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By using this card, I: (i) certify that the benefits being claimed under the benefit plan (“Benefit Plan”) were for myself or my eligible dependent (the “Claimant”); (ii) understand that the Benefit Plan is administered (wholly or partially) by ClaimSecure Inc. (“ClaimSecure”), and confirm that I have read and agreed to the terms of ClaimSecure’s Privacy Policy, available at: www.claimsecure.com/privacy-policy/ ; and (iii) agree that ClaimSecure may collect, use and share the Claimant’s personal information to assess and manage claims and administer the Benefit Plan, including to report details of fraudulent claims to the Benefit Plan sponsor where applicable, and as otherwise described in ClaimSecure’s Privacy Policy. ClaimSecure uses personal information when making decisions related to products and services. These decisions may be made using automated processing. To learn more about your privacy rights see the privacy policy at www.claimsecure.com/privacy-policy/.

This card is not transferable and the terms and conditions governing its use (including ClaimSecure’s Privacy Policy) are subject to change without prior notice.