IMPORTANT NOTICE PLEASE READ CAREFULLY BEFORE COMPLETING CLAIM FORM INSTRUCTIONS FOR COMPLETING CLAIM FORM

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1 IMPORTANT NOTICE PLEASE READ CAREFULLY BEFORE COMPLETING CLAIM FORM Failure to complete all required sections and/or provide the requested documentation will delay processing your claim. If applicable, use a separate sheet of paper to include the name and account numbers of multiple accounts also covered by Assurant Solutions. You are responsible for continuing to make your minimum monthly payments until a decision is made by us on any claim submitted under this Certificate. After mailing your claim, allow 15 business days for processing. FOR ALL CLAIMS INSTRUCTIONS FOR COMPLETING CLAIM FORM Complete and sign Section 1. Complete and sign Section 6 if you wish to authorize a family member or firend to speak on your behalf. This authorization will allow them to discuss your claim with a representative of Assurant Solutions if you are not available FOR DISABILITY / HOSPITALIZATION / CRITICAL ILLNESS / DISMEMBERMENT CLAIMS For Disability, please submit your claim form after 30 consecutive days of Disability. Have your family physician complete Section 2. For Disability or Hospitalization claims, have your current employer complete Section 3 or if self-employed, complete the self-employment affidavit and questionnaire. FOR UNEMPLOYMENT CLAIMS For Unemployment, please submit your claim form after 30 consecutive days of Unemployment. Have your former employer complete Section 3. If unable to have Employers Statement completed, please include a letter explaining the reason with a copy of your Record of Employment. FOR PROPERTY CLAIMS Complete Section 4. Attach receipts for all items on your account that you are claiming as a loss. Include a completed police/incident/fire report, if applicable. Have a physician complete Section 5. FOR LIFE CLAIMS Attach a copy of death certificate. Complete the enclosed estate authorization form or include a copy from the page of the Will indicating the executor of the Estate. Mail or fax the completed forms and all supporting documentation to: Assurant Solutions, Financial Claims PO Box 7000 Kingston, ON K7L 5V3 Fax We recommend that you retain copies of all documentation submitted to us for review. You May Check the Status of Your Claim by Visiting our Website: American Bankers Life Assurance Company of Florida and affiliates may collect, use and share personal information provided to them by you and obtained from others with your consent. may be subject to access by US authorities under applicable laws. name of Assurant Solutions.

2 Call us if you have a question about submitting a claim. We re here to help you. Call toll-free or fax O O5110 1DBB 1DBB 011G G22 Assurant, Assurant, Inc Inc Printed Printed In Canada In Canada American Bankers Life Assurance Company of Florida and affiliates may collect, use and share personal information provided to them by you and obtained from others with your consent. merican Bankers Life Assurance Company of Florida and affiliates may collect, use and share personal information provided to them by you and btained may be from subject others to access with by your US authorities consent. under They applicable may use laws. the information to establish and serve you as a customer or when required or permitted y law. Your information may be processed and stored in the Untied States and may be subject to access by US authorities under applicable aws. name of Assurant Solutions.

3 American Bankers Life Assurance Company of Florida and affiliates may collect, use and share personal information provided to them by you and obtained from others with your consent. American Bankers Life Assurance Company of Florida and affiliates may collect, use and share personal information provided to them by you and obtained may be from subject others to access with by US your authorities consent. under They applicable may laws. use the information to establish and serve you as a customer or when required or permitted by law. American Your Bankers information Life Assurance may Company be processed of Florida and American stored in Bankers the Untied Insurance States Company and of Florida may be and subject their subsidiaries to access and affiliates by US carry authorities on business under in Canada applicable under the laws. name of Assurant Solutions.

4 American Bankers Life Assurance Company of Florida and affiliates may collect, use and share personal information provided to them by you and obtained from others with your consent. They American may use Bankers the information Life Assurance to establish and Company serve you of as a Florida customer and or when affiliates required may or permitted collect, by law. use Your and information share personal may be processed information and stored provided in the Untied to them States by and you may and be obtained subject to access from by others US authorities with your under applicable consent. laws. They may use the information to establish and serve you as a customer or when required or permitted by law. Your information may be processed and stored in the Untied States and may be subject to access by US authorities under name of Assurant Solutions applicable laws..

5 American Bankers Life Assurance Company of Florida and affiliates may collect, use and share personal information provided to them by you and obtained from others with your consent. American Bankers Life Assurance Company of Florida and affiliates may collect, use and share personal information provided to them by you may be subject to access by US authorities under applicable laws. and obtained from others with your consent. They may use the information to establish and serve you as a customer or when required or permitted name of Assurant by law. Solutions Your information may be processed and stored in the Untied States and may be subject to access by US authorities under. applicable laws.

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