RL-ACC3-WELL2-23-IN 3 WELL-12967 (11/25) EXCLUSIONS The EXCLUSIONS section of the Certificate and riders does not apply to this rider. CLAIMS The PHYSICAL EXAMINATION provision does not apply to this rider. A claimant includes you or your Spouse if your Spouse has continued coverage under a PORTABILITY provision. NOTICE OF CLAIM Notice of claim must be given to us during the same calendar year the health screening test occurs or within 30 days of the end of the calendar year, whichever is later. 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 description of the health screening test, 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 the health screening test. 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. BENEFITS We will pay you a WELLNESS benefit as shown on the SCHEDULE OF BENEFITS if a Covered Person has a health screening test on or after the Covered Person’s coverage effective date. A benefit is payable up to a maximum of one time per Covered Person per calendar year. The amounts are shown on the SCHEDULE OF BENEFITS. Health screening tests include, but are not limited to:  Blood test for triglycerides  Pap smear or thin prep pap test;  Flexible sigmoidoscopy  CEA (blood test for colon cancer)  Bone marrow testing  Serum cholesterol test for HDL & LDL levels  Hemoccult stool analysis  Serum Protein Electrophoresis (myeloma)  Breast ultrasound, sonogram, MRI  Chest x-ray  Mammography  Colonoscopy  CA 15-3 (breast cancer)  Stress test on bicycle or treadmill  Fasting blood glucose test  Thermography  PSA (prostate cancer)  Electrocardiogram (EKG)  Endoscopy  Carotid Doppler  Routine Eye exam  Routine dental exam  Well child/preventive exams for ages 1 through age 18  Biometric screenings  Molecular or antigen test (Coronavirus)