Application for Specified Disease Coverage (NY78000 Series) Application to: American Family Life Assurance Company of New York (herein referred to as Aflac) 22 Corporate Woods Boulevard Suite 2 Albany, New York 12211 New Conversion Policy Number: Please Print in Black Ink To Be Completed by Proposed Insured Proposed Insured s Name Last First MI DOB Sex SSN - - Month/Day/Year (Optional) Address Street or Post Office Box Apt. No. City State ZIP Telephone ( ) Home Work Cell Email Address (optional) Are you applying for Dependent Child(ren) coverage? If yes, Dependent Children must be under age 26 at the time of application. Write Spouse s name below if you are applying for Two-Parent Family or Named Insured/Spouse Only coverage; if you have no Spouse or your Spouse is not to be covered, put N/A in the space below. Spouse s Name DOB Sex Last First MI Month/Day/Year Name of Employer Account No. (Optional) Does anyone to be covered have any other Cancer coverage with Aflac, other than a Lump Sum Cancer Benefit Rider? If yes, this must be a conversion of that coverage. Please indicate the current policy number below and see Applicant s Statements and Agreements concerning conversions. Policy Number: Does anyone to be covered have an Aflac Lump Sum Specified Disease policy with a Lump Sum Cancer Benefit Rider? If yes, please complete the Supplemental Notification section at the end of this application and be aware that you cannot have this policy without canceling the Aflac Lump Sum Cancer Benefit Rider. 1. Are you (and, if family coverage is applied for, anyone to be insured) currently covered by at least major medical insurance or at least basic hospital and basic medical insurance? If yes, please proceed to the next section. (a) If you do not have such coverage, a policy will not be issued. If you do have such coverage, but your spouse and/or dependent children do not, please list their names in the space provided: Any person(s) listed will not be covered by this policy or any applicable rider. Form NY78002cR2 1 of 9 NY78002cR2.1
2. Are you (or, if family coverage is applied for, anyone to be insured) currently covered by (or have an application(s) pending as of the date of application) specified disease insurance either with us or another insurer? If yes, please answer the questions below. (a) Does the other specified disease insurance provide coverage for Cancer? If you answered yes and do not replace your other coverage (or rescind your application(s) pending as of the date of application), then a policy will not be issued. If your spouse and/or dependent children have (or have an application(s) pending as of the date of application) such coverage and are not replacing it (or rescinding their application(s) pending as of the date of application), please list their names here: Any person(s) listed will not be covered by this policy or any applicable rider. (b) Does the other specified disease insurance cover 8 or more diseases? If you answered yes and do not replace your other coverage (or rescind your application(s) pending as of the date of application) such that you are no longer covered for 8 or more specified diseases, then a policy will not be issued. If your spouse and/or dependent children have (or have an application(s) pending as of the date of application) such coverage covering 8 or more specified diseases and are not replacing it (or rescinding their application(s) pending as of the date of application), please list their names here: Any person(s) listed will not be covered by this policy or any applicable rider. Check Coverage Desired: Individual Named Insured/ Spouse Only One-Parent Family Two-Parent Family Preferred: Policy (Series NY78100) Select: Policy (Series NY78200) Classic: Policy (Series NY78300) Premier: Policy (Series NY78400) Pre-Tax After-Tax Optional Riders: Initial Diagnosis Building Benefit Rider (Series NY78050) Units Options: No rider New rider Retain current rider Dependent Child Rider (Series NY78051) (only available with One-Parent Family or Two-Parent Family coverage) Options: No rider New rider Retain current rider IF YOU ARE APPLYING FOR ANY SPECIFIED HEALTH EVENT RIDER PLEASE ANSWER THE FOLLOWING QUESTION: Does anyone to be covered have any other Specified Health Event coverage with Aflac? If yes, this must be a replacement of that coverage. If yes, give current policy number and see the Supplemental Notification listed on page 7. Policy Number: PLEASE CHOOSE ONLY ONE SPECIFIED HEALTH EVENT RIDER: Specified Health Event with First Occurrence Building Benefit Rider (Series NY78055) New rider Retain Current Rider No Rider Specified Health Event with First Occurrence Building Benefit and Recovery Benefit Rider (Series NY78056) New rider Retain Current Rider No Rider Form NY78002cR2 2 of 9 NY78002cR2.1
Billing Method: Direct Bank Draft (B/D, ACH) Credit Card (C/C) List Bill Mode: 01 Monthly (B/D & C/C Only) 03 Quarterly 06 Semiannual 12 Annual Employee No. Dept. No. Assoc./Agent s No. Billable Premium $ Premium Collected $ Sit. Code ASSOCIATED CANCEROUS CONDITION: a myelodysplastic blood disorder, myeloproliferative blood disorder, or internal carcinoma in situ (in the natural or normal place, confined to the site of origin without having invaded neighboring tissue). An Associated Cancerous Condition is limited to only the conditions listed above. CANCER: a disease manifested by the presence of a malignant tumor characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue. "Cancer" also includes but is not limited to leukemia, Hodgkin's disease, and melanoma. INTERNAL CANCER: all Cancers other than Nonmelanoma Skin Cancer. BENEFICIARY INFORMATION PLEASE NOTE: We do not recommend that you name a minor child as your beneficiary. If you name a minor child as your beneficiary, any benefits due your minor beneficiary will not be payable until a guardian for the financial estate of the minor is appointed by the court or such beneficiary reaches the age of majority as defined by your state. If there is no beneficiary, Aflac will pay any applicable benefit to your estate. PRIMARY BENEFICIARY FULL NAME (Last, First, MI) RELATIONSHIP CITY/STATE DATE OF BIRTH % OF PROCEEDS CONTINGENT BENEFICIARY FULL NAME (Last, First, MI) RELATIONSHIP CITY/STATE DATE OF BIRTH % OF PROCEEDS PLEASE COMPLETE THE FOLLOWING UNDERWRITING QUESTIONS. 1. To the best of your knowledge and belief, have you or has anyone to be covered under this policy ever been diagnosed with or treated for Cancer or an Associated Cancerous Condition of any type or form? If yes, please complete Questions 2, 3, and 4. 2. To the best of your knowledge and belief, have you or has anyone to be covered had Internal Cancer or an Associated Cancerous Condition that was diagnosed or last treated within the last ten years or received preventive hormonal therapy within the last 12 months? Any person(s) so designated will not be covered under the policy or any applicable rider. If the named person is the Proposed Insured, a policy will not be issued. If a child, are any other children to be covered? Form NY78002cR2 3 of 9 NY78002cR2.1
3. To the best of your knowledge and belief, have you or has anyone to be covered had Internal Cancer or an Associated Cancerous Condition that was diagnosed or last treated over five years ago? If yes, please complete a Specified Disease History Form provided by your agent on any individual(s) listed. Additional underwriting may be required. 4. To the best of your knowledge and belief, have you or has anyone to be covered had Nonmelanoma Skin Cancer that was diagnosed or last treated within the last 12 months? Any person(s) so designated will not be covered under the policy or any applicable rider. If yes, and this is a conversion, the person(s) so designated is not eligible for coverage under the converted policy or any applicable rider. 5. To the best of your knowledge and belief, have you or has anyone to be covered received a health screening (such as a mammogram, Pap smear, PSA, chest X-ray or colonoscopy) that tests for the presence of Cancer or an Associated Cancerous Condition, for which you have not received the results? Any person(s) so designated will not be covered under the policy or any applicable rider. If the named person is the Proposed Insured, a policy will not be issued. If a child, are any other children to be covered? 6. To the best of your knowledge and belief, have you or has anyone to be covered been advised by a member of the medical profession to receive a follow-up test for the potential presence of Cancer or an Associated Cancerous Condition for which you have not received the results? Any person(s) so designated will not be covered under the policy or any applicable rider. If the named person is the Proposed Insured, a policy will not be issued. If a child, are any other children to be covered? 7. To the best of your knowledge and belief, within the past 90 days have you or has anyone to be covered received abnormal test results from a health screening test? Any person(s) so designated will not be covered under the policy or any applicable rider. If the named person is the Proposed Insured, a policy will not be issued. If a child, are any other children to be covered? Form NY78002cR2 4 of 9 NY78002cR2.1
PLEASE COMPLETE THE FOLLOWING QUESTIONS IF APPLYING FOR ANY SPECIFIED HEALTH EVENT RIDER 8. To the best of your knowledge and belief, has anyone to be covered ever been diagnosed with or received medical treatment for any of the following by a member of the medical profession? Impaired kidney function Cardiomyopathy (not including stones or acute infection) Stroke or TIA (two or more) Cerebral vascular insufficiency Liver disease or disorder Congenital heart disease (excluding Hepatitis A) (excluding surgically corrected atrial septal defect) Cystic fibrosis Heart Attack (two or more) Systemic lupus 9. To the best of your knowledge and belief, has anyone to be covered ever been diagnosed with or received medical treatment by a member of the medical profession for diabetes (1) requiring the use of insulin within the last five years, or (2) with complications to include retinopathy, neuropathy, or nephropathy, or (3) with continued tobacco use, or (4) diagnosed prior to age 30 (excluding gestational)? 10. To the best of your knowledge and belief, has anyone to be covered ever had or been advised to have a major organ transplant or consulted with or been evaluated by a member of the medical profession of the need to have a major organ transplant? 11. To the best of your knowledge and belief, has anyone to be covered ever been diagnosed with or medically treated for acquired immune deficiency syndrome (AIDS) by a member of the medical profession? 12. To the best of your knowledge and belief, in the last five years, has anyone to be covered been diagnosed with or received medical treatment for any of the following by a member of the medical profession? Angina Stroke or TIA (single event) Coronary artery disease Angioplasty, stent placement or bypass surgery Chronic obstructive pulmonary disease (COPD) Atrial fibrillation Arterial blockage Heart Attack (single event) Peripheral vascular disease 13. To the best of your knowledge and belief, within the last two years, has anyone to be covered received chemotherapy treatment by a member of the medical profession for any medical condition, not to include hormonal treatment for cancer? 14. To the best of your knowledge and belief, within the last 12 months, has anyone to be covered been prescribed or received treatment with blood thinners, not including aspirin, by a member of the medical profession? 15. To the best of your knowledge and belief, within the last 12 months, has anyone to be covered received medical treatment by a member of the medical profession in an emergency room or hospital for hypertension/high blood pressure (not related to pregnancy), or had a medication change to improve blood pressure readings? 16. To the best of your knowledge and belief, within the last 12 months, has anyone to be covered been prescribed medication for irregular heartbeat, heart palpitation, or tachycardia (not including preventive treatment with antibiotics prior to dental appointment), or has anyone to be covered ever required treatment by a member of the medical profession with a pacemaker or defibrillator? Form NY78002cR2 5 of 9 NY78002cR2.1
17. To the best of your knowledge and belief, within the last six months, has anyone to be covered had or been advised by a member of the medical profession of the need to have diagnostic tests performed to evaluate symptoms of chest pain, shortness of breath, blackouts, fainting, or dizziness? IF ANY ONE OF QUESTIONS 8 THROUGH 17 IS ANSWERED YES, A SPECIFIED HEALTH EVENT RIDER WILL NOT BE ISSUED. 18. The following information must be completed on each dependent child to be covered. Name Last, First, MI Date of Birth Sex SSN APPLICANT S STATEMENTS AND AGREEMENTS I acknowledge that I was offered the optional riders, and I have personally determined which, if any, are best for me. I understand that the Effective Date of the policy will be the date recorded in the Policy Schedule by Aflac. It is not the date I signed this application. This policy contains a 30-day waiting period. If a Covered Person has Cancer or an Associated Cancerous Condition diagnosed before coverage has been in force 30 days, benefits for treatment of that Cancer or Associated Cancerous Condition will apply only to treatment occurring after 12 months from the Effective Date of the policy or, at my option, I may elect to void the policy from its beginning and receive a full refund of premium. I understand that the policy I am applying for will not cover any person who has attained age 76 before the Effective Date of the policy. I understand that Dependent Children, if any, must be under age 26 at the time of application. Once covered, Dependent Children will continue to be covered until their 26th birthday. I acknowledge receipt of, if applicable: Disclosure Statement Conditional Receipt Guide to Health Insurance for People with Medicare If this is an application for a conversion, the following conditions apply: (a) If Cancer or an Associated Cancerous Condition is diagnosed between the date this application is signed and the Effective Date of the policy shown in the Policy Schedule, the policy for which this application is made will be void, and coverage will continue under the terms of the previous policy, which may remain in force. Any benefits that may be due will be paid under the previous policy. (b) The waiting period provision of the new policy will run from the Effective Date of the original policy, and the original policy will be terminated as of the Effective Date of the new policy. Any premium paid on the original policy that is unearned as of the Effective Date of the new policy will be applied to the new policy. Form NY78002cR2 6 of 9 NY78002cR2.1
I understand that (1) the policy, together with this application, endorsements, benefit agreements, riders, and attached papers, if any, constitutes the entire contract of insurance, and (2) no change to the policy will be valid until approved by Aflac's president and secretary, and noted in or attached to the policy. I understand that (1) Aflac is not bound by any statement made by me, or any agent of Aflac, unless written herein, and (2) the agent cannot change the provisions of the policy or waive any of its provisions either orally or in writing. If I am applying to replace existing Aflac coverage with this policy, I acknowledge that the policies may have different benefits and that I should make a comparison to personally determine which is best for me. I understand and agree that I am terminating my current Aflac policy and its benefits for the benefits provided in this Aflac policy. I have reviewed the statements and answers I have provided on this application. I understand that this policy is to be issued based upon these statements and answers, and any other pertinent information Aflac may require for proper underwriting. The answers are complete and true to the best of my knowledge and belief. I understand that all statements made in this application are deemed representations and not warranties, but that material misrepresentations herein may result in loss of coverage under this policy. I understand that the purchase of this policy is intended to supplement my existing comprehensive health care coverage. It is not intended to replace or be issued in lieu of that coverage. I understand that the policy for which I am applying is designed to supplement my basic health coverage and should not be viewed as a substitute for such coverage. SUPPLEMENTAL NOTIFICATION COMPLETE IF YOU ARE REPLACING/TERMINATING EXISTING AFLAC COVERAGE THAT CONTAINS CANCER BENEFITS. is applying for Aflac's Cancer policy and currently has cancer benefits under a Lump Sum Cancer Benefit Rider on Aflac s Lump Sum Specified Disease policy number. Existing Aflac Cancer coverage must be cancelled to purchase this Cancer policy. Please cancel the existing Lump Sum Cancer Benefit Rider attached to Lump Sum Specified Disease policy number, but keep the Lump Sum Specified Disease policy in force. Existing benefits provided for in the current Lump Sum Cancer Rider will not be provided for in the new Cancer policy. Please cancel the entire Lump Sum Specified Disease policy (with Lump Sum Cancer Benefit Rider) number. Existing benefits provided for in the current Lump Sum Specified Disease policy and Lump Sum Cancer Benefit Rider are not provided for in the new Cancer policy. SUPPLEMENTAL NOTIFICATION COMPLETE IF YOU ARE REPLACING/TERMINATING EXISTING SPECIFIED HEALTH EVENT COVERAGE. I,, am applying for Aflac's Specified Health Event Rider. I currently have specified health event benefits under Aflac s Cancer Policy Number. I understand that I must cancel my existing Aflac Specified Health Event Rider. Please cancel my Specified Health Event Rider under Cancer Policy Number. I understand that I will be terminating benefits provided for in my current Specified Health Event Rider that may not be provided for in the new Specified Health Event Rider. OTHER INSURANCE WITH AFLAC: If any person is covered under more than one Aflac Cancer policy or rider, only the one chosen by you, your beneficiary, or your estate, as the case may be, will be effective. Aflac will pay benefits under the policies for claims that may have been incurred since their respective Effective Dates. Aflac will also return all premiums paid for all other such policies. The coverage applied for provides specified disease coverage only. If applied for and issued, coverage will be provided for Specified Health Events under optional riders. This coverage does not meet the minimum requirements for basic hospital, basic medical, major medical, Medicare supplement, long term care insurance, nursing home insurance only, home care insurance only, or nursing home and home care insurance in the state of New York. Purchase of this coverage may be unnecessary if you already have or intend to purchase Medicare supplement insurance or long term care insurance. Form NY78002cR2 7 of 9 NY78002cR2.1
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. I prefer to receive an electronic copy of my policy instead of a paper copy. If yes, please enter your email address on Page 1. Signed and Dated at City and State on Date Proposed Insured s Signature I certify that I personally saw the Proposed Insured when the application was written, and each question was asked of the Proposed Insured and answered as recorded. All answers above are correct to the best of my knowledge and belief. Agent s Signature Licensed Resident Agent Date MAKE CHECK OR MONEY ORDER PAYABLE TO AFLAC. FOR INFORMATION, CALL TOLL-FREE 1.800.366.3436. VISIT OUR WEBSITE AT AFLAC.COM. Form NY78002cR2 8 of 9 NY78002cR2.1
For policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy. IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS IS NOT MEDICARE SUPPLEMENT INSURANCE Some health care services paid for by Medicare may also trigger the payment of benefits from this policy. This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one of the specific diseases or health conditions named in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: * hospitalization * physician services * hospice * outpatient prescription drugs if you are enrolled in Medicare Part D * other approved items and services This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance. Before You Buy This Insurance * Check the coverage in all health insurance policies you already have. * For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. * For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIP). Form NY78002cR2 9 of 9 NY78002cR2.1