I hereby apply to be a Plan Participant of the Fairmont Specialty Trust (the“Trust”) and to participate in the insurance coverage extended to Plan Participants under the Trust by Crum & Forster SPC (“the Company”) to Plan Participants under the Trust (the “Coverage”).

I understand that the Coverage is not a general health insurance product, but is intended for use in the event of a sudden and unexpected event while traveling outside my Home Country.

I understand that the Coverage extended to me will terminate upon my return to my Home Country.

I understand that I may obtain full details of the insurance by requesting a copy of the Master Policy from the Plan Manager.

I understand that the liability of the Company as insurer of the Coverage is as provided in the Master Policy.

By acceptance of coverage and/or submission of any claim for benefits, the Plan Participant ratifies the authority of the signer to so act and bind the Plan Participant. The Plan Participant undertakes to make all premium payments as they fall due in respect of the Coverage extended to them. The Plan Administrator shall not be responsible for the administration of such payments. If the Plan Participant fails to make any premium payment due in respect of the Coverage extended to them, subject to the discretion of the Insurance Company, such Coverage will lapse.

The Plan Participant hereby confirms the accuracy of all information validity of all representations and warranties provided to the Plan Administrator in connection with its participation in the Plan and/or the subscription for the Coverage , howsoever provided, including the terms of this Subscription Agreement, (together “Representations & Warranties”).

The Plan Participant acknowledges that certain of such information will be relied upon by the Company as insurers of the Coverage and that any inaccuracy therein may result in the invalidity of such Coverage as it relates to the Plan Participant, the loss of Coverage and all monies paid in relation thereto.

The Plan Participant hereby undertakes to inform the Plan Administrator of any change to any of matter that forms the subject of any of the Representation & Warranties.

The Plan Participant hereby undertakes to indemnify and hold harmless the Plan Administrator against any loss or damage (including attorney’s fees) occasioned by any inaccuracy in any Representation & Warranty or failure to advise the Plan Administrator of any change in any matter that forms the subject of any of the Representation & Warranties.

The Plan Participant agrees that the Plan Administrator shall be entitled to rely on and to act in accordance with any written instruction purported to be provided by the Plan Participant and the Plan Participant hereby undertakes to indemnify and hold harmless the Plan Administrator against any loss or damage (including attorney’s fees) occasioned by the Plan Administrator acting in accordance with any such instruction.

Payments under the terms of the Coverage shall be paid by the Insurers to the Plan Participant or directly to a provider if assignment of benefits has been authorized. The Plan Administrator shall not be responsible for the administration of such payments. I confirm that I have satisfied myself that the insurance is appropriate for me and that I meet the eligibility criteria.