Retirement Healthcare Program Claims Activation Form Page 2 of 2 TA CRH/OTCMNTRHSP F11292 (2/24) 2. SPOUSE AND/OR ELIGIBLE DEPENDENTS * Federal tax law limits reimbursement of qualified medical expenses incurred by the participant, spouse and eligible dependents. Medical expenses incurred by nondependent domestic partners may be eligible for reimbursement subject to the rules of the employer’s Retirement Healthcare Plan (see the Summary Plan Description for more details). 1. First Name M.I. Last Name Suffix Relationship* (Spouse, Domestic Partner, Dependent) Date of Birth (mm/dd/yyyy) / / Social Security Number/ Taxpayer Identification Number Gender Male Female 2. First Name M.I. Last Name Suffix Relationship* (Spouse, Domestic Partner, Dependent) Date of Birth (mm/dd/yyyy) / / Social Security Number/ Taxpayer Identification Number Gender Male Female 3. SIGN AND DATE FORM Relationship to Participant: Self Spouse Eligible Dependent Other Please sign your full legal name with suffix, if applicable, using black ink. Digital signatures are not accepted. Your Signature Today’s Date (mm/dd/yyyy) / / 2 0 Name (please print) Daytime Telephone Number