Group Long Term Care Insurance Medical Questionnaire Enrollment Form -- L Fairfax County

Transcription

1 A Aetna Life Insurance Company P.O. Box Lexington, KY Group Long Term Care Insurance Medical Questionnaire Enrollment Form -- L Fairfax County Instructions Each enrollee must complete and sign a separate form and print all responses in BLACK ink. 1. Please complete this Enrollment Form if you are enrolling for the first time as described in one of the groups below or you are already an enrolled person requesting an increase in existing long term care coverage: A parent, parent-in-law, grandparent, grandparent-in-law, adult child, of an eligible active employee; a retiree; spouse, surviving spouse, adult child, of a retired employee (*for eligibility purposes, the term spouse includes domestic partner; for residents of CT, NJ and VT, Civil Union partners are eligible; for residents of MT, domestic partners are eligible); or An eligible active employee or spouse enrolling outside of a designated enrollment period; or A newly hired eligible or newly eligible employee or spouse enrolling after 60 days of first becoming eligible; or An employee who was on leave of absence or disability and did not enroll during a designated enrollment period. 2. Provide complete dates and details for all Yes answers. 3. Be sure to provide complete information to avoid delays in processing your request for coverage. 4. Make a copy of this completed enrollment form for your records and return the original in the envelope provided to: Aetna Life Insurance Company, Long Term Care, P.O. Box 14550, Lexington, KY Note if this form is not completed in its entirety and signed, it will be returned for completion. The following definition applies to any reference on this form to AIDS Related Complex: AIDS RELATED COMPLEX (ARC) is a condition with signs and symptoms which may include generalized Lymphadenopathy (swollen lymph nodes), loss of appetite, weight loss, fever, oral thrush, skin rashes, unexplained infections, dementia, depression, or other psychoneurotic disorders with no known cause. Part A: Prescreen Check Yes if you have ever experienced or been specifically diagnosed, treated for, or told that you have any of the following conditions. Check No if you have not. If you are unsure how to answer, ask your doctor. If you have any questions about a particular condition or circumstance, or if you have questions about your enrollment process, call Aetna s Long Term Care Hotline at If you do not have any of these conditions and you do complete the form, you should not assume that we will approve your coverage. Aetna will review the information you provide regarding your health status and decide whether to approve your request for coverage. The same guidelines apply to requests for an increase in existing coverage. 1. Alzheimer s Disease, dementia or chronic permanent memory loss?... Yes No 2. Acquired Immune Deficiency Syndrome (AIDS), ARC or AIDS related conditions?... Yes No 3. Organ, stem cell or bone marrow transplant that is pending?... Yes No 4. Post Polio Syndrome?... Yes No 5. Permanent paralysis?... Yes No 6. Parkinson s Disease, Multiple Sclerosis (MS), Huntington s Chorea, Amyotrophic Lateral Sclerosis (ALS)?... Yes No 7. Stroke or Transient Ischemic Attack (TIA/mini-stroke) within the last two years?... Yes No For questions #8 through #10: Do you currently and on an ongoing basis: 8. Receive home health care or adult day care, reside in (or have been recommended to) a nursing home or home 10. Receive assistance from or the supervision of another person for bathing, dressing, toileting, walking, eating for the aged?... Yes No or transferring (moving from chair to chair or bed to chair)?... Yes No 9. Use a walker, wheelchair, oxygen, catheter, or kidney 11. Do you currently receive permanent Social Security dialysis?... Yes No Disability Income benefits?... Yes No If you answered No to all of the questions above, continue to Part B. If you need assistance completing this form, contact us toll-free at GR-700-W-E2-REV-VA -1- ED. (03/05)

2 Part B: Enrollee Information Policyholder Name Fairfax County Enrollee Name (Last, First, Middle Initial) Policyholder Number Control Number Social Security Number - - Street Address City State Zip Code Country Work Phone Number ( ) - Date of Birth (MM/DD/YYYY) / / Home Phone Number ( ) - Address: M Sex F Height Return of Contribution Beneficiary Name (Last, First, Middle Initial) Complete only if you choose the ROC option in Part C Ft. In. Weight lbs. Marital Status Single Married Divorced Widowed Separated Other Beneficiary Social Security Number - - Beneficiary Street Address City State Zip Code Country Individual requesting coverage (check one) Pay Frequency Billing Method Active Employee Spouse of Employee Individual requesting coverage (check one) Semi Monthly (24x) Billing Method (select one) Payroll Deduction Retiree Spouse of Retiree Surviving Spouse of Retiree Parent Parent-in-law Grandparent Grandparent-in-law Bill at Home Quarterly or EFT* Semi-Annually Annually Adult child * Electronic Fund Transfer (EFT): I authorize Aetna Life Insurance Company to initiate monthly deductions from my checking account, by electronic or other method, as payment becomes due for Long Term Care Insurance and authorize the bank to accept the deduction initiated by Aetna. I have ENCLOSED A SAMPLE VOIDED check for the account from which I want deductions to be made. Note: If you select the EFT method of payment, we will withdraw the amount of your premium from your account on the first business day of each month. If you are a family member of an Employee or Retiree, complete the following section. I am a family member of an Employee I am a family member of a Retiree Employee/Retiree Name (Last, First, Middle Initial) Employee/Retiree Social Security Number - - Employee must sign below for payroll deductions: I authorize deductions from my earnings ( payroll deductions ) as applicable, for any contributions required for long term care coverage for myself and/or spouse. Employee s Signature Date GR-700-W-E2-REV-VA -2- ED. (03/05)

3 Part C: Daily Benefit Amount Options/Plan Options/Increase Options Select your daily benefit amount and applicable plan option(s). Refer to the Outline of Coverage in the enrollment package for additional information. Core Plan Options: Please select one of the 3 Core Plans A, B, or C. Plan A $100 Daily Benefit Amount Three-year Lifetime Maximum 50% Home & Community Care Voluntary Inflation No Return of Contribution (ROC) No Nonforfeiture Benefit OR Customized Plan Indicate your Plan Choice by checking the boxes: Daily Benefit Amount (DBA) $100 $150 $200 $250 (Choose one): Lifetime Maximum Amount 3 Years 5 Years (Choose one): Home & Community Care (Choose one): 50% of DBA or 75% of DBA Inflation Protection (Choose one) Indicate yes or no for the additional plan options** Eligibility Option (Not available for residents of MT) Voluntary Future Purchase Inflation Plan B $200 Daily Benefit Amount Three-year Lifetime Maximum 50% Home & Community Care Voluntary Inflation No Return of Contribution (ROC) No Nonforfeiture Benefit Plan C $250 Daily Benefit Amount Five-year Lifetime Maximum 75% Home & Community Care Voluntary Inflation With Return of Contribution (ROC) With Nonforfeiture Benefit Automatic Inflation* (*See rate page for additional cost) Yes No Nonforfeiture Benefit (if you check no, you must sign the Rejection of Nonforfeiture Benefit below) Return of Contributions Limited Payments (greater of age 65 or 10 years) **See rate pages for the additional cost of the plan options listed above. Is your spouse also applying for coverage? Yes No If you answered "Yes" to the above question, please provide name below: Spouse s Name (Last, First, Middle Initial) Each person must complete a separate enrollment form. Your rates will be reduced by 10% when both your coverage and your spouse's coverage become effective. * If you selected one of the Core Plans or if you did NOT elect the Automatic Inflation Protection, you must sign the Rejection of Automatic Inflation Protection Option on the next page. GR-700-W-E2-REV-VA -3- ED. (03/05)

4 Part C: Daily Benefit Amount Options/Plan Options/Increase Options (Continued) Rejection of Automatic Inflation Protection Option: If you want to DECLINE the Automatic Inflation Protection Option, check this box and sign below. I have reviewed the Outline of Coverage and the graphs that compare the benefits and premiums of this plan with and without Inflation Protection. Specifically, I have reviewed the Automatic Inflation Protection Option, and I REJECT the Automatic Inflation Protection Option. Enrollee s Signature Date Rejection of Nonforfeiture Benefit: If you want to DECLINE the Nonforfeiture Benefit Option, check this box and sign below. I have reviewed the Outline of Coverage and the explanation of Nonforfeiture Benefits described therein, and I REJECT the Nonforfeiture Benefit Option. Enrollee s Signature Date GR-700-W-E2-REV-VA -4- ED. (03/05)

5 Part D : Medical Questionnaire If you check Yes to any questions in Part D, provide an explanation in the space provided on the next page. Explanations should include dates, treatments and any residual effects of the condition or disease. If you need more space, attach additional pages and indicate that you have done so. Be sure to put your name and Social Security Number on any additional pages. For questions #1 -- #12: 1. Emphysema, other respiratory or lung diseases, or breathing conditions?... Yes No In the past five (5) years, have you been diagnosed or treated or have you consulted with a health professional for 7. Chest pains, headaches, dizziness, fainting spells, blood pressure, heart attack, heart failure (CHF), anemia or other diseases of the blood, heart or blood vessels (circulatory system)?... Yes No 2. Mental, emotional or nervous disorder, depression, memory impairment, confusion, anxiety, Alzheimer s Disease or other disorders of the brain?.. Yes No 3. Parkinson s Disease, Multiple Sclerosis, Muscular Dystrophy, seizures, or any other neurological or muscle disorder?... Yes No 4. Cancer, tumor, or other malignancy or growth including skin and lymph glands?... Yes No 5. Stroke, TIA (mini-stroke), paralysis, numbness, or visual disturbances?... Yes No 6. Diseases of the kidney (including dialysis), bladder, prostate, reproductive organs or breasts?. Yes No 8. Diseases of the liver (e.g., cirrhosis, hepatitis), stomach, intestines and/or pancreas?... Yes No 9. Osteoarthritis, rheumatoid arthritis, osteoporosis, pain in the joints, or other disease or injury (fractures, amputations) of the bones, joints, or spine?... Yes No 10. Lupus, scleroderma, vasculitis, or other Immune System Disorder* (except AIDS, ARC, or any AIDS related disorder)?... Yes No 11. Diabetes : insulin or non-insulin?... Yes No 12. Been advised to have surgery, a diagnostic work-up or a hospitalization?... Yes No * The following definition applies to any reference on this form to Immune System Disorder. IMMUNE SYSTEM DISORDER includes the hyperimmune conditions, disorders of gammaglobulin synthesis (hypogammaglobulinemia) of white blood cell production and maturation, and the immune-deficiency disorders, both congenital and acquired. Also included in disorders of the immune system are lupus erythematosus, Grave s disease, rheumatoid arthritis, primary biliary cirrhosis and others. For questions #13 and #14: In the past five (5) years, have you 13. Received or been advised to have treatment for alcohol or 14. Been diagnosed or treated for AIDS, ARC, or AIDS related substance abuse?... Yes No disorder?... Yes No For questions #15 -- #17: Within the past year have you 15. Experienced an unexplained weight loss? Yes No 17. Received disability or worker s compensation from your 16. Sustained any injuries due to falls or other employer, the U.S. Government or State Worker s trauma?... Yes No Compensation Fund?... Yes No For questions #18 -- #25: 18. Need any assistance in taking medications (e.g., setting them out for you, giving them to you to take, or reminding you to take them)?... Yes No Do you currently 21. Use medical equipment or device such as a cane (specify type), brace, walker, wheelchair, oxygen, respirator, catheter, bedside commode, or ostomy device?... Yes No 19. Take any medications?... Yes No If Yes, list drugs, dosages, and conditions in the space on the next page 20. Use tobacco products?... Yes No If Yes, indicate frequency/amount on the next page. 22. Receive assistance or supervision of any kind to perform every day tasks such as shopping, meal preparation, housekeeping, getting around inside your home, or getting around outside your home?... Yes No 23. Receive assistance or supervision of any kind to perform activities such as bathing, walking, transferring, dressing, toileting, or eating?... Yes No GR-700-W-E2-REV-VA -5- ED. (03/05)

6 Part D: Medical Questionnaire (Continued) 24. Use alcoholic beverages?... Yes No If Yes, indicate frequency/amount below. 25. Receive home care, adult day care or has confinement to a nursing home, home for the aged, or any other institution been recommended?... Yes No 26. Have you ever been declined coverage for any long term care plan because of a medical condition? Give details below.... Yes No Explain any Yes answers to questions Attach a page if you need additional space. 27. Describe your day: It is important that you complete this to help us evaluate your health. In a sentence or two, describe how you spend an average day (household chores, full-time job, part-time job, activities, etc.) 28. If you did not complete this questionnaire yourself, indicate below the name and relationship of the individual who helped you and why you required assistance. Name: Relationship: Reason: Privacy Notice In evaluating your insurability, we rely primarily on the health information you furnish to us in this statement. In addition, however, we may request additional medical information about you from any of the sources specified in the authorization below or you may be contacted for a telephone interview or a home visit. Disclosure of Information to Others All of this information will be treated as confidential and will not be disclosed to others without your authorization, except to the extent necessary for the conduct of our business and not contrary to any law. In addition, information may be furnished to regulators of our business and to others as may be required by law, and to law enforcement authorities when necessary to prevent or prosecute fraud or other illegal activities. Your Right of Access and Correction In general, you have a right to learn the nature and substance of any information in our files about you. You also have a right of access to such files (except information which relates to a claim or a civil or criminal proceeding) and to request correction, amendment or deletion of recorded personal information in states which provide such rights and grant immunity to insurers providing such access. We may elect, however, to disclose details of any medical information you request to your (attending) physician. If you wish to exercise this right, or if you wish to have a more detailed explanation of our information practices, contact: Aetna Life Insurance Company, Long Term Care, 151 Farmington Avenue, Hartford, CT GR-700-W-E2-REV-VA -6- ED. (03/05)

7 Part E: Certification and Authorization Read, sign and date where indicated. No one can sign this form except you or your legal representative. Fraud Notice Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto may have violated state law. Attention Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. Attention District of Columbia Residents: Any person who knowingly and with intent to injure, defraud or deceive 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 subjects such person to criminal and civil penalties. Attention Florida Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an enrollment form containing any false, incomplete or misleading information is guilty of a felony of the third degree. Attention Kentucky Residents: 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 may subject such person to criminal and civil penalties. Attention Louisiana and West Virginia Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Attention New Jersey Residents: Any person who includes any false or misleading information on an enrollment form for an insurance policy is subject to criminal and civil penalties. Attention Tennessee Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance. I acknowledge that the Group Long Term Care coverage for which I am requesting coverage is underwritten by Aetna Life Insurance Company ( Aetna ). I agree that this document is my enrollment request for Group Long Term Care Insurance or for an increase in existing coverage. I also agree and state that I will inform Aetna, in writing, if between the date I complete this form and the effective date of my coverage or increase in existing coverage (a) the condition of my health changes from that indicated on this form, or (b) I receive any medical advice, diagnosis or treatment from a physician or other health professional. I understand that coverage will be effective only if and when Aetna Life Insurance Company gives its written consent. I understand I may be contacted in person or by telephone by a representative of Aetna as part of the medical review process. I understand and agree that the responses on this enrollment form will determine coverage and that there is no coverage unless and until the enrollment request has been accepted and approved by Aetna. I agree to make any necessary payments for coverage either directly to Aetna or by payroll deductions, as required, and in accordance with the terms of the Group Long Term Care Policy. GR-700-W-E2-REV-VA -7- ED. (03/05)

8 Part E: Certification and Authorization I authorize any physician, other health care professional, hospital or any other healthcare provider ("Providers") and employers, to give to Aetna or its agent information concerning the medical history, services or treatment provided to me, including information involving mental health, substance abuse and HIV/AIDS (The authorization for information concerning HIV status does not apply to a resident of California.). I further authorize Aetna to use such information for the purpose of determining eligibility for Group Long Term Care Insurance coverage, and to disclose such information to affiliates, Providers, payors, other insurers, third party administrators, vendors, consultants and governmental authorities with jurisdiction when necessary for my care or treatment, payment for services, the operation of my Group Long Term Care coverage, or to conduct related activities. I understand that this authorization is provided under state law, and that it is not an "authorization" within the meaning of the federal Health Insurance Portability and Accountability Act (HIPAA). This authorization will remain valid for 30 months. I understand that I or my authorized representative is entitled to receive a copy of this authorization upon request, and that a photocopy is as valid as the original. I acknowledge that I have read the Privacy Notice, Notice to Applicant (included with the enrollment package) and Fraud Notice (shown above). If I am accepted, the Group Long Term Care Policy will determine the rights and responsibilities of member(s) and will govern in the event they conflict with any benefits comparison, summary or other description of the long term care coverage. I certify that I have read, or had read to me, the completed enrollment form and I realize that any false statement or misrepresentation in the enrollment form may result in loss of coverage under the Policy. I certify that the answers and statements on this form are complete and true to the best of my knowledge and belief and that I am eligible to request enrollment or an increase in existing coverage for Group Long Term Care Insurance. CAUTION: If your answers on this enrollment form are incorrect or untrue, Aetna has the right to deny benefits or rescind your Policy. If your coverage is voided, or if your certificate is rescinded, you will receive a refund of your premium contributions. Enrollee MUST Sign Here Date Part F: Protection Against Unintended Lapse If, after your coverage takes effect, you stop paying premiums, you will receive notice that your coverage is about to lapse (terminate). You have the right to designate at least one person who, besides you, will receive notice of termination of your long term care coverage for nonpayment of premium. That person will not be responsible for payment of the premium, and you will always receive your own copy of the notice. If you want a copy of the lapse notice to be sent to another person in addition to yourself, give us that person s name and address. Notice will not be given until 30 days after premium is due and unpaid. If you elect NOT to designate another person, you must sign the waiver below. Aetna is required to offer this protection against unintended lapse. Lapse Designee Name (Last, First, Middle Initial) Street Address City State Zip Code Waiver of protection against unintended lapse: If you are waiving your right to designate a contact, sign below. I understand that I have the right to designate at least one other person other than myself to receive notice of lapse or termination of this long term care insurance coverage for nonpayment of premium. I understand that notice will not be given until 30 days after a premium is due and unpaid. I elect NOT to designate any person to receive the notice. Enrollee s Signature Date GR-700-W-E2-REV-VA -8- ED. (03/05)

9 Part G: Replacement Questions Answer all four questions and sign below or we will not be able to process your enrollment request. If, after reviewing these questions, your decision is to replace existing coverage you may have, read the Notice to Applicant in the enrollment package. 1. Do you have other long term care insurance in force (including a health care service contract or health maintenance organization contract)?... Yes No 2. Did you have other long term care insurance in force during the last twelve (12) months?... Yes No If YES, with which Company? Name of Company Street Address of Company City, State, Zip Code of Company If that insurance lapsed, when did it lapse (Date) 3. Are you covered by Medicaid (NOT Medicare)?... Yes No 4. Do you intend for this coverage to replace your existing medical or health coverage?... Yes No If YES, with what Company is your existing medical or health coverage? Name of Company Street Address of Company City, State, Zip Code of Company Policy Number: Enrollee s Signature Date GR-700-W-E2-REV-VA -9- ED. (03/05)

10 Long Term Care Insurance Personal Worksheet INSTRUCTIONS Employees/Spouses: Acknowledge (check the box on the last page) the Premium Information, Aetna s Right to Increase Premiums, Rate Increase History and the Potential Rate Increase Disclosure Form; then sign and return this form. All Other Family members: You must complete two (2) areas on the last page: 1) Indicate by selecting the appropriate box whether or not you want to provide the personal financial information and 2) Acknowledge (check the box) the Premium Information, Aetna s Right to Increase Premiums, Rate Increase History and the Potential Rate Increase Disclosure Form; then sign and return this form. This form is used for the benefit of prospective insureds. It assists Aetna Life Insurance Company (Aetna) in selling long term care insurance to people who need the coverage and who can afford it. Aetna is required to present this form to you and to offer to discuss the affordability of this insurance. Aetna is also required to fill out part of the information on this worksheet and ask you to fill out the rest to help you and Aetna decide if you should buy this insurance. However, you may choose not to discuss any or all of the information elicited by this form. People buy long term care insurance for a variety of reasons, including: to avoid spending assets for long term care; to make sure there are choices regarding the type of care received; to protect family members from having to pay for care; or to decrease the chances of going on Medicaid. By state law, Aetna must fill out part of the information on this worksheet and ask you to fill out the rest to help you and Aetna decide if you should buy this policy. These are all very important reasons to keep in mind when considering the purchase of long term care insurance. Long term care insurance, however, can be expensive, and may not be appropriate for everyone. One way to help you decide if long term care insurance is right for you is to review your financial status. The following list of questions is a financial guideline to help you review your financial status. Please consider protection of assets, freedom of choice, family and financial reasons before making your decision. Premium Information (Please refer to the enrollment kit for the premium rate for your age and plan selection options.) Policy Form Numbers: Group policy # GR-700-W (In certain states, the group policy form number may be: GR-700; GR-700-WFQ; GR-700-WQF; or GR-700-W-NQ.) The premium for the coverage you are considering will be $ per. Type of Policy (noncancellable/guaranteed renewable): Coverage under the group policy is guaranteed renewable to each covered person, except for non-payment of any required premium. Aetna s Right to Increase Premiums Aetna has a limited right to increase premiums after you have purchased your coverage. Any increase must apply identically to all such group policies with similar rating characteristics in the plan sponsor s state such as age, rate classification and selected benefit options. You cannot be singled out for a premium increase for any reason, including increasing age or use of long term care coverage. GLTCPW (VA) Please make a copy of this form for your records. Rev 04/05

11 Rate Increase History Aetna has sold long term care insurance since 1987 and has sold this policy since Aetna has never raised its rates for long term care insurance in this Commonwealth or any other state; however, rates may change at any time you elect to modify benefits for your coverage. Questions Related to Your Income (You are not required to answer these questions; they are intended to help you) How will you pay each year s premium? (Please check one) From my Income From my Savings/Investments My Family will Pay Have you considered whether you could afford to keep this coverage if the premiums were raised, for example, by 20%? What is your annual income? (Please check one) 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? (Please check one) No change Increase Decrease If you will be paying premiums with money received only from your own income, a rule of thumb is that you may not be able to afford this policy if the premiums will be more than 7% of your income. Will you buy inflation protection if it is offered as an option under this group policy? (Please check one) Yes No If not, have you considered how you will pay for the difference between future costs and your daily benefit amount? From my Income From my Savings/Investments My Family will Pay The national average annual cost in 2002 was $54,900 1, but this figure varies across the country. In ten years, the national average annual cost would be about $89,426 if costs increase 5% annually. Please refer to the enrollment kit for the elimination period (deductible period) for the group policy you are considering. Approximate cost $ for that period of care. In order to determine the approximate cost, you will need to know costs in the area of the country where you will likely receive long term care. A good way to do this is to check nursing facility costs for that area. For example: If the elimination period were [90] days and the national average daily cost in 2002 were $ , then the approximate cost for that period of care would be $13, How are you planning to pay for your care during the elimination period? (Please check one) From my Income From my Savings/Investments My Family will Pay 1 GE LTC Survey, 3/02 GLTCPW (VA) Please make a copy of this form for your records. Rev 04/05

12 Questions Related to Your Savings and Investments (You are not required to answer these questions either) Not counting your home, about how much are all your assets (savings and investments) worth? (Please check one) Under $20,000 $20,000-$30,000 $30,000-$50,000 Over $50,000 How do you expect your assets to change over the next ten years? (Please check one) Stay about the same Increase Decrease If you are buying this policy to protect your assets and your assets are less than $30,000, you may wish to consider other options for financing your long term care. Disclosure Statement (Please check one) The answers to the questions above describe my financial situation. OR I choose not to complete this information. However, I have reviewed the information provided on the Personal Worksheet, and I wish to purchase this long term care insurance coverage. Please proceed with your review of my Enrollment Form/Medical Questionnaire. (This box must be checked) I acknowledge that I have reviewed this form including the premium, premium rate history and potential for premium increases in the future. I understand the above disclosures. I understand that the rates for this group policy may increase in the future. Signed: (Enrollee) Printed Name: (Enrollee) Date: Plan Sponsor: Fairfax County Enrollee s State of Residence: IN ORDER FOR US TO PROCESS YOUR ENROLLMENT REQUEST, PLEASE RETURN THIS SIGNED STATEMENT TO AETNA IN THE SELF-ADDRESSED ENVELOPE PROVIDED, ALONG WITH YOUR ENROLLMENT FORM/MEDICAL QUESTIONNAIRE. Aetna may contact you to verify your answers. GLTCPW (VA) Please make a copy of this form for your records. Rev 04/05