Third Party Liability Information Statement

MSSICS Screens for Third Party Liability Inputs

FACSIMILE 1:  BTPL - THIRD PARTY LIABILITY

MSSICS                     THIRD PARTY LIABILITY           PAGE 1 OF BTPL

                                                            [1-O]

SSS-SS-SSSS    SSSSS SSSSSSSSSS                             TRANSFER TO: XXXX

 [2-O]

 SERVICES COVERED (Y)

              HOSPITAL: X                        DENTAL: X

             PHYSICIAN: X                     EMERGENCY: X

            OUTPATIENT: X                  PRESCRIPTION: X

   LABORATORY SERVICES: X                         OTHER: X

     [3-O]

     IF OTHER, EXPLAIN:  XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

 [4-O]

 NAME OF POLICY HOLDER: P    1=CLAIMANT     2=OTHER

     [5-O]

     IF OTHER, NAME: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX

               [6-O]

               RELATIONSHIP TO CLAIMANT:  9  1=SPOUSE   2=PARENT   3=OTHER

                  [7-O]

                  IF OTHER, EXPLAIN:  XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

               [8-O]

               POLICY HOLDER SSN: 999-99-9999

               [9-O]

               POLICY HOLDER BIRTHDATE (MMDDCCYY): 99999999

 [10-O]

 COMPANY: PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

 [11-O]

 ADDR: PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP  PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

       PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP  PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

   [12-M]                         [13-C]      [14-C]      [15-C]

   CITY: XXXXXXXXXXXXXXXXXXXXXX   STATE: XX   ZIP: 99999  CONSULAR CODE: 999

   [16-C]                                    [17-C]

   FOREIGN COUNTRY: XXXXXXXXXXXXXXXXXXXXXX   POSTAL ZONE: XXXXXXXXXXXXXXX

 [18-O]

 POLICY NUMBER: XXXXXXXXXXXXXXXXXXXX

 [19-O]

 POLICY EFFECTIVE DATE (MMDDYY): 999999

 [20-O]

 POLICY ENDING DATE (MMDDYY): 999999

 [21-O]

 GROUP NO. OR NAME OF EMPLOYER:  XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

 [22-O]                                                         [23-O]

 ANOTHER POLICY (Y): X                                          REMARKS (Y): X

MSSICS Screens for Third Party Liability Inputs

FACSIMILE 2:  BTPL - THIRD PARTY LIABILITY

MSSICS                     THIRD PARTY LIABILITY           PAGE 2 OF BTPL

                                                            [1-O]

SSS-SS-SSSS    SSSSS SSSSSSSSSS                             TRANSFER TO: XXXX

 [24-O]

 CLAIM/LEGAL ACTION PENDING/PLANNED DUE TO ILLNESS/INJURY (Y/N): X

    [25-O]

    IF YES, NATURE OF CLAIM: 9     1=WORKER'S COMPENSATION

                                   2=AUTOMOBILE ACCIDENT

                                   3=OTHER (EXPLAIN)

           [26-O]

           IF OTHER, EXPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

           [27-O]

           INJURY/ILLNESS BEGIN DATE (MMDDYY):  999999

           CLAIM PENDING AGAINST:

[28-O]

NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

[29-O]

ADDR: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX  XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

      XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX  XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

  [30-M]                         [31-C]      [32-C]      [33-C]

  CITY: XXXXXXXXXXXXXXXXXXXXXX   STATE: XX   ZIP: 99999  CONSULAR CODE: 999

  [34-C]                                    [35-C]

  FOREIGN COUNTRY: XXXXXXXXXXXXXXXXXXXXXX   POSTAL ZONE: XXXXXXXXXXXXXXX

           ATTORNEY INFORMATION:

[36-O]

NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

[37-O]

ADDR: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX  XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

      XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX  XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

  [38-M]                         [39-C]      [40-C]      [41-C]

  CITY: XXXXXXXXXXXXXXXXXXXXXX   STATE: XX   ZIP: 99999  CONSULAR CODE: 999

  [42-C]                                    [43-C]

  FOREIGN COUNTRY: XXXXXXXXXXXXXXXXXXXXXX   POSTAL ZONE: XXXXXXXXXXXXXXX

                                                                [23-O]

                                                                REMARKS (Y): X

2