ICC19 RL-STD-CERT-19 19 D12972 (11/25) CLAIMS NOTICE OF CLAIM Written notice of your claim should be given to us within 30 days after the date your Disability begins. The notice may be given to us at our home office or to our authorized agent or 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 after the date your Disability begins. 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 covers the requirements described below for proof of claim, 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) requires completion by you and the Employer and your 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 your elimination period ends. 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. Your proof of claim, provided at your expense, must show all of the following:  That you are under the Appropriate Care of a Doctor.  The date your Disability began.  The cause of your Disability.  The appropriate documentation of your earnings and your activities.  The extent of your Disability, including restrictions and limitations preventing you from performing your Regular Occupation.  The names and addresses of all Hospitals, Health Facilities and Institutions where you received treatment or consultation.  The names and addresses of all Doctors with whom you treated or consulted.  Documentation of prior disability coverage, if applicable. CONTINUING PROOF OF CLAIM We may require you to provide continuing proof of your claim as often as it is reasonable to do so during the pendency of your next benefit payment. You will have 60 days from the date of our request to provide us with continuing proof of your claim. As part of this process, we may require you to provide us with a signed authorization to allow us to obtain information as part of your continuing proof of claim. Failure to provide continuing proof of your claim or a signed authorization in 60 days may delay your payments until the required proof of continuing claim is received. You must notify us immediately when you return to work in any capacity. PAYMENT OF CLAIMS Once your claim has been approved, we will send you a payment at the end of each week for any period for which we are liable. Any balance remaining unpaid by us upon termination of such period will be paid within 30 days upon receipt of proof of your claim. A delayed payment of your claim will be subject to a simple interest at a rate of 10% per year beginning on the 31st day after receipt of satisfactory proof of your claim and ending on the day the claim is paid.