NGL AssetGuard Application Guide

Transcription

1 NGL AssetGuard Application Guide National Guardian Life Insurance Company Two East Gilman Street. Madison, WI option 1 Insured Information: Please make sure to check spelling of Insured s name. Payment Plan: Include funeral price, face and if opting for multi pay, please indicate which multi pay plan should be used as well as the premium details under Initial Premium, Multi pay Premium and Total Premium Amount. Plan: Please choose your growth rate for Single Pay Plans only. Payment Mode (Do not complete for Single Pay): Complete for any payment plans and remember to include the Premium Withdrawal Authorization for EFT or Credit Card. Statement of Health: If nothing is checked the policy will be issued as guaranteed. Please see the Health Question FAQ. Beneficiary Information: Write the name and address of where proceeds should be directed to. If it is Insured s estate, please put Estate of Insured. If assigning to one of NGL s trusts please make sure to specify which one. Form Number: 2735FE 06/11 Mail Policy To: Where you would like the policy sent. Social Security Number: If an Insured does not want to provide, please indicate N/A on application. Date of Birth: Must have Insured s date of birth. Initial Premium: This is the portion of the total premium collected at the time of application to be issued as a lump sum or single pay policy. Multi pay Premium: This is the amount of premium that will be paid on an ongoing basis (only one modal payment is required at issue), and in the case of a down-payment the portion of the total premium with application to pay the first modal premium. Total Premium Amount: This is the total amount of premium collected at time of application. Signatures: Signed at: City where the application was signed. Signatures: State: State where the application was signed. Signatures: Questions on how to sign correctly? Please refer to NGL s Signature Guidelines on MyNGLIC. Agent s Statement: Include your NGL agent number and printed name. Please Note: If your state requires replacement questions, they will appear above the Applicant Signatures section. Please be sure to answer all replacement questions and include any required replacement forms. Applications will vary by state.

2 Form Number: 2735FE 06/11 (reverse side) Agent Split Designation: If you would like to split commission with another agent, please enter commission split percentage above 0%. Acknowledgment of Payment: Please complete and leave a copy with the applicant.

3 NGL Funeral Expense Trust Assignment Form Form Number: 2591-FET Insured Information: Please make sure to check spelling of Insured s name. Agreement: On the NGL Funeral Expense Trust excess proceeds are paid to the estate of the Insured (or state if the state requires it). By: Please leave blank. This is to be completed by NGL as trustee of the Trust. Immediate Transfer: Use only if your client needs to immediately apply for Medicaid and transfer the ownership rights immediately. If you don t sign this section, the policy will automatically be transferred to the Trust in 45 days. Insured For Home Office Use Only Policy Number Owner (If other than Insured) Effective 45 days from the date NGL receives this form, I hereby assign ownership and change the beneficiary of this policy to the Trust. This transfer, once effective, is made to comply with the requirements of any applicable state public assistance and federal public assistance programs. I understand that by transferring ownership of this policy to the Trust, as of the effective date: 1. This policy is accepted by the Trust subject to all the terms of the Trust which includes payment of the policy proceeds for the funeral expenses, burial and cremation for the Insured, as listed below. My Funeral Home of choice is or any other Funeral Home (Insert funeral home name or leave blank if none chosen at this time) as their interest may appear; 2. The change of ownership is permanent and, except as stated herein, I renounce my power to control ownership of the policy; 3. I give up any remaining right to cancel the policy and receive a return of premium under the Right to Cancel provision; 4. I waive all rights under the policy to surrender it for cash, or to obtain a loan against the policy; 5. I give up the right to change the beneficiary on this policy or riders, if any; 6. Policy proceeds that exceed the cost of the approved goods and services for the Insured s funeral, burial or cremation shall be paid to the State, if required by the applicable State s Medicaid recovery program. If payment to the State is not required, or if excess proceeds exist after payment to the State, all such excess proceeds shall be paid to the Estate of the Insured. This supersedes any Beneficiary named on my policy application; and 7. It is my personal obligation to pay all premiums due on this policy (if any) and, if my failure to pay premiums results in the lapse of the policy, the Trust will have no obligation to pay my funeral expenses. I may obtain a full copy of the Trust, at any time, upon written request to: National Guardian Life Insurance Company (NGL) Two East Gilman Street Madison WI Signature of Owner Date The Trust accepts this assignment and agrees to use the proceeds of the Policy for the payment of funeral expenses. By: Administrator or Trustee Date Authorized Expense Directive Insured hereby expressly authorizes and directs Trustee to expend Trust assets to service or product providers in payment of expenses related to the provision of the following services and/or products. List of possible goods and services qualifying for reimbursement Basic Services of Funeral Director & Staff Other Professional Funeral Services Embalming Other Care of Deceased Dressing/Cosmetology/Casketing Funeral Home Facilities and/or Staff Services Viewing/Visitation Funeral Service Memorial Service Graveside Service Other Cremation Services To be used for purposes of Immediate Medicaid Eligibility ONLY For Applicant: I hereby elect to make this irrevocable assignment effective immediately. I understand that by making this election I give up all rights to cancel the Policy and receive a return of premium under the Right to Cancel provision of the policy. To make an immediate transfer election please sign here For Agent: I certify that on I have explained to this insured that by signing the above line, he/she is forfeiting their right to cancel the policy and assert that he/she is aware of the consequences of immediate transfer. I understand that this option should only be used if there is an immediate need to reduce assets in order to qualify for Medicaid. Agent Signature: Date 2591-FET 09/09 Irrevocable Assignment of Ownership to NGL Funeral Expense Trust (herein called Trust ) National Guardian Life Insurance Company (NGL) PO Box 1191 Madison WI Phone: Other Funeral Merchandise Clergy Honorarium Death Certificates Musicians Temporary Marker Stationery Package Obituary Notices Flowers Clothing Cemetery Charges Opening & Closing of Grave Memorial Meal Casket Alternative Container Outer Burial Container Other Services Transportation Equipment & Driver Transfer of Deceased Funeral Vehicle/Hearse Car/Limousine Utility/Service Vehicle Other Type of Trust: Please make sure to use the trust form that is named NGL Funeral Expense Trust if the client is concerned with Medicaid qualification. Signature: Policyowner must sign. If Power of Attorney, then you must include the Power of Attorney paperwork. The maximum amount of the NGL Funeral Expense Trust is $15,000 per life. This trust should be used if the client is concerned with Medicaid qualification without a 5-year look back period. **Medicaid limits the face amount of policies assigned to the NGL Funeral Expense Trust which they will consider excluded assets in the following states: AZ - $8,000; CT - $5,400; DE - $15,000; GA - $10,000; IA - $11,566; IN - $10,000; KS - $7,000; LA - $10,000; NE - $4,762; ND - $6,000 (premium); OK - $10,000; PA - Limit varies based on where the applicant resides; SD - $10,000; TN - $6,000; UT - $7,000; VT - $10,000

4 NGL Estate Planning Trust Assignment Form Form Number: 2591-EPT Irrevocable Assignment of Ownership to NGL Estate Planning Trust (herein called Trust ) Insured Information: Please make sure to check spelling of Insured s name. Trust Beneficiary: Where the client may name a beneficiary for excess Trust proceeds only. Agreement: On the NGL Estate Planning Trust excess proceeds are paid to the named beneficiary. By: Please leave blank. This is to be completed by NGL as trustee of the Trust. Insured For Home Office Use Only Policy Number Owner (If other than Insured) Trust Beneficiary for excess proceeds Effective 45 days from the date NGL receives this form, I hereby assign ownership of this policy to the Trust. I understand that by transferring ownership of this policy to the Trust, as of the effective date: 1. This policy is accepted by the Trust subject to all the terms of the Trust which, if the Trust is the primary beneficiary on the policy, includes payment of the policy proceeds for the funeral, burial and cremation expenses for the Insured, as listed below; 2. The change of ownership is permanent and, except as stated herein, I renounce my power to control ownership of the policy; 3. I give up any remaining right to cancel the policy and receive a return of premium under the Right to Cancel provision; 4. I waive all rights under the policy to surrender it for cash, or to obtain a loan against the policy; 5. I give up the right to change the beneficiary on this policy or riders, if any; 6. I give up the right to change the Trust Beneficary; 7. Any proceeds received by the Trust in excess of the amount required to cover the cost of the approved goods and services for the Insured s funeral, burial or cremation will be paid to the Trust Beneficiary named at the time of this assignment if any, otherwise, to the estate of the Insured; 8. It is my personal obligation to pay all premiums due on this policy (if any) and, if my failure to pay premiums results in the lapse of the policy, the Trust will have no obligation to pay my funeral or burial expenses; and 9. My ability to qualify for state and federal public assistance is not guaranteed. I may obtain a full copy of the Trust, at any time, upon written request to: National Guardian Life Insurance Company (NGL) Two East Gilman Street Madison WI Signature of Owner National Guardian Life Insurance Company (NGL) PO Box 1191 Madison WI Phone: Date The Trust accepts this assignment and agrees to use the proceeds of the Policy for the payment of funeral expenses. By: Date Authorized Expense Directive Insured hereby expressly authorizes and directs Trustee to expend Trust assets to service or product providers in payment of expenses related to the provision of the following services and/or products. List of possible goods and services qualifying for reimbursement Signature: Policyowner must sign. If Power of Attorney, then you must include the Power of Attorney paperwork. Basic Services of Funeral Director & Staff Other Professional Funeral Services Embalming Other Care of Deceased Dressing/Cosmetology/Casketing Funeral Home Facilities and/or Staff Services Viewing/Visitation Funeral Service Memorial Service Graveside Service Other Cremation Other Funeral Merchandise Clergy Honorarium Death Certificates Musicians Temporary Marker Stationery Package Obituary Notices Flowers Clothing Open/Close Casket Alternative Container Outer Burial Container Other Services Transportation Equipment & Driver Transfer of Deceased Funeral Vehicle/Hearse Car/Limousine Utility/Service Vehicle Other Cemetery Charges 2591-EPT 12/08 The maximum face amount of the NGL Estate Planning Trust is $100,000 per life. The NGL Estate Planning Trust has a 5-year look back period.

5 New Business Fax Cover Page Form 2802 p1 11/12 When you submit your business via fax, please send the fax cover page first. Please note, the Premium Withdrawal Authorization (Form # 2802 p1 11/12) must be completed to authorize the initial premium withdrawal on every faxed application.

6 Premium Withdrawal Authorization Form 2802 p2 11/12 Please complete the Premium Withdrawal Authorization (Form # 2802 p2 11/12) if the premium is being paid via credit card or electronic funds transfer. Amount of Initial Premium Withdrawal: This is the total payment being authorized at the time of issuance. In situations where a lump sum payment and the first periodic payment are collected, you should list the total of the two. Amount of Ongoing Withdrawal: This is the total periodic premium amount paid on an ongoing basis. One-time initial: Check this option if you would like NGL to withdraw the listed amount once, upon issuance. One-time initial and ongoing monthly: Check this option if you would like NGL to withdraw the listed initial premium amount and the ongoing monthly amount on the next draw date. Ongoing monthly only: Check this option if you are paying the initial premium with a check, but would like subsequent payments made from the specified account. If the initial or ongoing premium is from a savings account, contact the bank to confirm EFT drafts are allowed and to verify the routing and account numbers. Please include a void check if the withdrawal is coming from a bank account.

7 Signature Guidelines NGL has compiled the following guidelines to assist you when completing applications: For all Standard Issue Applications (Health Question = No ) the Insured OR a Power of Attorney OR a Guardian must sign the Insured Signature box on the application. A copy of appropriate papers must also accompany the application. This is regardless of the actual Owner of the policy. If the Insured does not sign the application and no POA/Guardianship papers for the Insured are submitted, only a Guaranteed Issue policy will be issued. For Single Pay Guaranteed Issue or Annuity plans that are irrevocably assigned to a funeral home, cemetery or trust, we will allow individuals without actual Power of Attorney or Guardianship of the Insured to sign the application. If they are signing for the Insured as Owner, they should sign in the Insured Signature box. If they are applying as Owner of the policy, they should sign in the Owner Signature box and will need to certify that they have an insurable interest in the Insured s life. For Multi Pay plans or policies not irrevocably assigned, only the following can sign on behalf of the Insured with the Insured as Owner or apply as Owner of the policy (Guaranteed Issue only): Spouse/ Domestic Partner (as recognized by state) Mother/ Father Stepmother/ Stepfather Sister/ Brother Child/ Stepchild Grandparent/ Grandchild Aunt/ Uncle Niece/ Nephew Power of Attorney/ Guardian (papers must accompany application) The Owner or a properly empowered POA/Guardian for the Owner must sign the application. If the Insured is a minor child under state law, then a parent, a grandparent, or a legal guardian signature is required. If a competent insured signs with an X or uses a printed or stamped signature, a separate explanation, signed by two witnesses, must accompany the application. The printed or stamped signature on the application must match the signature on the check. Additional information on POA/Guardianship signatures can be found on MyNGLIC.com under the Frequently Asked Questions link. Signature Guidelines - Frequently Asked Questions Q: What is the correct way for a POA or Guardian to sign? A: Insured & Owner is John Smith POA for John Smith is Suzie Doe Signature in Insured section on application should be: John Smith by Suzie Doe, POA Q: What is the correct way for an immediately family member to sign for the Insured? A: Insured & Owner is John Smith Daughter is Suzie Doe Signature in Insured section on application should be: John Smith by Suzie Doe, Daughter Q: What if the Owner is someone other than the Insured and the Owner isn t present to sign the application? A: It is necessary to have the Owner sign the application. In these instances, there are two options: Forward the application form to the Owner for signature Name the Insured as Owner on the application and complete a Policy Service Request form to transfer ownership to another individual upon policy issue. Q: Who signs if the Funeral Home as Trustee is actually purchasing the policy? A: In cases where the Funeral Home is purchasing the policy because a consumer has entrusted monies to the Funeral Home, the Funeral Home owner must sign as Owner/ Trustee. Insured is John Smith Jones Funeral Home is Owner Signature in Owner section on application should be: Funeral Home Owner, Trustee (ex: Bob Jones, Trustee)

8 Statement of Health - Frequently Asked Questions The Statement of Health on all applications must be completed by the proposed insured. The following list of common questions is not intended to be all inclusive but to address some frequently asked questions. Please feel free to contact Agent Support at for any specific questions. Please remember that if the health question is not answered, Guaranteed Issue will apply. Q: What is considered Treatment? A: Treatment includes, but is not limited to: Any medication prescribed to treat diseases or disorders listed in the Statement of Health; any surgical procedure performed or recommended; therapy including oxygen, chemotherapy and/or radiation; counseling, dialysis, and organ/tissue/cell/marrow transplant. Implanted treating devices like a pacemaker or artificial heart valve, for instance, would be considered current treatment if still present, even if the device was placed more than two years ago. Q: What is considered Congestive Heart Failure? A: Congestive Heart Failure (CHF) or heart failure is a condition in which the heart can t pump enough blood to the body s other organs. The failing heart keeps working but not as efficiently as it should. People with heart failure can t exert themselves because they become short of breath and tired. This can result from: narrowed arteries that supply blood to the heart muscle coronary artery disease past heart attack, or myocardial infarction, with scar tissue that interferes with the heart muscle s normal work heart valve disease due to past rheumatic fever or other causes primary disease of the heart muscle itself, called cardiomyopathy. heart defects present at birth congenital heart defects. infection of the heart valves and/or heart muscle itself endocarditis and/or myocarditis Q: What does Heart Disease include? A: Heart Disease includes such things as: Heart Attack (myocardial infarction) Angina (pain in chest or heart) High Blood Pressure (not controlled by routine medication) Irregular Heart Rhythm Valve Disease of the Heart Heart Murmur Coronary Artery Disease (CAD) Heart Arrhythmia Enlarged Heart ASHD Arteriosclerotic Heart Disease Heart Disease will also include things such as bypass surgery or use of a pacemaker that will require lifetime treatment in the way of medication, or other medical intervention. Q: Do we consider High Blood Pressure or Elevated Cholesterol controlled by medication alone to be Heart Disease? A: No, not if they are well controlled by medication, exercise or diet and there is no underlying heart disease. Q: What is a stroke? A: Stroke (also known as a cerebrovascular accident) is an event characterized by either the sudden interruption of the blood supply to part of the brain or by the rupture of a blood vessel in the brain. Some of the disabilities that can result from a stroke include paralysis, cognitive deficits, speech problems, emotional difficulties, problems with activities of daily living, and pain.

9 Statement of Health - Frequently Asked Questions Continued Q: What is Chronic Obstructive Pulmonary Disease? A: Chronic Obstructive Pulmonary Disease, also known as COPD, is any form of chronic respiratory disease. The following are some conditions that are considered COPD: Chronic Asthma Chronic Bronchitis Emphysema Bronchietasis Pneumoconiosis (Black Lung, Farmers Lung, Asbestosis, Silicosis) Pulmonary Sarciodosis Active Tuberculosis Histoplasmosis Nocardiosis Pulmonary Cryptococcosis Coccidiodomycosis Q: What is Diabetic Coma/Insulin Shock? A: Diabetic coma is a medical emergency in which a person with diabetes mellitus is comatose (unconscious) because of complications of diabetes. Insulin shock is a severe condition in which glucose (blood sugar) levels drop quickly, leading to unconsciousness. Q: I am on insulin (or medication) for treatment of diabetes; does that require a yes answer? A: It would not, as long as you have not experienced diabetic coma or insulin shock. Q: I use oxygen at night; do I need to answer the question yes? A: Any current oxygen use would require a yes answer. Treatment with oxygen for any diseases or disorders noted in the Statement of Health during the past two years would also require a yes answer. Q: If I am currently receiving Hospice Care, confined to a Hospital; Nursing Home; Long Term or Residential Care Facility; or Group Home (for any reason) at the time of application, does the living arrangement alone denote a Yes answer? A: It would require a yes answer because of the living arrangement (including any hospice care whether in a separate facility, or within a residence) at the time of application as listed in the Statement of Health. Q: I have been advised to have to have my hip replaced, but have not scheduled the procedure yet, does that necessitate a yes answer? A: It would require a yes answer if you have been advised to have any surgical procedure in the past two years that has not been performed. Q: I was diagnosed with breast cancer five years ago with no recurrence and have routine follow up mammograms. Are the mammograms considered treatment? A: Diagnostic follow-ups performed, such as a mammogram for history of Breast Cancer, or a PSA for past history of Prostate Cancer with normal results and no recurrence would not be considered treatment. Any abnormal result for example; an elevated PSA or an abnormality found on a follow-up mammogram could result in a diagnosis of recurrence of the cancer and recommendation of further treatment. Of note, any medication used to treat the cancer during the past two years, would be considered treatment. Q: My mother has mild dementia; does that require a yes answer? A: It would as listed in the Statement of Health. Q: My leg was amputated one year ago in an industrial accident, would that require a yes answer? A: No, as it was not amputated due to disease. Q: I had a stroke four years ago and now only take maintenance medications; does that require a yes answer? A: Yes, it would be considered treatment of a stroke and may prevent future strokes.

10 NGL AssetGuard Agent FAQ Q: What is an early payoff? A: NGL s Early Payoff Program is discount program offered to policyowners who are able to fully pay their policy prior to the expiration of the payment term. For example, if a policyowner who had elected to pay the policy over a period of 10 years (120 months) was able to pay the policy in month 10, the total payoff amount due would be discounted based on the total premium payments remaining in the payment term, in this case 110 months. This discount varies based on the plan and the total remaining payments. If a policyowner is able to fully pay the policy in the first 13 months, the discounted payoff amount will total the premium due had the policy originally been issued as a single pay policy less the total premium already paid essentially making the payoff same as cash. To obtain an early payoff quote, please contact the NGL Agent Support Team (800) or visit MyNGLIC.com. Q: How will my commissions be affected if my client elects to pay off their multi pay policy before the end of the payment term? A: If the payoff occurs within the first thirteen months, the commissions are adjusted to those of the 2% percent of premium single pay commissions. If the payoff occurs after the thirteenth month, there is no commission chargeback for early payoff. A renewal commission will be paid on the total payoff premium amount applied. Q: Can I accept down-payments? A: There may be situations when a client would like to purchase a policy for a set total amount, but is only able to pay a portion of this total at the time of application. For situations such as this, you have the option of applying for both a lump sum policy and a multi pay policy using one application. To take advantage of this option, you will simply send in the application materials and the $5000 premium payment. From this $5000 premium, NGL will deduct the lump sum (must total $500 minimum) and the first periodic premium payment. On the application payment plan section, you will list the total lump sum premium in the initial premium section and the multi pay premium amount in the multi pay premium section. In the total premium with application section, you will list $5000. Please note, if you use one application form to apply for a lump sum policy and an ongoing multi pay policy, both the single and multi pay policies will be issued at 2% growth. Q: How are commissions paid for down-payments? A: If you use one application to apply for a lump sum policy and an ongoing multi pay policy, you will receive commissions for both the single pay and the multi pay policy. Single pay commissions are paid at issuance as a flat percent of face. The multi pay commissions are paid as a percent of premium at issuance, and renewal commissions are paid upon receipt of additional premium payments. Q: What is the total face amount allowed per life for this product? A: $100,000 is the maximum allowed on one life in one or more NGL policies. National Guardian Life Insurance Company (NGL) Two East Gilman Street. Madison, WI option FE-APPGuide 05/14