Optional Accident Benefits Form

Insureds name: _______________________________________ Policy number: ________________________________________

Optional accident benefits available through your automobile insurance policy

COVERAGE STANDARD ACCIDENT BENEFITS EFFECTIVE September 1st, 2010 OPTIONAL BUY-BACK OPTIONS OPTIONAL ENHANCEMENT OPTIONS PLEASE INDICATE IF OPTIONAL BENEFITS ARE REQUIRED YES NO

Income Replacement Benefit

70% of gross income up to $400 per week

70% of gross income up to $600, $800, or $1000 weekly No options for minor injury $1,100,000 noncatastrophic $2,000,000 catastrophic No coverage for minor injury $1,072,000 noncatastrophic $2,000,000 catastrophic

If YES, select one: $600

Medical and Rehabilitation Benefit

$3,500 minor injury $50,000 non-catastrophic $1,000,000 catastrophic No coverage for minor injury $36,000 non-catastrophic $1,000,000 catastrophic Up to $250 per week for first dependant, $50 for each additional, available for catastrophic injuries only Up to $100 per week available for catastrophic injuries

No options for minor injury $100,000 non-catastrophic $1,000,000 catastrophic No coverage for minor injury $72,000 non-catastrophic $1,000,000 catastrophic Up to $250 per week for first dependant, $50 for each additional, available for ALL injuries Up to $100 per week available for ALL injuries

YES

NO

Attendant Care Benefit

YES

NO

Caregiver Benefit

YES

NO

Housekeeping and Maintenance Dependent Care

YES Up to $75 per week for the first dependant , $25 per week for each additional, a total maximum of $150 per week $50,000 for spouse $20,000 for each dependant $8,000 maximum Annual adjustment according to the Consumer Price Index for Canada YES

NO

Not provided

YES

NO

$25,000 for spouse Death benefit $10,000 for each dependant $6,000 maximum None

NO

Funeral Benefit Indexation

YES YES

NO NO

All coverages are subject to policy conditions, limitations end exclusions. Additional premiums apply for buy-back options and enhancement options. The insured must qualify to receive claim payments for standard and/or optional coverage(s). Signature of Insured(s): _______________________________________ Date: _____________________________

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Please note: ALL boxes must be checked off yes OR no Failure to return this form to us means that you understand and accept the coverages in your present automobile policy. Mac Vanderhout Insurance Brokers Limited 1005 Skyview Dr. Suite 102 Burlington, ON L7P 5B1 Phone: 905-336-5001 or 1-800-668-0214 Fax: 905-336-3157 www.macvanderhout.com Email: service@macvanderhout.com