IMPORTANT INSTRUCTIONS FOR COMPLETING CLAIM FORM(S)

Please use this form to submit Accident claims to your claim administrator, Health Special Risk, Inc. following the instructions below. We will evaluate your claim based on the terms and conditions of your insurance coverage. If we need additional information or documentation, we will contact you.

Please review your policy to see your specific benefits. If you have uestions, call us toll-free at 1- 77- 2 -111 or send an email Claims HSRI.com.

Part I – Policyholder’s Statement☐

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orm is to be completed in its entirety and signed by the Official Representative of the Policyholder/Plan.If death benefits are being sought, beneficiary designation form(s) on file with the Employer/Plan must besubmitted. If a beneficiary election is not on file, Employer/Plan shall certify to that fact on the claim form.

Part II – Claimant’s Statement ☐

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orm is to be completed in its entirety and signed by the individual or representative of the party claiming benefits.

Review the Re uired Attachments and Signature section of the Claimant’s Statement (Part II - Section C), and submit the necessary items depending on the benefit claimed. ailure to include the Re uired Attachments may delay the processing of your claim.

Read and sign the raud Warning Notice on page

Please detach this page and forward the completed Claim Form and re uired attachments to the address listed below. We recommend you retain copies of the items you have submitted for future reference.

Submit your completed form and required documentation by mail or email:Mailing Address: Health Special Risk, Inc.

100 edical Parkway, Suite 200Carrollton, Texas 7 007-1 17Telephone: 1- 00- 2 -111 Email: Claims HSRI.com

The acceptance of a claim form by a Claims Administrator is not a determination that a benefit is available, nor does it recognize the validity of any claim.

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Part III – Physician's Statement

Provide Part III to your Attending Physician to complete the Physician Statement. Both pages of the Physician Statement must be completed by the Attending Physician.

Miscellaneous – All Claims☐

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Please sign the edical Release of Information Authori ation on page .

If applicable, provide any police, motor vehicle accident, autopsy and/or toxicology, trip itinerary, and other pertinent information regarding your claim.

If benefits are payable to an Estate, Part II (Claimant's Statement) must be completed by the Administrator of the Estate. Any official certificate of legal appointment must be attached to the claim form. Include the Estate Tax Identification Number (if applicable).

oreign Death - include the Official Death Certificate and Consular Report of Death of a U.S. Citi en Abroad form.☐

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Liberty Insurance Underwriters Inc School Travel Accident

Injury, Illness, Sickness, Dismemberment,Death Claim Form

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PART I - POLICYHOLDER’S STATEMENT – To be completed by the Official Representative of the Policyholder/Organization A. Information About the Policyholder

Policy Number: Policyholder Name:

Policyholder Email Address: Policyholder Telephone Number: Policyholder Fax Number:

Policyholder Address (Street, City, State, & Zip Code):

Branch/Location (or “n/a” if this does not apply):

B. Information About the Party Claiming BenefitsParty claiming benefits is Student EmployeePlease complete regarding the Claimant:Name: DOB: Social Security Number:

Address (Street, City, State, & Zip Code: Telephone Number: ( )

Date of Hire/Enrollment: Occupation/Job Title (if Employee): Program (if Student)

C. Information About the ClaimBenefits claimed due to (check all that apply):

Scheduled Start Date of Trip: Scheduled End Date of Trip: Trip Origination and Destination:

Describe the purpose of the Trip:

D. Required Attachments and Signature

Please attach copies of the following documents as applicable: Itineraries, etc. related to the trip. Incident/policereports or beneficiary election form, if applicable or available.

I hereby certify the Insured is a member of the group insured under the above Policy and the loss was sustained while participating in an official Policy Holder Activity.

I certify that the information provided on the Policyholder’s Statement is true and complete according to the records of the Policyholder. By signature below, I acknowledge that I have read the applicable fraud warning notice on page 4.

Name of Policyholder Representative Policyholder Representative Signature Date

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Liberty Insurance Underwriters Inc School Travel Accident Injury, Illness, Sickness, Dismemberment,Death Claim Form

Mail forms to: Health Special Risk, Inc.4100 Medical Parkway, Suite #200Carrollton, Texas 75007-1517Telephone: 1-800-328-1114 Email: Claims@HSRI.com

☐Injury ☐Dismemberment☐Illness/Sickness ☐Loss of Sight, Hearing, Speech☐ Loss of Use ☐Death

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Mail forms to: Health Special Risk, Inc.4100 Medical Parkway, Suite #200Carrollton, Texas 75007-1517Telephone: 1-800-328-1114 Email: Claims@HSRI.com

PART II – CLAIMANT’S STATEMENT – To be completed by the Claimant A. Information About the Party Claiming Benefits

Please complete the following: Name: DOB: Social Security Number:

Address (Street, City, State, & Zip Code): Telephone Number: ( )

B. Information About the ClaimCircumstances of Accident or onset of symptoms

Benefits claimed for:

Nature of Injuries, Illness, or Sickness:

C. Required Attachments and Signature

Signature of Claimant or Authorized Representative Date

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Date of Accident/Onset: Time of Accident/Onset (hh:mm): AM PM

Fully describe the circumstances of the incident resulting in the claim for benefits:

Location of Accident/Onset of Symptoms:

☐ ☐Injury ☐Dismemberment☐Illness/Sickness ☐Loss of Sight, Hearing, SpeechLoss of Use ☐Death

Name of Deceased/Injured if Different than above: Relationship (if Different than above)Dependent Spouse

Has a Workers' Compensation claim been filed? Yes No If "Yes", what is the claim status?

Prior to the incident, did the Claimant have any chronic disease or deformity?

If "Yes", please describe in detail:Yes No

List all Healthcare Providers and Hospitals consulted for care due to this injury/illness/sickness/death:NAME PHONE NUMBERADDRESS PERIOD TREATED

Please submit a copy of patient’s hospital admission and discharge papers and/or itemized bills or receipts pertaining to this claim, such as physician’s treatment, surgery, anesthesia, laboratory, ambulance and lodging, if applicable. If dismemberment or loss of use benefits are sought, medical records must be provided in support of the claim for benefits.If death benefits are sought, coroner's report or autopsy report must be submitted.

The above statements are true to the best of my knowledge and belief, and I have read the applicable fraud warning notice on page 4.

Liberty Insurance Underwriters Inc School Travel Accident Injury, Illness, Sickness, Dismemberment,Death Claim Form

FRAUD WARNING NOTICEPlease read the statement that applies to your state of residence and sign the bottom of the page.

For residents of all states EXCEPT Arizona, California, Colorado, Florida, Kentucky, Maine, Maryland, New Jersey, New York, OregonPennsylvania, Puerto Rico, Tennessee and Washington: 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 tofines and confinement in prison.

For Residents of Arizona: For your protection, Arizona law requires the following 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.For Residents of California: For your protection, California law requires the following to appear on this form: Any person who knowingly presents 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.

For residents of Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance companyfor the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civildamages. 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 asettlement award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

For residents of Florida: 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.

For residents of Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statementof claim or an application for insurance 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.

For residents of Maine, Tennessee and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines and denial of insurance benefits.

For residents of Maryland: 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 confinementin prison.

For residents of New Jersey: Any person who knowingly files a statement of claim containing any false or misleading nformation is subject to criminal and civil penalties. Any person who includes any false or misleading information on an application for insurance policy is subject tocriminal and civil penalties.

For residents of New York: Any person who knowingly and with intent to defraud any insurance company or other person files an applicationfor insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, informationconcerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not toexceed five thousand dollars and the stated value of the claim for each such violation.

For residents of Oregon: Any person who knowingly and with intent to defraud any insurance company or other person files an application forinsurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material is subject to a denial and/or reduction in insurance benefits and may be subject to any civil penalties available.

For residents of Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files anapplication for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material hereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

For residents of Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insuranceapplication, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents morethan 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 notless 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.

For residents of Virginia: Any person who, with the 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 the state law.

Claimant Signature Date

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AUTHORIZATION FOR THE RELEASE OF INFORMATION, INCLUDING PROTECTED HEALTH INFORMATION

I hereby authorize the use or disclosure of information about me as described below:

1. Person(s) or group(s) of persons authorized to use or disclose the information:Any physicians, medical practitioners, hospitals, clinics, HMOs, long-term care facilities, medical or medically-relatedfacilities, insurance companies, current or former employers, and insurance support organizations.

2. Person(s) or group(s) of persons authorized to collect or otherwise receive the information:Liberty Insurance Underwriters Inc. and Health Special Risk, Inc., as Claims Administrator, and its authorizedrepresentatives, agents and/or employees and other organizations providing claims management services.

3. Description of the information that may be used or disclosed:This authorization specifically includes the release of all information related to:▪ My physical and mental health and my insurance policies and claims, including but not limited to those containing

diagnosis, treatments, prognosis, prescription drug information, alcohol or drug abuse or information regardingcommunicable or infectious conditions, including HIV/AIDS.

▪ Personnel records and other work-related information.

4. Information will be used or disclosed only for the following purpose(s):For investigating, evaluating and processing my claim, and/or for claims-related functions.

STATEMENTS OF UNDERSTANDING & ACKNOWLEDGEMENT I understand that information used or disclosed pursuant to this authorization could be subject to

redisclosure as necessary by the recipient and if so, may not be subject to federal or state law protecting itsconfidentiality.

I understand that I may revoke this authorization in writing at any time by sending a written revocation to Health SpecialRisk, Inc., as Claims Administrator (“Company”), except to the extent that action has been taken in reliance on thisauthorization, or to the extent that other law provides the Company with the right to contest a claim. I also understandthat the revocation of this authorization will not affect uses and disclosures of my health information for purposes oftreatment, payment and health care operations.

I understand that authorizing the disclosure of my health information is voluntary and the provision of health careservices to me is not conditioned on whether I sign this authorization. If I choose not to sign this authorization,payments of benefits may be denied or delayed.

This authorization shall remain in force for 24 months from the date of signing, except to the extent applicable state lawimposes or allows a different duration. The information obtained under this authorization will be retained in accordancewith the Company’s standard retention policy and applicable law.

I understand that I may request a copy of this authorization.

Signature of Insured, Beneficiary, or Authorized Representative Date Relationship to Claimant (if signed by Authorized Representative)

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Mail forms to: Health Special Risk, Inc.4100 Medical Parkway, Suite #200Carrollton, Texas 75007-1517Telephone: 1-800-328-1114 Email: Claims@HSRI.com

PART III – PHYSICIAN'S STATEMENT (To be completed for all claims except Death )Please complete the following: Patient Name: Patient DOB:

Address (Street, City, State, & Zip Code):

☐Injury ☐Dismemberment☐Illness/Sickness ☐☐ Loss of Use ☐ ParalysisNature of Injury, Illness, or Sickness resulting from incident (Check all that apply)

Information regarding Injury, Illness, and/or SicknessProvide a description of the injuries or illness, diagnoses, and affected body part(s) Please include ICD-10 code(s):

Date of Injury or Illness Onset: Date patient first examined by you for this injury or illness:

Had patient previously had medical attention for this injury, illness, or sickness?:If "Yes", by whom?

☐ ☐Yes

No Has patient ever had same or similar condition or injury? If "Yes", indicate when and describe:

Was claimant under the influence of alcohol and/or drugs at the time of accident or illness? ☐ ☐Yes No☐ ☐ ☐ Unknown

☐ ☐Yes

No

Report of ServicesDate(s) of Service Place of Service* Description of Services CPT Code

*IH – inpatient hospital, OH – outpatient hospital, OA – outpatient ambulatory surgical facility, DO – doctor’s office, OL – other location

Did patient's injury, illness, or sickness result in a Coma? If "Yes" please provide information as noted below.☐ Yes ☐ No

Date Coma Began: Date Coma Ended: If Coma has not ended, Current Duration (days): Was Coma confirmed by EEG?

No☐ ☐Yes Report of Accidental Dismemberment, Paralysis, and/or Loss of Use (if applicable)If the injury described caused an amputation or loss of body usage, is this amputation or loss irrecoverable?Please describe in detail any dismemberment or loss of use, precise location of dismemberment or severance, and prognosis of use.

If injury resulted in paralysis, what type? Quadriplegia Paraplegia Hemiplegia Other (Please Explain):☐☐ ☐ ☐

Please indicate location of amputation or area of injury on the below chart. Add any necessary comments below:

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Liberty Insurance Underwriters Inc School Travel Accident Injury, Illness, Sickness, Dismemberment,Death Claim Form

Loss of Hearing, Sight, or Speech

Mail forms to: Health Special Risk, Inc.4100 Medical Parkway, Suite #200Carrollton, Texas 75007-1517Telephone: 1-800-328-1114 Email: Claims@HSRI.com

PART III – PHYSICIAN'S STATEMENT – CONTINUED

In your medical opinion, has this patient sustained complete and irrecoverable hearing loss due to an injury? ☐ Yes ☐ No

☐ Left Ear ☐ Right Ear ☐ Both Ears If hearing loss applies, please attach copies of any auditory test results. ☐ NoIn your medical opinion, has this patient sustained complete and irrecoverable speech loss due to an injury? ☐ Yes

If hearing loss applies, please attach copies of any speech test results. If the described injury or illness described caused loss of sight, please provide copies of vision test and complete below. Right Eye: Corrected Uncorrected

Left Eye: Corrected UncorrectedIs this loss of sight (due to injury or illness) irrecoverable? ☐ Yes ☐ No

Loss of Hearing, Speech, and Sight (if applicable)

Physician Information and CertificationThe above statements are true to the best of my knowledge and belief, and I have read the applicable fraud warning notice on page 4.Physician Name (please print):

Specialty: License Number: EIN/Tax ID:

Street Address: City/Town: State: Zip Code:

Telephone Number: Fax Number:

Physician's Signature: Date:

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Liberty Insurance Underwriters Inc School Travel Accident Injury, Illness, Sickness, Dismemberment,Death Claim Form