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