NOTICE FOR RESIDENTS OF MISSISSIPPI (continued) GCERT2000 12 notice/ms dis claim or the health care provider shall be entitled to recover damages in an amount up to three (3) times the amount of the benefits that remain unpaid until the claim is finally settled or adjudicated. Items to be Submitted for a Disability Income Insurance Claim When submitting Proof on an initial or continuing claim for Disability Income insurance, the following items may be required: ● documentation which must include, but is not limited to, the following information: 1. the date Your Disability started; 2. the cause of Your Disability; 3. the prognosis of Your Disability; 4. the continuity of Your Disability; and ● Your application for: ● Other Benefit Sources; ● Federal Social Security disability benefits; and ● Workers compensation benefits or benefits under a similar law. ● Written authorization for Us to obtain and release medical, employment and financial information and any other items We may reasonably require to document Your Disability or to determine Your receipt of or eligibility for Other Benefit Sources; ● any and all medical information, including but not limited to: 1. x-ray films; and 2. photocopies of medical records, including: a) histories, b) physical, mental or diagnostic examinations; and c) treatment notes; and ● the names and addresses of all: 1. physicians and medical practitioners who have provided You with diagnosis, treatment or consultation; 2. hospitals or other medical facilities which have provided You with diagnosis, treatment or consultation; 3. pharmacies which have filled Your prescriptions within the past three years; and ● additional proof elements as required and described within the additional plan provisions for which you are filing a claim for benefits. Time Limit on Legal Actions. A legal action on a claim may only be brought against Us during a certain period. This period begins 60 days after the date Proof is filed and ends 3 years after the date such Proof is required.