[Form] File a Accident/Hospital Claim

CONTINENTAL AMERICAN INSURANCE COMPANY . Post Office Box 427* Columbia, South Carolina 29202 Phone (800) 433-3036 Fax (866) 849-2970 Email: CSC@caicworksite.com CAF001ACC/HI Accident and Supplemental Hospital and Medical Indemnity Claim Instructions 1. Please complete sections 1 through 7. 2. Read and sign the Authorization, section 8. The authorization will be used in obtaining information needed to process your claim. Failure to complete the Authorization will result in a delay in processing. 3. If your loss is the result of an Accident, please provide a complete description of your accident. If the accident was a motor vehicle accident attach a copy of the police or accident report. If you were injured in an on-job or occupational injury, attach a copy of the first report of injury filed with your employer. 4. If you were first treated at an emergency room, please attach a copy of the discharge papers from the hospital in order for us to verify the first date of treatment. 5. Please attach a copy of all bills and supporting documents related to the treatment of your loss. The medical bills and supporting documents should include the diagnosis, the specific procedure or treatment the covered insured received, the date of service, and the amount charged for physician services, emergency room treatment and supplies. If you are filing for hospital confinement benefits, attach a copy of the itemized hospital bill showing the number of days of hospitalization or an admission and discharge summary. If you are filing during the first year of your coverage effective date and subject to a pre-existing investigation, complete the enclosed pre-existing statement form in full and return to our office with your claim form. PART A POLICYHOLDER/CLAIMANT’S STATEMENT 1 EMPLOYER’S NAME POLICYHOLDER’S E-MAIL ADDRESS 2 POLICYHOLDER’S NAME POLICY/CERTIFICATE NO. SOCIAL SECURITY NO. DATE OF BIRTH SEX 3 POLICYHOLDER’S ADDRESS STREET CITY STATE ZIP CODE 4 CLAIMANT’S NAME (PERSON WHO IS SICK OR INJURED) DATE OF BIRTH RELATIONSHIP TO POLICYHOLDER POLICYHOLDER’S TELEPHONE NO. (INCLUDE AREA CODE) 5 DESCRIBE WHEN AND HOW YOUR ACCIDENT OCCURRED OR THE ONSET AND NATURE OF YOUR ILLNESS. 6 IS YOUR ACCIDENT OR SICKNESS RELATED TO YOUR OCCUPATION � NO � YES HAS A WORKER’S COMPENSATION CLAIM BEEN FILED? � NO STATUS � YES � APPROVED � PENDING � DENIED AUTHORIZATION DOCTOR TREATED OR REFERRED BY WITHIN THE LAST YEAR: DATE NAME ADDRESS CITY STATE ZIP CODE TELEPHONE NO. 7 DATE SYMPTOMS FIRST APPEARED IF HOSPITALIZED WITHIN THE LAST YEAR: DATE NAME ADDRESS CITY STATE ZIP CODE TELEPHONE NO. 8 Several states require that the following statement appear on the claim forms: Any person who knowingly and with intent to defraud any insurance company, files a statement of claim containing any materially false, incomplete or misleading information, is guilty of a crime. I hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my knowledge and belief. I have read the fraud notice included in this form. Policyholder’s Signature: Date: Claimant’s Signature: Date: 1. To ensure your claim gets processed efficiently, please check the appropriate box for the coverage you are filing a claim under. If both, please check both boxes: Accident Hospital Indemnity 2. Please complete the claim form below in its entirety (if information is missing, it may delay the processing of your claim). 3. Be sure sign & date the authorization and claim form 4. Provide the date and description of your accident or onset of illness. 5. Please provide Physician's documentation to support your accident. 6. If you are filing for an accident due to motor vehicle collision, provide the police report. If your accident occurred on the job, provide the first report of injury. 7. Provide documentation of your first date of treatment following the accident. 8. Provide all bills associated with your claim, including treatment dates, total charges, diagnoses and procedure codes. 9. If you are filing for hospital admission/confinement benefits, include the hospital bill with admission & discharge dates and room & board charges. 10. If you are filing for specific loss benefits, provide the objective test findings, to include X-ray reports, MRIs, and CT scans. If filing for surgery benefits, provide the operative report. Accident and Supplemental Hospital and Medical Indemnity Claim Instructions

Phone (800) 433-3036 Fax (866) 849-2970 CAIC-H4/03 HIPAA Privacy Rule rev. 4/12 INSURED_________________________________________ COVERAGE ID/ CERTIFICATE NUMBER_____________________________ AUTHORIZATION TO OBTAIN INFORMATION CONTINENTAL AMERICAN INSURANCE COMPANY For the purpose of evaluating my eligibility for insurance and eligibility for benefits under an existing policy/certificate, including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application for coverage and/or claim form, I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below to Continental American Insurance Company (CAIC) and its duly authorized representatives. Disclosure of Health Information Health information may be disclosed by any health care provider, health plan (including CAIC or Aflac, with respect to other CAIC or Aflac coverages) or health care clearinghouse that has any records or knowledge about me. Health care provider includes, but is not limited to, any licensed physician, medical or nurse practitioner, nurse, pharmacist, osteopath, psychologist, physical or occupational therapist, chiropractor, dentist, audiologist or speech pathologist, podiatrist, hospital, medical clinic or laboratory, pharmacy, rehabilitation facility, nursing home or extended care facility, prescription drug database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company or the Medical Information Bureau (MIB). Health information includes my entire medical record, but does not include psychotherapy notes. Financial or credit history, earnings, or employment history may be disclosed by any entity, person, or organization that has these records about me, including but not limited to my employer, employer representative and compensation sources, insurance company, financial institution, or any consumer reporting agency. Federal, state, and local government organizations including but not limited to the Veteran’s Administration, Internal Revenue Service, Social Security Administration, and Medicare or Medicaid agencies, may disclose health or financial information or records about me. Any information CAIC obtains pursuant to this authorization will be used for the purpose of evaluating and administering my application for coverage and/or claim for benefits. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. CAIC will not disclose the information unless permitted or required by those laws. I understand that if the information disclosed is protected health information relating to a health plan and the person or entity receiving the information is a not a health care provider or health plan covered by federal privacy regulations, the information disclosed may be redisclosed by such person or entity and will likely no longer be protected by the federal privacy regulations. This authorization may be revoked by me or my authorized representative at any time except to the extent CAIC has relied on the authorization prior to notice of revocation or has a legal right to contest coverage under the contract or the contract itself. If I revoke this authorization, CAIC may not be able to evaluate my application for coverage and/or claim. I may revoke this authorization by sending written notice to: Continental American Insurance Company, ATTN: New Business Department (for applications) or ATTN: Claims Department (for claims), P.O. Box 427, Columbia, SC 29202. You may refuse to sign this form; however, CAIC may not be able to evaluate and administer your application for coverage and/or your claim without this authorization. This authorization is valid for two (2) years from its execution or for the duration of my claim, whichever is later. A copy of this authorization is as valid as the original. I know that I or my authorized representative may request a copy of this authorization and access to this information. I am the individual to whom this authorization applies or that person’s legal Guardian, Power of Attorney Designee, Conservator, Beneficiary or personal representative. _________________________________________________________________ ____________________________________________ (Printed Name of Individual Subject to Disclosure) (Date of Birth) _________________________________________________________________ ____________________________________________ (Signature) (Date Signed) _________________________________________________________________ (Optional: Social Security number (SSN) of individual subject to disclosure (or last four digits of SSN)) If applicable, I signed on behalf of the insured as ____________________________________________________________________________. (Indicate relationship, legal Guardian, Power of Attorney Designee, Conservator, Beneficiary or personal representative.) _________________________________________________________________ (Printed Name of Legal Representative) _________________________________________________________________ ____________________________________________ (Signature of Legal Representative) (Date Signed)

Rev 4/12 Expires 4/14 ALASKA: A person who knowingly and with intent to injure, defraud or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law. ARIZONA: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. ARKANSAS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. CALIFORNIA: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. DELAWARE: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. DISTRICT OF COLUMBIA: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant. FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. IDAHO: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony. INDIANA: A person who knowingly and with intent to defraud any insurer files a statement of claim containing Any false, incomplete, or misleading information commits a felony. KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. LOUISIANA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. MAINE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. MARYLAND: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. MINNESOTA: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in NH Rev.Stat. Ann. § 638:20. NEW JERSEY: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. FRAUD WARNING NOTICES For use with Claim Forms PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE

Rev 4/12 Expires 4/14 NEW MEXICO: any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. OKLAHOMA: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. OREGON: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud. PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. PUERTO RICO: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances are present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. TENNESSEE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. TEXAS: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. VIRGINIA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. WASHINGTON: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. RHODE ISLAND and WEST VIRGINIA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. ALL OTHER STATES: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. FRAUD WARNING NOTICES (CONT.) For use with Claim Forms PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE