Group Long Term Disability Claim Form

500469 Rev. 04/2021 PLEASE DESCRIBE IN YOUR OWN WORDS WHAT IS WRONG WITH YOU (IF ACCIDENT, OR WORK-RELATED, DESCRIBE CIRCUMSTANCES) Are you married, or do you have a domestic partner or civil union partner? Do you have any children under age 25? Do you have any handicapped children (regardless of age)? If you answered "Yes" to any of the above questions, please list below. SOCIAL SECURITY NO. NAME ( Last, First, M.I.) MAILING ADDRESS (Address where you may be reached during the next six months) DATE OF ACCIDENT OR BEGINNING OF SICKNESS FIRST DATE YOU WERE UNABLE TO WORK DATE YOU PLAN TO RETURN TO WORK NAMES OF HOSPITALS COMPLETE ADDRESS NAMES OF ALL ATTENDING PHYSICIANS CONSULTED FOR THE DISABILITY LIST STATES IN WHICH YOU MAY BE LIABLE FOR FILING TAX RETURNS COMPLETE ADDRESS AND PHONE NUMBER DATE FIRST CONSULTED DATE ENTERED-DATE DISCHARGED Please provide the name of your medical insurance carrier 5. If yes, please attach a copy of your Social Security notice for you and your dependents or a copy of your Social Security denial. If you have not applied, please do so as soon as possible. If you have not received a determination, please attach a copy of your receipt for application. 1. Date Paid Thru Salary Continuance State Disability Benefits Group Disability Benefits Workers Compensation Pension Benefits No-Fault Auto Disability insurance Any other Disability Income (please identify) Veterans Benefits Date Began $ Amount/Frequency Are you receiving or eligible to receive: I CERTIFY THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT. SIGNATURE OF EMPLOYEE: DATE: TO BE COMPLETED BY THE EMPLOYEE SEX (Zip Code) PLEASE TYPE OR PRINT BE SURE TO ANSWER ALL QUESTIONS - FAILURE TO DO SO MAY DELAY YOUR CLAIM USE SEPARATE PIECE OF PAPER TO COMPLETE ANSWERS IF NECESSARY DATE OF BIRTH NAME RELATIONSHIP GENDER DATE OF BIRTH SOCIAL SECURITY NO. PHONE NUMBER (Includes Area Code) Have you applied for Social Security Benefits? 2. 3. 4. F M No Yes No Yes No Yes F M F M F M F M F M No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes 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. For residents of the following states, please see the last page of this form: California, Colorado, District of Columbia, Florida, Kansas, Kentucky, Louisiana, Maryland, Minnesota, New Jersey, Oregon, Pennsylvania, Puerto Rico, Rhode Island, Tennessee, Texas, Virginia or Washington. New York Life Group Benefit Solutions P.O. Box 709015 Dallas, TX 75370-9015 Facsimile (800) 642-8553 MAIL OR FAX TO: Life Insurance Company of North America New York Life Group Insurance Company of NY Group Long Term Disability 2021, 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. New York Life 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.

500469 Rev. 04/2021 PLEASE COMPLETE IN FULL TO BE COMPLETED BY THE EMPLOYER NAME OF EMPLOYEE ( Last, First, M.I.) SOCIAL SECURITY NO. ACCOUNT NUMBER DATE HIRED EFFECTIVE DATE OF EMPLOYEES LTD COVERAGE WITH NEW YORK LIFE GROUP BENEFIT SOLUTIONS WAS EMPLOYEES LTD INSURANCE ISSUED ON THE BASIS OF A STATEMENT OF PHYSICAL CONDITION? IF YES, ATTACH COPY BASIC EARNINGS Wk. Mo. DATE OF LAST CHANGE IN EARNINGS LAST DATE(S) WORKED # Hrs. Supervisory DATE(S) RETURNED TO WORK PLEASE CHECK THE APPROPRIATE BLOCKS: Exempt Management Union Local # Salaried Full Time Part Time Non-Supervisory Non-Exempt Non-Management Non-Union Hourly Hrs/wk: HAS EMPLOYEE BEEN TERMINATED? NAME AND ADDRESS OF WC CARRIER AND WC CLAIM NUMBER IS EMPLOYEE ELIGIBLE FOR GROUP PENSION $ % IF YES, MONTHLY AMOUNT EMPLOYEE % CONTRIBUTION To Pension $ IF YES, DATE REASON PERCENTAGE OF EMPLOYEE CONTRIBUTION TOWARD DISABILITY PREMIUM(see Internal Revenue Code Section 105(a) and Regulations thereunder) PREMIUM PAID THRU DATE % WAS SALARY CONTINUED BEYOND LAST DAY WORKED? HAS EMPLOYEE RECEIVED SHORT TERM BENEFITS? HAS EMPLOYEE RECEIVED STATE DISABILITY BENEFITS? HAS EMPLOYEE FILED A WORKERS COMPENSATION CLAIM? DISABILITY PENSION IF YES, WEEKLY AMOUNT PAID THRU EFFECTIVE IF YES, WEEKLY AMOUNT FROM IF YES, WEEKLY AMOUNT IS THIS A FROM $ EARLY RETIREMENT IF YES, WEEKLY AMOUNT $ $ THRU approved or pending? NORMAL RETIREMENT If yes, THRU FROM THRU LIST ANY OTHER SOURCE OF INCOME TO WHICH THE EMPLOYEE IS ENTITLED AS A RESULT OF THIS DISABILITY OCCUPATION (ATTACH JOB DESCRIPTION IF AVAILABLE: IF NOT, DESCRIBE JOB DUTIES BELOW) Was employees job primarily sedentary or did it involve considerable physical activity? AS CLOSELY AS POSSIBLE, PLEASE ESTIMATE THE PERCENT OF TIME SPENT (TOTAL PERCENTAGE MUST EQUAL 100%): Sitting Standing Walking Climbing Stooping Bending Pushing Lifting Carrying* *If job duties require lifting or carrying, indicate average and maximum weights handled. REMARKS EMPLOYER DIVISION ADDRESS TELEPHONE NUMBER AUTHORIZED REPRESENTATIVE DATE PRINT: SIGNATURE: HAVE ALL PAGES OF THE FORM BEEN COMPLETED IN FULL? ATTACH THE ATTENDING PHYSICIANS STATEMENT OF DISABILITY AND ANY OTHER DOCUMENTATION. Page 2 of 4 EMPLOYEES CONTRIBUTIONS WERE MADE ON: No Yes No Yes No Yes No Yes No Yes No Yes No Yes Post-tax Basis Pre-tax or

500469 Rev. 04/2021 Page 3 of 4 Information about my health may relate to any disorder of the immune system including but not limited to HIV and AIDS; use of drugs or alcohol; and mental and physical history, condition, advice or treatment, but does not include psychotherapy notes or genetic information. Disclosure Authorization Claimants Name: NOTE: This authorization is designed to comply with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and relates to information necessary to administer benefits and services under Employers employee health and welfare plan(s) ("the Plan") and statutory and/or private leave of absence or job accommodation programs. "Employer is defined to mean your employer, or your family members employer to the extent benefits, services, or leave are being sought under your family members employers Plan. You are not required to sign the authorization, but if you do not, the Plan, insurers or other providers may not be able to process your (or your family members) request for benefits or services under the Plan or statutory and/or private leave of absence or job accommodation programs. AUTHORIZATION I authorize any physician, medical professional or other health care provider, hospital or other medical facility; pharmacy; health plan; other medically related entity; rehabilitation professional; vocational evaluator; employee assistance plan; insurance company, reinsurer, health maintenance organization, third party administrator, broker or other insurance service provider, or similar entity; the Medical Information Bureau; the Association of Life Insurance Companies, which operates the Health Claims Index and the Disability Income Record System; government organization or agency, including the Social Security Administration; social security disability advocate or representative; financial institution, accountant or tax preparer; consumer reporting agency; and employer or group policyholder that has information about my health, prescriptions, financial, earnings or employment history, or other insurance claims and benefits, to provide access to or copies of this information (whether by written, telephonic or electronic means) to Life Insurance Company of North America; New York Life Group Insurance Company of NY (Life Insurance Company of North America and New York Life Group Insurance Company of NY shall be collectively referred to as "Insurance Company"); and any other individual or entity (including nonaffiliated third parties) that provides services to or insurance benefits on behalf of the Plan and/or Employers statutory and/or private leave of absence or job accommodation programs. If I am also covered by Cigna Health and Life Insurance Company or its affiliates (Cigna), I authorize Insurance Company to disclose the health and other information described above to Cigna to assist me with my health coverage and to provide its services and benefits. This information will be shared to coordinate benefits and provide other services to you. I agree and understand that any information obtained with this authorization may be used and disclosed for the following purposes: 1) evaluating and administering coverage, including any claim for benefits, or otherwise providing services related to or on behalf of the Plan; 2) evaluating and administering services related to Employers statutory and/or private leave of absence or job accommodation programs; 3) determining my eligibility for any governmental benefits similar to or that coordinate with benefits available to me under the Plan and assisting me in applying for such benefits; and 4) evaluating and administering benefits or services under any other plans sponsored by or offered through Employer such as health management, disease management, wellness, or employee/member assistance programs. I understand that the information disclosed under this authorization is subject to redisclosure and may no longer be protected by HIPAA or other federal regulations governing the privacy of health information, although it may continue to be protected by other applicable privacy laws and regulations. I further understand that if any information is used for services relating to Employers leave of absence or job accommodation programs, that information may be disclosed to Employer at any time. Additionally, I understand that information may be disclosed to the employee who elected my coverage or submitted a claim for benefits under my coverage, or requested leave. This authorization shall be valid for 12 months or the duration of my claim for insurance benefits, whichever is longer. I also understand that Insurance Company will maintain a copy of this authorization, and that I am entitled to a copy of this authorization and a photographic or electronic copy of it is as valid as the original. I understand that I do not have to give this authorization. If I choose not to give the authorization - or if I later revoke - I understand that the Plan, insurers, or other providers of services or benefits related to the Plan or Employers statutory and/or private leave of absence or job accommodation programs who rely on this authorization may not be able to evaluate or administer any request for benefits, coverage or services and that any request for benefits, coverage or services may be denied as a result. I may revoke this authorization by sending written notice to the Claim Manager handling the claim. (Claimants Signature) (Date Signed) (Print Name) (Date of Birth) I signed on behalf of the claimant as (indicate relationship). If Power of Attorney Designee, Guardian, or Conservator, please attach a copy of the document granting authority. 2020 - 2021, 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. Cigna Health and Life Insurance Company is not affiliated with New York Life Insurance Company.

500469 Rev. 04/2021 Page 4 of 4 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: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. 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. IMPORTANT CLAIM NOTICE 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 settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. 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. 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. 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. 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. 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. 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. 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. 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. 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. California 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. 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. 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. 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. 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.