Short Term Recovery Care Insurance. Kentucky. Agent Use Only TR-235-KY

Transcription

1 TM Short Term Recovery Care Insurance Kentucky Agent Use Only TR-235-KY

2 PRIVACY NOTICE Thank you for selecting MedAmerica Insurance Company. Although your application is our initial source of information, we may also need to obtain information about you from doctors, hospitals, health care providers, pharmacies or pharmacy benefit manager who have information about you or your mental or physical health or from a medical examination we may ask you to take; an inperson health interview; or the Medical Information Bureau (MIB). We will treat any information we obtain as confidential. We will not disclose information to anyone unless we are permitted to do so by law without your express written permission. It may be necessary to share information we obtain with an individual or organization performing a function for us. We will provide you with any information contained in our files upon your request. If you wish to correct, amend or delete any of the information in the file you dispute, please contact us and we will advise you of the required procedures. Please refer to the Authorization to Disclose Protected Health Information form for further details. LTC Privacy Officer PO Box Rochester, NY LTCPrivacy.Officer@MedAmericaltc.com Ext. 3413

3 I. APPLICANT INFORMATION: 1. IDENTIFYING INFORMATION: Short Term Recovery Care Application TRS-336-KY EP/ASSOC. NAME/#: Administrative Offices: 165 Court Street Rochester, NY Applicant Name (First, MI, Last) Social Security Number Address Legal Residence Street Address (PO Box Not Adequate-Must Provide Street) Mailing/Delivery Street Address (if different) City State Zip City State Zip ( ) ( ) / / Male Married Single with Domestic Partner MM/DD/YYYY Female Single (Sign Domestic Partner Statement) Home Phone Work Phone Date of Birth Age Sex Marital Status 2. SPOUSE / DOMESTIC PARTNER INFORMATION: Complete IF your Spouse/Domestic Partner is applying at this time OR if they have 3. ALTERNATE BILLING ADDRESS: Address applicant requests billing be mailed to IF different than above. another MedAmerica Policy in force. ( ) Name (First, MI, Last) Name (First, MI, Last) Phone Number - - Social Security Number Street Address City State Zip II. INSURABILITY PROFILE-MUST BE COMPLETED BY ALL APPLICANTS (Answer each question, check YES or NO.) 1. Have you had Diabetes, other than diet controlled, for greater than ten (10) years? YES NO 2. Do you have any complications of Diabetes including peripheral vascular disease, kidney disease, neuropathy, YES NO retinopathy, or amputations? 3. In the past 3 years have you received Medical Advice, Consultation, or Treatment for any of the following: YES NO Alzheimer s Disease, Memory Loss, Dementia, Schizophrenia, Manic-Depression, or Mental Retardation Amyotrophic Lateral Sclerosis (ALS), Myasthenia Gravis, Multiple Sclerosis or Parkinson s Disease Muscular Dystrophy, Any Chronic Muscular or Connective Tissue Diseases, or Rheumatoid Arthritis 2 or more Joint Replacements, 2 or more Fractures, any Spinal Surgery, or any Narcotic or Epidural pain management Congestive Heart Failure, Cardiomyopathy, Stroke, or Transient Ischemic Attack (TIA) AIDS, Kidney Disease, Liver Cirrhosis, or Hepatitis (Other than Hepatitis A) Cancer (Other than Basal or Squamous Cell Skin Cancer), Organ Transplants, or Bone Marrow Transplants Alcohol abuse, prescription drug abuse, or illegal drug use 4. In the past 3 years have you needed assistance or supervision from another person to eat, bathe, dress, get YES NO in or out of a bed or chair, use the toilet, or maintain personal hygiene due to incontinence? 5. In the past 3 years have you used a Wheelchair, Walker, Motorized Scooter, Quad Cane, Dialysis, Catheters, YES NO Ventilators, Oxygen, Stairlift, Hospital Bed at Home, or Home Intravenous Medications? 6. In the past 3 years have you been advised to receive Home Health Care, Adult Day Care services or Rehabilitative YES NO Services for a period of 6 months or longer, including Physical or Occupational Therapy? 7. In the past 3 years have you been confined to or advised to enter a Nursing Home, Assisted Living Facility, or any YES NO other type of Long-Term Care Facility? 8. In the past 3 years have you been advised to be hospitalized or have any surgery that has not yet taken place? YES NO 9. In the past 3 years have you qualified to receive federal, state, or local government assistance in any form, such as, YES NO Supplemental Social Security Income, Social Security Disability Income, Medicare premiums paid by the state, Medicare due to disability, or Medicaid OR received Worker s Compensation or Long Term Disability benefits? 10. In the past 3 years have you been declined for any long term care insurance? YES NO STOP! Any Yes Response, we cannot offer coverage at this time. Do not submit the application. OFFICE USE ONLY App. Rec: App Status: UW Date: Init: Issued Declined Effective Date: TRS-345-KY-0711 COMPLETE AND RETURN 1

4 III. POLICY BENEFIT SELECTION: STEP 1: SELECT DAILY BENEFIT AMOUNT: $ ($50 - $300 in $10 increments) STEP 2: SELECT BENEFIT PERIOD: (Choose One) 100 Days 200 Days 360 Days STEP 3: ELIMINATION PERIOD: (Choose One) 20 Days 30 Days 60 Days STEP 4: INFLATION: (Choose One) None 5% Simple IV. INSURANCE HISTORY 1. Do you currently or have had in the last 12 months a nursing home (NH), home health care, long term care insurance policy, rider or certificate or any other accident or health insurance policy in force? If Lapsed, Provide Termination Date. If YES, please provide the following information. (Please use extra paper if needed) YES NO Company Name Address (Street, City, State, Zip) Policy Type: Nursing Home Home Care LTC Accident Health In Force YES NO Policy Number Daily Benefit Amount Years Coverage Effective Date Term Date 2. Are you allowing any nursing home (NH), home health care, long term care insurance policy, rider or certificate or any other accident or health insurance policy to lapse or do you intend to replace any other nursing home, home health care, long term care insurance policy, rider or certificate or any other accident or health insurance policy in force with this policy? If Lapsed, Provide Termination Date. If YES, please provide the following information. (Use extra paper if needed). YES NO Company Name Address (Street, City, State, Zip) Policy Type: Nursing Home Home Care LTC Accident Health In Force Yes No Policy Number Daily Benefit Amount Years Coverage Effective Date Term Date V. PREMIUM PAYMENT INFORMATION: All Applicants must CHOOSE ONE method and complete required information. 1. DIRECT BILL 2. ELECTRONIC FUNDS 3. CREDIT CARD 4) Payroll Deduction TRANSFER (EFT) Select the frequency of your Direct Billing payment Quarterly Semi-Annual Annual Select the frequency of your EFT payment. Signature required below. Monthly Quarterly Semi-Annual Annual Bank Name Bank Account Number Routing Number (9 digits) Requires Minimum of 2 months Conditional Premium. Attach Voided Check if Requesting EFT from Different Bank Account than Conditional Premium Check. Select the frequency of your Credit Card payment. Signature required below. Monthly Semi-Annual VISA MASTERCARD Quarterly Annual Credit Card Number Expiration Date MM/YY (Must be available through a group program and your employer.) Signature required below. I authorize my employer to deduct the applicable premium from my salary. I authorize MedAmerica Insurance Company to adjust these deductions based on rate changes or changes in coverage to my Policy. I may revoke this authorization at any time by written notice to my employer and to MedAmerica Insurance Company. Please attach Payroll stub. *Authorization for EFT, Credit Card and Payroll Deduction: Required IF Choosing EFT OR Credit Card Payment Method I authorize my financial institution, credit card company or employer as indicated above, to automatically make payments to MedAmerica Insurance Company for my insurance. This authorization shall remain in force until I give notification of termination to my financial institution and MedAmerica Insurance Company in writing. Account Holder Signature Joint Account Holder Signature (only required for joint accounts) TRS-345-KY-0711 COMPLETE AND RETURN 2

5 VII. HIPAA MEDICAL AUTHORIZATION (Uses and Disclosures of Medical Information) Must be signed by all applicants. This is a HIPAA compliant authorization. HIPAA is the Health Insurance Portability and Accountability Act of 1996, as amended. I hereby authorize the following uses and disclosures of medical information about me. From Me. I agree to permit company representatives to contact me to ascertain my health status to determine if my application is accepted. From My Health Care Providers. I authorize any physician, medical practitioner, hospital, clinic, pharmacy, pharmacy benefit manager or other health care provider or health related facility, including but not limited to those identified above, insurance or reinsurance company or employer, having information available as to any diagnosis, treatment and prognosis with respect to any of my physical or mental conditions and/or treatments (including medications), to furnish MedAmerica Insurance Company and/or designated business associates acting as insurance support organizations on MedAmerica Insurance Company's behalf any such protected health information, which may include my entire medical record, needed to determine my eligibility for insurance. THIS AUTHORIZATION EXPRESSLY INCLUDES INFORMATION ABOUT DRUGS, ALCOHOLISM, MENTAL ILLNESS AND COMMUNICABLE DISEASES. This authorization does not include psychotherapy notes. Regulations require a separate authorization for psychotherapy notes. We will contact you if we determine that such an authorization is needed. For 24 Months. I agree that this authorization will be valid for 24 months from the date signed below and that a photocopy shall be as valid as this original. You may revoke this authorization at any time by giving written notice of revocation to the LTC Privacy Officer, PO Box 41930, Rochester, New York or LTCPrivacy.Officer@MedAmericaLTC.com. Revocation will not affect any action taken in reliance on this authorization before written notice of revocation is received. Your Rights. Although voluntary, this authorization is required to determine your eligibility for enrollment. If you choose not to complete this authorization, we will be unable to determine your eligibility for insurance. By signing this authorization, you acknowledge that if you authorize a person or organization to receive your protected health information that is not a health plan, covered health care provider or health care clearinghouse subject to federal health information privacy laws, they may further disclose the protected health information and it may no longer be protected by federal health information privacy laws. PRINT APPLICANT NAME: APPLICANT DATE OF BIRTH: APPLICANT SOCIAL SECURITY NUMBER: - - MM / DD / YYYY APPLICANT S SIGNATURE: DATE: TRS-345-KY-0711 COMPLETE AND RETURN 3

6 VIII. SIGNATURES AND AUTHORIZATIONS: To be completed by ALL Applicants. 1. FRAUD NOTICE: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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. 2. PROTECTION AGAINST UNINTENDED LAPSE: I understand that I have the right to designate at least one person other than myself to receive notice of lapse or termination of this insurance policy for nonpayment of premium. I understand that notice will not be given until 31 days after a premium is due and unpaid. I understand, also, that I have the right not to appoint a lapse designee. Therefore, I select one of the following options: I elect NOT to designate any person to receive such notice. I designate the person listed below to be notified by MedAmerica Insurance Company if my premium is not paid: Name: Phone Number: Address: Street City State Zip 3. INFLATION PROTECTION OPTION: I have reviewed the Outline of Coverage and the graph that compare the benefits and premiums of this Policy with and without inflation protection, and I ACCEPT inflation protection. I REJECT inflation protection. 4. DECLARATION AND APPLICATION CONDITIONS: To the best of my knowledge and belief, I have answered all questions completely and truthfully. I understand this application is for consideration and the company will use the information contained herein to determine if my application is accepted. I understand that the coverage I am applying for is medically underwritten and that my coverage will begin only when I am notified of the effective date of coverage, or if selected, my alternate effective date. To receive benefits under the policy, I understand I must satisfy the elimination period and the benefit eligibility requirements as set forth in the policy. I acknowledge receipt of the Outline of Coverage and, if over 65, a Medicare Buyer s Guide: Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare. I understand the Producer or subsequent assignee, and any managing entities (which may include an affiliate of the Company), may receive compensation, monetary and/or non-monetary, as a result of my purchasing this insurance. CAUTION: If your answers on this application are incorrect or untrue, or you fail to include all material medical information requested, MedAmerica Insurance Company may have the right to deny benefits or rescind your policy. I understand that with this signature I am agreeing with all applicable conditions contained in this Section. Dated at: City State Month Day Year APPLICANT SIGNATURE: TRS-345-KY-0711 COMPLETE AND RETURN 4

7 VIII. PRODUCER STATEMENT 1. Has the Applicant purchased any other health insurance policy from you during the past five (5) years? If Yes, provide the following information: COMPANY TYPE OF POLICY POLICY NUMBER IN FORCE: YES NO 2. By my signature on this form I certify that: (a) I have reviewed the current health insurance coverage of the Applicant and find that additional coverage of the type and amount applied for is appropriate for the Applicant s needs. (b) I have consulted with the Applicant and have accurately recorded information supplied to me by the Applicant at the time application was made. (c) I am in compliance with the insurance requirements in the state this application was solicited in and signed by the applicant. (d) I have delivered the Outline of Coverage, and if over 65, a Medicare Buyer s Guide: Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare. YES NO Soliciting Producer Name (Please print) Writing Number Supervising General Agency Name Telephone Number (Best number to reach soliciting producer) : ( ) - SOLICITING PRODUCER SIGNATURE: DATE: 3. Are you SPLITTING the Commission Payment? YES NO If YES, List all producers receiving compensation, their Writing Number(s), and % splits. The first producer listed MUST be the soliciting producer and the producer of record. Case splits must total 100%. (Only Licensed and Appointed Producers/Brokers may receive compensation.) Soliciting Producer Name: Writing#: % Please Print First and Last Name Co-Producer Name: Writing#: % Please Print First and Last Name Co-Producer Name: Writing#: % Please Print First and Last Name Co-Producer Name: Writing#: % Please Print First and Last Name TOTAL: 100 % Amount of Conditional Premium Check (attached): $ As per the Conditional Receipt, Modal Premium is Required* *If EFT, 2 months premium is required Special Requests, Remarks, and Instructions: TRS-345-KY-0711 COMPLETE AND RETURN 5

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9 Administrative Offices: 165 Court Street Rochester, NY NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND SICKNESS INSURANCE According to your application, you intend to lapse or otherwise terminate existing accident and sickness insurance and replace it with a policy to be issued by MedAmerica Insurance Company. For your own information and protection, you should be aware of and seriously consider certain factors that may affect the insurance protection available to you under the new policy. 1) Health conditions which you may presently have, (pre-existing conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits present under the new policy, whereas a similar claim might have been payable under your present policy. 2) You may wish to secure the advice of your present insurer or its agents regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interests to make sure you understand all the relevant factors involved in replacing your present coverage. 3) If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical/health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, reread it carefully to be certain that all information has been properly recorded. The above Notice to Applicant was delivered to me on: Date Agent Name (Print) Applicant s Signature Agent Signature TR-RPL Notice to Applicant Regarding Replacement of Accident and Sickness Insurance Company Copy Complete and Return

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11 Administrative Offices: 165 Court Street Rochester, NY NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND SICKNESS INSURANCE According to your application, you intend to lapse or otherwise terminate existing accident and sickness insurance and replace it with a policy to be issued by MedAmerica Insurance Company. For your own information and protection, you should be aware of and seriously consider certain factors that may affect the insurance protection available to you under the new policy. 1) Health conditions which you may presently have, (pre-existing conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits present under the new policy, whereas a similar claim might have been payable under your present policy. 2) You may wish to secure the advice of your present insurer or its agents regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interests to make sure you understand all the relevant factors involved in replacing your present coverage. 3) If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical/health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, reread it carefully to be certain that all information has been properly recorded. The above Notice to Applicant was delivered to me on: Date Agent Name (Print) Applicant s Signature Agent Signature TR-RPL Notice to Applicant Regarding Replacement of Accident and Sickness Insurance Applicant Copy Complete and Leave with Applicant

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13 Administrative Offices: 165 Court Street Rochester, NY DOMESTIC PARTNER STATEMENT Please Print Domestic Partner Name: Domestic Partner Name: SSN: SSN: The undersigned attest that we satisfy the definition of Domestic Partner set forth in Section 1 below and agree to the requirements set forth in Section 2 below. 1. A Domestic Partner is defined as follows: A Domestic Partner consists of the applicant and one other person of the same or opposite sex. Such persons must satisfy all of the following requirements: a. Each is at least 18 years of age; b. Each is mentally competent to consent to contract; c. They are not related by blood or a degree of closeness which would prohibit marriage in the law of the state in which they reside; d. They have a single dedicated relationship of at least 12 months duration and intend to remain in the relationship indefinitely; e. They share the same permanent residence and have done so for at least 12 months; f. Neither is currently married to another person under either statutory or common law; g. They are financially interdependent as evidenced by actions or conditions such as joint ownership of real property or a common leasehold interest in real property; common ownership of an automobile; a joint bank account; a will which designates the other as primary beneficiary; or completion of a beneficiary designation form for a retirement plan or life insurance policy signed and completed to the effect that one Domestic Partner is beneficiary of the other. 2. We affirm the statements made above are true and complete to the best of our knowledge. We understand that false statements may result in a premium charge retroactive to the original effective date of coverage under the terms of the short term recovery care insurance policy this is attached to. Both must sign: DOMESTIC PARTNER SIGNATURE: DOMESTIC PARTNER SIGNATURE: Date: Date: TR-DPS Domestic Partner Statement Complete & Return

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15 Administrative Offices: 165 Court Street Rochester, NY CONDITIONAL PREMIUM RECEIPT This acknowledges receipt of the initial premium in connection with your application for a MedAmerica Insurance Company short term recovery care insurance policy. All premium checks must be made payable to MedAmerica. Do not make check payable to the producer or leave the payee blank. PAYMENT OF PREMIUM DOES NOT PROVIDE INSURANCE COVERAGE UNTIL THE CONDITIONS SPECIFIED BELOW ARE SATISFIED. APPLICANT NAME: APPLICATION DATE: PREMIUM RECEIPT DATE: INITIAL PREMIUM*: $ * For Monthly EFT: A minimum of 2 months conditional premium is required. * For Credit Card: We will debit your card once you are accepted for coverage. SIGNATURE OF LICENSED AND APPOINTED PRODUCER Producer Name and Business Address(Please Print) X The initial and subsequent premiums will differ from the amount submitted if coverage is issued other than as applied for or an anticipated discount does not apply. The premium for coverage applied for is based on medical underwriting guidelines and the premium quoted includes certain assumptions regarding the applicant s health. If coverage is declined, the full conditional premium will be returned. CONDITIONS THAT MUST BE SATISFIED BEFORE COVERAGE IS EFFECTIVE 1. THIS RECEIPT IS SIGNED BY THE SAME PRODUCER THAT SIGNED THE APPLICATION; 2. AN AMOUNT EQUAL TO THE PREMIUM NOTED ABOVE HAS BEEN COLLECTED WITH THE APPLICATION; AND 3. MEDAMERICA, UPON INVESTIGATION, IS SATISFIED THAT ON THE EFFECTIVE DATE OF COVERAGE, SUCH PERSON WAS INSURABLE ACCORDING TO THE COMPANY S RULES AND REGULATIONS. EFFECTIVE DATE OF COVERAGE IF THE APPLICANT IS INSURABLE, THE POLICY WILL BECOME EFFECTIVE ON THE LATEST OF THE FOLLOWING DATES: 1. DATE OF COMPLETION OF ALL PARTS OF THE APPLICATION AND SUPPLEMENTS THERETO; OR 2. DATE OF COMPLETION OF ALL REPORTS, MEDICAL EXAMINATIONS OR TESTS, INCLUDING A SECOND MEDICAL EXAMINATION, AS REQUESTED FOR ANY PERSON TO BE INSURED BECAUSE OF AGE, MEDICAL HISTORY, THE PLAN, OR THE AMOUNT OF INSURANCE APPLIED FOR; OR 3. THE DATE AS REQUESTED ON THE APPLICATION, WHICH MAY BE NO GREATER THAN SIXTY DAYS BEYOND THE COMPANY ASSIGNED EFFECTIVE DATE AND NOT EARLIER THAN THE APPLICATION SIGNATURE DATE. IF YOU HAVE SELECTED THIS OPTION, YOU AGREE TO THE FACT THAT YOU MAY BE WAIVING CERTAIN RIGHTS AND GUARANTEES UNDER THE CONDITIONAL RECEIPT. TR-103 CONDITIONAL PREMIUM RECEIPT COMPLETE AND LEAVE WITH APPLICANT

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17 I. APPLICANT INFORMATION: 1. IDENTIFYING INFORMATION: Short Term Recovery Care Application TRS-336-KY EP/ASSOC. NAME/#: Administrative Offices: 165 Court Street Rochester, NY Applicant Name (First, MI, Last) Social Security Number Address Legal Residence Street Address (PO Box Not Adequate-Must Provide Street) Mailing/Delivery Street Address (if different) City State Zip City State Zip ( ) ( ) / / Male Married Single with Domestic Partner MM/DD/YYYY Female Single (Sign Domestic Partner Statement) Home Phone Work Phone Date of Birth Age Sex Marital Status 2. SPOUSE / DOMESTIC PARTNER INFORMATION: Complete IF your Spouse/Domestic Partner is applying at this time OR if they have 3. ALTERNATE BILLING ADDRESS: Address applicant requests billing be mailed to IF different than above. another MedAmerica Policy in force. ( ) Name (First, MI, Last) Name (First, MI, Last) Phone Number - - Social Security Number Street Address City State Zip II. INSURABILITY PROFILE-MUST BE COMPLETED BY ALL APPLICANTS (Answer each question, check YES or NO.) 1. Have you had Diabetes, other than diet controlled, for greater than ten (10) years? YES NO 2. Do you have any complications of Diabetes including peripheral vascular disease, kidney disease, neuropathy, YES NO retinopathy, or amputations? 3. In the past 3 years have you received Medical Advice, Consultation, or Treatment for any of the following: YES NO Alzheimer s Disease, Memory Loss, Dementia, Schizophrenia, Manic-Depression, or Mental Retardation Amyotrophic Lateral Sclerosis (ALS), Myasthenia Gravis, Multiple Sclerosis or Parkinson s Disease Muscular Dystrophy, Any Chronic Muscular or Connective Tissue Diseases, or Rheumatoid Arthritis 2 or more Joint Replacements, 2 or more Fractures, any Spinal Surgery, or any Narcotic or Epidural pain management Congestive Heart Failure, Cardiomyopathy, Stroke, or Transient Ischemic Attack (TIA) AIDS, Kidney Disease, Liver Cirrhosis, or Hepatitis (Other than Hepatitis A) Cancer (Other than Basal or Squamous Cell Skin Cancer), Organ Transplants, or Bone Marrow Transplants Alcohol abuse, prescription drug abuse, or illegal drug use 4. In the past 3 years have you needed assistance or supervision from another person to eat, bathe, dress, get YES NO in or out of a bed or chair, use the toilet, or maintain personal hygiene due to incontinence? 5. In the past 3 years have you used a Wheelchair, Walker, Motorized Scooter, Quad Cane, Dialysis, Catheters, YES NO Ventilators, Oxygen, Stairlift, Hospital Bed at Home, or Home Intravenous Medications? 6. In the past 3 years have you been advised to receive Home Health Care, Adult Day Care services or Rehabilitative YES NO Services for a period of 6 months or longer, including Physical or Occupational Therapy? 7. In the past 3 years have you been confined to or advised to enter a Nursing Home, Assisted Living Facility, or any YES NO other type of Long-Term Care Facility? 8. In the past 3 years have you been advised to be hospitalized or have any surgery that has not yet taken place? YES NO 9. In the past 3 years have you qualified to receive federal, state, or local government assistance in any form, such as, YES NO Supplemental Social Security Income, Social Security Disability Income, Medicare premiums paid by the state, Medicare due to disability, or Medicaid OR received Worker s Compensation or Long Term Disability benefits? 10. In the past 3 years have you been declined for any long term care insurance? YES NO STOP! Any Yes Response, we cannot offer coverage at this time. Do not submit the application. OFFICE USE ONLY App. Rec: App Status: UW Date: Init: Issued Declined Effective Date: TRS-345-KY-0711 COMPLETE AND RETURN 1

18 III. POLICY BENEFIT SELECTION: STEP 1: SELECT DAILY BENEFIT AMOUNT: $ ($50 - $300 in $10 increments) STEP 2: SELECT BENEFIT PERIOD: (Choose One) 100 Days 200 Days 360 Days STEP 3: ELIMINATION PERIOD: (Choose One) 20 Days 30 Days 60 Days STEP 4: INFLATION: (Choose One) None 5% Simple IV. INSURANCE HISTORY 1. Do you currently or have had in the last 12 months a nursing home (NH), home health care, long term care insurance policy, rider or certificate or any other accident or health insurance policy in force? If Lapsed, Provide Termination Date. If YES, please provide the following information. (Please use extra paper if needed) YES NO Company Name Address (Street, City, State, Zip) Policy Type: Nursing Home Home Care LTC Accident Health In Force YES NO Policy Number Daily Benefit Amount Years Coverage Effective Date Term Date 2. Are you allowing any nursing home (NH), home health care, long term care insurance policy, rider or certificate or any other accident or health insurance policy to lapse or do you intend to replace any other nursing home, home health care, long term care insurance policy, rider or certificate or any other accident or health insurance policy in force with this policy? If Lapsed, Provide Termination Date. If YES, please provide the following information. (Use extra paper if needed). YES NO Company Name Address (Street, City, State, Zip) Policy Type: Nursing Home Home Care LTC Accident Health In Force Yes No Policy Number Daily Benefit Amount Years Coverage Effective Date Term Date V. PREMIUM PAYMENT INFORMATION: All Applicants must CHOOSE ONE method and complete required information. 1. DIRECT BILL 2. ELECTRONIC FUNDS 3. CREDIT CARD 4) Payroll Deduction TRANSFER (EFT) Select the frequency of your Direct Billing payment Quarterly Semi-Annual Annual Select the frequency of your EFT payment. Signature required below. Monthly Quarterly Semi-Annual Annual Bank Name Bank Account Number Routing Number (9 digits) Requires Minimum of 2 months Conditional Premium. Attach Voided Check if Requesting EFT from Different Bank Account than Conditional Premium Check. Select the frequency of your Credit Card payment. Signature required below. Monthly Semi-Annual VISA MASTERCARD Quarterly Annual Credit Card Number Expiration Date MM/YY (Must be available through a group program and your employer.) Signature required below. I authorize my employer to deduct the applicable premium from my salary. I authorize MedAmerica Insurance Company to adjust these deductions based on rate changes or changes in coverage to my Policy. I may revoke this authorization at any time by written notice to my employer and to MedAmerica Insurance Company. Please attach Payroll stub. *Authorization for EFT, Credit Card and Payroll Deduction: Required IF Choosing EFT OR Credit Card Payment Method I authorize my financial institution, credit card company or employer as indicated above, to automatically make payments to MedAmerica Insurance Company for my insurance. This authorization shall remain in force until I give notification of termination to my financial institution and MedAmerica Insurance Company in writing. Account Holder Signature Joint Account Holder Signature (only required for joint accounts) TRS-345-KY-0711 COMPLETE AND RETURN 2

19 VII. HIPAA MEDICAL AUTHORIZATION (Uses and Disclosures of Medical Information) Must be signed by all applicants. This is a HIPAA compliant authorization. HIPAA is the Health Insurance Portability and Accountability Act of 1996, as amended. I hereby authorize the following uses and disclosures of medical information about me. From Me. I agree to permit company representatives to contact me to ascertain my health status to determine if my application is accepted. From My Health Care Providers. I authorize any physician, medical practitioner, hospital, clinic, pharmacy, pharmacy benefit manager or other health care provider or health related facility, including but not limited to those identified above, insurance or reinsurance company or employer, having information available as to any diagnosis, treatment and prognosis with respect to any of my physical or mental conditions and/or treatments (including medications), to furnish MedAmerica Insurance Company and/or designated business associates acting as insurance support organizations on MedAmerica Insurance Company's behalf any such protected health information, which may include my entire medical record, needed to determine my eligibility for insurance. THIS AUTHORIZATION EXPRESSLY INCLUDES INFORMATION ABOUT DRUGS, ALCOHOLISM, MENTAL ILLNESS AND COMMUNICABLE DISEASES. This authorization does not include psychotherapy notes. Regulations require a separate authorization for psychotherapy notes. We will contact you if we determine that such an authorization is needed. For 24 Months. I agree that this authorization will be valid for 24 months from the date signed below and that a photocopy shall be as valid as this original. You may revoke this authorization at any time by giving written notice of revocation to the LTC Privacy Officer, PO Box 41930, Rochester, New York or LTCPrivacy.Officer@MedAmericaLTC.com. Revocation will not affect any action taken in reliance on this authorization before written notice of revocation is received. Your Rights. Although voluntary, this authorization is required to determine your eligibility for enrollment. If you choose not to complete this authorization, we will be unable to determine your eligibility for insurance. By signing this authorization, you acknowledge that if you authorize a person or organization to receive your protected health information that is not a health plan, covered health care provider or health care clearinghouse subject to federal health information privacy laws, they may further disclose the protected health information and it may no longer be protected by federal health information privacy laws. PRINT APPLICANT NAME: APPLICANT DATE OF BIRTH: APPLICANT SOCIAL SECURITY NUMBER: - - MM / DD / YYYY APPLICANT S SIGNATURE: DATE: TRS-345-KY-0711 COMPLETE AND RETURN 3

20 VIII. SIGNATURES AND AUTHORIZATIONS: To be completed by ALL Applicants. 1. FRAUD NOTICE: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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. 2. PROTECTION AGAINST UNINTENDED LAPSE: I understand that I have the right to designate at least one person other than myself to receive notice of lapse or termination of this insurance policy for nonpayment of premium. I understand that notice will not be given until 31 days after a premium is due and unpaid. I understand, also, that I have the right not to appoint a lapse designee. Therefore, I select one of the following options: I elect NOT to designate any person to receive such notice. I designate the person listed below to be notified by MedAmerica Insurance Company if my premium is not paid: Name: Phone Number: Address: Street City State Zip 3. INFLATION PROTECTION OPTION: I have reviewed the Outline of Coverage and the graph that compare the benefits and premiums of this Policy with and without inflation protection, and I ACCEPT inflation protection. I REJECT inflation protection. 4. DECLARATION AND APPLICATION CONDITIONS: To the best of my knowledge and belief, I have answered all questions completely and truthfully. I understand this application is for consideration and the company will use the information contained herein to determine if my application is accepted. I understand that the coverage I am applying for is medically underwritten and that my coverage will begin only when I am notified of the effective date of coverage, or if selected, my alternate effective date. To receive benefits under the policy, I understand I must satisfy the elimination period and the benefit eligibility requirements as set forth in the policy. I acknowledge receipt of the Outline of Coverage and, if over 65, a Medicare Buyer s Guide: Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare. I understand the Producer or subsequent assignee, and any managing entities (which may include an affiliate of the Company), may receive compensation, monetary and/or non-monetary, as a result of my purchasing this insurance. CAUTION: If your answers on this application are incorrect or untrue, or you fail to include all material medical information requested, MedAmerica Insurance Company may have the right to deny benefits or rescind your policy. I understand that with this signature I am agreeing with all applicable conditions contained in this Section. Dated at: City State Month Day Year APPLICANT SIGNATURE: TRS-345-KY-0711 COMPLETE AND RETURN 4

21 VIII. PRODUCER STATEMENT 1. Has the Applicant purchased any other health insurance policy from you during the past five (5) years? If Yes, provide the following information: COMPANY TYPE OF POLICY POLICY NUMBER IN FORCE: YES NO 2. By my signature on this form I certify that: (a) I have reviewed the current health insurance coverage of the Applicant and find that additional coverage of the type and amount applied for is appropriate for the Applicant s needs. (b) I have consulted with the Applicant and have accurately recorded information supplied to me by the Applicant at the time application was made. (c) I am in compliance with the insurance requirements in the state this application was solicited in and signed by the applicant. (d) I have delivered the Outline of Coverage, and if over 65, a Medicare Buyer s Guide: Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare. YES NO Soliciting Producer Name (Please print) Writing Number Supervising General Agency Name Telephone Number (Best number to reach soliciting producer) : ( ) - SOLICITING PRODUCER SIGNATURE: DATE: 3. Are you SPLITTING the Commission Payment? YES NO If YES, List all producers receiving compensation, their Writing Number(s), and % splits. The first producer listed MUST be the soliciting producer and the producer of record. Case splits must total 100%. (Only Licensed and Appointed Producers/Brokers may receive compensation.) Soliciting Producer Name: Writing#: % Please Print First and Last Name Co-Producer Name: Writing#: % Please Print First and Last Name Co-Producer Name: Writing#: % Please Print First and Last Name Co-Producer Name: Writing#: % Please Print First and Last Name TOTAL: 100 % Amount of Conditional Premium Check (attached): $ As per the Conditional Receipt, Modal Premium is Required* *If EFT, 2 months premium is required Special Requests, Remarks, and Instructions: TRS-345-KY-0711 COMPLETE AND RETURN 5

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23 Administrative Offices: 165 Court Street Rochester, NY NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND SICKNESS INSURANCE According to your application, you intend to lapse or otherwise terminate existing accident and sickness insurance and replace it with a policy to be issued by MedAmerica Insurance Company. For your own information and protection, you should be aware of and seriously consider certain factors that may affect the insurance protection available to you under the new policy. 1) Health conditions which you may presently have, (pre-existing conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits present under the new policy, whereas a similar claim might have been payable under your present policy. 2) You may wish to secure the advice of your present insurer or its agents regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interests to make sure you understand all the relevant factors involved in replacing your present coverage. 3) If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical/health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, reread it carefully to be certain that all information has been properly recorded. The above Notice to Applicant was delivered to me on: Date Agent Name (Print) Applicant s Signature Agent Signature TR-RPL Notice to Applicant Regarding Replacement of Accident and Sickness Insurance Company Copy Complete and Return

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25 Administrative Offices: 165 Court Street Rochester, NY NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND SICKNESS INSURANCE According to your application, you intend to lapse or otherwise terminate existing accident and sickness insurance and replace it with a policy to be issued by MedAmerica Insurance Company. For your own information and protection, you should be aware of and seriously consider certain factors that may affect the insurance protection available to you under the new policy. 1) Health conditions which you may presently have, (pre-existing conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits present under the new policy, whereas a similar claim might have been payable under your present policy. 2) You may wish to secure the advice of your present insurer or its agents regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interests to make sure you understand all the relevant factors involved in replacing your present coverage. 3) If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical/health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, reread it carefully to be certain that all information has been properly recorded. The above Notice to Applicant was delivered to me on: Date Agent Name (Print) Applicant s Signature Agent Signature TR-RPL Notice to Applicant Regarding Replacement of Accident and Sickness Insurance Applicant Copy Complete and Leave with Applicant

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27 Administrative Offices: 165 Court Street Rochester, NY CONDITIONAL PREMIUM RECEIPT This acknowledges receipt of the initial premium in connection with your application for a MedAmerica Insurance Company short term recovery care insurance policy. All premium checks must be made payable to MedAmerica. Do not make check payable to the producer or leave the payee blank. PAYMENT OF PREMIUM DOES NOT PROVIDE INSURANCE COVERAGE UNTIL THE CONDITIONS SPECIFIED BELOW ARE SATISFIED. APPLICANT NAME: APPLICATION DATE: PREMIUM RECEIPT DATE: INITIAL PREMIUM*: $ * For Monthly EFT: A minimum of 2 months conditional premium is required. * For Credit Card: We will debit your card once you are accepted for coverage. SIGNATURE OF LICENSED AND APPOINTED PRODUCER Producer Name and Business Address(Please Print) X The initial and subsequent premiums will differ from the amount submitted if coverage is issued other than as applied for or an anticipated discount does not apply. The premium for coverage applied for is based on medical underwriting guidelines and the premium quoted includes certain assumptions regarding the applicant s health. If coverage is declined, the full conditional premium will be returned. CONDITIONS THAT MUST BE SATISFIED BEFORE COVERAGE IS EFFECTIVE 1. THIS RECEIPT IS SIGNED BY THE SAME PRODUCER THAT SIGNED THE APPLICATION; 2. AN AMOUNT EQUAL TO THE PREMIUM NOTED ABOVE HAS BEEN COLLECTED WITH THE APPLICATION; AND 3. MEDAMERICA, UPON INVESTIGATION, IS SATISFIED THAT ON THE EFFECTIVE DATE OF COVERAGE, SUCH PERSON WAS INSURABLE ACCORDING TO THE COMPANY S RULES AND REGULATIONS. EFFECTIVE DATE OF COVERAGE IF THE APPLICANT IS INSURABLE, THE POLICY WILL BECOME EFFECTIVE ON THE LATEST OF THE FOLLOWING DATES: 1. DATE OF COMPLETION OF ALL PARTS OF THE APPLICATION AND SUPPLEMENTS THERETO; OR 2. DATE OF COMPLETION OF ALL REPORTS, MEDICAL EXAMINATIONS OR TESTS, INCLUDING A SECOND MEDICAL EXAMINATION, AS REQUESTED FOR ANY PERSON TO BE INSURED BECAUSE OF AGE, MEDICAL HISTORY, THE PLAN, OR THE AMOUNT OF INSURANCE APPLIED FOR; OR 3. THE DATE AS REQUESTED ON THE APPLICATION, WHICH MAY BE NO GREATER THAN SIXTY DAYS BEYOND THE COMPANY ASSIGNED EFFECTIVE DATE AND NOT EARLIER THAN THE APPLICATION SIGNATURE DATE. IF YOU HAVE SELECTED THIS OPTION, YOU AGREE TO THE FACT THAT YOU MAY BE WAIVING CERTAIN RIGHTS AND GUARANTEES UNDER THE CONDITIONAL RECEIPT. TR-103 CONDITIONAL PREMIUM RECEIPT COMPLETE AND LEAVE WITH APPLICANT

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29 TM Short Term Recovery Care Insurance Agent Rate Tool Agent Use Only

30 No Inflation Annual Premium Rates 1 - Single Insureds 2 Transitions Agent Rate Tool 20 Day Elimination Period 30 Day Elimination Period 60 Day Elimination Period Issue Age Agent Use Only TR-RI-1-KY 100 Day Benefit Period 200 Day Benefit Period 360 Day Benefit Period <50 $19.38 $23.84 $ $20.18 $25.26 $ $20.97 $26.68 $ $21.77 $28.10 $ $22.62 $29.53 $ $23.47 $30.97 $ $24.31 $32.40 $ $25.16 $33.84 $ $26.01 $35.27 $ $27.32 $37.51 $ $28.63 $39.74 $ $29.94 $41.98 $ $31.24 $44.21 $ $32.55 $46.44 $ $34.74 $50.22 $ $36.93 $53.99 $ $39.12 $57.76 $ $41.31 $61.53 $ $43.51 $65.30 $ $46.78 $72.34 $ $50.06 $79.38 $ $53.34 $86.42 $ $56.62 $93.46 $ $59.89 $ $ $66.15 $ $ $72.41 $ $ $78.67 $ $ $84.93 $ $ $91.19 $ $ $99.98 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Day Benefit Period 200 Day Benefit Period 360 Day Benefit Period $19.08 $23.45 $29.52 $19.83 $24.82 $31.74 $20.59 $26.19 $33.96 $21.35 $27.56 $36.19 $22.16 $28.95 $38.39 $22.98 $30.34 $40.60 $23.79 $31.74 $42.81 $24.61 $33.13 $45.02 $25.42 $34.52 $47.22 $26.69 $36.69 $50.68 $27.95 $38.86 $54.15 $29.21 $41.03 $57.61 $30.47 $43.20 $61.07 $31.73 $45.37 $64.53 $33.84 $49.05 $70.43 $35.96 $52.72 $76.34 $38.08 $56.39 $82.24 $40.19 $60.06 $88.14 $42.31 $63.74 $94.05 $45.42 $70.55 $ $48.53 $77.36 $ $51.64 $84.18 $ $54.75 $90.99 $ $57.87 $97.80 $ $63.95 $ $ $70.04 $ $ $76.13 $ $ $82.22 $ $ $88.31 $ $ $96.83 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Day Benefit Period 200 Day Benefit Period 360 Day Benefit Period $18.28 $22.24 $27.77 $18.93 $23.45 $29.75 $19.59 $24.65 $31.74 $20.24 $25.86 $33.72 $20.96 $27.10 $35.72 $21.68 $28.35 $37.71 $22.40 $29.60 $39.70 $23.12 $30.84 $41.69 $23.85 $32.09 $43.68 $24.97 $34.04 $46.81 $26.09 $35.99 $49.95 $27.21 $37.94 $53.08 $28.33 $39.89 $56.21 $29.45 $41.84 $59.34 $31.34 $45.15 $64.70 $33.23 $48.46 $70.05 $35.12 $51.77 $75.41 $37.01 $55.07 $80.77 $38.90 $58.38 $86.12 $41.48 $64.34 $96.96 $44.06 $70.30 $ $46.64 $76.26 $ $49.22 $82.22 $ $51.79 $88.18 $ $57.28 $97.84 $ $62.76 $ $ $68.24 $ $ $73.72 $ $ $79.20 $ $ $86.78 $ $ $94.37 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Per $10 of coverage 2 10% spouse / domestic partner discount

31 TM Transitions Agent Rate Tool How to Calculate Premium Part A: Benefit Selection 1. Choose a Daily Benefit between $50 and $300, and enter that amount here: ($10 Incerements Only) 2. Choose a Benefit Period. X (100, 200 or 360) 3. Multiply the Daily Benefit and the Benefit Period to determine your Lifetime Maximum Benefit. This is the total amount of benefits being quoted. (Lifetime Maximum) Part B: Calculate Rates Using Premium Calculation Worksheet* 1. Take the Daily Benefit you chose in step one above and divide by Enter that amount in the Number of $10 Units field. 3. Find your Base Policy Rate on the adjacent chart by choosing the Elimination Period, Benefit Period and Issue Age. 4. Enter that amount in the Base Policy Rate field. 5. Multiply the Number of $10 Units by the Base Policy Rate to calculate the Gross Annual Premium. 6. If the client is married or has a domestic partner, Multiply Gross Annual Premium by If client wishes to pay semi-annually, quarterly, or monthly, multiply by the appropriate modal factor. Premium Calculation Worksheet Number of $10 Units: Base Policy Rate: Gross Annual Premium: Marital Discount: (If client has a spouse/domestic partner) Discounted Rate: Modal Factor: (If other than annual - see below) Total Modal Premium: x $ = $ x 0.9 = $ x = $ Premium Calculation Worksheet Number of $10 Units: Base Policy Rate: Gross Annual Premium: Marital Discount: (If client has a spouse/domestic partner) Discounted Rate: Modal Factor: (If other than annual - see below) Total Modal Premium: x $ = $ x 0.9 = $ x = $ Modal Factors Modal Factors Semi-Annual Quarterly Monthly Semi-Annual Quarterly Monthly * Two worksheets are provided to make it easy for you to offer comparative quotes. Agent Use Only TR-RI-2 Agent Rate Tool - Complete and Return