HOSPITAL INDEMNITY CLAIM FORM

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1 HOSPITAL INDEMNITY CLAIM FORM Please ead the impotant infomation below: Please send the completed claim fom, signed authoization, and itemized bills to: Please be sue you policy numbe(s) is/ae witten on the claim fom. The claim fom must be completed and signed by the Insued. If you policy has been in foce less than two yeas fom when you claim was incued, a completed claim fom, signed authoization and the billing statements mentioned below. If you policy has been in foce moe than two yeas fom when you claim was incued, a claim fom only needs to be completed fo a claim involving an injuy The HIPAA Authoization to Pemit Use and Disclosue of Health Infomation must be signed, dated and included with you submission, so that we can contact you medical povide on you behalf if additional infomation is needed. Fo faste pocessing of you hospital benefits, ask you medical povide to pint a UB-04 fom along with an itemized bill (fo hospital expenses). A UB-04 fom with itemized bill ae statements that indicate: Guaantee Tust Life Insuance P.O. Box 1144 Glenview, Illinois OR Fax to: (847) OR to: If you signed an Assigment of Benefits with the hospital and you have a balance still due, we will have to pay benefits diectly to the povide; othewise, benefits will be sent to you. NOTE: You Policy may have a 6 Month Pe-Existing Conditions Limitation and a 2 Yea Policy Contestability Peiod. If you claim happened duing one of these peiods, additional infomation may be equied. If we need to equest any additional infomation and we have you signed HIPAA Authoization, we will handle these equests diectly with you medical povide(s) and will notify you of ou action and any delays. We suggest you make photocopies of any infomation sent fo you own ecods. Pocessing delays may esult if you do not povide the above infomation. 1. The date(s) of teatment, 2. The type(s) of sevice, 3. The diagnosis, 4. The medical povide s name and addess, 5. The individual chage fo each expense. Fo assistance, please contact ou Custome Sevice Depatment (800) HICF 07/16

2 Mail claims to: P.O. Box 1144 Glenview, Illinois O fax to: (847) O to: Fo Custome Sevice, please call: (800) HOSPITAL INDEMNITY CLAIM FORM COMPLETED BY THE INSURED Policy Numbe(s) Name of Insued Name of Patient Altenate Name Addess (Steet) (City) (State) (Zip Code) Phone (Please povide fo faste sevice) COMPLETED ON PATIENT What condition is causing the claim? Date patient fist became ill o date of accident If an accident, how did it happen? Date patient fist saw docto fo this condition? / / Did you o will you file a Wokes Compensation claim? Yes No If yes, what is the employe s name and addess? Teating docto s name, addess and phone numbe Family docto s name, addess and phone numbe Othe doctos seen duing the last two yeas please include thei addess and phone numbe (if moe space is needed, attach sepaate sheet) I undestand that this infomation will be used by Guaantee Tust Life Insuance Company fo the pupose of evaluating my claim fo insuance benefits. I epesent that the answes to the above questions ae complete, tue and coect to the best of my knowledge and belief. I undestand that I o my authoized epesentative is entitled to eceive a copy of the authoization upon equest. Insued Membe Signatue Pint Name: Date: HICF 07/16

3 Guaantee Tust Life Insuance Company P.O Box 1144, Glenview, Illinois HIPAA AUTHORIZATION To Pemit Use and Disclosue of Health Infomation This Authoization was pepaed by GTL fo puposes of obtaining infomation necessay to pocess a claim fo benefits. Policy/Cetificate # Upon pesentation of the oiginal o a photocopy of this signed Authoization, I authoize, without estiction (except psychotheapy notes), any licensed physician, medical pofessional, hospital o othe medical-cae institution, insuance suppot oganization, phamacy, govenmental agency, insuance company, goup policyholde, employe o benefit plan administato to povide Guaantee Tust Life Insuance Company (GTL) o an agent, attoney, consume epoting agency o independent administato, acting on it s behalf, all infomation concening advice, cae o teatment povided the patient, employee o deceased named below, including all infomation elating to, mental illness, use of dugs o use of alcohol. This Authoization also includes infomation povided to ou health division fo undewiting o claim sevicing and infomation povided to any affiliated insuance company on pevious applications. If this Authoization is fo someone othe than myself, that individual and my authoity to act on thei behalf is explained below. I undestand that I o my authoized epesentative is entitled to eceive a copy of the Authoization upon equest. I undestand that I have the ight to evoke this Authoization, in witing, at any time by sending witten notification to my (ou) agent o to the Company at the above addess. I undestand that a evocation will not be effective to the extent the Company has elied on the use o disclosue of the potected health infomation o if my Authoization was obtained as a condition to detemine my eligibility fo benefits. Revocation equests must be sent in witing to the attention of the Claim Depatment Manage. I undestand that Guaantee Tust Life Insuance Company may condition payment of a claim upon my signing this Authoization, if the disclosue of infomation is necessay to detemine the level o validity of the claim payment. I also undestand once infomation is disclosed to us pusuant to this Authoization, the infomation will emain potected by GTL in accodance with fedeal o state law. This authoization shall emain in foce and in effect until two (2) yeas fom the date this authoization is signed at which time this authoization will expie. (Pint Please) Name of Patient Date of Bith Signatue of Patient Date (Please Pint) Name of Authoized Repesentative, o Next of Kin Relationship of Authoized Repesentative o Next of Kin to Patient Signatue of Authoized Repesentative o Next of Kin Date AUTH15-01 CLAIM (A) 07/15

4 Dea Insued: Below is a listing of the faud language that you State Depatment of Insuance equies us to give to you. Please fist locate you state of esidence and then ead the faud language that petains to you state. Thank you. Connecticut Geogia Hawaii Iowa Illinois Kansas Massachusetts Michigan Missoui Mississippi Montana Nebaska Noth Caolina Noth Dakota Nevada South Caolina South Dakota Utah Vemont Wisconsin Wyoming Geneic Faud Waning (to be used fo above states only) Any peson who knowingly pesents a faudulent claim containing any false o misleading infomation is guilty of insuance faud and may be subject to fines and confinement in pison. Alabama Any peson who knowingly pesents a false o faudulent claim fo payment of a loss o benefit o who knowingly pesents false infomation in an application fo insuance is guilty of a cime and may be subject to estitution, fines, o confinement in pison, o any combination theeof. Alaska A peson who knowingly and with intent to injue, defaud, o deceive an insuance company files a claim containing false, incomplete, o misleading infomation may be posecuted unde state law. Aizona - Fo you potection Aizona law equies the following statement to appea on this fom. Any peson who knowingly pesents a false o faudulent claim fo payment of a loss is subject to ciminal and civil penalties. Akansas, Louisiana, Rhode Island and West Viginia Any peson who knowingly pesents a false o faudulent claim fo payment of a loss o benefit o knowingly pesents false infomation in an application fo insuance is guilty of a cime and may be subject to fines and confinement in pison. Califonia Fo you potection Califonia law equies the following to appea on this fom: Any peson who knowingly pesents false o faudulent claim fo the payment of a loss is guilty of a cime and may be subject to fines and confinement in state pison. Coloado It is unlawful to knowingly povide false, incomplete, o misleading facts o infomation to an insuance company fo the pupose of defauding o attempting to defaud the company. Penalties may include impisonment, fines, denial of insuance and civil damages. Any insuance company o agent of an insuance company who knowingly povides false, incomplete, o misleading facts o infomation to a policyholde o claimant fo the pupose of defauding o attempting to defaud the policyholde o claimant with egad to a settlement o awad payable fom insuance poceeds shall be epoted to the Coloado division of insuance within the depatment of egulatoy agencies. Delawae Any peson who knowingly, and with intent to injue, defaud o deceive any insue, files a statement of claim containing any false, incomplete, o misleading infomation is guilty of a felony. Distict of Columbia WARNING: It is a cime to povide false o misleading infomation to an insue fo the pupose of defauding the insue o any othe peson. Penalties include impisonment and/ o fines. In addition, an insue may deny insuance benefits if false infomation mateially elated to a claim was povided by the applicant. Floida Any peson who knowingly and with intent to injue, defaud o deceive any insuance company files a statement of claim o an application containing any false, incomplete, o misleading infomation is guilty of a felony of the thid degee. Idaho Any peson who knowingly, and with intent to defaud o deceive any insuance company, files a statement containing any false, incomplete, o misleading infomation is guilty of a felony. Indiana A peson who knowingly and with intent to defaud an insue files a statement of claim containing any false, incomplete, o misleading infomation commits a felony. Faud 2-16

5 Kentucky A peson who knowingly and with intent to defaud any insuance company o othe peson files a statement of claim containing any mateially false infomation o conceals, fo the pupose of misleading, infomation concening any fact mateial theeto commits a faudulent insuance act, which is a cime. Maine It is a cime to knowingly povide false, incomplete, o misleading infomation to an insuance company fo the pupose of defauding the company. Penalties may include impisonment, fines, o a denial of insuance benefits. Mayland Any peson who knowingly and willfully pesents a false o faudulent claim fo payment of a loss o benefit o who knowingly and willfully pesents false infomation in an application fo insuance is guilty of a cime and may be subject to fines and confinement in pison. Minnesota A peson who files a claim with intent to defaud o helps commit a faud against an insue is guilty of a cime. New Hampshie Any peson who, with a pupose to injue, defaud o deceive any insuance company, files a statement of claim containing any false, incomplete o misleading infomation is subject to posecution and punishment fo insuance faud, as povided in RSA 638:20. New Jesey Any peson who knowingly files a statement of claim containing any false o misleading infomation is subject to ciminal and civil penalties. Ohio and Oegon Any peson who, with intent to defaud o knowing that he is facilitating a faud against an insue, submits an application o files a claim containing a false o deceptive statement is guilty of insuance faud. Oklahoma WARNING: Any peson who knowingly, and with intent to injue, defaud o deceive any insue, makes any claim fo the poceeds of an insuance policy containing any false, incomplete o misleading infomation is guilty of a felony. Pennsylvania Any peson who knowingly and with intent to defaud any insuance company o othe peson files statement of claim containing any mateially false infomation o conceals fo the pupose of misleading, infomation concening any fact mateial theeto commits a faudulent insuance act, which is a cime and subjects such peson to ciminal and civil penalties. Tennessee, Viginia and Washington State It is a cime to knowingly povide false, incomplete, o misleading infomation to an insuance company fo the pupose of defauding the company. Penalties include impisonment, fines, and denial of insuance benefits. Texas Any peson who knowingly pesents a false o faudulent claim fo the payment of a loss is guilty of a cime and may be subject to fines and confinement in state pison. 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. Faud 2-16

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