RL-CI4-WELL2-20-IN 3 WELL-12969 (11/25) Health screening tests include, but are not limited to: - Blood test for triglycerides - Pap smear or thin prep pap test - Flexible sigmoidoscopy - Fasting blood glucose test - Thermography - PSA (prostate cancer) - 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 - Electrocardiogram (EKG) - Endoscopy - Carotid Doppler - Routine eye exam - Routine dental exam - Well child/preventive exams for ages 1 through 18 - Biometric screenings - Molecular or antigen test (Coronavirus) CLAIMS The PHYSICAL EXAMINATION provision does not apply to this rider. NOTICE OF CLAIM Written notice of your 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 you can request a claim form from us. If you do not receive the form from us within 15 days of your request, you may send us Written proof of claim without waiting for the form. If such Written proof of claim covers the occurrence, character and extent of the loss within the time period below for proof of claim, you 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 you 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 You must send us Written proof of your claim 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, in any event, you must provide proof of claim no later than one year after the time proof is otherwise required, except in the absence of legal capacity. BENEFIT PAYMENTS Benefits under this rider are payable to you unless otherwise specified. Once a claim has been approved, we will make payment immediately upon receipt of due written of proof of claim. Any accrued benefits that are payable at your death will be paid according to the BENEFIT PAYMENTS provision in the Certificate. For PORTABILITY FOLLOWING DEATH OR DIVORCE, benefits are payable to your Spouse, and any accrued benefits that are payable at the time of your Spouse’s death will be paid to your Spouse’s estate.