The original signed copies of these forms must be sent to the Savanna

Benefits Department.

Attention: Benefits Department

Savanna Energy Services Corp

Suite 800, 311 – 6 Ave SW

Calgary AB T2P 3H2

The next two pages titled “Application for Group Coverage” must be completed

and the original signed forms must be sent to the benefits team.

The last page titled “Trustee Appointment” only needs to be completed and

returned if you are designating a beneficiary who is a minor or who lack legal

capacity.

Please read these forms careful before completing.

Tw;:

Great-West Life APPLICATION FOR GROUP COVERAGE For GWL Head Office Use Only

GWL CertificatQ Number

Please print clearly and complete both sides of this form, in INK. Section 1 is to be completed by the plan administrator and sections 2 through 7 are to be completed by the plan member.

1. Plan Sponsor Section This section is to be completed by the plan administrator.

2. Plan Member Information This section is to be completed by the plan member.

Please print clearly, in INK.

3. Refusal of Benefits This section is to be completed by the plan member.

4. Beneficiary Designation This section is to be completed by the plan member.

This section must be completed to designate a beneficiary for your life benefits, if applicable.

The original of this form will be required for a life claim.

Crossed out beneficiary designations must be initialed.

Please print clearly, in INK.

M6191-12107

Plan number: 55374 and 328620 Division number: -------- Benefit class: ------

Plan sponsor: Savanna Energy Services Corp.

Plan member ID: ------------- Cost centre (if applicable):-- --------

Eligible date of employment: Month ------- Day-------- Year _______ _

Effective date of coverage: Month ------- Day ------- Year _ _____ _

Occupation: -------- Earnings: $ - - ---per D year D month D week [] hour

Plan member province of residence: Plan member province of employment:

Plan member name (print): -:---:--------------:--:-------------:--:-::--:-:::-:--last name first name middle initial

Gender: D Male [] Female Date of birth: Month ____ Day ____ Year ___ _

Plan member mailing address:

Street address:----------------------------------

City: --------------- Province:--------- Postal code:-------

Do you have a spouse (married, common-law or civil union spouse)?

Do you have dependant children, including full time students or disabled adults?

How many dependants in total, including spouse?

0 Yes 0 No

[] Yes 0 No

Note: Health and/or dental coverage can only be refused if you and/or your dependants are covered by duplicate group benefits through your spouse's employer. I understand the plan of group benefits offered to me, but I decline to participate in :

Healthcare for [] myself and my dependants [J my dependants only

Dentalcare for D myself and my dependants D my dependants only

Spousal insurer's name: Plan number: ---------­If you lose spousal coverage you must apply for coverage within 31 days of loss of such coverage. If you do not apply within 31 days you and your dependants may be required to provide proof of insurability acceptable to Great-West Life to be covered. If you are approved, coverage for dental benefits may be limited. Please see your plan administrator for details.

Beneficiary Designation

Beneficiary's name(s)

last name first name

last name first name

last name first name

m1ddle Initial

middle lnllial

middle inllial

Percent allocated

To be divided as follows: [J As per the percentages indicated above, or U In equal shares to the survivor(s)

Relationship to plan member

You may change this beneficiary designation at any time upon notice to Great-West Life. If you wish to make the beneficiary designation irrevocable (meaning you may not change the designation or make certain changes to your coverage under the plan without the written consent of the beneficiary) please complete form #M6348 BIL Note: Where Quebec law applies and you have designated your married spouse or civil union spouse as beneficiary, the designation will be irrevocable unless you check the circle marked "Revocable", below. I hereby make the above beneficiary designation:

D Revocable, I may change this beneficiary designation at any time If designating a beneficiary who is a minor or who lacks legal capacity you may wish to appoint a trustee/administrator by completing form #M6242 BtL. This appointment may not be suitable for all purposes. If you are designating a trustee/administrator, we recommend you consult with a legal advisor, and with any proposed trustee/administrator.

CONTINUE ON REVERSE SIDE Page 1 of 2 ©The Great-West Life Assurance Company (Great-West Life), all rights reserved. Any modification

of this document without the express written consent of Great-West Life is strictly prohibited.

To be completed by the plan administrator

Plan number: Plan member name: Plan member ID:

5. Dependant Information This section is to be completed by the plan member. Complete this section If the plan includes health and/or dental coverage and you have not refused such coverage for your dependants in section 3. If there are more than four dependants, please attach a separate list. Please print clearly, in INK.

Spouse Information

last name

Date of birth (month/day/year)

Deoendant Information

last name

last name

last name

last name

6. Privacy This section explains Great-West Life's commitment to privacy.

7. Authorizations and Declarations This section must be signed and dated in INK by the plan member.

first name

first name

first name

first name

first name

middle initial

Gender

Male Female

D 0

middle initial

middle initial

middle initial

middle initial

What group benefits coverage does your spouse have through his/her employer?

HEAL THCARE I DENTALCARE I VISIONCARE Single Family Wa"Ned None Single Family Wa"Ned None Si1gle Family Wa"Ned None

D D D U D D 0 D D D D D IMJere ~. benefit P'¥flfY!Is will be roorcJin3ted between tns pm and your ~·span.

Full time Disabled Date of birth Gender student dependant

month I day I year Male Female Yes Yes

D D D D

[l D [] 0

[] lJ [] 0

D lJ 0 0

Protecting Your Personal Information

At The Great-West Life Assurance Company (Great-West Life), we recognize and respect the importance of privacy. When you apply for coverage, we establish a confidential file that contains your personal information. This file is kept in the offices of Great-West Life or the offices of an organization authorized by Great-West Life. You may exercise certain rights of access and rectification with respect to the personal information in your file by sending a request in writing to Great-West Life. Great-West Life may use service providers located within or outside Canada. We limit access to personal information in your file to Great-West Life staff or persons authorized by Great-West Life who require it to perform their duties, to persons to whom you have granted access, and to persons authorized by law. Your 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 determine your el igibility for coverage and to administer the plan, including investigating and assessing claims, and creating and maintaining records concerning our relationship.

Authorizations and Declarations

I hereby apply for coverage under the group benefits plan issued by Great-West Life.

I authorize: my plan sponsor to deduct from my pay and remit to Great-West Life the plan member contributions required under the plan, if applicable;

Great-West Life to use my social insurance number for tax reporting purposes and as an identification number where it is required in the administration of the plan;

Great-West Life, any healthcare provider, my plan administrator, other insurance or reinsurance companies, administrators of government benefits or other benefits programs, other organizations, or service providers working with Great-West Life to exchange personal information, when necessary to determine my eligibility for coverage and to administer the plan.

If applying for coverage for my spouse and/or dependants, I confirm that I am authorized to act on their behalf.

I agree that a photocopy or electronic copy of this Authorizations and Declarations section is as valid as the original.

I certify that the information given is true, correct and complete to the best of my knowledge.

For Quebec applicants: I request that this form be in English. Je demande que ce formulaire me soil remis en anglais.

Plan member signature: ----------- -------- Date: ______ _ _

Page 2 of 2

~Hr

Great:-West: Life AltUJANCI o-- C:OU,ANV

TRUSTEE APPOINTMENT For GWL Head Office Use Only

·, ., 'f/.L .. •. ll!~le .. ~.~.!·

~;·\:.: .. \\\~: ~<;g ::·\/ :; Please print clearly and complete this form, in INK. The plan administrator should keep a copy of the completed form for their records and aend lhe original to Tile Great-West Ufe Assurance Company. For sell-administered plans, GroupNet clients who maintain their own plan members' records and ClimTEL administered plans: the plan administrator should attach !his form 1o the plan member's application.

"1 ::' ·:: ... ·- ,. .• • ... • '·:·..... . . : ... •• • .. ... .

~ ~2~T~t,~~~e.~ AppoJ~l!m.~nt -;· ': '~·' t • • ·: • • ·~ • • l'"' ·, •

•. •:You may wlsJ.t to appoJp.tJl ·•. · • ·· .. trusteeladminlsttator~by : ·. ' . :.

l\~\':~~JJ:IDJetiiip !hls .~eptlo,n •. ' .. :~': ' ' ' '". ""... .... . · .. ,: ... T~~ oilgloaJ of ws f~rm wJII ·:

' · :b.e .r~9.u)red_l$!r ~ ~lfe P!@lrn- •. ·.. ... . . ( , '· · .. :--' ;'_ '·. ~~{~aJle prl~~- ~ l!a(ly, _In IN~. • -

. : .. , ; ~ ..

'I> • • ··: • • •• • . . .. .. • ' .; •• ~~-. ~.. • ••

-~;4·A~tb.91'~ttoQ~ _.Qc:r ~·: ·. '·, ·: .-. \.':P.~·~rarati~ul~-< ,_;·::·~~.:,: :_· :·: ~: ~""' ~' . ... ~~',tt\" .. :1! .... . -. . . • ~ .•... t .. \ "·

·• · This section m~ ·bt signed ·. \··.-;·~d .. ~!'l~~~!]:l~~' ~y· u,~:P.la!l :··~:.

Me242 BIL-6104

Plannumber: ........................................................................................................................................................... ......

Plan sponsor:--------------------------------

~nmembername: ~~~~----------------------~~~--------------~~~~--last name first name middle Initial

Division number: ----------------------- Plan member 10: ....................................................... _

If designating a beneficiary whO is a minor or who lacks legal capacity you may wish to appoint a trustee/administrator by completing this form. This appointment may not be suitable for all purposes.

If you are designating a trustee/administrator, we recommend you consult with a legal advisor, and with any proposed trustee/administrator.

Do not complete this section If you have already, In any document, made a trustee/administrator appointment which might apply. Consult first with your legal advisor. I hereby appoint the following trustee to receive and to hold In trust, on behalf of any beneficiary, money payable to the beneficiary under this group benefits plan where, allhe time payment is to be made, the beneficiary is a minor or otherwise lacks legal capacity. Ally such payment, to its extent, will release The Great-West Life Assurance Company from further liability. The trustee shall act prudently and may use the money, Including any returns on it or Investments made, for the education and/or maintenance of the tienellclary. The trust will terminate once the beneficiary is of the age of majority and has legal capacity. At that time, the trustee shall deliver to the beneficiary all assets held In trust.

Trustee last nama lir$t name mld<le tnttlal Relationship to plan membef

FOR QUEBEC ONLY

Where this appointment is governed by Quebec Jaw, "trustee• shall be read as "administratot', and all related terms and concepts interpreted accordingly. This appOintment shall be interpreted in accordance wilh the provisions governing the administration of the property of others, under the Quebec Civil Code.

Protecting Your Personal Information

At The Great-West Life Assurance Company (Great-West Llfe), we recognize and respect the Importance of privacy. When you apply for coverage, we establish a confidential file that is kept In lhe offices of Great-West Ufe or the offiCes of an organization authorized by Great-West Life. We limit access to personal information In your file to Great-West Life staff or persons authorized by Great-West Life who require it to perform their duties, to persons to whom you have granted access, and to persons authorized by law. We use lhe personal Information to administer lhe group benefits plan.

Authorizations and Declarations

I authorize:

• Great-West Life, my plan administrator, other insurance or reinsurance companies, administrators of government benefits or other benefits programs, other organizations, or service providers working wilh Great-West Ufe to exchange personal Information, when necessary to administer the plan.

I agree that a photocopy or electronic copy of lhis Authorizations and Declarations sec1ion is as valid as lha original.

I certify that the Information given Is true, correct and complete to the best of my knowledge.

For Quebec applicants: I request that this form be in English. Je demande que ce formulalre me soit remis en anglais.

Plan member •lgnature: Date:

CThe Great·West Uft Assurance Co~any rGreat·West llle"), aU rights reserved. My mod~lcaliOn of this documert without the express wrtltan consent ol Great-West Ulals strlclly prohibited.