ No

Class ➞ a) Annual Dental Single Deductible (indicate amount) b) Annual Dental Family Deductible (indicate amount) c) Recall Frequency; indicate 5 Month, 9 Month, or 12 Month d) Fee Guide Year; Fixed (indicate year), or Current Year (indicate “C”) e) Fee Guide based on Province of employee residence (Y or N) f) If not based on Province of residence, specify Province g) Level 1: Basic Restorative- Coinsurance percentage h) Level 2: Periodontics & Endodontics- Coinsurance percentage i) Level 3: Major Restorative- Coinsurance percentage j) Level 4: Orthodontics- Coinsurance percentage k) Annual Maximum: Level 1 & 2 Combined l) Annual Maximum: Level 3

m) Annual Maximum: Level 1, 2 & 3 Combined n) Lifetime Maximum: Level 4

o) Are Adults to be included in Orthodontic coverage (Y or N) p) Termination Age (indicate age)

q) Survivor Benefit (if Yes, indicate 1 or 2 years)

r) Benefit Period: Indicate “Cal” for Calendar Yr., “Pol” for Policy Yr. s) Are claim forms to be authorized by the Policyowner? (Y or N) t) Are claim payments to be sent directly to the employee? (Y or N)

Cost Plus Addendum is included for Dental, if Dental is insured under the Policy.

The Termination Age for Insured Dependant Children is the attainment of age 22; 26 if full-time student at an accredited educational institute. The Termination Age for Dependant’s Orthodontic Coverage is the attainment of age 20.

Notes:

001 A

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25. Unit Premium Rates

The actual premium rates at inception of the Plan will be determined in accordance with the employee data as at the Effective Date of the Policy. Note “All” in the Class row if Rates are the same for all Classes.

Division

➞

Class

➞

a) Employee Life (per $1,000 of insurance) b) Employee A.D. & D. (per $1,000 of insurance) c) Dependant Life

d) Dependant A.D. & D.

e) Weekly Indemnity (per $10 of insurance) f) Long Term Disability (per $100 of insurance) g) Extended Health Benefit: Single

h) Extended Health Benefit: Family i) Dental Benefit: Single

j) Dental Benefit: Family

Optional Life (per $1,000 of insurance)

Age Band Smoker Male Smoker Female Non-Smoker Male Non-Smoker Female

Under 30 $0.12 $0.06 $0.07 $0.04 30-34 $0.12 $0.08 $0.07 $0.05 35-39 $0.17 $0.11 $0.09 $0.07 40-44 $0.27 $0.19 $0.15 $0.11 45-49 $0.47 $0.30 $0.24 $0.17 50-54 $0.79 $0.47 $0.41 $0.27 55-59 $1.32 $0.69 $0.70 $0.42 60-64 $2.00 $1.02 $1.07 $0.63 65-69 $2.89 $1.53 $1.57 $0.92

Optional A.D. & D. Rate (per $1,000 of insurance):

Premium Rates for Spousal Optional Life (and A.D. & D.) equal Employee Optional Life Premium Rates, if Spousal Optional Life (and A.D. & D.) insured under the Policy.

26. Special Considerations

001 A

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28. General Information

a) If there have been any lay-offs in the past five years, indicate the class and number of eligible employees who were so affected.

Is a lay-off provision required? ■ ■ Yes ■ ■ No If “Yes”, number of months (not to exceed 6). Layoff provision will be provided for all insured benefits except Weekly Indemnity and Long Term Disability.

b) Are all employees covered by the provincial Workplace Safety and Insurance Board (WSIB) / Workers Compensation Board (WCB) ? ■■ Yes ■ ■ No If “No”, indicate those employees not covered.

c) Are benefits Union negotiated? ■ ■ Yes ■■ No If “Yes”, include a copy of the collective agreement. Are all Classes Union negotiated? ■ ■ Yes ■■ No If “No”, which Classes are union Negotiated?

d) Are any proposed insureds employed on a contract or consultant basis, or as directors or sub-contractors of the Policyowner? ■

■ Yes ■■ No If “Yes”, indicate those employees.

If “Yes”, are such employees working exclusively for the Policyowner? ■■ Yes ■■ No

If “Yes”, are such employees ongoing employees? ■■ Yes ■■ No If “No”, are there known termination dates regarding their term of employment?

e) Do any employees work a “reduced work week” or participate in a “workshare” programme? ■■ Yes ■■ No If “Yes”, indicate those employees.

f) If the Policyowner is primarily based in a Province other than Quebec:

i) Is there a physical business location (e.g. branch, warehouse, sales office) in the Province of Quebec? ■■ Yes No ii) Do you have employees who hold their principle residence in Quebec, but work in a province other than Quebec? ■■ Yes ■■ No

If “Yes” to ii), do you wish to provide such employees with Drug coverage which complies with Quebec Universal Drug Legislation?

■

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29. Disabled Employees

1) Are there any employees absent from work due to sickness or injury? ■ ■ Yes ■ ■ No If “Yes”, please provide details below. 2) Are there any individuals who are not insured with the present carrier and who are currently receiving disability benefits from a

prior carrier? ■■ Yes ■■ No If “Yes”, please provide details below. 3) Are there any individuals who are absent from work due to:

i) Maternity/Parental Leave? Yes No Please provide details under 4) below. ii) Layoff? Yes No Please provide details under 4) below. i) Leave of Absence? Yes No Please provide details under 4) below.

Employee Name a) Date of Disability

b) Date of Birth

c) Class and/or Occupation d) Nature of Disability

e) Prognosis

f) Present coverage?

g) Is this a WSIB Claim?

h) Applied for LTD with present carrier? i) Approved for LTD with present carrier? j) Applied for Life Waiver of Premium? k) Approved for Life Waiver of Premium?

l) If approved, provide copy of approval for waiver letter or a copy of the present carrier’s billing

If any question f) through k) has been answered “No”, an explanation must be provided and submitted with this Application for Group Insurance.

4) Employees on Maternity/Lay-Off/Leave of Absence

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30. Pre-authorized Payment Plan How does the plan work?

You continue to receive your monthly statement as usual, detailing all the changes. The total amount due is deducted automatically from your bank account each month.

The automatic withdrawal is processed on the 10th day of each month (or the next business day) for the premium due for the billing period for that month.

When does the plan start?

You will be notified on the billing statement when your account has been switched to the Pre-Authorized Payment Plan. Please continue to pay your monthly statement in the usual manner until you receive this notification. If you should make any changes in your banking arrangements or need to notify us of any changes in your banking procedures, please call 1-800-267-0215.

Terms & Conditions

This Pre-Authorized Payment Plan is for the convenience of our client. There are no charges to enroll in the plan.

The client certifies that the information provided in the authorization is correct and that the client will notify Empire Life in the event of any changes.

The client certifies that his/her bank account is in good standing with sufficient funds to cover pre-authorized payments as they come due.

All pre-authorized payments will be drawn on Canadian financial institutions only and will be withdrawn in Canadian Funds. Cancellation

This agreement can be terminated, upon written notification, at any time, by either the client or Empire Life. Upon termination, any amount due shall be paid directly to Empire Life.

Cancellation of pre-authorization payment does not constitute cancellation of service by Empire Life and the client shall be liable for any past, present or future amounts owing.

AUTHORIZATION AGREEMENT

Yes, I/we hereby authorize Empire Life to withdraw the amount due on my/our billing statement from my/our financial institution on the 10th_{day of each month (or the next business day).}

Please attach a void cheque.

31. Ontario Retail Sales Tax (RST) - Election Form To be used:

a) If you are/would be licensed under the Ontario Retail Sales Tax Act in order to submit RST on employee premium due on a Group Insurance Policy only. (Section 3.2(3))

b) If you are a licensed vendor under the Ontario Retail Sales Tax Act, however you want the Empire Life Insurance Company to submit the RST on employee premiums. (Section 3.1(3))

DECLARATION

Yes, the Applicant for this Group Insurance Policy elects to remit the full Ontario Retail Sales Tax payable on both the employee and employer premiums to The Empire Life Insurance Company in accordance with Regulation 1013 of the Revised Regulations of Ontario, 1990 made under the Retail Sales Tax Act, Section 3.1(3) and 3.2(3), as applicable.

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32. Declaration and Signatures(Signatures must be originals)

The Applicant hereby declares that, to the best of the Applicant’s knowledge, the statements and answers contained above are full, complete and true as of the date hereof and agrees that:

(1) such statements and answers shall constitute the Application for and form part of the Contract, and

(2) the insurance will become effective in accordance with and subject to the terms and conditions of the Policy to be issued to the Applicant but in no case shall it become effective until this Application has been approved by The Empire Life Insurance Company.

In the case of errors or omissions discovered by The Empire Life Insurance Company in this Application, the said Company is hereby authorized to amend this Application by noting the change in the section entitled “Corrections/Amendments/Clarifications” and acceptance by the Applicant of the Policy accompanied by a copy of this Application so amended, shall constitute ratification of such “Corrections/Amendments/Clarifications”.

An initial Premium Deposit Cheque in the sum of $ is included with this Application. The amount of the Premium Deposit must be no less than 80% of the value of the first month’s premium. Negotiation of the cheque will not, of itself, constitute approval of the Application.

I request that any contract issued as a result of this Application be issued in the English language.

Dated at this day of ,

Applicant - Full Company legal name - please print

Signature of Authorized Company Official Title - please print

Name of Authorized Company Official - print name in full

Signature of Witness Title - please print

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33. Producer’s Information

Producer’s Commitment: • To the best of my/our knowledge and belief all statements in this Application are true and complete. I/we have read and understand the form.

Signature of Producer Signature of Second Producer - print name in full

Name of Producer - print name in full Name of Second Producer - print name in full

Use this column if there are two Producers Producer’s Name Company Name Address - Street/Suite City, Province Postal Code Telephone Fax

Internet E-Mail Address

Resource Centre

Group Office

Empire Life Producer Code

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An Empire to Be Proud Of

For more than 75 years we’ve worked together to provide total income security and investment opportunities to Canadians.

Empire has grown considerably since its founding in 1923 and today we are among the top 15 life insurance companies

in Canada. We’re proud of our heritage and our reputation for offering quality, innovative products with a dedication to

personalized service.

How We Measure Up

A.M. Best Company: “A (Excellent)” as of September 27, 2000

A.M. Best Co. has affirmed our “A (Excellent)” financial strength rating. The rating reflects our strong capitalization and

stable earnings from our core individual life insurance business.

One of the Top 15 Life Insurance Companies in Canada

Empire ranked 11th in the National Post Business 500: “Top 25 Life Insurers”, June 2000, based on consolidated general

fund assets, Canadian and worldwide, excluding segregrated funds.

MCSSR: 244%

Empire has maintained a strong MCSSR (Minimum Continuing Capital and Surplus Requirement) ratio of 244% at the

end of 1999, which is well in excess of the minimum regulatory requirement of 120%.

Our Employee Benefits Division

We have provided Canadian Business with outstanding products and services for over 30 years. Since our establishment,

we have continued to grow as a significant, competitive force within the group insurance industry by capitalizing on our

unique strengths:

â

People: Our network of highly qualified, experiences sales and service oriented support staff provides

customized, personal service to our clients.

â

Performance: We pride ourselves on our reputation of superior implementation of new benefits and we

commit to service in writing. Empire has printed Service Standards for issue, claims payment and

administration and a proven track record for meeting these standards.

â

Technology & Innovation: Our modern systems architecture allows us to be most efficient and adaptive

to the business environment of today and of the future. Our website can be located at www.empire.ca.

â

Focus: Our focus is to serve Canadian small business.

â

Location: We currently insure more than 3000 group accounts from Vancouver to Halifax. Regional offices

can be found in most major centres across Canada, with corporate Head Offices in Kingston and Montreal.

TM_{Trademark of The Empire Life Insurance Company}

THE EMPIRE LIFE INSURANCE COMPANY APPLICATION FOR GROUP INSURANCE