Wellness Claim Form

GCIFM-7261 Wellness Benefit Reimbursement 1 of 4 04/23 Sun Life Assurance Company of Canada Wellness / Cancer Screening Claim Statement I nstructions The following benefits, subject to the election of your employer, may be covered under your Certificate. The Accident, Critical Illness, and Hospital Indemnity policies provide one Wellness Benefit per calendar year per covered person from the list of covered benefits. The Cancer policy provides one Cancer Screening Benefit per calendar year per covered person from the policy list of covered benefits. See the policy for details of covered items and services. Only tests and procedures listed in the policy are eligible for benefit payment. Complete a separate form for each family member and date of service. Complete all applicable sections. You must include the: • name of the provider of the service • type of service • date of service Submit this form to the address, fax number or e-mail address stated at the bottom of this form. Note: Some policies do not contain the Wellness Benefit. 1 | Employer infor m ation Employer name Policy number 2 | Insured information Insured name M F Social Security number Date of birth (mm/dd/yyyy) Insured street address City State Zip code Insured phone number E-mail address 3 | Claimant information Claiming benefits for: Insured Spouse Dependent child Check all the coverages in place for the insured on the service date of the screening: Accident policy Critical Illness policy Cancer policy Hospital Indemnity policy Claimant name M F Social Security number Date of birth (mm/dd/yyyy) Provider name Provider phone number Date of service (mm/dd/yyyy) Provider street address City State Zip code Claimant home phone number Claimant work phone number

GCIFM-7261 Wellness Benefit Reimbursement 2 of 4 04/23 4 | Wellness /Cancer screening information Please check off the appropriate box that best describes the screening test completed. Annual physical examination Abdominal and aortic aneurysm ultrasonography Biopsy for cancer Bone density screening Bone marrow testing Breast Cancer Screening (clinical breast exam, mammography*, MRI, thermography, ultrasound, cervical cancer screening BRCA testing CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) Cardiac Exercise Stress Test Carotid Doppler CEA (blood test for colon cancer) Chest x-ray Colorectal Cancer Screening (fecal occult blood test, colonoscopy, sigmoidoscopy) CT angiography CT scans or MRI scans Dental examination Diabetes tests (fasting blood glucose test, hemoglobin A1c) Double contrast barium enema Echocardiogram Electrocardiogram (ECG) - resting or stress Gynecological exam (PA only) Hemocult Stool Analysis Immunizations (includes flu shots) Interscholastic Sports Physical Exam Lipid panel (cholesterol, triglycerides, HDL, LDL) Lymphocyte genome sensitivity test (LGS) (universal blood test for cancer) Pap smear (including ThinPrep) Prostate Cancer Screening (digital rectal exam, PSA blood test) Serum Protein Electrophoresis (blood test for myeloma) Skin Cancer Screening Smoking cessation program Testicular ultrasound Vision examination Weight reduction program *For TN, see policy for mammography benefit

GCIFM-7261 Wellness Benefit Reimbursement 3 of 4 04/23 5 | Fraud warnings General 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 subjects such person to criminal and civil penalties. AK : 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. AL : Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. AR, LA, MA, MN, TX and WV : 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. AZ : 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. CA : 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. CO : 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. DC : 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. DE, ID and IN : 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. FL : 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. KS : 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 may be guilty of insurance fraud as determined by a court of law. KY : 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. MD : 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. ME: 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. NH : 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 RSA 638:20. NJ : Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. NM: 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.

Contact us By mail Sun Life Assurance Company of Canada P.O. Box 9757 Portland, ME 04104 By fax 866.376.9480 By e-mail [email protected] www.sunlife.com/us Customer Service 877 - 820 - 5306 M–F 8:00 a.m. – 8:00 p.m., ET Sun Life Assurance Company of Canada is a member of the Sun Life group of companies. © 2023 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. The Sun Life name and logo are registered trademarks of Sun Life Assurance Company of Canada. GCIFM-7261 Wellness Benefit Reimbursement 4 of 4 04/23 5 | Fraud warnings , continued O H: 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. OK : 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. OR : Any person who, with intent to defraud or knowingly providing false information may be guilty of fraud and may be subject to civil or criminal penalties. PR : 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. RI : 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. TN and WA: 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. VA : 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 have violated state law. VT : Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. 6 | Signature I/we understand that all or part of the information provided may be communicated between the Sun Life Assurance Company of Canada (the “Company”) and its affiliates. The information provided may be shared to process transactions that concern any coverage I may have requested or have with the Company or as permitted by law. I have read or had read to me the fraud warning for my state. Claimant name Policy number Claimant signature or authorized representative X Date