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GL.2017.139 Submitting Your Disability Claim Personalized support- every step of the way! By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization and I instruct my providers to release and disclose my entire medical record without restriction. This information is to be disclosed under this authorization so that Prudential may: 1) administer claims and determine or fulfill responsibility for coverage and provision of benefits; 2) obtain reinsurance; 3) administer coverage; and 4) conduct other legally permissible activities that relate to any coverage I have or have applied for with Prudential. This authorization shall remain in force for 24 months following the date of my signature below, while the coverage is in force, except to the extent that state law imposes a shorter duration. A copy of this authorization is as valid as the original. I understand that I have the right to revoke this authorization in writing, at any time, by sending a written request for revocation to Prudential at: P.O. Box 13480, Philadelphia, PA 19176. I understand that a revocation is not effective to the extent that any of my providers have relied on this authorization to the extent that Prudential has a legal right to contest a claim under an insurance policy or to contest the policy itself. I understand that any information that is disclosed pursuant to this authorization may be redisclosed and not covered by federal rules governing privacy and confidentiality of health information. I understand that if I refuse to sign this authorization to release the entire medical record, Prudential may not be able to process my claim for benefits and may not be able to make any benefit payments. I understand that I have the right to receive a copy of this authorization. The statements made by me on this claim are true and complete. Employee/Claimant Signature Date Print Name Prudential, the Prudential logo and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide. Group Short Term and Long Term Disability Insurance coverages are issued by The Prudential Insurance Company of America, a Prudential Financial company, 751 Broad Street, Newark, NJ 07102. Contract Series: 83500. Please refer to the Booklet-Certificate for all plan details, including any exclusions, limitations, and restrictions, which may apply. If there is a discrepancy between this document and the Group Contract issued by Prudential, the terms of the Group Contract will govern. New York Residents: This policy provides disability income insurance only. It does NOT provide basic hospital, basic medical, or major medical insurance as defined by the New York Department of Financial Services. North Carolina Residents: THIS IS NOT A MEDICARE SUPPLEMENT PLAN. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare, which is available from the company. 2017 Prudential Financial, Inc. and its related entities. Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide. GL.2017.139 Ed. 0417 MAINE and WASHINGTON RESIDENTS: Any person who knowingly provides false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company commits a crime. Penalties include imprisonment, fines, and denial of insurance benefits. MARYLAND RESIDENTS: 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 confinement in prison. NEW HAMPSHIRE RESIDENTS: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. NEW JERSEY RESIDENTS: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. NEW YORK RESIDENTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. This notice ONLY applies to accident and disability income coverage. NORTH CAROLINA RESIDENTS: Any person who, with the intent to injure, defraud, or deceive an insurer or insurance claimant, knowing that the statement contains false information concerning a fact or matter material to the claim may be guilty of a class H felony. PENNSYLVANIA and UTAH RESIDENTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any material fact thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. PUERTO RICO RESIDENTS: Any person who knowingly and with the intention to defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than 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 not less 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. VERMONT RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under state law. VIRGINIA RESIDENTS: Any person who, with the intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law. 000813-1219 Job Name: 192648 PDF Page: 000813 Cameron Ashley Buildingducts, Inc Disability Brochure 1.p1.pdf Process Plan: Doc6060_File61ecfd481ad0474ebd37eebf5c9f731f Date: 20-01-08 Time: 11:33:58 Operator: ____________________________ PageMark-Color-Comp OK to proceed Make corrections and proceed Make corrections and show another proof Signed: ___________________ Date: ______Have this information ready To help us process your claim for benefits promptly, you'll be asked to provide this information: n Company Name: n Company Control Number: n Employee ID or Social Security number n Address and telephone number n Date of birth n Job title n Doctor's name, phone number, and fax n Your last day worked and your first day out due to this condition n If the absence is work-related n The date you expect to return to work What you can expect To process your claim for disability, Prudential needs statements from you, your doctor, and your employer. When you speak with a Prudential specialist, they will obtain your information. Prudential will get your doctor's and employer's information for you. A decision will be made after we review this information. If you have Short Term Disability (STD) and Long Term Disability (LTD) coverage with Prudential, you do not have to submit a LTD claim. When should I contact Prudential again? Notify us by phone or online if: n You have updated information n You are unable to return to work when planned n You have returned to work or are returning n You want to report your delivery date n You need forms Find out about your claim To get claim status or payment information about your claim for disability benefits, call 800-842-1718 or log in to www.prudential.com/mybenefits Important Notice CLAIM FRAUD WARNING STATEMENTS For residents of all states and jurisdictions except Alabama, Arizona, Arkansas, California, the District of Columbia, Florida, Kentucky, Louisiana, Maine, Maryland, New Hampshire, New Jersey, New York, North Carolina, Pennsylvania, Puerto Rico, Rhode Island, Utah, Vermont, Virginia, and Washington: WARNING - Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive, or misleading facts or information when filing an insurance application or a statement of claim for payment of a loss or benefit commits a fraudulent insurance act, is/may be guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil damages, and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto. ALABAMA RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. ARIZONA RESIDENTS: For your protection Arizona law requires the following statement 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. ARKANSAS, DISTRICT OF COLUMBIA, LOUISIANA and RHODE ISLAND RESIDENTS - 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 fines and confinement in prison. CALIFORNIA RESIDENTS: For your protection, California law requires the following to appear on this form. Any person who knowingly presents a 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. FLORIDA RESIDENTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing false, incomplete, or misleading information is guilty of a felony of the third degree. KENTUCKY RESIDENTS: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim 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. Filing a disability claim Authorization Card n Notify your n Call Prudential toll-free at 800-842-1718 OR Log in to www.prudential.com/mybenefits and click on "Claims and Absence" and then "File a Claim / Report an Absence." n Make a copy of this authorization. n Sign and date the copy. n Present the copy to your doctor to file. n Keep the blank original. Do not date or sign it. This entire card must be presented to your doctor for release of information. Make a copy of this authorization. Sign and date the copy. Authorization for Release of Information to The Prudential Insurance Company of America This Authorization is not intended for use with FMLA leave or similar absences. This Authorization is intended to comply with the HIPAA Privacy Rule. I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, or other health care provider that has provided treatment, payment, or services to me or on my behalf ("my providers") to disclose my entire medical record and any other health information concerning me to The Prudential Insurance Company of America (Prudential) and its agents, employees, and representatives. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco, but excludes psychotherapy notes. How to file a disability claim Disability coverage is a valuable benefit because it helps protect your income when you are unable to work due to an illness, injury, or pregnancy. Prudential is pleased to provide you with disability coverage and wants to make your claim for benefits as easy as possible. Just follow these steps 1. Notify your 2. Call Prudential at 800-842-1718, You can speak to a trained disability specialist or follow the prompts to record your disability information. OR Log in to www.prudential.com/mybenefits Click on "Claims and Absence" and then "File a Claim / Report an Absence." There, you can input your information and download any forms you may need. 3. Ask your doctor's office to make a copy of the attached Authorization Card. This will allow your doctor's office to release information Prudential needs to process your claim for disability benefits.

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