Group/Association - Proof of Loss: Life Insurance Accidental Death Insurance

Group/Association - Proof of Loss Life Insurance Accidental Death Insurance MAIL TO: New York Life Group Benefit Solutions Connecticut General Life Insurance Company P.O. Box 22328 Life Insurance Company of North America CLEAR FORM Pittsburgh, PA 15222-0328 New York Life Group Insurance Company of NY E-mail: claims.pghlif2@newyorklife.com Fax: 877-300-6770 NEW YORK FRAUD WARNING: 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 $5000 and the stated value of the claim for each such violation. CAUTION: Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; (2) conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act. For residents of the following states, please see the last page of this form: Arizona, California, Colorado, District of Columbia, Florida, Kansas, Kentucky, Louisiana, Maryland, Minnesota, New Jersey, Oregon, Pennsylvania, Puerto Rico, Rhode Island, Tennessee, Texas, Virginia or Washington. Instructions for Filing a Claim This form is for Life Insurance or Accidental Death proceeds only. Complete the form according to the instructions, to avoid delay or return i of the form. In boxes which contain the symbol , additional information is provided when hovering over the field to be completed. This feature is only available on the fillable version of this form. To The Employer/Administrator: 1. If claiming employee death benefits, please complete Sections A and C. If claiming dependent spouse or child benefits, please complete Sections A, B, and C. 2. If claiming voluntary or employee-paid benefits, please provide all of the enrollment history for the employee and the dependent (if claiming dependent benefits). 3. Please have each beneficiary review pages 1 through 7 and complete the appropriate pages. 4. Submit completed form to your assigned Claim Office with a Death Certificate, Beneficiary Designation and Enrollment Information, if applicable. Section A: Employee Information i Name of Employee/Member (Last Name) (First Name) (Middle Initial) Date of Birth Social Security Number Sex M F Address (Street) (City) (State) (Zip Code) Employee’s/Member’s Marital Status Single Married Widow/Widower Separated Divorced Domestic Partner Relationship Civil Union Policy Number(s): List all policies under which benefits are due. Occupation i Was insurance issued on the basis of a statement of physical condition? (If yes, attach copy) Yes No i Check all of the boxes that apply to the Employee/Member’s employment/membership status and job classification. Hours per week Active Exempt Management Supervisory Union Local Number Salaried Full-time Retired Non-Exempt Non-Management Non-Supervisory Non-Union Hourly Part-time i Basic Annual Earnings i Effective Date of Earnings i Employee’s Division/Location i Policy Class Number i Amount of Insurance: If claiming voluntary benefits, please provide enrollment information. Basic: AD&D (Please complete only if Basic: Life Voluntary: claiming AD&D benefits): Voluntary: SIB: BTA: i Has voluntary coverage for the employee/dependent been in effect continuously since enrollment? i Date Hired/Member i Effective Date of Yes No If No, please include enrollment history and enrollment forms if not already provided. of Assoc. Insurance i Date Last Worked Date of Death Cause of Death i Premium Paid Through Date i Has an assignment been taken? (If yes, attach copy) Yes No Was the above Considered an Employee/Association Member until i Was the Employee actively at work until the date of the Dependent’s death? his/her Date of Death? Yes No If No, Please Explain Yes No If No, indicate reason below. i If the Employee was not actively at work immediately prior to his/her death or Dependent’s death, what was the reason? Disability (STD) Paid Leave of Absence FMLA Temporary Layoff Resigned Minnesota Continuation (Please attach COBRA form.) Disability (LTD) Unpaid Leave of Absence Vacation Sabbatical Discharged Other: Was coverage still in effect through the Date of Death? If No, Please Explain Yes No i Is there a Beneficiary Designation on file for this Employee/Member? Yes No Please provide the most recent beneficiary designation with the claim. Please provide the Name of your Medical Insurance Carrier Beneficiary: please review and keep for your records. © 2023, New York Life Insurance Company, New York, NY. All rights reserved. NEW YORK LIFE and the New York Life box logo are registered trademarks of New York Life Insurance Company. Life Insurance Company of North America and New York Life Group Insurance Company of NY are subsidiaries of New York Life Insurance Company. Connecticut General Life Insurance Company is not affiliated with New York Life Insurance Company. Page 1 of 9 LMS-613500 Revised 10/2023

Section B: Dependent Spouse or Dependent Child Information Name of Dependent (Last Name) (First Name) (Middle Initial) Date of Birth Social Security Number Sex M F Relationship to Employee/Association Member Amount of Dependent Insurance Dependent’s Occupation Life Basic: Voluntary: AD&D Basic: Voluntary: Was the Dependent Totally Yes No If yes, Date Disability Began Dependent’s Last Day Worked Date of Marriage Date of Death Disabled? Dependent’s Employer Dependent’s Employer’s Telephone Number Is Child Full-time student Date Last Attended School Part-time student Name & Address of School (Street) (City) (State) (Zip Code) School Telephone Number Section C: Employer’s/Administrator's Certification Name of Employer/Association Email Address Address (Street) City (State) (Zip) Telephone Number This is to certify that the facts as indicated on this form are true to the best of my knowledge and belief. Signature Title Date Section D: Accidental Death Information i Where and How Did the Accident Happen? Please Describe in Detail Date and Time of Accident Section E: Beneficiary Information i Name of Beneficiary (Last Name) (First Name) (Middle Initial) Date of Birth Social Security Number Sex M F Mailing Address (Street) (City) (State) (Zip Code) Relationship to Deceased Daytime Telephone Number Email Address Name and Address of Legal Guardian if Beneficiary is A Minor If guardianship of the minor’s estate has been established, please attach court order. Did the Deceased convert or port his/her life insurance coverage prior to his/her death? Yes No If claiming voluntary life or basic and/or voluntary AD&D benefits, please list all hospital, clinics or physicians that treated the deceased within the past 5 years. Name Phone Number Complete Address Treatment Period I certify that the foregoing information is true, correct and complete to the best of my knowledge. Beneficiary Signature Date Page 2 of 9 LMS-613500 Revised 10/2023

New York Life Group Benefit Solutions (NYL GBS) Survivor Assurance If your insurance benefit is $5,000 or more, NYL GBS will automatically open a free, interest-bearing account in your name. This account, called the NYL GBS Survivor Assurance, is a convenient and secure place to keep your proceeds while you decide how to best use them. Please review the attached NYL GBS Survivor Assurance Disclosure Notice for full details about the account.* Account balances are the liability of the insurance company and are not insured by the Federal Deposit Insurance Corporation or any federal agency. The insurance company reserves the right to reduce account balances for any payment made in error. If your life insurance benefit is less than $5,000, NYL GBS will send you a check for the total benefit amount. *Please read the NYL GBS Survivor Assurance Disclosure Notice before signing below. I understand that if my benefit is $5,000 or more, I will receive a NYL GBS Survivor Assurance account. I understand that I may write a draft for the total amount in my account at any time. I understand that the account balance may be reduced for any benefit payment by the insurance company made in error. I acknowledge that, if I do not separately sign the NYL GBS Survivor Assurance Section of this Claim Form, I am not participating in the NYL GBS Survivor Assurance and that I will receive a single lump sum check for the proceeds due if my claim is approved. Signature* Date *Please sign as you would sign on a check, as signature may be used for draft verification. The issuance of this form is not an admission of the existence of any insurance nor does it recognize the validity of any claim and is without prejudice to the company’s legal rights. Beneficiary: Please complete and return to the Employer or New York Life Group Benefit Solutions. Page 3 of 9 LMS-613500 Revised 10/2023

Disclosure Authorization Life Insurance Company of North America Connecticut General Life Insurance Company New York Life Group Insurance Company of NY Deceased’s Name: Deceased’s Date of Birth: I AUTHORIZE: any doctor, physician, healer, health care practitioner, hospital, clinic, other medical facility, professional, or provider of health care, medically related facility or association, medical examiner, pharmacy, employee assistance plan, insurance company, health maintenance organization or similar entity to give the Insurance Company named below (Company) or their employees and authorized agents or authorized representatives, any medical and nonmedical information or records that they may have concerning the deceased’s health condition, or health history, or regarding any advice, care or treatment provided to the deceased. This information and/or records may include, but is not limited to: cause, treatment, diagnoses, prognoses, consultations, examinations, tests, prescriptions, or advice of the deceased’s physical or mental condition, or other information concerning the deceased which may be needed to determine policy claim benefits with respect to the deceased. This may also include (but is not limited to) information concerning: mental illness, psychiatric, drug or alcohol use and any disability, and also HIV related testing, infection, illness, and AIDS (Acquired Immune Deficiency Syndrome), as well as communicable diseases and genetic testing. I understand that I may choose whether to receive the results of any laboratory tests or medical examinations performed. This information may also be extracted for use in audits or for statistical purposes. I AUTHORIZE: any financial institution, accountant, tax preparer, insurance company or reinsurer, consumer reporting agency, insurance support organization, Insured’s agent, employer, group policyholder, business associate, benefit plan administrator, family members, friends, neighbors or associates, governmental agency including the Social Security Administration or any other organization or person having knowledge of the deceased to give the Company or their employees and authorized agents, or authorized representatives, any information or records that they have concerning the deceased’s occupation, activities, employee/employment records, earnings or finances, applications for insurance coverage, prior claim files and claim history, work history and work related activities. I UNDERSTAND: the information obtained will be included as part of the proof of claim and will be used by the Company to determine eligibility for claim benefits, any amounts payable and to administer any other feature described in the plan with respect to the deceased. This authorization shall remain valid and apply to all records, information and events that occur over the duration of the claim, but not to exceed 24 months. A photocopy of this form is as valid as the original and I or my authorized representative may request one. I or my representative may revoke this authorization at any time as it applies to future disclosures by writing the Company. The information obtained will not be released to anyone EXCEPT: a) reinsuring companies; b) the Medical Information Bureau, Inc., which operates Health Claim Index (HCI); c) fraud or overinsurance detection bureaus; d) anyone performing business, medical or legal functions with respect to the claim; e) for audit or statistical purposes; f) as may be required or permitted by law; g) as I may further authorize. A valid authorization or court order for information does not waive other privacy rights. If the medical information contains information regarding drug or alcohol abuse, I understand that the deceased’s records may be protected under federal (42 CFR Part 2) and some state laws. To the extent permitted under law, I can ask the party that disclosed information to the Company to permit me to inspect and copy the information it disclosed. I understand that I can refuse to sign this disclosure authorization; however, if I do so, Company may deny my claim for benefits pursuant to the plan. The use and further disclosure of information disclosed hereunder may not be subject to the Health Insurance Portability and Accountability Act (HIPAA). I hereby represent that I am authorized to execute this Disclosure Authorization for the release of this information. Signature of Claimant or Claimant’s Authorized Representative: Date: Relationship, if other than Claimant: Claimant’s Date of Birth: “Company” refers to: Life Insurance Company of North America Connecticut General Life Insurance Company New York Life Group Insurance Company of NY CLICK TO SUBMIT © 2020-2023, New York Life Insurance Company, New York, NY. All rights reserved. NEW YORK LIFE and the New York Life box logo are registered trademarks of New York Life Insurance Company. Life Insurance Company of North America and New York Life Group Insurance Company of NY are subsidiaries of New York Life Insurance Company. Connecticut General Life Insurance Company is not affiliated with New York Life Insurance Company. Page 4 of 9 LMS-613500 Revised 10/2023

Electronic Communications Disclosure and Consent Please read this information carefully. Then, print and keep a copy for yourself. As a valued New York Life Group Benefit Solutions (NYL GBS) customer, we send you information about your benefits through the mail. This information may include: • Claim forms, authorizations, disclosures, affidavits, electronic funds transfer agreements, privacy notices, and letters letting you know about changes to any of these items • Claim status updates letting you know that we’ve received a claim, or that we’ve updated the status of a claim • Letters asking you, or someone else, for additional information to help with the review of a claim. Did you know that you may also give us consent to send you this information electronically? NYL GBS has an easy to use secure email encryption tool that allows us to communicate with you electronically. All you need is a computer, internet access, and a personal email address (called a Designated Email). By giving us your consent, you understand you may no longer receive information in paper form and you accept responsibility for promptly reviewing the secure emails you receive. This ensures you can take appropriate action so that any benefits you are eligible for are not delayed or that any rights you have are not affected. If downloading communications from a secure portal, delivery of information sent to you is deemed complete once all of data comprising the information has been uploaded to our secure web portal. If receiving communications by secure email, delivery of information sent to you is deemed complete once all data comprising the information has been received by the email server of the system used to provide your Designated Email. What do I need to know before I give my consent? Access to Paper Copies At any time, you can still request paper copies of information. Simply email us from your valid Designated Email, call or send us a letter by mail to: New York Life Group Benefit Solutions, P.O. Box 22328, Pittsburgh, PA 15222-0328 We keep copies of the information we email for the time periods required by law. We recommend saving or printing copies of the information you get electronically to ensure you have it when you need it. System Requirements To use the NYL GBS secure email tool, access messages, and keep copies of the information we send, you must have a working, personal Designated Email address and a computing or communications device with: • Working Internet access • Web browser that supports 128-bit encryption (such as Chrome ®, Firefox®, Microsoft Edge® , or Safari®), • 16 MB of available memory (32 MB of RAM recommended) and • ® Reader® 4.0 or higher). Program that can view, save and print PDF files (such as Adobe Our Right to Send Paper We have the right to send you information through the mail even if you agreed to receive it electronically. For example, we may send you a letter through the mail if we have a system outage, if we suspect fraud, if for any reason your Designated Email does not accept emails from us, or if we receive notification that you have not opened your email messages. Modification of Consent Terms We reserve the right to modify (change) these terms and conditions if we choose. We will provide you with notice of a modification electronically, and the date it is to go into effect. If you do not agree to the new terms and conditions in the notice, you may provide your Withdrawal of Consent before the effective date. Failure to withdraw your consent, or follow the instructions in the notice, lets us know that you agree to the new terms. Please review and keep for your records. © 2023, New York Life Insurance Company, New York, NY. All rights reserved. NEW YORK LIFE and the box logo are trademarks of New York Life Insurance Company. New York Group Benefit Solutions products and services are provided by Life Insurance Company of North America and New York Life Group Insurance Company of NY, subsidiaries of New York Life Insurance Company. Page 5 of 9 LMS-613500 Revised 10/2023

Withdrawal of Consent Your consent remains in effect until you tell us otherwise and provide a Withdrawal of Consent. You may withdraw your consent at any time if you decide you want to go back to paper information. To contact us, you may email using the same valid, personal e-mail address you used to register for secure emails, call, or send us a letter by mail (See office address above). Withdrawing your consent will let us know that you want to stop receiving secure emails. It will not change the outcome of any information we have already sent you. Your Consent Please read the following paragraph, make your selection, print and sign your name, enter the date, give us your email address. By signing my name below, I agree that I have read the information about the NYL GBS secure email tool and I wish to receive information electronically from NYL GBS. I also agree that: 1. I have technology that meets the System Requirements highlighted above. 2. I have received written instruction on how to receive and manage messages using the email tool. 3. I will provide and maintain a valid Designated Email and verify that this email belongs to me. I agree to notify GBS of any changes to my Designated Email, including the email address itself, by calling or sending a letter through the mail. (See office information listed above). 4. I understand that NYL GBS may only send me information electronically from this point forward unless I withdraw my consent. 5. I understand that the date my signature is affixed below is the effective date of my consent. If NYL GBS does not receive your signed Consent, NYL GBS will continue to send paper communications. If you do not wish to receive information electronically from NYL GBS, do not sign or return this form to NYL GBS. Select One: I consent to receive information electronically for ALL claims for which I may be eligible for benefits. Name: Email Address: (Please print clearly) (Please print clearly) Signature: Date: Employee Name: Employee Date of Birth: Please review and keep for your records. Page 6 of 9 LMS-613500 Revised 10/2023

New York Life Group Benefit Solutions (NYL GBS) Survivor Assurance Disclosure Notice NYL GBS Survivor Assurance Disclosure If your insurance benefit is $5,000 or more, NYL GBS will establish a free, interest-bearing draft account in your name. This account is a convenient and secure place to keep your proceeds while you decide how to best use them. A supply of personalized drafts (checks) will be mailed to you, once your claim has been approved. Personalized drafts are provided free of charge, and there are no per-draft fees, maintenance charges or penalties for withdrawal. There are charges for the following special services: drafts returned unpaid ($10), stop payment ($12) and copy of draft or statement ($2). You will receive a quarterly statement for your NYL GBS Survivor Assurance account, which will detail your account balance, interest earned, drafts cleared, and current interest rate. You may also check your account balance online at any time at www.nylgbssurvivorassurance.com. Drafts are cleared through a draft account at BNY Mellon Bank (contact information on next page). NYL GBS’s obligation to pay is satisfied by depositing the total proceeds in the retained asset account. Drafts draw upon funds held by NYL GBS (whereas a "check" draws upon funds held by a banking institution). You may write an unlimited number of drafts, in any amount, at any time up to your account balance. If you wish to withdraw the proceeds in full, you can write a draft for the total amount of the account at any time. You also have the right to receive an initial lump-sum payment in the form of a bank check. Please note that NYL GBS reserves the right to reduce account balances for any payment made in error. You also have the right to name a beneficiary to your account. If an account becomes inactive (as defined by your State’s Department of Insurance), NYL GBS will return any remaining balance held in a RAA to your State of residence if no named beneficiary can be located. This account is not insured by the Federal Deposit Insurance Corporation or any federal agency, but is guaranteed by the state guarantee association. Please contact the National Organization of Life and Health Insurance website (www.nolhga.com ) to learn more about the coverage limitations to the account under a state guaranty association. All funds are held by the insurance company, or one of its affiliates, which, like a bank, may earn money on the invested amounts that exceed the interest credited to the account and the cost of the additional benefits and services described below. For beneficiaries under policies issued by Connecticut General Life Insurance Company (CGLIC) and Life Insurance Company of North America (LINA), the custodian of the account funds will be CGLIC. For beneficiaries under policies issued by New York Life Group Insurance Company of NY (NYLGICNY), the custodian of the accounts funds will be NYLGICNY. Disclosure on Interest Earned You earn an attractive interest rate on the funds in your NYL GBS Survivor Assurance Account from the day it is established until the date it is closed. The NYL GBS Survivor Assurance interest rate is reviewed weekly and will be based upon the previous week’s Bank Rate Monitor Index (BRM) or any successor money market index. The BRM Index is the average annual effective yield earned on the money market accounts offered by 100 large US Bank and Thrifts across the country. Any amount that remains in the account will continue to earn interest at a rate equal to the national average bank money market rate. Please call our toll-free number 855.836.0697 for the current rate. Both your principal and any interest you earn are guaranteed by the insurance company. Any interest earned on the account may be taxable and you should consult a tax, investment, or other financial advisor regarding tax liability and investment options. Interest earned on your account is compounded daily and is credited to your account at the end of each month. All funds, including earned interest, are fully guaranteed by the insurance company. If you have additional questions or would like additional information about the NYL GBS Survivor Assurance, you can call us at 800.570.3778 Or write us at: NYL GBS Survivor Assurance PO Box 534029 Pittsburgh, PA 15253-4029 For further information, please contact your State Department of Insurance using the information provided on the next page. Draft Accounts are setup by BNY Mellon Bank, located at 500 Ross Street, Pittsburgh, PA 15262. The issuance of this notice is not the admission of the existence of any insurance nor does it recognize the validity of any claim and is without prejudice to the company’s legal rights with respect to the insurance. Page 7 of 9 LMS-613500 Revised 10/2023

NYL GBS Survivor Assurance Disclosure Notice State Insurance Department Contact Information Alabama Alaska Arizona Arkansas California PO Box 303351 PO Box 110805 100 N. 15th Ave, Suite 261 1 Commerce Way, Bldg 4, Suite 502 300 South Spring Street, 14th Floor Montgomery, AL 36130 Juneau, AK 99811 Phoenix, AZ 85007-2630 Little Rock, AR 72202 South Tower (334) 269-3550 (907) 465-2515 (602) 364-3100 (800) 282-9134 Los Angeles, CA 90013 www.aldoi.gov https://www.commerce.alaska.gov/web/ins/ https://insurance.az.gov www.insurance.arkansas.gov (800) 927-4357 www.insurance.ca.gov Colorado Connecticut Delaware District of Columbia Florida 1560 Broadway, Suite 850 153 Market Street, 7th Floor Delaware Dept of Insurance 1050 First Street, NE, Suite 801 The Edwin A. Larson Building Denver, CO 80202 Hartford, CT 06103 1351 W. North Street, Suite 101 Washington, DC 20002 200 East Gaines Street, RM 1001A (800) 930-3745 (800) 203-3447 Dover, DE 19004 (202) 727-8000 Tallahassee, FL 32399 https://doi.colorado.gov/ www.ct.gov/cid/site/default.asp (800) 282-8611 http://disb.dc.gov (877) 693-5236 http://insurance.delaware.gov www.floir.com Georgia Hawaii Idaho Illinois Indiana Office of Insurance and PO Box 3614 700 West State Street 122 S. Michigan Avenue, 19th Floor 311 W Washington Street Safety Fire Commissioner Honolulu, HI 96811 PO Box 83720 Chicago, Illinois 60603 STE 103 Two Martin Luther King, Jr. Drive (808) 586-2790 Boise, ID 83720 (312) 814-2420 Indianapolis, IN 46204 West Tower, Suite 704, Floyd Bldg. https://cca.hawaii.gov/ins/ (208) 334-4250 https://insurance.illinois.gov/ (317) 232-2385 Atlanta, Georgia 30334 www.doi.idaho.gov https://www.in.gov/idoi (800) 656-2298 https://oci.georgia.gov Iowa Kansas Kentucky Louisiana Maine 1963 Bell Avenue, Suite 100 1300 SW Arrowhead Road 500 Mero Street, 2 SE11 PO Box 94214 34 State House Station Des Moines, Iowa 50315 Topeka, Kansas 66604 Frankfort, KY 40601 Baton Rouge, Louisiana 70802 Augusta, ME 04333 (515) 654-6600 (800) 432-2484 (800) 595-6053 (800) 259-5300 (800) 300-5000 www.iid.state.ia.us https://insurance.kansas.gov https://insurance.ky.gov/ https://ldi.la.gov https://www.maine.gov/pfr/insurance/home Maryland Massachusetts Michigan Minnesota Mississippi 200 St. Paul Place, Suite 2700 1000 Washington Street, Suite 810 PO Box 30220 85 7th Place East, Suite 280 PO Box 79 Baltimore, MD 21202 Boston, MA 02118 Lansing, MI 48909 Saint Paul, MN 55101 Jackson, MS 39205 (800) 492-6116 (877) 563-4467 (877) 999-6442 (651) 539-1500 (800) 562-2957 http://insurance.maryland.gov https://www.mass.gov www.michigan.gov/ofir https://mn.gov/commerce www.mid.state.ms.us Missouri Montana Nebraska Nevada New Hampshire PO Box 690 840 Helena Ave. PO Box 95087 1818 E. College Pkwy., Suite 103 21 South Fruit Street, Suite 14 Jefferson City, MO 65102 Helena, MT 59601 Lincoln, NE 68509 Carson City, NV 89706 Concord, NH 03301 (800) 726-7390 (800) 332-6148 (877) 564-7323 (888) 872-3234 (800) 852-3416 www.insurance.mo.gov https://csimt.gov www.doi.nebraska.gov https://doi.nv.gov www.nh.gov/insurance New Jersey New Mexico New York North Carolina North Dakota 20 West State Street 1120 Paseo De Peralta One State Street 1201 Mail Service Center 600 E. Boulevard Ave., 5th Floor PO Box 325 Santa Fe, New Mexico 87501 New York, NY 10004 Raleigh, NC 27699 Bismarck, ND 58505 Trenton, NJ 08625 (855) 427-5674 (800) 342-3736 (855) 408-1212 (701) 328-2440 (800) 446-7467 www.osi.state.nm.us www.dfs.ny.gov www.ncdoi.gov https://www.insurance.nd.gov www.state.nj.us/dobi/index.html Ohio Oklahoma Oregon Pennsylvania Puerto Rico 50 W. Town Street, Suite 300 400 NE 50th Street PO Box 14480 1326 Strawberry Square 361 Calle Calaf Columbus, OH 43215 Oklahoma City, Oklahoma 73105-1816 Salem, OR 97309 Harrisburg, PA 17120 PO Box 195415 (800) 686-1526 (800) 522-0071 (888) 877-4894 (877) 881-6388 San Juan, Puerto Rico 00919 www.insurance.ohio.gov https://www.oid.ok.gov http://dfr.oregon.gov www.insurance.pa.gov (787) 304-8686 English: https://ocs.pr.gov/English Spanish: https://ocs.pr.gov Rhode Island South Carolina South Dakota Tennessee Texas 1511 Pontiac Avenue, Building 69-2 PO Box 100105 124 South Euclid Avenue, 500 James Robertson Pkwy. PO Box 12030 Cranston, RI 02920 Columbia, SC 29202 2nd Floor Nashville, TN 37243 Austin, TX 78711-2030 (401) 462-9500 (803) 737-6180 Pierre, SD 57501 (800) 342-4029 (800) 578-4677 https://www.dbr.ri.gov/divisions/insurance www.doi.sc.gov (605) 773-3563 www.tn.gov/commerce/insurance www.tdi.texas.gov https://dlr.sd.gov/insurance Utah Vermont Virginia Virgin Islands Washington 4315 S. 2700 W., Suite 2300 89 Main Street Bureau of Insurance - SCC For St. Croix PO Box 40255 Taylorsville, Utah 84129 Montpelier, VT 05620-3101 PO Box 1157 1131 King Street, 3rd Floor, Suite 101 Olympia, WA 98504 (800) 439-3805 (833) 337-4685 Richmond, VA 23218 Christiansted, St. Croix, VI 00820 (800) 562-6900 www.insurance.utah.gov https://dfr.vermont.gov (800) 552-7945 (340) 773-6449 www.insurance.wa.gov www.scc.virginia.gov/boi https://ltg.gov.vi West Virginia Wisconsin Wyoming PO Box 50540 PO Box 7873 106 East 6th Avenue For St. Thomas/St. John Charleston, WV 25305 Madison, WI 53707 Cheyenne, WY 82002 5049 Kongens Gade (888) 879-9842 (800) 236-8517 (800) 438-5768 St. Thomas, Virgin Islands 00802 www.wvinsurance.gov www.oci.wi.gov https://doi.wyo.gov (340) 774-2991 https://ltg.gov.vi The issuance of this notice is not the admission of the existence of any insurance nor does it recognize the validity of any claim and is without prejudice to the company’s legal rights with respect to the insurance. Page 8 of 9 LMS-613500 Revised 10/2023

Important Claim Notice Arizona Residents: Arizona Residents: 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. California Residents: California Residents: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Colorado Residents: Colorado Residents: 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. District of Columbia Residents: District of Columbia Residents: 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 Residents: Florida Residents: 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. Kansas Residents: Kansas Residents: Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any material fact thereto, may be guilty of insurance fraud determined by a court of law. Kentucky Residents: Kentucky Residents: 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 Residents: Louisiana Residents: 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. Maryland Residents: Maryland Residents: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or 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 Residents: Minnesota Residents: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. New Jersey Residents: New Jersey Residents: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Oregon Residents: Oregon Residents: Any person who includes any false or misleading information on an application for an insurance policy, may be guilty of fraud and may be subject to civil or criminal penalties if intentional and material to the risk assumed. Pennsylvania Residents: Pennsylvania Residents: 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 Residents: Caution: Puerto Rico Residents: Caution: 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 by 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 be 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. Rhode Island Residents: Rhode Island Residents: 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. Tennessee Residents: Tennessee Residents: 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 Residents: Texas Residents: 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 Residents: Virginia Residents: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits application or files a claim containing a false or deceptive statement may have violated state law. Washington Residents: Washington Residents: 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. CLICK TO PRINT Page 9 of 9 LMS-613500 Revised 10/2023