GA Channel MoneyGuard Ticket

Transcription

1 General Agency Team FAX: GA Channel MoneyGuard Ticket Insured Information First Name: MI: Last Name: SSN: Address: City: State: Zip: Gender: Male Female Smoker or Non-Smoker Date of Birth: Insured Contact Information - (This Information Will Be Critical To Complete The Underwriting Process.) Primary Phone Number: ext. Secondary Phone Number: Contract Information NOTE: Policy will be issued if approved with Specified Amount, Premium amount and frequency, Inflation Option, Benefit Duration and Non-Forfeiture Benefit Option as indicated on illustration or simplified quote accompanying this ticket. Contract State: Product: Owner (if not Insured): DOB: SSN: Primary Beneficiary: Relationship: SSN: Contingent Beneficiary: Relationship: SSN: Use additional page to list additional owner/beneficiary information. Policy Dating: Note - Insured s Issue Age Will Be Determined By Age On The Date The Ticket Is Received By Lincoln Writing Agent Information First/Last Name: Agent #: SSN/TIN: Split % First/Last Name: Agent #: SSN/TIN: Split % First/Last Name: Agent #: SSN/TIN: Split % Primary Case Contact: Phone: NOTE: We will send all correspondence concerning this case to the address listed below. This includes where the policy is sent for the Financial Advisor to deliver to the client. Name: Address: City: State: Zip: GA associated with this business (if applicable): FOR AGENT BROKER USE ONLY. NOT TO BE USED WITH THE PUBLIC. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 1 LF07415GAC 11/14

2 Lincoln MoneyGuard Application Checklist For use in all states EXCEPT California Instructions to Financial Advisor or Agent (You must be state insurance licensed, including required long-term care continuing education before submitting business): Prequalify your client using Lincoln MoneyGuard solutions Presubmission underwriting tool Complete ticket and paperwork listed below. Fax or mail to Lincoln or submit according to your firm s instructions. Submission must also include a Projection of Values (illustration). The Projection of Values must be signed by the Applicant and Financial Advisor or Agent. If applicable, submit all firm required forms to Lincoln or your back office according to your firm s instructions. Submissions not in good order will result in delays in processing and may require additional client signatures. Please provide your client with the Personal History Interview Worksheet. This worksheet does not have to be submitted with the paperwork as it is an aid for the client prior to their telephone interview. The form will help the client gather critical data and shorten the overall interview. Please return the completed forms listed below with all submissions: h MoneyGuard Ticket LF07415 (firm variations) h Replacement of Life Insurance or Annuities Form LF10087 (state variations) Includes required agent certification questions. You must complete the form regardless of replacement status. All yes and no check boxes must be answered. NOTE: in NY Form LF10087 is called Regulation 60: Appendix 11 h Long-Term Care Insurance Personal Worksheet (state & product variations) h Confirmation of Personal Worksheet Financial Information Opt Out Form LF10581 This form is required if the client opts out of completing the financial information on the Long Term Care Personal Worksheet. h Receipt of Required Notice(s) Acknowledgement Form Form LF10580 h Authorization for Release of Information (HIPAA) Form LF02896 (state variations) Please provide copies of the following to the applicant: h Important Notice for underwriting process Form MG10579 (state variations) h Privacy Practices Notice Form GB06714 h Privacy Notice for Protected Health Information Form GB06735 h Outline of Coverage (state and product variations) h A Shopper s Guide to Long-Term Care Insurance Please return the completed forms listed below for Replacements where applicable: h Appropriateness Verification Statement Form This form must be completed if a long term care or life insurance policy or annuity is being replaced. h Exchange Agreement / Absolute Assignment for Life Insurance Form LF06591 This form must be completed if the policy applied for is to be funded by a 1035 exchange. h Notice to Applicant Regarding Replacement of Accident and Sickness or Long-Term Care Insurance Form LTC06291 This form must be completed if a long-term care contract is being replaced. h Important Notice Regarding Replacement Form state variations when required Replacements for New York Only h Regulation 60 Appendix 10C Form LFF h Authorization to Disclosure Policy Information Form 29603NY h Appendix 11 Form LFF Client Information (Optional) Date Completed: Plan of Insurance: Insured Name: Date of Birth: Financial Advisor Name: Financial Advisor Number: Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 1 MG /16

3 Please check the appropriate servicing address of the underwriting company: h Lincoln Life & Annuity Company of New York, Life Service Office: PO Box 21008, Greensboro, NC h Lincoln Life & Annuity Company of New York, Annuity Service Office: PO Box 2348, Fort Wayne, IN (hereinafter referred to as the Company ) Authorization for Release of Information I (the undersigned) authorize any licensed physician, medical practitioner, nurse, records custodians, hospital, clinic, Pharmacy Benefit Manager or any other medically related facility, insurance support organizations, insurance company, Medical Information Bureau (MIB), or other organization, institution or person that has any records or knowledge of: Proposed Insured/Patient Date of Birth or the proposed insured s health, including but not limited to complete medical records in paper or electronic format, (including information regarding insurance, referral documents and records from other facilities) or if other, indicate here:. to give all such information to Lincoln Life & Annuity Company of New York (the Company), their licensed representatives and/or their reinsurers, approved vendors, or if other, indicate here:. I authorize the Company or its reinsurer to make a brief report of my protected health information to MIB, Inc. I understand that an Authorization for Release or disclosure of psychotherapy notes may not be combined with an Authorization for Release or disclosure of any other information (a separate Authorization must be completed for release or disclosure of psychotherapy notes). I understand that information released may include information regarding testing, diagnosis, and/or treatment of communicable diseases. I understand that the information released may include information obtained through my telephonic interview or Personal Health Interview. I understand that the information obtained may be used by the Company to determine eligibility for insurance, or to administer my coverage. The Company may not give the information to any person or entity except: 1) a reinsurer, or other insurers to whom I have applied or may apply; 2) MIB; 3) any other person or entity who performs business or legal services in connection with the application for or administration of my insurance coverage; or 4) the agent and/or agency. I understand that some of these people or entities may not be covered by federal or state privacy regulations and that the information they receive may be redisclosed, however the Company contractually requires them to protect the information we disclose to them. Information may be disclosed as allowed by law or regulation. I understand this consent may be revoked in writing to the address above, at any time, except to the extent: 1) the Company has previously taken action in reliance on this Authorization; or 2) the Company is using this Authorization in connection with a contestable claim regarding my policy. If written revocation is not received, this Authorization will be considered valid for 24 months from the date of signing. I understand that if I refuse to sign this Authorization to release my complete medical records in paper or electronic format, that medical treatment cannot be withheld. If I refuse to sign this Authorization, the Company may not be able to process my application for insurance. I understand that there is a possibility of re-disclosure of any information disclosed pursuant to this Authorization and that information, once disclosed, may no longer be protected by federal rules governing privacy and confidentiality. I agree that a copy of the Authorization shall be as valid as the original and that I may have a copy upon request. I understand that I do not have to sign this Authorization in order to obtain health care benefits (treatment, payment or enrollment). I understand the entries made in the Vendor Use box below do not alter this Authorization. SIGNATURE: DATE: Proposed insured/patient or legal representative (Next-of-kin or legal guardian to sign only if patient is a minor, legally incompetent, or deceased) Relationship to proposed insured/patient of personal/legal representative signing for proposed insured/patient: For Vendor Use Only Page 1 of 1 LF02896NY 10/15

4 The Lincoln National Life Insurance Company Lincoln Life & Annuity Company of New York Service Office: One Granite Place, P.O. Box 515, Concord, NH (hereinafter referred to as the Company ) Confirmation of Personal Worksheet Financial Information Opt Out You received a personal worksheet which asked questions about your finances and your reasons for buying long-term care insurance. For your protection, state law requires us to consider this information to avoid selling a policy to those who may not need coverage. You chose not to provide any financial information for us to review. We suggest that you review the information provided including the booklet Shopper s Guide to Long-Term Care Insurance and the page titled Things You Should Know Before Buying Long- Term Care Insurance. Your state insurance department also has information about long-term care insurance and may be able to refer you to a counselor free of charge who can help you decide whether to buy this policy. If, after careful consideration you still believe this policy is what you want, check the appropriate box below and return this form to us within the next 60 days. We will then continue with your application process and issue a policy if you meet our underwriting standards. If we do not hear from you within the next 60 days, we will close your file and not issue you a policy. You should understand that you will not have any coverage until we hear back from you, approve your application, and issue you a policy. Do you acknowledge you have reviewed the information provided and wish to purchase this coverage? h Yes, I acknowledge I have reviewed the information provided and wish to purchase this coverage. Please resume review of my application. h No. I have decided not to buy a policy at this time. Signature of Applicant/Owner/Trustee Date Printed Name of Applicant/Owner/Trustee Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. LF /13

5 Lincoln Life & Annuity Company of New York Service Office: One Granite Place, PO Box 515, Concord, NH (hereinafter referred to as the Company ) (Please give a copy of this notice to the Proposed Insured.) IMPORTANT NOTICE Since you are applying for insurance, we would like you to know more about our underwriting process. THE UNDERWRITING PROCESS All forms of insurance are based on the concept of risk-sharing. Underwriters seek to determine the level of risk represented by each applicant, and then assign that person to a group with similar risk characteristics. In this way, the risk potential can be spread among all policyholders within a given risk group, assuring that each assumes his fair share of the insurance cost. Underwriters collect and review risk factors such as age, occupation, physical condition, medical history, cognitive assessment and any hazardous avocations. The level of risk and premium for the amount of coverage requested is based on this information. CONSUMER REPORT As a part of our routine procedure for processing your initial application, we may request a consumer report. The agency making the report may keep a copy of the report and disclose its contents to others for whom it performs similar services. The report typically includes information such as identity and residence verification, character, reputation, marital status, estimate of net worth and income, occupation, avocations, medical history, driving records, habits, mode of living and other personal characteristics. Additional information is usually obtained from several different sources. Confidential interviews may be conducted with a business, banks, accountants, or other financial advisors as designated by the applicant. Public records are carefully reviewed. Past experience shows that information from reports usually does not have an adverse effect on our underwriting decision. If it should, we will notify you in writing and identify the reporting agency. At that point, if you wish to do so, you may discuss the matter with the reporting agency. If you request it, we will supply the name, address and telephone number of the consumer reporting agency so you may obtain a copy of the report. CONTESTABILITY We strongly urge you to review the completed application closely for accuracy. During the 2 year contestability period described in the policy, a claim may be denied if the application contains false statements or misrepresentations or fails to disclose material facts. In such a case, the policy could be void and coverage could be lost. PHARMACY BENEFIT MANAGER (RX DATABASE SEARCH) As part of our routine procedure for determining eligibility for insurance, we may request information on the medications you are taking provided by a Pharmacy Benefit Manager. The report we will receive typically contains the name of the medication, the number of prescriptions filled and the time frame the medications were prescribed. If any adverse action is taken based on the information provided, we will notify you in writing and also provide you with the name, address and telephone number of the provider if you wish to obtain a copy of the pharmaceutical report. MIB, INC. Information you provide regarding your insurability or claims will be treated as confidential except that the Company or its reinsurers, may make a brief report of it to MIB, Inc. This is a nonprofit membership organization of life insurance companies which operates an information exchange on behalf of its members. Upon request by another member insurance company to which you have applied for life or health insurance coverage or submitted a claim, MIB, Inc. will provide the information it may have in its file. Information for consumers about MIB may be obtained on Upon receipt of a request from you, MIB, Inc. will arrange disclosure of any information it may have in your file. If you question the accuracy of information in MIB, Inc. s file, you may contact MIB at: 50 Braintree Hill Park, Suite 400, Braintree, MA You can reach MIB by phone toll free at (866) (TTY {866} ). Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. MG /13

6 Long-Term Care Insurance Personal Worksheet Lincoln Life & Annuity Company of New York Administrative Mailing Address: 350 Church Street Hartford, Connecticut Home Office Location: 100 Madison Street Syracuse, New York People buy long-term care insurance for many reasons. Some don t want to use their own assets to pay for long-term care. Some buy insurance to make sure they can choose the type of care they get. Others don t want their family to have to pay for care or don t want to go on Medicaid. But long-term care insurance may be expensive, and may not be right for everyone. By state law, the insurance company must ask you to fill out this worksheet to help you and the company decide if you should buy this policy. Premium Information: Policy and Rider Form Numbers: LN850 (8/05) Flexible Premium Adjustable Life Insurance Policy LR851 (8/05) Convalescent Care Benefits Rider LR852 (8/05) Extension of Benefits Rider The premium for this policy is: Initial premium of $ then $ per year Type of Rider Guaranteed Renewable and Noncancellable The Company s Right to Increase Extension of Benefits Rider Charge: The Company cannot raise the rates for the Extension of Benefits Rider. Rate Increase History: Lincoln has sold long-term care insurance since 1990 and has sold linked benefit policies combining long-term care insurance riders with life insurance policies or annuity contracts since Lincoln has not raised its long-term care insurance rider rates for this linked benefit policy form or similar policy forms it has sold in this state or in any other state in the last 10 years NY (8/14) 1

7 Questions Related to Your Income How will you pay for this policy? Income Savings and/or Investments Family Member Other What is your annual income? Under $10,000 $10-$20,000 $20-$30,000 $30-$50,000 Over $50,000 How do you expect your income to change over the next 10 years? No change Increase Decrease If you will be paying the premium with money received only from your own income, for annual premium policies a rule of thumb is that you may not be able to afford this policy if the premium is more than 7% of your income. Will you buy inflation protection? Yes No If not, have you considered how you will pay for the difference between future costs and your daily benefit amount? Income Savings and/or Investments Family Member Other In 2003, the national average annual cost of care was $57,700. In ten years, the national average annual cost will be approximately $93,987 if costs increase 5% annually. (MetLife Market Survey of Nursing Home and Home Care Costs, 2003) What elimination period are you considering? Number of days Approximate cost $ for that period of care The elimination period noted above must be satisfied prior to accelerating the Policy s death benefit to fund LTC related expenses. When the accelerated death benefit payments are exhausted, the monthly maximum benefit under the Extension of Benefits Rider, if selected, becomes immediately available. How are you planning to pay for your care during the elimination period? Income Savings and/or Investments Family Member Other Questions Related to Your Savings and Investments Not counting your home, automobiles and personal property, what is the approximate value of all of your assets (savings and investments)? Under $50,000 $50-$100,000 $100-$150,000 Over $150,000 How do you expect your assets to change over the next 10 years? No change Increase Decrease If you are buying this policy to protect your assets and your assets are less than $50,000, you may wish to consider other options for financing your long-term care NY (8/14) 2

8 Disclosure Statement In order for us to complete the processing of your application, please check one of the boxes below, sign, and return form to The Lincoln Life & Annuity Company of New York along with the application. The company may contact you to verify your answers. The answers to the questions above describe my financial situation. I choose not to complete this information. I acknowledge that the carrier and/or its agent (below) has reviewed this form with me including the monthly rider charges, long-term care rider charge increase history and potential for long-term care rider charge increases in the future. I understand the above disclosures. Signature of Applicant Date Agent s Statement I have explained to the Applicant the importance of completing this information. Signature of Agent Date Agent s Printed Name: If applicable, please check box and sign below. My agent has advised me that this policy does not seem to be suitable for me. However, I still want the company to consider my application. Signature of Applicant Date NY (8/14) 3

9 Lincoln Financial Group Privacy Notice for Protected Health Information THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. You have received this Notice because you have applied for, or currently have, insurance coverage or an annuity ( Coverage ), that contains benefit provisions subject to the federal privacy regulations that were issued as a result of the Health Insurance Portability and Accountability Act, as amended ( HIPAA ). This is Coverage that has been, or will be issued with one of the Lincoln Financial Group insurance companies* ( Company ). This Notice sometimes refers to the Company by using the terms us, we, or our. We value our relationship with you and are committed to protecting the confidentiality and security of information we collect about you, especially health information. We collect, use and disclose information about you to evaluate and process any requests for Coverage and claims for benefits you may make regarding your Coverage. This Notice describes how we protect the individually identifiable health information we have about you which relates to your Coverage ( Protected Health Information ), and how we may use and disclose this information. Protected Health Information includes individually identifiable information that relates to your past, present or future health, treatment or payment for health care services. The Company will never share your information for marketing purposes or allow for the sale of your information, unless you give us your written permission. This Notice also describes your rights with respect to the Protected Health Information and how you can exercise those rights. We are required to provide you with this Notice in accordance with federal health privacy regulations that were issued as a result of HIPAA. We are required by law to maintain the privacy of your Protected Health Information; to provide you this Notice of our legal duties and privacy practices with respect to your Protected Health Information; and to follow the terms of this Notice. The Company reserves the right to change this Notice at any time. We can make any changes effective for Protected Health Information we already have about you, as well as any Protected Health Information we receive in the future. If the revised Notice contains material changes, we will send you the revised Notice, as well as post it on the Company internet sites. Uses and Disclosures of your Protected Health Information The following describes when we may use and disclose your Protected Health Information with your written authorization and without your authorization: Authorization: Except as described below, we will not use or disclose your Protected Health Information for any reason unless we have a signed authorization from you or your legal representative to use or disclose your Protected Health Information. You or your legal representative has the right to revoke an authorization in writing, except to the extent that we have taken action relying on the authorization or if the authorization was obtained as a condition of obtaining your Coverage. Treatment: We may use and disclose your Protected Health Information as necessary for your treatment. For instance, a doctor or health facility involved in your care may request Protected Health Information that we hold about you in order to make decisions about your care. Payment of Claims: We may use and disclose your Protected Health Information to pay for benefits under your Coverage. For example, when you present a claim for benefits, we may obtain medical records from the doctor or health facility involved in your care to determine if you are eligible for benefits under the insurance policy and to reimburse you for services provided. Other payment-related uses and disclosures that are permitted and we may engage in include: making claim decisions, coordinating benefits with other insurers or payers, billing, claims management, collection activities, obtaining payment under a contract for reinsurance, and related health care data processing. Health Care Operations: We may use and disclose your Protected Health Information for our insurance operations. Our insurance operations may include underwriting, premium rating, and other activities related to the issuance, renewal or replacement of Coverage, or for reinsurance purposes. For example, when you apply for insurance we may collect medical information from your doctor (health care provider) or a medical facility that provided you health care services to determine if you qualify for insurance. We may also use and disclose Protected Health Information to conduct or arrange for medical review, legal services, contract for reinsurance, business planning and development regarding the management and operation of our Coverage processes, or auditing, including fraud and abuse detection and compliance programs. Protected Health Information may also be disclosed for customer service, servicing our current and future customer relationships as permitted by law, resolution of internal grievances and as part of a potential sale, transfer, merger, or consolidation in order to make an informed business decision regarding any such prospective transaction. For group plans, Protected Health Information may be disclosed to your Plan Sponsor for purposes of administering your Plan or other health plan maintained by your employer to facilitate claims payments under the plan. If we use or disclose Protected Health Information for underwriting purposes, the Protected Health Information used or disclosed for that purpose will not include information that constitutes genetic information. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 4 GB /15

10 Business Associates: We may also disclose Protected Health Information to non-affiliated business associates of ours, but only if the business associate s receipt of Protected Health Information is necessary to provide a service to us and the business associate agrees to protect the Protected Health Information in accordance with, and use it, only as allowed by HIPAA regulations. Examples of business associates are: billing companies, data processing companies, auditors, claims processing companies and companies that provide general administrative services. Uses and Disclosures to Family, Friends or Others Involved in Your Care: With your written approval, we may disclose your Protected Health Information to a designated member of your family, friend, personal representative, or other individual that you may identify as involved in your care or involved in the payment for your care. Should you become incapacitated or be in an emergency medical situation and not able to provide us with your written approval, we may disclose Protected Health Information about you that is directly relevant to such person s involvement in your care or payment for such care. Where Required by Law, for Public Health or Similar Activities: We may also disclose Protected Health Information where required or permitted by law, for public health or similar activities, the protection of you or others, legal proceedings and other reasons as provided in the HIPAA regulations. Examples of disclosures that may be required or permitted by law include: Releasing Protected Health Information to state or local health authorities, as required by law, of particular communicable diseases, injury, birth, death, and for other required public health investigations; Releasing Protected Health Information to a governmental agency or regulator with health care oversight responsibilities; Releasing Protected Health Information to a coroner, medical examiner or funeral director to assist in identifying a deceased individual or to determine the cause of death; Releasing Protected Health Information to public health or other appropriate authorities, as required by law, when there is reason to suspect abuse, neglect, or domestic violence; Releasing Protected Health Information to the Food and Drug Administration (FDA) for purposes related to quality, safety or effectiveness of FDA-regulated products or activities; Releasing Protected Health Information if required by law to do so by a court or administrative tribunal ordered subpoena or discovery request, or for law enforcement purposes as permitted by law. We will make efforts to notify you of such requests or to obtain an order protecting the Protected Health Information requested. We may disclose Protected Health Information to any governmental agency or regulator with whom you have filed a complaint or as part of a regulatory agency examination; Releasing Protected Health Information for certain research purposes when such research is approved by an institutional review board with established rules to ensure privacy; Releasing Protected Health Information if you are a member of the military as required by armed forces services; Releasing Protected Health Information to federal officials for intelligence, counterintelligence, and other national security activities authorized by law; Releasing Protected Health Information to worker s compensation agencies if necessary for your worker s compensation benefit determination; Releasing Protected Health Information to avert a serious threat to someone s health or safety, including the disclosure of Protected Health Information to government or privacy disaster relief or assistance agencies to allow such entities to carry out their responsibilities to specific disaster situations; Releasing Protected Health Information to organizations that manage organ procurement or organ, eye or tissue transplant or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplant. Releasing Protected Health Information to a correctional institution or law enforcement official if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. Required Disclosures The following is a description of two specific disclosures of your Protected Health Information that we are required to make. Government Audits. We are required to disclose your Protected Health Information to the Secretary of the United States Department of Health and Human Services when the Secretary is investigating or determining our compliance with the HIPAA privacy rule. Disclosures to You. When you request, we are required to disclose to you the portion of your Protected Health Information that contains medical records, billing records, and any other records used to make decisions regarding your health care benefits. We are also required, when requested by you, to provide you with an accounting of most disclosures of your Protected Health Information if the disclosure was for reasons other than for payment, treatment, or health care operations, and if the Protected Health Information was not disclosed pursuant to your individual authorization. Please refer to the further description of your right to receive an accounting below. Page 2 of 4 GB /15

11 Your Rights Regarding Your Protected Health Information You have the following rights as a consumer under HIPAA concerning the Protected Health Information we have about you in our records. Any request to exercise your rights as described below should be made in writing and sent to Lincoln Financial Group, Attn: Corporate Privacy Office - 7C-01, 1300 S Clinton Street, Fort Wayne IN Also, should you wish to terminate a request for a restriction that has been accommodated, such termination request must also be in writing and sent to the same address listed above. Your request to exercise the rights described below should include the following information: your full name, address, and policy number. Generally, we will respond to these requests within 30 days of receipt. Right to Request Restrictions: You have the right to request that we restrict or limit our use or disclosure of your Protected Health Information that would otherwise be permitted for purposes related to treatment, payment or our health care operations, including disclosure to someone who may be involved in your care or payment for your care, like a family member, friend or personal representative. While we will consider your request, we are not required to agree to your restriction. If we do agree to the restriction, we will restrict the use or disclosure of your Protected Health Information as requested, but we reserve the right to terminate the agreed to restriction if we deem appropriate. In your request to restrict use and disclosure, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse or parent). We will not agree to restrictions on Protected Health Information uses or disclosures that are legally required or which are necessary to administer our business. Right to Request Confidential Communications: You have the right to request that we communicate with you about Protected Health Information in a certain way or using a certain address or address, if you make such a request in writing and send it to the address provided above. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests. Right to Inspect and Copy Your Protected Health Information: In most instances, you have the right to inspect and obtain a copy of the Protected Health Information that we maintain about you. Your request must be in writing and sent to the address provided above. We will deny inspection and copying of certain Protected Health Information, for example psychotherapy notes and Protected Health Information collected by us in connection with, or in reasonable anticipation of, any claim or legal proceeding. We reserve the right to charge a fee for the costs of copying, mailing or other supplies associated with your request. In those limited circumstances that we deny your request to inspect and obtain a copy of your Protected Health Information, you have the right to request a review of our denial. Your request to review our denial should be submitted in writing and sent to the address provided above. If the information you request is maintained electronically and you request an electronic copy, we will provide a copy in the electronic form and format you request, if the information can be readily produced in that form and format. If the information cannot be readily produced in that form and format, we will work with you to come to an agreement on an alternative electronic form and format. If we cannot agree on an electronic form and format, we will provide you with a paper copy. Right to Amend Your Protected Health Information: You have the right to request that we amend your Protected Health Information in our records if you believe it is inaccurate or incomplete. Your request must be in writing and sent to the address provided above. Your request must provide your reason(s) for seeking the amendment or correction. If an amendment or correction request is accepted, we will amend or correct all appropriate records as well as notify others to whom we have disclosed the erroneous Protected Health Information. We may deny your request if you ask us to amend Protected Health Information that is accurate and complete; was not created by us, unless the creator of the Protected Health Information is no longer available to make the amendment; is not part of the Protected Health Information kept by or for us; or is not part of the Protected Health Information which you would be permitted to inspect and copy. If we deny your request, you have the right to file a statement of disagreement with us and any future disclosures of your Protected Health Information will include your statement. Right to Receive an Accounting of Disclosures of Your Protected Health Information: You have the right to request an accounting or list of disclosures we have made of your Protected Health Information. This list will not include disclosures. For treatment; For payment or health care operations; To law enforcement, for purposes of national security; To department of corrections personnel; Pursuant to your authorization; or directly to you. To request this list, you must submit your request in writing to the address provided above. Your request must state the time period from which you want to receive a list of disclosures. The time period may not be longer than six years. Your request should indicate in what form you want the accounting (e.g., paper or electronic). The first list you request within a 12-month period will be free. We reserve the right to charge you for responding to any additional requests within that 12-month period. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. Right to be Notified of a Breach: You have the right to be notified in the event that we (or our business associate) discover a breach of your unsecured Protected Health Information. Page 3 of 4 GB /15

12 Right to a Paper Copy of this Notice: You have the right to obtain a paper copy of this Notice upon request, even if you agreed to receive this Notice electronically. Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with us, by sending it to the address listed below. You may also file a complaint with the U.S. Department of Health and Human Services ( HHS ) Office of Civil Rights. If you send your complaint to HHS by mail or fax, you should send it to the regional office of the HHS Office of Civil Rights covering the area where the potential violation occurred. You can find more information about how to file a complaint with HHS, including the addresses of the regional offices of the HHS Office of Civil Rights on the HHS website: privacy/hipaa/complaints/index.html. Or, complaints may be sent to HHS by to: OCRComplaint@hhs.gov. The Company supports your right to protect the privacy of your Protected Health Information. No action will be taken against you if you file a complaint. For Further Information: For further information regarding this Notice or the Company s privacy practices, please contact Lincoln Financial Group, Attn: Corporate Privacy Office - 7C-01, 1300 S Clinton Street, Fort Wayne IN 46802, or call Effective Date: This Notice is effective November 16, *This information applies to the following Lincoln Financial Group companies: First Penn-Pacific Life Insurance Company Lincoln Life & Annuity Company of New York The Lincoln National Life Insurance Company Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 4 of 4 GB /15

13 Lincoln Financial Group Privacy Practices Notice The Lincoln Financial Group companies* are committed to protecting your privacy. To provide the products and services you expect from a financial services leader, we must collect personal information about you. We do not sell your personal information to third parties. This Notice describes our current privacy practices. While your relationship with us continues, we will update and send our Privacy Practices Notice as required by law. Even after that relationship ends, we will continue to protect your personal information. You do not need to take any action because of this Notice, but you do have certain rights as described below. Information We May Collect And Use We collect personal information about you to help us identify you as our customer or our former customer; to process your requests and transactions; to offer investment or insurance services to you; to pay your claim; to analyze in order to enhance our products and services; or to tell you about our products or services we believe you may want and use; and as otherwise permitted by law. The type of personal information we collect depends on the products or services you request and may include the following: Information from you: When you submit your application or other forms, you give us information such as your name, address, Social Security number; and your financial, health, and employment history. Information about your transactions: We maintain information about your transactions with us, such as the products you buy from us; the amount you paid for those products; your account balances; and your payment and claims history. Information from outside our family of companies: If you are purchasing insurance products, we may collect information from consumer reporting agencies such as your credit history; credit scores; and driving and employment records. With your authorization, we may also collect information, such as medical information from other individuals or businesses. Information from your employer: If your employer purchases group products from us, we may obtain information about you from your employer in order to enroll you in the plan. How We Use Your Personal Information We may share your personal information within our companies and with certain service providers. They use this information to process transactions you have requested; provide customer service; to analyze in order to enhance our products and services; and inform you of products or services we offer that you may find useful. Our service providers may or may not be affiliated with us. They include financial service providers (for example, third party administrators; broker-dealers; insurance agents and brokers, registered representatives; reinsurers and other financial services companies with whom we have joint marketing agreements). Our service providers also include non-financial companies and individuals (for example, consultants; vendors; and companies that perform marketing services on our behalf). Information we obtain from a report prepared by a service provider may be kept by the service provider and shared with other persons; however, we require our service providers to protect your personal information and to use or disclose it only for the work they are performing for us, or as permitted by law. When you apply for one of our products, we may share information about your application with credit bureaus. We also may provide information to group policy owners, regulatory authorities and law enforcement officials, and to other non-affiliated or affiliated parties as permitted by law. In the event of a sale of all or part of our businesses, we may share customer information as part of the sale. We do not sell or share your information with outside marketers who may want to offer you their own products and services; nor do we share information we receive about you from a consumer reporting agency. You do not need to take any action for this benefit. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 2 GB /16

14 Security of Information We have an important responsibility to keep your information safe. We use safeguards to protect your information from unauthorized disclosure. Our employees are authorized to access your information only when they need it to provide you with products, services, or to maintain your accounts. Employees who have access to your personal information are required to keep it confidential. Employees are trained on the importance of data privacy. Your Rights Regarding Your Personal Information Access: We want to make sure we have accurate information about you. Upon written request we will tell you, within 30 business days, what personal information we have about you. You may see a copy of your personal information in person or receive a copy by mail, whichever you prefer. We will share with you who provided the information. In some cases we may provide your medical information to your personal physician. We will not provide you with information we have collected in connection with, or in anticipation of, a claim or legal proceeding. If you request a copy of the information, we may charge you a fee for copying and mailing costs. In very limited circumstances, your request may be denied. You may then request that the denial be reviewed. Accuracy of Information: If you feel the personal information we have about you is inaccurate or incomplete, you may ask us to amend the information. Your request must be in writing and must include the reason you are requesting the change. We will respond within 30 business days. If we make changes to your records as a result of your request, we will notify you in writing and we will send the updated information, at your request, to any person who may have received the information within the prior two years. We will also send the updated information to any insurance support organization that gave us the information, and any service provider that received the information within the prior 7 years. If your requested change is denied, we will provide you with reasons for the denial. You may write to request the denial be reviewed. A copy of your request will be kept on file with your personal information so anyone reviewing your information in the future will be aware of your request. Accounting of Disclosures: If applicable, you may request an accounting of disclosures made of your medical information, except for disclosures: For purposes of payment activities or company operations; To the individual who is the subject of the personal information or to that individual s personal representative; To persons involved in your health care; For notification for disaster relief purposes; For national security or intelligence purposes; To law enforcement officials or correctional institutions; or For which an authorization is required. You may request an accounting of disclosures for a time period of less than two years from the date of your request. You may ask in writing for the specific reasons for an adverse underwriting decision. An adverse underwriting decision is where we decline your application for insurance, offer to insure you at a higher than standard rate, or terminate your coverage. Your state may provide for additional privacy protections under applicable laws. We will protect your information in accordance with these additional protections. Questions about your personal information should be directed to: Lincoln Financial Group Attn: Enterprise Compliance and Ethics Corporate Privacy Office, 7C S. Clinton St. Fort Wayne, IN Please include all policy/contract/account numbers with your correspondence. *This information applies to the following Lincoln Financial Group companies: First Penn-Pacific Life Insurance Company Lincoln Financial Group Trust Company, Inc. Lincoln Investment Advisors Corporation Lincoln Financial Distributors, Inc. Lincoln Life & Annuity Company of New York Lincoln Retirement Services Company, LLC Lincoln Variable Insurance Products Trust The Lincoln National Life Insurance Company Page 2 of 2 GB /16

15 The Lincoln National Life Insurance Company Lincoln Life & Annuity Company of New York Service Office: One Granite Place, P.O. Box 515, Concord, NH (hereinafter referred to as the Company ) Receipt of Required Notice(s) Acknowledgement Form Instructions to Agent: This form must be completed and signed by the Proposed Insured. Submit a copy of this form with the ticket to the Underwriting Department. I/We acknowledge receipt of the following disclosures: -- Lincoln Financial Group Privacy Practices Notice GB06714 (For MT also provide: GB06974MT) -- Lincoln Financial Group Privacy Practices Notice for Protected Health Information GB Important Notice MG10579 (For all states except CA: MG ; ME: MG ; MA: MG ; MD: MG ; MI: MG ; NY: MG ; PR: MG ; UT: MG ; WV: MG ) Signature of Proposed Insured Date Printed Name of Proposed Insured Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. LF /13

16 TEMPORARY LIFE INSURANCE AGREEMENT LINCOLN LIFE & ANNUITY COMPANY OF NEW YORK ( Company ) B44 NY ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO THE INSURANCE COMPANY-DO NOT MAKE CHECKS PAYABLE TO THE AGENT OR LEAVE THE PAYEE BLANK. If any of the questions below are answered yes or left blank with respect to a Proposed Insured(s), no representative of the Company is authorized to accept money, and NO COVERAGE will take effect under this Agreement with respect to such Proposed Insured(s). Has Proposed Insured(s): Questions apply to all Proposed Insured(s) shown on application. 1. Does Amount applied for exceed $3,000,000? Yes No 2. Within the past 90 days, has any Proposed Insured been admitted to a hospital or other medical facility, been advised to be admitted or had surgery performed or recommended? Yes No 3. Within the past 2 years has any Proposed Insured been treated for heart trouble, stroke, or cancer, or had such treatment recommended by a physician or other medical practitioner? Yes No N/A if applying for a MoneyGuard product. 4. Is Age of Proposed Insured under 15 days old or over age 70? Yes No N/A if applying for a MoneyGuard product. This Agreement provides a Limited Amount of Life Insurance protection for a Limited Period of time, subject to the terms of this Agreement, in consideration of advance payment in the amount of $ in connection with the Application dated made on the life of:. Name(s) of Proposed Insured(s) TERMS AND CONDITIONS AMOUNT OF COVERAGE - $500,000 MAXIMUM FOR ALL APPLICATIONS OR AGREEMENTS If money has been accepted by the Company as advance payment for an application for Life Insurance and death of a Proposed Insured(s) (and death of the surviving Proposed Insured under Survivorship Life Insurance) occurs while this Agreement is in effect, the Company will pay to the beneficiary designated in the Application the lesser of a) the amount of all death benefits applied for in the Application(s) with respect to said Proposed Insured(s), including any accidental or supplemental death benefits, if applicable, or b) $500,000. This total benefit limit applies to all insurance applied for under this and any current Applications to the Company and any other Temporary Life Insurance Agreements. Temporary Long-Term Care coverage is not available under this Agreement. DATE COVERAGE BEGINS Coverage under this Agreement will begin on the date of this Agreement but only if Part I of the Application(s) has been completed on the same date or not more than 30 days prior to the date of this Agreement. DATE COVERAGE TERMINATES 90 DAY MAXIMUM Coverage under this Agreement will terminate automatically on the earliest of: a) 45 days from date of this Agreement if a required Exam or Non medical is not received by the Company, or b) 90 days from the date of this Agreement, or c) the date the insurance takes effect under the policy applied for, or d) the date the Company mails notice of termination of coverage to the premium notice address designated in Part I of the Application(s). The Company may terminate coverage at any time. SPECIAL LIMITATIONS This Agreement does not guarantee the Company will issue a life insurance policy or any special riders or endorsement thereto. Fraud or material misrepresentations in the Application(s) or in the answers to the Health Questions of this Agreement invalidates this Agreement and the Company s only liability is for refund of any payment made. If a Proposed Insured(s) (or the surviving Proposed Insured under Survivorship Life Insurance) dies by suicide within 2 years, the Company s liability under this Agreement is limited to a refund of the payment made. There is no coverage under this Agreement if the check or draft submitted as payment is not honored by the bank. No one is authorized to waive or modify any of the provisions of this Agreement. I (WE) HAVE RECEIVED A COPY OF AND HAVE READ THIS AGREEMENT AND DECLARE THAT THE ANSWERS ARE TRUE TO THE BEST OF MY (OUR) KNOWLEDGE AND BELIEF. I (WE) UNDERSTAND AND AGREE TO ALL ITS TERMS. Signature of Proposed Insured A Witness (Licensed Representative/Agent) Date Signature of Proposed Insured B Witness (Licensed Representative/Agent) Date Signature of Applicant/Owner/Trustee (Provide Officer s Title if policy is owned by a Corporation.) Witness Date B44 NY