Common use of REQUIREMENT   TO   NOTIFY   THE   INSURER Clause in Contracts

REQUIREMENT   TO   NOTIFY   THE   INSURER. The Insured must contact Bupa Insurance Company’s Claims Administrator, USA Medical Services, at least seventy-two (72) hours in advance of receiving any medical care. Emergency treatment must be notified within forty-eight (48) hours of commencement of such treatment. If the Insured fails to contact USA Medical Services as stated herein, the Insured will be responsible for thirty percent (30%) of all covered medical and hospital charges related to the claim, in addition to the plan’s deductible and coinsurance (if applicable). USA Medical Services can be contacted 24 hours a day, 365 days a year at the following telephone numbers: In the U.S.A.: (000) 000-0000 Free of charge from the U.S.A.: 0-000-000-0000 Fax: (000) 000-0000 Visit My Bupa in our display options: xxx.xxxxxxxxx.xxx/XxXxxx Outside the USA: Phone number can be located on your ID card, or at xxx.xxxxxxxxx.xxx YOUR HEALTHCARE PARTNER ONLINE TO MAKE YOUR LIFE EASIER! Log in to xxx.xxxxxxxxx.xxx, search for "My Bupa" in our display options and follow the registration steps with your email to manage your policy from the comfort of your home or office. Enjoy our online services: • Access to your policy documents and ID cards • Payments • Changes request • Claim request and update information • Pre-authorization services request • Costumer Service • Virtual Care (Telemedicine) You are responsible for checking all documents and correspondence online. BUPA SELECT BENEFITS • See applicable sections of the policy for details, limitations, and restrictions. • The plan Bupa Select policy provides coverage in the Preferred Provider Network only. No benefits are payable for services rendered outside the Preferred Provider Network, except under the emergency medical treatment provision. • Maximum coverage is two million dollars ($2,000,000) per insured, per lifetime for all covered medical and hospital charges while the policy is in force, subject to the limitations herein. • The insurer, USA Medical Services, and/or any of their applicable related subsidiaries and affiliates will not engage in any transactions with any parties or in any countries where otherwise prohibited by the laws in the United States of America. Please contact USA Medical Services for more information about this restriction. SCHEDULE OF BENEFITS Coverage (per Insured) Maximum benefit Standard private or semi-private hospital room and board No limit Intensive care room and board No limit Maternity care (except plans Select 5 and Select 7) (no deductible or coinsurance applies) $2,000 Newborn coverage (no deductible or coinsurance applies) $10,000 Congenital and Hereditary Disorders: • Manifested before age 18 (per Insured, per lifetime) • Manifested on or after age 18 (per Insured, per lifetime) $100,000 $2,000,000 Air ambulance transportation (per Insured, per lifetime) $50,000 Ground ambulance transportation (per incident) $1,000 Repatriation of mortal remains $5,000 Emergency treatment outside the Preferred Provider Network (per incident) $25,000 BENEFITS DEDUCTIBLE COINSURANCE • All insureds under the policy have • The Insured is responsible for twenty an in-country and an out-of-country deductible responsibility per policy year according to the plan selected by the Policyholder. When applicable, the corresponding deductible amount percent (20%) of approved charges for the first five thousand dollars ($5,000) after satisfaction of the applicable deductible (except plans Select 5 and Select 7). is applied per Insured, per policy year • One (1) coinsurance per Insured, per before benefits are paid or reimbursed policy year. to the insured. All deductible amounts • In the event of an accident involving paid accumulate towards the corre- sponding maximum deductible per policy, which is equivalent to the sum of two individual deductibles. All insureds under the policy contribute to meeting the in-country and out- of-country maximum amounts of the policy. Once the maximum deductible amounts of the policy are met, the multiple members of an insured family on the same policy, a maximum of two (2) coinsurances will be charged for this incident. Other coinsurance may be applicable for the members who were not charged coinsurance, for other illnesses or injuries not related to the accident. insurer will consider all individual • If USA Medical Services is notified in deductible responsibilities as met. • Any eligible charges incurred by an insured during the last three (3) months ofbthe policy year will apply to that policy year’s deductible and will also be carried over to be applied towards that insured’s deductible for the following policy year, as long as there are no expenses incurred during the first nine (9) months of the policy year. If the benefit is granted to carry over the insured's deductible to the following policy year, and subse- quently the insured submits claims or requests for reimbursement for eligible expenses that occurred during the first nine (9) months of the policy year, the benefit will be reversed, and the insured will be responsible for the following policy year's deductible. accordance with the policy require- ments, then coinsurance will not apply to medical services in the country of residence (except Mexico).

REQUIREMENT   TO   NOTIFY   THE   INSURER. The Insured must contact Bupa Insurance Company’s Claims Administrator, USA Medical Services, at least seventy-two (72) hours in advance of receiving any medical care. Emergency treatment must be notified within forty-eight (48) hours of commencement of such treatment. If the Insured fails to contact USA Medical Services as stated herein, the Insured will be responsible for thirty percent (30%) of all covered medical and hospital charges related to the claim, in addition to the plan’s deductible and coinsurance (if applicable). USA Medical Services can be contacted 24 hours a day, 365 days a year at the following telephone numbers: In the U.S.A.: (000) 000-0000 Free of charge from the U.S.A.: 0-000-000-0000 Fax: (000) 000-0000 Visit My Bupa in our display options: xxx.xxxxxxxxx.xxx/XxXxxx Outside the USA: Phone number can be located on your ID card, or at xxx.xxxxxxxxx.xxx YOUR HEALTHCARE PARTNER ONLINE TO MAKE YOUR LIFE EASIER! Log in to xxx.xxxxxxxxx.xxx, search for "My Bupa" in our display options and follow the registration steps with your email to manage your policy from the comfort of your home or office. Enjoy our online services: • Access to your policy documents and ID cards • Payments • Changes request • Claim request and update information • Pre-authorization services request • Costumer Service • Virtual Care (Telemedicine) You are responsible for checking all documents and correspondence online. BUPA SELECT PRESTIGE BENEFITS • Insurance for high risk disorders. • See applicable sections of the policy for details, limitations, and restrictions. • The plan Bupa Select Unless otherwise stated herein, insureds under this policy provides coverage in the Preferred Provider Network only. No benefits are payable for services rendered outside not required to obtain treatment from the Preferred Provider Network, except under the emergency medical treatment provision. • Maximum coverage is two million dollars ($2,000,000) per insured, per lifetime for all covered medical illnesses and hospital charges injuries while the policy is in force. • This policy only covers the disorders or medical necessities in the Schedule of Benefits, subject to the limitations herein, for any treatment, service and supply provided in Latin America, the Caribbean, and the United States of America. • The insurer, USA Medical Services, and/or any of their applicable related subsidiaries and affiliates will not engage in any transactions with any parties or in any countries where otherwise prohibited by the laws in the United States of America. Please contact USA Medical Services for more information about this restriction. SCHEDULE OF BENEFITS BENEFITS Coverage (per Insured) Maximum benefit Standard private or semi-private hospital room and board No limit Intensive care room and board No limit Maternity care (except plans Select 5 and Select 7) (no deductible or coinsurance applies) $2,000 Newborn coverage (no deductible or coinsurance applies) $10,000 Congenital and Hereditary Disorders: • Manifested before age 18 (per Insured, per Policy Year) Maximum benefit Neurological disorders, including cerebrovascular accidents $150,000 Cardiac surgery and angioplasty $150,000 Cancer treatment, including chemotherapy, radiotherapy and reconstructive surgery $200,000 Severe trauma (multiple trauma), including rehabilitation $150,000 Chronic renal insufficiency (dialysis) $100,000 Severe xxxxx, including reconstructive surgery $300,000 Major infectious disorder (Septicemia) $150,000 Organ transplants (per insured, per lifetime) • Manifested on or after age 18 Heart • Heart / Lung • Lung • Pancreas • Pancreas / Kidney • Kidney • Liver • Bone Marrow $300,000 $300,000 $250,000 $250,000 $300,000 $200,000 $200,000 $250,000 Air ambulance (per Insured, per lifetime) $100,000 25,000 In Providers Network Not in Providers Network Regular room and board No limit $2,000,000 Air ambulance transportation (500 per Insured, per lifetime) $50,000 Ground ambulance transportation (per incident) day Intensive care room and board No limit $1,000 Repatriation of mortal remains $5,000 Emergency treatment outside the Preferred Provider Network (per incident) $25,000 BENEFITS day DEDUCTIBLE COINSURANCE • All insureds under the policy have • The Insured is responsible for twenty an in-country and an out-of-country a deductible responsibility per policy year according to the plan selected by the Policyholder. When applicable, the corresponding deductible amount percent (20%) of approved charges for the first five thousand dollars ($5,000) after satisfaction of the applicable deductible (except plans Select 5 and Select 7). is applied per Insured, per policy year • One (1) coinsurance per Insured, per before benefits are paid or reimbursed policy year. to the insured. All deductible amounts • In the event of an accident involving paid accumulate towards the corre- sponding maximum deductible per policy, which is equivalent to the sum of two individual deductibles. All insureds under the policy contribute to meeting the in-country and out- of-country maximum amounts of the policy. Once the maximum deductible amounts of the policy are met, the multiple members of an insured family on the same policy, a maximum of two (2) coinsurances will be charged for this incident. Other coinsurance may be applicable for the members who were not charged coinsurance, for other illnesses or injuries not related to the accident. insurer will consider all individual • If USA Medical Services is notified in deductible responsibilities as met. • Any eligible charges incurred by an insured during the last three (3) months ofbthe policy year will apply to that policy year’s deductible and will also be carried over to be applied towards that insured’s deductible for the following policy year, as long as there are no expenses incurred during the first nine (9) months of the policy year. If the benefit is granted to carry over the insured's deductible to the following policy year, and subse- quently the insured submits claims or requests for reimbursement for eligible expenses that occurred during the first nine (9) months of the policy year, the benefit will be reversed, and the insured will be responsible for the following policy year's deductible. accordance with to meeting the maximum deduct- COINSURANCE ible amount of the policy. Once the maximum deductible amount of the • The Insured is responsible for twenty policy is met, the insurer will consider all individual deductible responsibili- ties as met. • Any eligible charges incurred by an insured during the last three (3) percent (20%) of approved charges for the first five thousand dollars ($5,000) after satisfaction of the applicable deductible (Except xxxx XX0, XX0, XX0, XX0). months of the policy require- mentsyear will apply • One (1) coinsurance liability per to that policy year’s deductible and will also be carried over to be applied Insured, then coinsurance will not apply to medical services in the country of residence (except Mexico)per policy year.

REQUIREMENT   TO   NOTIFY   THE   INSURER. The Insured must contact Bupa Insurance Company’s Claims Administrator, USA Medical Services, at least seventy-two (72) hours in advance of receiving any medical care. Emergency treatment must be notified within forty-eight (48) hours of commencement of such treatment. If the Insured fails to contact USA Medical Services as stated herein, the Insured will be responsible for thirty percent (30%) of all covered medical and hospital charges related to the claim, in addition to the plan’s deductible and coinsurance (if applicable). USA Medical Services can be contacted 24 hours a day, 365 days a year at the following telephone numbers: In the U.S.A.: (000) 000-0000 Free of charge from the U.S.A.: 0-000-000-0000 Fax: (000305) 000-000- 0000 Visit My Bupa in our display options: xxx.xxxxxxxxx.xxx/XxXxxx Outside the USA: Phone number can be located on your ID card, or at xxx.xxxxxxxxx.xxx YOUR HEALTHCARE PARTNER ONLINE TO MAKE YOUR LIFE EASIER! Log in to xxx.xxxxxxxxx.xxx, search for "My Bupa" in our display options and follow the registration steps with your email to manage your policy from the comfort of your home or office. Enjoy our online services: • Access to your policy documents and ID cards • Payments • Changes request • Claim request and update information • Pre-authorization services request • Costumer Service • Virtual Care (Telemedicine) You are responsible for checking all documents and correspondence online. BUPA SELECT CHOICE BENEFITS • See applicable sections of the policy for details, limitations, and restrictions. • The plan Bupa Select Choice policy provides coverage in the Preferred Choice Provider Network only. No benefits are payable for services rendered outside the Preferred Choice Provider Network, except under the emergency medical treatment provision. • Maximum coverage is two one million dollars ($2,000,0001,000,000) per insuredInsured, per lifetime for all covered medical and hospital charges charges, while the policy is in force, subject to the limitations herein. • The insurer, USA Medical Services, and/or any of their applicable related subsidiaries and affiliates will not engage in any transactions with any parties or in any countries where otherwise prohibited by the laws in the United States of America. Please contact USA Medical Services for more information about this restriction. SCHEDULE OF BENEFITS BENEFITS Coverage (per Insured, per Policy Year) Maximum benefit Standard private Private or semi-private hospital room and board No limit Intensive care room and board No limit Maternity care (except plans Select 5 and Select 7) (no deductible or coinsurance applies) $2,000 Newborn coverage (no deductible or coinsurance applies) $10,000 Congenital and Hereditary Disorders: • Manifested before age 18 (per Insured, per lifetime) • Manifested on or after age 18 (per Insured, per lifetime) $100,000 $2,000,000 Air ambulance transportation (per Insured, per lifetime) $50,000 25,000 Ground ambulance transportation (per incident) $1,000 Repatriation of mortal remains $5,000 Emergency treatment outside the Preferred Choice Provider Network (per incident) $25,000 BENEFITS 10,000 DEDUCTIBLE COINSURANCE • All insureds under the policy have • The Insured is responsible for twenty an in-country and an out-of-country deductible responsibility per policy year according to the plan selected by the Policyholder. When applicable, the corresponding deductible amount percent (20%) of approved charges for the first five thousand dollars ($5,000) after satisfaction of the applicable deductible (except plans Select 5 and Select 7). is applied per Insured, per policy year • One (1) coinsurance per Insured, per before benefits are paid or reimbursed policy year. to the insured. All deductible amounts • In the event of an accident involving paid accumulate towards the corre- sponding maximum deductible per policy, which is equivalent to the sum of two individual deductibles. All insureds under the policy contribute to meeting the in-country and out- of-country maximum amounts of the policy. Once the maximum deductible amounts of the policy are met, the multiple members of an insured family on the same policy, a maximum of two (2) coinsurances will be charged for this incident. Other coinsurance may be applicable for the members who were not charged coinsurance, for other illnesses or injuries not related to the accident. insurer will consider all individual • If USA Medical Services is notified in deductible responsibilities as met. • Any eligible charges incurred by an insured during the last three (3) months ofbthe policy year will apply to that policy year’s deductible and will also be carried over to be applied towards that insured’s deductible for the following policy year, as long as there are no expenses incurred during the first nine (9) months of the policy year. If the benefit is granted to carry over the insured's deductible to the following policy year, and subse- quently the insured submits claims or requests for requestsfor reimbursement for eligible expenses that occurred during the first nine (9) months of the policy year, the benefit will be reversed, and the insured will be responsible for the following policy year's deductible. accordance with before benefits are paid or reimbursed COINSURANCE to the insured. All deductible amounts • The Insured is responsible for twenty paid accumulate towards the corre- sponding maximum deductible per policy, which is equivalent to the sum of two individual deductibles. All insureds under the policy require- mentscontribute percent (20%) of approved charges for the first five thousand dollars ($5,000) after satisfaction of the applicable deductible. to meeting the in-country and out- • One (1) coinsurance per Insured, then coinsurance will not apply to medical services in per of-country maximum amounts of the country of residence (except Mexico)policy year.

REQUIREMENT   TO   NOTIFY   THE   INSURER. The Insured must contact Bupa Insurance Company’s 's Claims Administrator, USA Medical Services, at least seventy-two (72) hours in advance of receiving any medical care. Emergency treatment must be notified within forty-eight (48) hours of commencement of such treatment. If the Insured fails to contact USA Medical Services as stated herein, the Insured will be responsible for thirty percent (30%) of all covered medical and hospital charges related to the claim, in addition to the plan’s 's deductible and coinsurance (if applicable). USA Medical Services can be contacted 24 hours a day, 365 days a year at the following telephone numbers: In the U.S.A.: (000) 000-0000 Free of charge from the U.S.A.: 0-000-000-0000 Fax: (000) 000-0000 Visit My Bupa in our display options: xxx.xxxxxxxxx.xxx/XxXxxx Outside the USA: Phone number can be located on your ID card, or at xxx.xxxxxxxxx.xxx YOUR HEALTHCARE PARTNER ONLINE TO MAKE YOUR LIFE EASIER! Log in to xxx.xxxxxxxxx.xxx, search for "My Bupa" in our display options and follow the registration steps with your email to manage your policy from the comfort of your home or office. Enjoy our online services: • Access to your policy documents and ID cards • Payments • Changes request • Claim request and update information • Pre-authorization services request • Costumer Service • Virtual Care (Telemedicine) You are responsible for checking all documents and correspondence online. BUPA SELECT GROUP BENEFITS • See applicable sections of the policy for details, limitations, and restrictions. • The plan Bupa Select Group policy provides coverage in the Preferred Provider Network only. No benefits are payable for services service rendered outside the Preferred Provider Network, except under the emergency medical treatment provision. • Maximum coverage is two five million dollars ($2,000,0005,000,000) per insured, per lifetime for all covered medical and hospital charges while the policy is in force, subject to the limitations herein. • The insurer, USA Medical Services, and/or any of their applicable related subsidiaries and affiliates will not engage in any transactions with any parties or in any countries where otherwise prohibited by the laws in the United States of America. Please contact USA Medical Services for more information about this restriction. SCHEDULE OF BENEFITS BENEFITS Coverage (per Insured, per Policy Year) Maximum benefit Standard private Private or semi-private hospital room and board No limit Intensive care room and board No limit Maternity care benefit (except plans Select 5 Except Plans IV, V and Select 7VI) (no No deductible or coinsurance applies) $2,000 2,500 Newborn coverage (no No deductible or coinsurance applies) $10,000 25,000 Congenital and Hereditary Disordershereditary disorders: • Manifested before age 18 (per Insured, per lifetime) • Manifested on or after age 18 (per Insured, per lifetime) $100,000 $2,000,000 5,000,000 Organ transplant (per Insured, per lifetime) $250,000 Air ambulance transportation (per Insured, per lifetime) $50,000 25,000 Ground ambulance transportation (per incident) $1,000 Repatriation of mortal remains $5,000 Emergency treatment outside the Preferred Provider Network (per incident) $25,000 BENEFITS Disclosed pre-existing conditions (Lifetime maximum, per Insured after twenty-four (24) months of continuous coverage) $25,000 DEDUCTIBLE COINSURANCE • All insureds under the policy Certificate have • The Insured is responsible for twenty an in-country and an out-of-country a deductible responsibility per policy year according to the plan selected by the PolicyholderCertificate Holder. When applicable, the corresponding deductible amount percent (20%) of approved charges for the first five thousand dollars ($5,000) after satisfaction of the applicable deductible (except plans Select 5 and Select 7). is applied per Insuredinsured, per policy year • One (1) coinsurance per Insured, per before benefits are paid or reimbursed policy year. to the insured. All deductible amounts • In the event of an accident involving paid accumulate towards the corre- sponding maximum deductible per policy, which is equivalent to the sum of two individual deductibles. All insureds under the policy contribute to meeting the in-country and out- of-country maximum amounts of the policy. Once the maximum deductible amounts of the policy are met, the multiple members of an insured family on the same policy, a maximum of two (2) coinsurances will be charged for this incident. Other coinsurance may be applicable for the members who were not charged coinsurance, for other illnesses or injuries not related to the accident. insurer will consider all individual • If USA Medical Services is notified in deductible responsibilities as met. • Any eligible charges incurred by an insured during the last three (3) months ofbthe policy year will apply to that policy year’s deductible and will also be carried over to be applied towards that insured’s deductible for the following policy year, as long as there are no expenses incurred during the first nine (9) months of the policy year. If the benefit is granted to carry over the insured's deductible to the following policy year, and subse- quently the insured submits claims or requests for reimbursement for eligible expenses that occurred during the first nine (9) months of the policy year, the benefit will be reversed, and the insured will be responsible for the following policy year's deductible. to the insured. All deductible amounts COINSURANCE paid accumulate towards the corre- • The Insured is responsible for twenty sponding maximum deductible per Certificate, which is equivalent to the sum of two individual deductibles. All insureds under the Certificate contribute to meeting the maximum percent (20%) of approved charges for the first five thousand dollars ($5,000) after satisfaction of the applicable deductible (except plans IV, V and VI). deductible amount of the policy. Once • One (1) coinsurance per Insured, per the maximum deductible amount policy year. of the Certificate is met, the insurer • In the event of an accident involving will consider all individual deductible responsibilities as met. • Any eligible charges incurred by an insured during the last three (3) months ofthe policy year will apply to that policy year’s deductible and will also be carried over to be applied towards that insured’s deductible for multiple members of an Insured family on the same certificate, a maximum of two (2) coinsurances will be charged for this incident. Other coinsurance may be applicable for the members who were not charged coinsurance, for other illnesses or injuries not related to the accident. the following policy year, as long as • If USA Medical Services is notified there are no expenses incurred during the first nine (9) months of the policy year. If the benefit is granted to carry over the insured's deductible to the following policy year, and subsequently in accordance with to the policy require- ments, then coinsurance will not apply to medical services in the country of residence (except Mexico).. BUPA GROUP