Application for Election of Accelerated Benefits for Survivor Product

Transcription

1 *L3193MT* Application for Election of Accelerated Benefits for Survivor Product Accelerated Death Benefits provided under life insurance coverage may provide benefits to pay for long-term care services but are NOT part of a long-term care or nursing home insurance policy and the amount these products pay may not be enough to cover your medical, nursing home or other bills. Accelerated Benefit Payments used to pay for long-term care services are subject to limits imposed by the federal government and any amounts received in excess of these limits are includible in taxable income. You may use the money you receive as an Accelerated Benefit for any purpose. Unlike conventional life insurance proceeds, amounts payable as Accelerated Benefits COULD BE TAXABLE UNDER SOME CIRCUMSTANCES. We recommend that you consult your personal tax advisor prior to electing an Accelerated Benefit. If you already have long-term care insurance, Medicaid, or similar coverage, you should consider whether the Accelerated Benefit provided under this policy are suitable for your needs. Receipt of accelerated benefits MAY AFFECT YOUR ELIGIBILITY FOR MEDICAID, SUPPLEMENTAL SECURITY INCOME ( SSI ), OR OTHER GOVERNMENT BENEFITS OR ENTITLEMENTS. Contact the Medicaid Unit of your local Department of Public Welfare and the Social Security Administration Office for more information. Section 1 Claimant Statement PART A Personal Information Policy Number Full Name of Survivor (Insured) Date of Birth (MM/DD/YYYY) Social Sec. # or Tax ID # Residence Address (Street, City, State, Zip) Daytime Phone (with area code) Provide name(s) and address(es) of all Medical Practitioners who attended the Survivor as well as name(s) and address(es) of all hospitals and institutions where the Survivor was treated within the past 5 years in the boxes below. NORTH AMERICAN COMPANY ADMINISTRATIVE OFFICE: P. O. BOX 5088 SIOUX FALLS, SD PRINCIPAL OFFICE: WEST DES MOINES, IA Phone: (800) Fax: (605) L-3193MT 1 1/2010

2 Full Name of Policyowner Daytime Phone (with area code) Address (Street, City, State, Zip) I certify that all the above statements are complete and accurate to the best of my knowledge. Signature of Survivor Signature of Witness Date Part B Accelerated Death Benefit Information To Be Completed By Owner Select One: 1. Terminal Illness Requested Death Benefit to Accelerate: OR The minimum Accelerated Death Benefit for Terminal Illness is the smaller of 10% of the Death Benefit on the Election Date or $100,000. The maximum Accelerated Death Benefit for Terminal Illness is the smaller of 75% of the Death Benefit on the Election Date or $750, Chronic Illness - Requested Death Benefit to Accelerate: The minimum amount you can accelerate at each Election, except the Final Election, is the smaller of 5% of the policy s Death Benefit on the Initial Election Date or $50,000. The maximum amount You can accelerate at each Election, except the Final Election, is the smaller of 24% of the policy s Death Benefit on the Initial Election Date or $240,000. The remaining Death Benefit in Your policy must at least equal the Residual Death Benefit. For further details, please refer to Your Accelerated Death Benefit Endorsement. Requested Number of Payments (Please select one): Lump Sum Payment Quarterly Payments (4 total Periodic Payments) Semi-Annual Payments (2 total Periodic Payments) Monthly Payments (12 total Periodic Payments) NOTE: The actual Payment You will receive will be lower than this amount since You are receiving the benefit prior to death. A portion of the Payment will be used to reduce any Policy Debt. We will send You a notice that describes the effect of the Accelerated Benefit Payment on your Policy Provisions. L-3193MT 2 1/2010

3 I certify under penalty of perjury that my correct taxpayer identification number is: I further certify that no bankruptcy proceedings filed for or against me are now pending, and no liens are outstanding against the policy except as follows: The information contained in this application is true to the best of my knowledge. I agree to provide further information upon request. Signature of Owner Signature of Witness Date Section 2 To Be Completed By Irrevocable Beneficiary or Collateral Assignee As a result of an acceptable application for Election of Accelerated Death Benefits, the Accelerated Death Benefit Payment will be made to the Owner listed above in Section 1. This Payment will eliminate a portion of the Death Benefit otherwise payable under the policy. As an Irrevocable Beneficiary or Collateral Assignee of the policy listed above in Section 1, I consent to the acceleration of the Death Benefit requested in this application. Signature of Irrevocable Beneficiary Signature of Collateral Assignee Date Section 3 Attending Medical Practitioner Statement to be completed by Medical Practitioner (Please Print) Terminal Illness means the Survivor has been certified through a written certification by a Medical Practitioner that the Survivor has been diagnosed with a medical condition which results in a drastically limited life span. A drastically limited life span is a life span of 24 months or less. Is the patient s condition terminal Yes No When did symptoms of the terminal illness first appear? / / When did you make the initial diagnosis? / / What is the patient s life expectancy? Months with % of medical certainty. Date of First Treatment: Date of Last Treatment: Frequency of Treatment: Weekly Monthly Other L-3193MT 3 1/2010

4 Please provide a description of the current diagnosis and prognosis (including complications) and include ICD9 and/or DSM IV Multi-Evaluation Nomenclature and Code Number Please indicate any subjective symptoms as well as objective findings (x-rays, laboratory data and any clinical findings) Chronic Illness means the Survivor has been certified through a written certification by a Medical Practitioner within the last 12 months as: (a) Being permanently unable to perform, for at least 90 consecutive days without Substantial Assistance from another person, at least two Activities of Daily Living; 90 consecutive days includes consecutive days immediately prior to the Policy being in effect; or (b) Requiring Substantial Supervision by another person, to protect oneself from threats to health and safety due to Severe Cognitive Impairment. Activities of Daily Living - Definitions "Bathing" means the ability to wash oneself by sponge, bath, or in either a tub or shower, including the task of getting into or out of the tub or shower. "Continence" means the ability to maintain control of bowel and bladder function; or, when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene (including caring for catheter or colostomy bag). "Dressing" means putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs. "Eating" means the ability to feed oneself by getting food into the body from a receptacle (such as a plate, cup or table) or by a feeding tube or intravenously. "Toileting" means getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene. "Transferring" means moving into or out of a bed, chair or wheelchair. "Severe Cognitive Impairment" means a loss of intellectual capacity in a person's short or long-term memory, orientation as to person, place and time, deductive or abstract reasoning, or judgment as it relates to safety awareness. Immediate Family means the spouse, children, siblings, parents, grandparents, grandchildren, and any of their spouses. Substantial Assistance means stand-by or hands-on assistance from another person without which the Survivor receiving such assistance would be unable to perform Activities of Daily Living. Stand-by assistance means the presence of another person within arm s reach of the Survivor that is necessary to prevent, by physical intervention, injury to the Survivor while he/she is performing Activities of Daily Living. Hands-on assistance means the direct physical assistance of another person. Substantial Supervision means requiring continual supervision by another person to protect the Survivor from threats to health or safety due to Severe Cognitive Impairment and may include cueing by verbal prompting, gestures, or other similar demonstrations. What date did the symptoms of the Chronic Illness first appear? / / L-3193MT 4 1/2010

5 What date did you make your initial diagnosis? / / Please provide a description of the current diagnosis and prognosis (including complications) and include ICD9 and/or DSM IV Multi-Evaluation Nomenclature and Code Number Describe and identify any limitations (what patient cannot do) in performing Activities of Daily Living Describe any Severe Cognitive Impairment requiring Substantial Supervision by another person to protect himself or herself from threats to health and safety Certification I certify that the Patient has a Chronic Illness, as defined above. I also certify that I am not the Survivor (Insured), or Owner, or an Immediate Family member of the Survivor/Patient or of the Owner indicated in this application. Signature of Medical Practitioner Date Social Sec # or Employer s ID Number: L-3193MT 5 1/2010