Supplementary Customer InformationAs an Intact Insurance Company customer, you provided us with information unique to you and the other drivers insured on your policy

through an application you filled out with your insurance broker. We have used this information to determine the rate you pay for

insurance coverage on your automobile. Below you will find what information we have on file for you and the other listed drivers on

your policy. Please review this information to ensure that it is correct and current. If you notice any incorrect or missing information,

simply contact your insurance broker and your information will be changed. Your protection limits (liability limit, deductible amounts

and special coverages) are shown on the first coverage page. For more detailed information on “How We Rate”, please visit us online at

www.intactinsurance.com/myrate.html or contact your insurance broker for a copy of this brochure.

Policy No.: .

Broker Name/No.: .

Effective Dates: to .

Number of Full Years with Intact Insurance Company: .

Driver Details:

Vehicle Details:

Driver Driver Name Marital D.O.B. Gender License Date License Driver GridNumber Status Class Obtained Training Level

1 John Doe S 01/01/45 M 5 02/02/61 Yes -010

2 Jane Smith M 01/01/45 F 5 / 6 01/02/61 No -015

3 John Doe S 01/01/45 M 5 02/02/61 Yes -010

4 Jane Smith M 01/01/45 F 5 01/02/61 No -015

Moving Traffic Convictions (past 3 years) and Chargeable Claims (past 6 years)

Driver Date of Conviction Conviction orNumber and/or Claim Chargeable Claim

1 07/07/05 At fault claim

02/02/06 Minor moving traffic conviction

2 No conviction or chargeable claim on file

3 15/03/07 Minor moving traffic violation

4 No conviction or chargeable claim on file

Vehicle Details

# Year/Make Vehicle Principal Operator KM/Year KM One Way Use Other Drivers Model Location Driver # to Work on Vehicle

1 1970/Ford/Pinto Calgary #1 40,000 25 KM Business #2, #3

2 1980/Datsun/B210 Edmonton #2 10,000 none Pleasure None

3 1994/Honda/Civic Edmonton #3 40,000 25 KM Business #1, #5

58

96

6 (0

7/0

8)

This section provides information on your pol-

icy number, who your broker on record is, the

effective dates of your policy and how long you

have been a client of Intact Insurance.

2

1

2

These 5 categories list the details we have on each

driver including their name, marital status, date

of birth and gender.

3

4

4

These 3 categories display the listed driver’s license class (please refer to the back of your driver’s license for a full listing), the date the driver’s license was obtained and whether or not a driver training course was completed.

5

5

This category displays the Alberta Government GRID level which reflects each driver’s years of driving experience and at fault claims activity. This number is used to calculate the maximum premium you will pay for mandatory coverage (third party liability and accident benefits protection). Please refer to the Alberta government’s website at http://www.finance.alberta.ca/business/insurance/index.html for more information on the Alberta governments maximum premium regulation.

This section outlines and displays all moving traffic

convictions in the past 3 years and all chargeable

(at fault) claims in the past 6 years.

66

3

This section outlines and displays all of the automobile details, including: the year, make and model of the insured automobile, where the vehicle is generally located/garaged, who primarily drives the automobile, how many KMs/year the automobile is driven, if and how much the automobile is driven one way to work, whether the automobile is used for pleasure or business purposes and who else operates the vehicle.

7

7

How to Read:

This section provides information to let

you know what Intact Insurance uses your information for and

where you can obtain more information

about these items. This section also reminds

you to contact your broker if you need to make changes to the

information.

1

At Intact Insurance Company, doing what’s right and making things easier and simpler for our customers is important to us. That’s why we created our “Supplementary Customer Information” page, which details the rating information you provided to us for you and all other drivers on your automobile insurance policy.

Please find your Supplementary Customer Information page attached. If you have any questions about the information on this page, please contact your broker - an excellent source of information and advice.

TM my home, my name, my umbrella, TravelWell, protect & collect and Rely Network are registered trademarks of Intact Insurance Company.

Our New Supplementary Customer Information Page

Prinect PDF Report 2.0.76 Heidelberger Druckmaschinen AG

131484 Intact.pdf - 1 - 04/20/2009 11:47:11 AM

Document overviewFile name: 131484 Intact.pdfLocation: E:\PTJobs\Jobs\131400-131499\131484 INTACT\System\Pagef iles\CurrentTitle: Not availableCreator: Adobe InDesign CS4 (6.0.1)Producer: Adobe PDF Library 9.0Author: Not availableCreation Date: 04/20/2009 11:43:17 AMModification Date: 04/20/2009 11:43:19 AMFile size: 163037 BytesPDF Version: 1.4

PDF/XTrapped: NoVersion: Not setOutput Intent: Not set

Document protection allows modify, print and saveNo PDF 1.4 transparency presentNo page is rotated using /Rotate keyPage content is not using overprint CMYK whitePage content is not using overprint DeviceGrayPage content is not using overprinting colorsNo OPI information presentPage content is not using PostScriptNo Action, JavaScript or Annotation within printable areaNo screening information presentPage content is not using transfer curvesLargest flatness is below 1.00 pixel thresholdSmallest line weight 0.000 pt is below hairline threshold 0.216 pt

Number of pages: 1MediaBox: 666.00 x 846.00 ptTrimBox: 612.00 x 792.00 pt

Color separations: 3BlackPANTONE 186 CPANTONE 7466 C

Color spacesDeviceCMYK / Separation

Prinect PDF Report 2.0.76 Heidelberger Druckmaschinen AG

131484 Intact.pdf - 2 - 04/20/2009 11:47:11 AM

Fonts: 7ConcordeBE-Regular Type1 / WinAnsi / embedded subsetFrutigerLT-Bold Type1 / Custom / embedded subsetFrutigerLT-Roman Type1 / Custom / embedded subsetSlateStd Type1 / WinAnsi / embedded subsetSlateStd-Bk Type1 / WinAnsi / embedded subsetSlateStd-Italic Type1 / WinAnsi / embedded subsetSlateStd-Medium Type1 / WinAnsi / embedded subset

Prinect PDF Report 2.0.76 Heidelberger Druckmaschinen AG

131484 Intact.pdf - 3 - 04/20/2009 11:47:11 AM

Page 1MediaBox: 666.00 x 846.00 ptTrimBox: 612.00 x 792.00 ptSmallest line weight 0.000 pt is below hairline threshold 0.216 ptPDF/X conform: No

Color separations: 3BlackPANTONE 186 CPANTONE 7466 C

Color spacesDeviceCMYK / Separation

Fonts: 7ConcordeBE-Regular Type1 / WinAnsi / embedded subsetFrutigerLT-Bold Type1 / Custom / embedded subsetFrutigerLT-Roman Type1 / Custom / embedded subsetSlateStd Type1 / WinAnsi / embedded subsetSlateStd-Bk Type1 / WinAnsi / embedded subsetSlateStd-Italic Type1 / WinAnsi / embedded subsetSlateStd-Medium Type1 / WinAnsi / embedded subset