*Include the date (MM/DD/YYYY) the. POS TI Complete 10/10/14 * Mailing address: P O Box 101, Hometown, VA Mailing address: P O Box 101,

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1 POS TI Complete 10/10/14 * 1 Mailing address: P O Box 101, Hometown, VA Jane Doe 100 Summitt Ave xxx-xxx-xxxx Anytown NJ 2 02/14/ Address: Application MUST include a physical address for EACH applicant. If applicant has a mailing address different from their physical address (such as a P O Box), indicate the preferred mailing address in the left margin. Provide their physical (residential) address in the space provided on the application. Use applicant s home zip code to determine rates (area factor). Applicant must reside in state of issue. 1 Mailing address: P O Box 101, Hometown, VA A Sam Doe 100 Summitt Ave Anytown /02/ /02/2012 xxx-xxx-xxxx NJ Social Security Number AND Medicare ID Claim Number: Please include both numbers and the alpha code that is part of their Medicare ID number. If no Medicare ID has been assigned, write Medicare ID # has not been assigned in the margin and instruct the applicant to call Policyholder Services when their Medicare ID has been assigned. 3 Legal U.S. Resident: Required of all applicants. 4 01/18/ A /01/ /01/ Type of Application: Mark the appropriate circle if the applicant is in Open Enrollment (first eligible for Medicare Part B) or Guaranteed Issue (GI). For GI, include a copy of credible coverage letter from prior insurance carrier. Leave blank for applications that require underwriting. *Include the date (MM/DD/YYYY) the Each applicant must answer all Eligibility questions. Point of Sale (POS) Telehone Interview (IT) was completed, when applicable. A TI is needed on all applications that require underwriting. TI can be done when the application is taken (POS); otherwise, advise the applicant that a telephone interviewer from the home office will be contacting them to conduct a telephone interview.

2 Plan F 05/01/2013 2, , , , , , , Example: Draft initial premium on effective date 7 Example: Draft initial premium on effective date 5 Effective date: Indicate the applicants desired Policy Effective Date. Allow 14 business days for the application to be processed when determining the desired Policy Effective Date. 6 Use the Outline of Coverage to calculate the premium. Agent Rate Guides (which are not part of the sales kit) are available to help agents calculate the premium. List the required policy fee separate from the premium. Policy fee is refunded if application is declined. 7 Initial Premium: Premiums collected by electronic funds transfer (EFT) are drafted on Policy Issue Date unless you indicate to draft on Policy Effective Date here. (Commissions are paid when initial premium is collected.) E-Apps must be EFT for initial premium Checks received at the lock box are automatically deposited when received. 8 Applicant A and B s initials: Required on pages 2 through 8. 9 Household discount: If applicants are applying together, please complete question 1. If applicant is requesting to be coupled with an existing policy, please complete question 2 in its entirety, including physical address.

3 Prior plans: Capture the name of applicant A and B s current insurance company (for which this policy will replace). If the policy is an internal replacement or policy exchange, the Company s internal replacement rules will apply regarding commission payment, if any is due. Internal replacement applies to Medicare Supplement applications that replace a Medicare Supplement policy underwritten by ACI, CLI, or AHLIC. Question 3 pertains to Medicare Advantage, Medicare HMO, or Medicare PPO. Question 4 pertains to Medicare Supplements. Question 5 pertains to Group coverage.

4 Ask all Health Questions exactly as they appear on the application. Do NOT submit an application if the applicants answer yes to any health question. Use the standard rate for any applicants who answer yes to the tobacco use question. In some states, the tobacco use question may appear in the first section of the application. Health questions should NOT be answered if applicants are in their Medicare Open Enrollment Period (first eligible for Medicare Part B) or in a Guaranteed Issue period. All other applicants must answer all health questions. Advise the applicants that a telephone interview will be required (underwritten applications only). During the interview, the applicants will be asked the same health questions as those listed on the application form. (Application forms, and therefore the health questions, may vary by state.)

5 Underwritten policies: Any yes answer to questions 10 or 11 do not submit Unacceptable drugs: Please consult your field underwriting guidelines for a list of declinable drugs. Do not submit the application if the applicant has been prescribed a drug listed in the guide. List all prescribed drugs regardless of the applicant s compliance to taking the prescribed drug. 13

6 8 Dr. John Smith Anytown NJ Dr. John Smith Anytown NJ

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8 Applicants signature: Applicants (not a Power of Attorney*) must sign the application. *A Power of Attorney signature is only acceptable if the applicant is Open Enrollment or Guaranteed Issue

9 Complete this section if the applicant wants their initial and MONTHLY renewal premiums to be drafted from their bank account automatically through electronic funds transfer (EFT). Include a voided check. This is the preferred method of payment for most Medicare Supplement applicants. Do NOT complete this section if the client wants to be billed (Direct Bill) quarterly, semi-annually, or annually for their renewal premiums. A completed check is required to include the policy fee. An Electronic Check Authorization form is available if the applicant wants to pay their quarterly, semi-annual, or annual premiums electronically by bank draft. See the Method of Payment chart on page 10 for a list of all payment methods, what is required from the applicant, and when premiums will be drafted based on the selected payment method. At any time after the policy is active, the policyholder can call the Policyholder Services team to change their method of payment and/or bank account information. Allow 15 business days for processing. 8 Example: Draft on 7 th of each month Draft date: If the applicant wants to request that renewal premiums are drafted on a specific day of the month, indicate the desired monthly draft date here. See item 7 regarding when the initial premium will be drafted. Draft dates cannot be on the 29 th, 30 th, and 31 st of the month. Requesting to have a draft date more than 10 days greater than the Policy s Paid To Date will draft a month in advance. Example: Draft on 7 th of each month. 15

10 8 16 Writing number: Use your 10-digit GNW writing number for all ACI, CLI, & AHLIC Med Supp policies. Applications without a GNW number will not be in good order. 16

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12 Complete this form and leave with the applicants. All other state required application documents must be completed, signed, and submitted to the home office for processing.

13 Follow the Agent Checklist, included in all sales kits to make sure you have completed all application documents and state required forms. All pages of the application and any state required forms must be completed and submitted to the home office before a policy can be issued. o If the applicant is in a Guaranteed Issue period, include the appropriate documentation. o Submit all documents as soon as possible. Retain a copy for your records and store all copies in a secure location. How to submit a paper application is determined by the Payment Method selected see chart below. o Fax the application (to the appropriate new business fax number) if the applicant is paying by electronic funds transfer (EFT). Faxing applications improves processing time and premiums that are paid by EFT help build business persistency. Fax all pages of all required documents. o Fax once. Do NOT fax an application multiple times UNLESS specifically requested by the home office. Fax receipt is not available at this time. A new business fax cover sheet is available to help ensure it is received by the appropriate area of new business. Separate applications (such as when a husband and wife both applying for coverage) can be submitted at the same time using a single Fax Cover Sheet. (A separate application including the EFT form or check is required for each applicant.) o Mail all Direct Bill applications (available to applicants paying quarterly, semi-annually, or annually) to the correct address (refer to the Home Office Directory available on aetnaseniorproducts.com). DO NOT mail new business direct to the home office address, as this will delay processing. A pre-addressed new business envelope is available. (DO NOT use old envelopes. Pre-printed USPS bar coding will result in misdirected mail.) o Checks should be made payable to the underwriting company. Premium Mode and Payment Options Use the chart below when advising a customer about their payment options. Premium Mode Payment Method Application must include: Submit Application Initial Payment Draft Renewal Premiums Monthly Monthly, Quarterly, Semi Annual, Annual Quarterly, Semi Annual, Annual EFT Electronic (Fax) Check Check (Direct Bill) o Section 11 (Account Information), and Section 12 (Electronic funds transfer authorization) on the application form must be completed. o A blank and voided check By Fax to the home office. o the new Electronic Check Authorization form must be completed o A copy/fax of a completed live check for the amount of the initial premium and policy fee. Note: The check is NOT deposited but used to establish the electronic draft. Agent should destroy the check upon policy issue. o A completed check made payable to the underwriting company (Do NOT mail any documents to the lockbox) By Mail (with check) to the appropriate lockbox (Do NOT fax.) Initial Draft (including Policy Fee drafts on Policy Issue Date or on Policy Effective Date, if requested on the application) Initial Draft (including Policy Fee drafts on Policy Issue Date or on Policy Effective Date, if requested on the application) Include policy fee with initial premium. Check is deposited when received at the lockbox. Monthly renewal premium to draft on the next Premium Due Date or on the requested draft date, if one is requested (in the margin) in Section 11 of the application. Renewal premium to automatically draft on the next Premium Due Date. (No check is required by the policyholder.) Policyholder will be billed for renewal premiums. Payment deposited when received at the lockbox.