Phone: 800-256-8606 Fax: 877-365-9423

File claims using the Online Service Center (OSC) for faster payments, claim status updates, direct deposit and more.

Instructions For the Insured or Patient

Complete the Statement of Insured (Sections A through F) as applicable to your claim. Completing Section G is not required; however, completing this section will reduce delays in processing should we need to request additional information regarding your claim. The following benefits require supporting documentation (refer to your Policy/Certificate for benefits covered under your plan The indicated documentation must accompany the completed Statement of Insured when filing a claim: Organized Sports Booster Benefit, provide proof of registration in the Organized Sport Event. Accidental Injury Benefit, provide an Itemized Medical Bill² Auto & Home Modification Benefit, provide an Itemized Invoice4 or Itemized Receipt5

Family Care Benefit, provide a copy of the Itemized Medical Bill² for the hospitalization and Itemized Invoice4 (Itemized Receipt55 for adult or childcare Coma, Paralysis, Brain Injury, and/or Post-Traumatic Stress Disorder Benefits, provide Medical Records¹ and the completed Attending Physician's Statement Accident Medical Expense Benefit, provide an Itemized Medical Bill² and a copy of the major medical carrier's explanation of benefits (EOB) for services rendered Family Member Lodging and/or Non-Local Transportation Benefits, provide an Itemized Invoice4 or Itemized Receipt5 and Itemized Medical Bill² Gunshot Wound Benefit, provide the Police Report Motor Vehicle Accident, provide the Motor Vehicle Accident Report Auto & Home Modification, provide an Itemized Invoice4 or Itemized Receipt5 Prescription Drug Benefit, provide an Itemized Invoice4 or Itemized Receipt5 Appliance Benefit, provide a Prescription6 Accident which resulted in death, provide the Death Certificate 3 Your signature is required for benefit consideration

1Medical Records should support diagnosis of the condition and include laboratory analysis, pathology report, imaging studies, other tests, and office notes. 2The itemized medical bill must include the diagnosis for which treatment was provided and the procedures that were performed. A copy of the standardized claim forms, commonly called a UB or CMS form, may be submitted in lieu of the itemized bill. ³riginal copies of death certificate will be returned. 4, 5 The itemized invoice, or itemized receipt, should include the service or item purchased, each date of service or date of purchase, charge amount, and vendor or company name, address location, and telephone number. The itemized invoice or itemized receipt should also include the origin and destination location when filing a claim for Repatriation and Non-Local Transportation. 6The Prescription should include a physician's written order authorizing a vendor to supply a specific appliance for a Patient, with instructions on its use.

Section C - Details of the Accident

Acknowledgement - Your signature is required for benefit consideration I hereby certify the answers I have provided in the foregoing questions are both complete and true to the best of my knowledge and

belief. I acknowledge I have read the fraud notice included in this claim form.

Phone: 800-256-8606 Fax: 877-365-9423

Section F - Claim Form Fraud Statements The following fraud language is attached to, and made part of, this claim form. Please read and do not remove this page from this claim form. materially false information or conceals, for the purpose of If you live in a jurisdiction not mentioned below, the following applies to you: Any misleading, information concerning any fact material thereto commits person who knowingly presents a false or fraudulent claim for payment of a loss or benefit is guilty of a crime and may be subject to fines and confinement in prison. a fraudulent insurance act, which is a crime. Alabama - Any person who knowingly presents a false or fraudulent claim Maine, Tennessee, Virginia and Washington - It is a crime to knowingly for payment of a loss or benefit or who knowingly presents false provide false, incomplete or misleading information to an insurance information in an application for insurance is guilty of a crime and may be company for the purpose of defrauding the company. Penalties may subject to restitution, fines, or confinement in prison, or any combination include imprisonment, fines or a denial of insurance benefits. thereof. Maryland - Any person who knowingly or willfully presents a false or Alaska - A person who knowingly and with intent to injure, defraud, or fraudulent claim for payment of a loss or benefit or who knowingly or deceive an insurance company files a claim containing false, incomplete, or willfully presents false information in an application for insurance is misleading information may be prosecuted under state law. guilty of a crime and may be subject to fines and confinement in prison. Arizona - For your protection Arizona law requires theMinnesota - A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. following statement to appear on this form. Any person New Hampshire - Any person who, with a purpose to injure, defraud, who knowingly presents a false or fraudulent claim for or deceive any insurance company, files a statement of claim containing payment of a loss is subject to criminal and civilany false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA penalties. Arkansas, District of Columbia, Louisiana, Rhode Island and West Virginia - New Jersey - Any person who knowingly files a statement of claim Any person who knowingly presents a false or fraudulent claim for payment containing any false or misleading information is subject to criminal and of a loss or benefit or knowingly presents false information in an application civil penalties. for insurance is guilty of a crime and may be subject to fines and New Mexico - ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR confinement in prison. California and Texas - For your protection California and Texas law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Ohio - Any person who, with intent to defraud or knowing that he is Colorado - It is unlawful to knowingly provide false, incomplete, or facilitating a fraud against an insurer, submits an application or files a misleading facts or information to an insurance company for the purpose claim containing a false or deceptive statement is guilty of insurance of defrauding or attempting to defraud the company. Penalties may include fraud. imprisonment, fines, denial of insurance, and civil damages. Any insurance Pennsylvania - Any person who knowingly and with intent to defraud company or agent of an insurance company who knowingly provides false, any insurance company or other person files an application for incomplete, or misleading facts or information to a policyholder or claimant insurance or statement of claim containing any materially false for the purpose of defrauding or attempting to defraud the policyholder or information or conceals for the purpose of misleading, information claimant with regard to a settlement or award payable from insurance concerning any fact material thereto commits a fraudulent insurance proceeds shall be reported to the Colorado division of insurance within the act, which is a crime and subjects such person to criminal and civil department of regulatory agencies. penalties. Delaware, Idaho and Oklahoma - WARNING: Any person who knowingly, Puerto Rico - Any person who knowingly and with the intention of and with intent to injure, defraud or deceive any insurer, makes any claim defrauding presents false information in an insurance application, or for the proceeds of an insurance policy containing any false, incomplete or presents, helps, or causes the presentation of a fraudulent claim for the misleading information is guilty of a felony. payment of a loss or any other benefit, or presents more than one claim Florida - Any person who knowingly and with intent to injure, defraud, or for the same damage or loss, shall incur a felony and, upon conviction, deceive any insurer files a statement of claim or an application containing shall be sanctioned for each violation by a fine of not less than five any false, incomplete, or misleading information is guilty of a felony of the thousand dollars ($5,000) and not more than ten thousand dollars third degree. ($10,000), or a fixed term of imprisonment for three (3) years, or both Indiana - A person who knowingly and with intent to defraud an insurer files penalties. Should aggravating circumstances [be] present, the penalty a statement of claim containing any false, incomplete, or misleading thus established may be increased to a maximum of five (5) years, if information commits a felony. extenuating circumstances are present, it may be reduced to a Kentucky - Any person who knowingly and with intent to defraud any insurance minimum of two (2) years. company or other person files a statement of claim containing any

FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.

Phone: 800-256-8606 Fax: 877-365-9423

Section G - Authorization to Disclose Information Including Protected Health Information The purpose of this form is to allow American Public Life Insurance Company (APL), or business partners acting on behalf of APL in the administration of APL products and services to obtain data including but not limited to employment information, financial information, and protected health information about me, from any party holding that information. Once obtained, APL may use this data to review or process benefits, confirm policy information, or otherwise review or process information related to my Customer relationship

I hereby authorize the entities specified below to disclose any information about me or my dependents' health or financial situation including my or my dependents' entire medical record and history of treatment for physical and/or emotional illness to include psychological testing, except psychotherapy notes, to individuals representing APL who are involved in determining whether I am eligible for benefits under my insurance coverage. Those so authorized are: a) licensed physicians or medical practitioners; b) hospitals, clinics or medically-related facilities or their business associates; c) health plans; d) Veteran's Administration; e) past or present employers; f) pharmacy; g) insurance companies; h) the Social Security Administration; i) retirement systems; j) Department of Motor Vehicles, k) banks or financial institutions and I) Workers' Compensation Carrier. APL will only disclose any data collected pursuant to this authorization as necessary for legitimate business purposes, and only to the extent allowed by law.

NOTICE: Information authorized for release may include information on communicable or venereal diseases such as hepatitis,

syphilis, gonorrhea, HIV/AIDS (Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome) or other conditions forwhichI may have been treated.

I understand APL may not condition payment of claims, enrollment, or eligibility for benefits on whether I sign this authorization. I understand

denial I may refuse to sign this authorization; however, if I do not sign the authorization, my failure to sign the authorization may resultina

or an inability to pay benefits under my policy if my failure to sign results in APL not having enough information to process my benefits.

Iunderstand I may revoke this authorization at any time by writing to APL, P.O. Box 248950, Oklahoma City, OK 73124-8950 or by calling the 800-256-8606. I understand that my right to revoke this authorization is limited to the extent that: APL has acted in reliance on of authorization; or the law provides APL with the right to contest my insurance coverage or a claim under my insurance coverage. A copy this authorization will be as valid as the original.

I understand if protected health information is disclosed to a person or organization that is not required to comply with federal privacy regulations, the information may be redisclosed and no longer protected by the federal privacy regulations. In addition to the types of information described above, I also authorize APL to access any other type of information deemed necessary to investigate my claim. This information includes but is not limited to financial information, information submitted or related to insurance claim(s) or insurance coverage(s) and employment records. Any party holding this information is hereby authorized to release it to APL.

For health insurance coverage, this authorization will expire 24 months from the date it is signed or upon termination of my insurance policy, whichever occurs first. For insurance coverage other than health insurance, this authorization will expire 24 months from the date it is signed or upon expiration of my claim for benefits, whichever occurs first.

Relationship of Personal Representative to Patient (if applicable) If authorization is supplied by a personal representative, a description of the authority to act on behalf of the Insured must be included.