NTA LIFE CLAIM PACKET

PROTECTING THE HEART OF OUR COMMUNITY NTA LIFE CLAIM PACKET Included in this packet yu will find: 1. Instructins fr Cmpleting the Health, Accident, and Disability Claim Frm 2. Health, Accident, and Disability Claim Frm 3. Authrizatin fr the Release f Health-Related Infrmatin Frm Receive Claim Payments Faster with Direct Depsit Fast and Cnvenient Claims payments are depsited directly int yur accunt. N mre waiting by the mailbx r driving t the bank. Sign Up Tday Simply cmplete the Direct Depsit/ACH Agreement frm in the Frms sectin f ntalife.cm and submit with yur claim frms. We will d the rest. It s that easy! Already Signed Up? Existing direct depsit custmers dn t have t d a thing. We will use yur mst recent electin. Need T Make Changes? Simply change yur preferences thrugh yur MyNTALife accunt r cmplete a new frm. MyNTALife: Access and Cnvenience in One Place Start experiencing the benefits f a MyNTALife accunt tday: Gain fast and cnvenient access t claim and plicy infrmatin View yur claim status 24 hurs a day Pay premiums nline Manage yur prfile and cmmunicatin delivery preferences Update direct depsit electins and mre Visit us at ntalife.cm and register fr yur accunt tday! THANK YOU FOR CHOOSING NTA LIFE! Questins? We re here t help. 888.671.6771

Hw t Cmplete and Submit a Health, Accident, & Disability Claim Frm GENERAL TIPS FOR COMPLETING AND SUBMITTING A CLAIM FORM -Fully cmplete each page f the claim frm. Unanswered r incmplete items can cause a delay in prcessing. -Read all instructins befre filling ut the claim frm. -Submit the cmpleted frm as directed at the bttm f the frm. PAGE ONE: CLAIMANT STATEMENT *1 2 1. List the plicy number fr each plicy n which yu are filing a claim. 2. Fully cmplete the Plicywner Infrmatin sectin. 3. Fully cmplete the Patient Infrmatin sectin. -The Patient is the cvered individual wh received medical treatment and/r services. 4. Fully cmplete each applicable sectin under Infrmatin Cncerning Accident, Disability r Sickness (i.e. T claim benefits n a disability plicy, cmplete the Filing a Claim fr a Disability Plicy sectin). 5. Sign and date the bttm f the frm. -Befre signing, review page 3 fr the fraud warning fr yur state. -A parent r legal guardian must sign if the patient is under 18 years f age. 3 4 PAGE TWO: ATTENDING PHYSICIAN S STATEMENT & EMPLOYER S STATEMENT 6. Cmplete the Plicywner and Patient Infrmatin sectins. 7. Submit a cpy f the Attending Physician Statement sectin t yur physician fr cmpletin. 8. Fr disability claims nly: Submit a cpy f the Emplyer Statement sectin t yur emplyer fr cmpletin. PAGE THREE: STATE-SPECIFIC FRAUD WARNING 5 9. This page cntains the state-specific fraud warning reviewed in step 5. PAGE FOUR: AUTHORIZATION FOR RELEASE OF HEALTH-RELATED INFORMATION 10. Review and sign the Authrizatin Fr Release f Health-Related Infrmatin frm. *The arrws, which crrespnd with the numbered instructins, indicate where t fill in the requested infrmatin n the claim frm. PAGE ONE: CLAIMANT STATEMENT Page 1 f 3

6 7 Natinal Teachers Assciates Life Insurance Cmpany HEALTH, ACCIDENT, & DISABILITY CLAIM FORM POLICYOWNER & PATIENT INFORMATION: T be cmpleted by the Plicywner POLICY OWNER S NAME DATE OF BIRTH POLICY # PATIENT NAME NAME AND ADDRESS OF REFERRING PHYSICIAN (IF APPLICABLE) Custmer Service Center 1-888-671-6771 ntalife.cm ATTENDING PHYSICAN STATEMENT: T be cmpleted by the Attending Physician DATE OF FIRST SYMPTOM (IF SICKNESS) DATE FIRST CONSULTED FOR THIS CONDITION HAS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS? Yes N OR / / / / / / DATE OF INJURY IF YES PLEASE GIVE THE DATE: 9 NAME AND ADDRESS OF HOSPITAL WHERE SERVICES RENDERED (IF APPLICABLE) DATE ADMITTED DATE DISCHARGED / / / / Diagnsis r Nature f Sickness r Injury ICD-9 r ICD-10 Cde 1. 2. 3. Is this cnditin related t pregnancy? Yes Vaginal LMP: / / Date f Delivery: / / Methd f delivery: N C-Sectin Date f Place f Describe Medical Prcedures Service Service CPT Cde and Services Prvided Charges Fr disability claims, please fill ut the fllwing: DATES OF TOTAL DISABILITY (UNABLE TO WORK) DATES OF PARTIAL DISABILITY DATE PATIENT RELEASED TO RETURN TO WORK / / t / / / / t / / / / FUNCTIONAL LIMITATIONS (i.e. physical hinderances such as the inability t walk r stand fr extended perids f time) DATE OF NEXT SCHEDULED OFFICE VISIT FOR THIS CONDITION / / CURRENT TREATMENT PLAN ADDITIONAL COMMENTS Prvider and Physician Infrmatin (physician signature is required fr all claim types) PROVIDER NAME PROVIDER ADDRESS PHONE PHYSICIAN PRINTED NAME SPECIALTY PHYSICIAN S FEDERAL ID # FAX 8 PHYSICIAN S SIGNATURE PATIENT ACCOUNT # X Date EMPLOYER STATEMENT: T be cmpleted by the Patient s Emplyer fr disability claims nly NAME OF EMPLOYER DATE STOPPED WORK DUE TO DISABILITY / / PHONE FAX DATE RETURNED TO WORK EMPLOYER ADDRESS / / IS THE EMPLOYEE OFF WORK DUE TO DISABILITY THAT AROSE FROM EMPLOYMENT-RELATED ACTIVITIES? IS THE EMPLOYEE SEEKING BENEFITS UNDER WORKER S COMPENSATION OR A SIMILAR EMPLOYER SPONSORED PLAN? YES NO YES NO SIGNATURE/TITLE OF OFFICIAL REPRESENTATIVE X Date SEND THIS COMPLETED FORM TO THE CLAIMS PROCESSING CENTER BY: EMAIL: Claims@NTALife.cm FAX: 1-855-512-5246 MAIL: P.O. Bx 2369 Addisn, TX 75001-2369 75-101 (8/13) 2 f 4 Attending Physician and Emplyer Statement PAGE TWO: ATTENDING PHYSICIAN AND EMPLOYER STATEMENT PAGE THREE: STATE-SPECIFIC FRAUD WARNINGS Page 2 f 3

AUTHORIZATION FOR RELEASE OF HEALTH RELATED INFORMATION This Authrizatin Cmplies with HIPAA Privacy Rule By executing this Authrizatin, I authrize all health care prviders that have been invlved in my care, diagnsis r treatment (including, but nt limited t, physicians, hspitals, clinics, medical practitiners, Pharmacy Benefit Managers, ther medically related facilities, ther insurance cmpanies, and MIB, Inc.) t disclse all medical recrds (including, but nt limited t, patient histries, prgress ntes, test results, x-rays and ther diagnstic infrmatin) and all pharmacy recrds t emplyees f Natinal Teachers Assciates Life Insurance Cmpany ( NTA Life ) and affiliated entities (including its reinsurers) invlved in determining eligibility fr an insurance plicy r prcessing a claim. This Authrizatin may be required t btain an insurance plicy r t determine eligibility fr benefits. Please fully cmplete the claim frm t avid any delays in prcessing yur request fr plicy benefits. If yu have any questins regarding the cmpletin f this frm please cntact ur Custmer Service Center, tll-free, at 1.888.671.6771. One f ur Assciates will be glad t assist yu. NTA Life and affiliated entities may disclse my medical recrds and the infrmatin cntained in thse medical recrds t business assciates, affiliated third parties, r ther rganizatins (such as reinsurers), fr the purpses stated abve and as permitted by law. I als understand that when my medical recrds and the infrmatin cntained in thse medical recrds are disclsed pursuant t this Authrizatin, they may be re-disclsed and may n lnger be prtected by federal privacy laws. I als, authrize NTA Life, r its reinsurers, t make a brief reprt f my prtected health infrmatin t MIB. I understand that I may revke this Authrizatin in writing, except t the extent that Natinal Teachers Assciates Life Insurance Cmpany r an affiliated entity has acted in reliance upn this Authrizatin. My revcatin in writing must be submitted t: Natinal Teachers Assciates Life Insurance Cmpany Attn: Directr f Cmpliance 4949 Keller Springs Rad Addisn, Texas 75001 This Authrizatin will expire tw (2) years frm the date that this Authrizatin is signed. I understand that I have the right t a cpy f this Authrizatin and I agree that a cpy f this Authrizatin is as valid as the riginal. 10 Signature f Individual Whse Infrmatin is t be Disclsed Date Printed Name f Individual Plicy Number 75-307 (1/15) PAGE FOUR: AUTHORIZATION FOR RELEASE OF HEALTH-RELATED INFORMATION Page 3 f 3

Natinal Teachers Assciates Life Insurance Cmpany HEALTH, ACCIDENT, & DISABILITY CLAIM FORM Custmer Service Center 1-888-671-6771 ntalife.cm Instructins fr filing a claim fr benefits: 1. Cmplete each sectin n page 1 and the Plicywner and Patient Infrmatin n page 2. 2. Sign and date page 1. 3. Have yur physician cmplete and sign the Attending Physician Statement n page 2. 4. Sign and date the Authrizatin fr Release f Health Related Infrmatin n page 4. List Yur Plicy Number(s) Here: POLICYOWNER INFORMATION 5. Submit itemized bills fr each benefit claimed (e.g. itemized medical bill, hspital discharge summary, etc.). 6. Fr disability claims: Have yur emplyer cmplete and sign the Emplyer Statement n page 2. 7. Fr cancer claims: Submit a pathlgy reprt dcumenting a psitive cancer diagnsis. Unanswered r incmplete items can cause a delay in prcessing. POLICY # POLICY # POLICY # POLICY # NAME OF POLICYOWNER SOCIAL SECURITY NUMBER OCCUPATION - - ADDRESS CITY STATE ZIP CODE EMAIL ADDRESS PHONE Hme: Mbile: Wrk: I wuld like t learn mre abut hw I can receive claim updates and ther crrespndence via the email address I have prvided. PATIENT INFORMATION NAME OF PATIENT SOCIAL SECURITY NUMBER DATE OF BIRTH RELATIONSHIP TO POLICYOWNER HEIGHT WEIGHT SEX Male PHONE ft. in. lbs. Female INFORMATION CONCERNING ACCIDENT, DISABILITY, OR SICKNESS Filing a Claim fr an Accident Plicy Date f accident: / / Time f accident: a.m. p.m. Where did the accident ccur? Hw did the accident/injury ccur? Describe injuries: Filing a Claim fr a Disability Plicy Dates f Disability: Frm / / t / / Date last wrked: / / Date released t return t wrk: / / This disabililty is related t: Sickness Injury Please describe. Is the patient receiving retirement benefits under any federal r state-spnsred retirement prgram? YES NO If Yes, please describe: Is the disability/cnditin a result f emplyment-related activities? YES NO If yes, is the patient seeking Wrker s Cmpensatin benefits? YES NO Filing a Claim fr a Specified Disease Plicy (e.g. Cancer r Heart Attack, Heart Disease & Strke) Date f sickness: / / at a.m. p.m. Date symptms first appeared: / / Nature f sickness: Has patient ever had the same r similar cnditin? YES NO If Yes give details: Date: / / Reasn: Dctr: Hspitalized? YES NO Has patient been treated fr anything else within the past tw years? YES NO If Yes give details: Date: / / Reasn: Dctr: Hspitalized? YES NO Date: / / Reasn: Dctr: Hspitalized? YES NO By signing belw, I represent that all infrmatin n this frm is true and crrect and that I have read the state-specific fraud warning n page 3. (Signed) Patient Date / / A parent r legal guardian must sign if the patient is under the age f 18. - - (Signed) Plicywner Date / / 75-101 (8/13) SEND THIS COMPLETED FORM TO THE CLAIMS PROCESSING CENTER BY: EMAIL: Claims@NTALife.cm FAX: 1-855-51 CLAIM (25246) MAIL: P.O. Bx 2369 Addisn, TX 75001-2369 1 f 3 Claimant s Statement

Natinal Teachers Assciates Life Insurance Cmpany HEALTH, ACCIDENT, & DISABILITY CLAIM FORM Custmer Service Center 1-888-671-6771 ntalife.cm POLICYOWNER & PATIENT INFORMATION: T be cmpleted by the Plicywner POLICY OWNER S NAME DATE OF BIRTH POLICY # PATIENT NAME ATTENDING PHYSICIAN STATEMENT: T be cmpleted by the Attending Physician DATE OF FIRST SYMPTOM (IF SICKNESS) DATE FIRST CONSULTED FOR THIS CONDITION HAS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS? Yes N r DATE OF INJURY IF YES PLEASE GIVE THE DATE: NAME AND ADDRESS OF REFERRING PHYSICIAN (IF APPLICABLE) NAME AND ADDRESS OF HOSPITAL WHERE SERVICES RENDERED (IF APPLICABLE) DATE ADMITTED DATE DISCHARGED / / / / Diagnsis r Nature f Sickness r Injury ICD-9 r ICD-10 Cde 1. 2. 3. Is this cnditin related t pregnancy? Yes N LMP / / Date f Delivery / / Methd f delivery: Date f Place f Describe Medical Prcedures Service Service CPT Cde and Services Prvided Charges Vaginal C-Sectin Fr Disability Claims, please fill ut the fllwing: DATES OF TOTAL DISABILITY (UNABLE TO WORK) DATES OF PARTIAL DISABILITY DATE PATIENT RELEASED TO RETURN TO WORK / / t / / / / t / / / / FUNCTIONAL LIMITATIONS (i.e. physical hinderances such as the inability t walk r stand fr extended perids f time) DATE OF NEXT SCHEDULED OFFICE VISIT FOR THIS CONDITION / / CURRENT TREATMENT PLAN ADDITIONAL COMMENTS PROVIDER NAME PROVIDER ADDRESS PHONE FAX PHYSICIAN PRINTED NAME SPECIALTY PHYSICIAN S FEDERAL ID # PHYSICIAN S SIGNATURE PATIENT ACCOUNT # EMPLOYER STATEMENT: T be cmpleted by the Patient s Emplyer DATE STOPPED WORK DUE TO DISABILITY SIGNATURE/TITLE OF OFFICIAL REPRESENTATIVE NAME OF EMPLOYER Date FAX DATE RETURNED TO WORK EMPLOYER ADDRESS IS THE EMPLOYEE OFF WORK DUE TO DISABILITY THAT AROSE FROM EMPLOYMENT-RELATED ACTIVITIES? IS THE EMPLOYEE SEEKING BENEFITS UNDER WORKER S COMPENSATION OR A SIMILAR EMPLOYER SPONSORED PLAN? YES NO YES NO PHONE Date SEND THIS COMPLETED FORM TO THE CLAIMS PROCESSING CENTER BY: EMAIL: Claims@NTALife.cm FAX: 1-855-51 CLAIM (25246) MAIL: P.O. Bx 2369 Addisn, TX 75001-2369 75-101 (8/13) 2 f 3 Attending Physician and Emplyer Statement

STATE SPECIFIC FRAUD WARNINGS Please review the fllwing fraud warning fr yur state befre signing the Claimant Statement n page 1. Alaska-Warning: A persn wh knwingly and with intent t injure, defraud r deceive an insurance cmpany files a claim cntaining false, incmplete r misleading infrmatin may be prsecuted under state law. Arizna-Warning: Fr yur prtectin Arizna law requires the fllwing statement t appear n this frm. Any persn wh knwingly presents a false r fraudulent claim fr payment f a lss is subject t criminal and civil penalties. Califrnia-Warning: Fr yur prtectin, Califrnia law requires the fllwing t appear n this frm: Any persn wh knwingly presents a false r fraudulent claim fr the payment f a lss is guilty f a crime and may be subject t fines and cnfinement in state prisn. Clrad-Warning: It is unlawful t knwingly prvide false, incmplete r misleading facts r infrmatin t an insurance cmpany fr the purpse f defrauding r attempting t defraud the cmpany. Penalties may include imprisnment, fines, denial f insurance and civil damages. Any insurance cmpany r agent f an insurance cmpany wh knwingly prvides false, incmplete r misleading facts r infrmatin t a plicyhlder r claimant fr the purpse f defrauding r attempting t defraud the plicyhlder r claimant with regard t a settlement r award payable frm insurance prceeds shall be reprted t the Clrad divisin f insurance within the department f regulatry agencies. Delaware, Idah, Indiana, and Oklahma-Warning: Any persn wh knwingly, and with intent t injure, defraud r deceive any insurer, files a statement f claim cntaining any false, incmplete r misleading infrmatin is guilty f a felny. Flrida-Warning: Any persn wh knwingly and with intent t injure, defraud r deceive any insurer files a statement f claim r an applicatin cntaining any false, incmplete r misleading infrmatin is guilty f a felny f the third degree. Kentucky-Warning: Any persn wh knwingly and with intent t defraud any insurance cmpany r ther persn files a statement f claim cntaining any materially false infrmatin r cnceals, fr the purpse f misleading, infrmatin cncerning any fact material theret cmmits a fraudulent insurance act, which is a crime. Maine, Tennessee, Virginia, and Washingtn-Warning: It is a crime t knwingly prvide false, incmplete r misleading infrmatin t an insurance cmpany fr the purpse f defrauding the cmpany. Penalties may include imprisnment, fines r a denial f insurance benefits. Minnesta-Warning: A persn wh files a claim with intent t defraud r helps cmmit a fraud against an insurer is guilty f a crime. New Jersey-Warning: Any persn wh knwingly files a statement f claim cntaining any false r misleading infrmatin is subject t criminal and civil penalties. New Mexic-Warning: Any persn wh knwingly presents a false r fraudulent claim fr payment f a lss r benefit r knwingly presents false infrmatin in an applicatin fr insurance is guilty f a crime and may be subject t civil fines and criminal penalties. New Yrk-Warning: Any persn wh knwingly with intent t defraud any insurance cmpany r ther persn files an applicatin fr insurance r statement f claim cntaining any materially false infrmatin r cnceals fr the purpse f misleading, infrmatin cncerning any fact theret, cmmits a fraudulent insurance act, which is a crime, and shall als be subject t a civil penalty nt t exceed five thusand dllars and the stated value f the claim fr each such vilatin. Ohi-Warning: Any persn wh, with intent t defraud r knwing that he is facilitating a fraud against an insurer, submits an applicatin r files a claim cntaining a false r deceptive statement is guilty f insurance fraud. Pennsylvania-Warning: Any persn wh knwingly and with intent t defraud any insurance cmpany r ther persn files an applicatin fr insurance r statement f claim cntaining any materially false infrmatin, r cnceals fr the purpse f misleading, infrmatin cncerning any fact material theret cmmits a fraudulent insurance act, which is a crime and subjects such persn t criminal and civil penalties. Texas-Warning: Any persn wh knwingly presents a false r fraudulent claim fr the payment f a lss is guilty f a crime and may be subject t fines and cnfinement in state prisn. All Other States-Warning: Any persn wh knwingly presents a false r fraudulent claim fr payment f a lss r benefit r knwingly presents false infrmatin in an applicatin fr insurance is guilty f a crime and may be subject t fines and cnfinement in prisn. 3 f 3 Fraud Warning

AUTHORIZATION FOR RELEASE OF HEALTH RELATED INFORMATION This Authrizatin Cmplies with HIPAA Privacy Rule By executing this Authrizatin, I authrize all health care prviders that have been invlved in my care, diagnsis r treatment (including, but nt limited t, physicians, hspitals, clinics, medical practitiners, Pharmacy Benefit Managers, ther medically related facilities, ther insurance cmpanies, and MIB, Inc.) t disclse all medical recrds (including, but nt limited t, patient histries, prgress ntes, test results, x-rays and ther diagnstic infrmatin) and all pharmacy recrds t emplyees f Natinal Teachers Assciates Life Insurance Cmpany ( NTA Life ) and affiliated entities (including its reinsurers) invlved in determining eligibility fr an insurance plicy r prcessing a claim. This Authrizatin may be required t btain an insurance plicy r t determine eligibility fr benefits. NTA Life and affiliated entities may disclse my medical recrds and the infrmatin cntained in thse medical recrds t business assciates, affiliated third parties, r ther rganizatins (such as reinsurers), fr the purpses stated abve and as permitted by law. I als understand that when my medical recrds and the infrmatin cntained in thse medical recrds are disclsed pursuant t this Authrizatin, they may be re-disclsed and may n lnger be prtected by federal privacy laws. I als, authrize NTA Life, r its reinsurers, t make a brief reprt f my prtected health infrmatin t MIB. I understand that I may revke this Authrizatin in writing, except t the extent that Natinal Teachers Assciates Life Insurance Cmpany r an affiliated entity has acted in reliance upn this Authrizatin. My revcatin in writing must be submitted t: Natinal Teachers Assciates Life Insurance Cmpany Attn: Directr f Cmpliance 4949 Keller Springs Rad Addisn, Texas 75001 This Authrizatin will expire tw (2) years frm the date that this Authrizatin is signed. I understand that I have the right t a cpy f this Authrizatin and I agree that a cpy f this Authrizatin is as valid as the riginal. Signature f Individual Whse Infrmatin is t be Disclsed Date Printed Name f Individual Plicy Number 75-307 (1/15)