In order to process a claim for benefits, I authorize any physician, hospital, or other Medical Provider to release to Co-ordinated Benefit Plans, LLC,Trawick
International, or its representative, any information regarding my medical history, symptoms, treatment, examination results or diagnosis. A photocopy of
this authorization shall be considered as effective and valid as the original. This authorization shall be considered valid for the duration of the claim, but
not to exceed two and one-half years from the date signed. I understand I have a right to receive a copy of this authorization.