RL-ACC3-ADR2-23-IN 4 ADR-12967 (11/25) CLAIMS A claimant includes you, or in the case of your death, a named Accidental death beneficiary. If there is no named beneficiary, a claimant includes the person eligible for benefits according to the BENEFIT PAYMENTS provision in the Certificate. A claimant may also include your Spouse if your Spouse has continued coverage under a PORTABILITY provision. NOTICE OF CLAIM Notice of claim should be given to us within 30 days after the date of loss. The notice may be given to us at our home office or to our authorized administrator. Failure to give notice within this timeframe will not invalidate or reduce any payable claim if it can be shown that it was not reasonably possible to give such notice within that time and the notice was given as soon as reasonably possible. CLAIM FORM The claim form is available from the Employer or can be requested from us. If the form is not received from us within 15 days of the request, Written proof of claim may be sent to us without waiting for the form. If such Written proof of claim covers the occurrence, character and extent of the loss, and is provided within the time period below for proof of claim, the claimant will be deemed to have complied with the requirements for providing proof of claim. FILING A CLAIM The claim form(s) may require completion by the claimant and the Employer and the Covered Person’s attending Doctor. The completed form(s) and any attachments indicated on the form(s) as required should be sent directly to us at the address indicated on the form. PROOF OF CLAIM Written proof of claim must be sent to us within 90 days after the date of loss. Failure to give such proof within this timeframe will not invalidate or reduce any payable claim if it can be shown that it was not reasonably possible to give such proof within that time, and the proof was given as soon as reasonably possible. However, proof of claim must be provided no later than one year after the time proof is otherwise required, except in the absence of legal capacity. EXCLUSIONS We will not pay benefits for any Accident-related condition that is contributed to, caused by or results from the following:  Suicide, attempted suicide or any intentionally self-inflicted Injury, while sane or insane.  Any Sickness or declining process caused by a Sickness.  Participation or attempt to participate in a felony or illegal activity.  An Accident while the Covered Person is operating a motorized vehicle while intoxicated. Intoxication means the Covered Person’s blood alcohol content meets or exceeds the legal presumption of intoxication under the laws of the state where the Accident occurred.  War or any act of war, whether declared or undeclared (excluding acts of terrorism).  Loss sustained while on active duty as a member of the armed forces of any nation. We will refund, upon Written notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion.  Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a Doctor.  Riding in or driving any motor-driven vehicle in a race, stunt show or speed test.  Operating, or training to operate, or service as a crew member of, or jumping, parachuting or falling from, any aircraft or hot air balloon, including those which are not motor-driven. Flying as a fare-paying passenger is not excluded.  Engaging in hang-gliding, bungee jumping, parachuting, sailgliding, parasailing, parakiting, kitesurfing or any similar activities.  Practicing for, or participating in, any semi-professional or professional competitive athletic contests for which any type of compensation or remuneration is received.  Work for pay, profit or gain.