Applying For Asset-Care Whole Life Insurance Under The ExpressUW SM Underwriting Program
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1 Applying For Asset-Care Whole Life Insurance Under The ExpressUW SM Underwriting Program Products and financial services provided by The State Life Insurance Company a OneAmerica company P.O. Box 6062 Indianapolis, IN You have expressed an interest in applying for Asset-Care, a whole life insurance policy that provides long-term care benefits. You have already been provided with other information about Asset-Care, including an Outline of Coverage. As a part of the application process in The State Life Insurance Company s ExpressUW underwriting program, the next step is a phone interview with you. To help you prepare for the interview, please review the attached form that lists some of the questions that you will be asked. You can complete these forms before the interview to help the interview proceed without delay. Each proposed insured should complete this form before the interviewer calls. This form is used only to assist you in providing medical information during the interview. It does not need to be returned to us. Why is the interview conducted? The interview is to obtain information that must be evaluated during the underwriting process. State Life will evaluate this information to determine if it will approve an Asset-Care policy for you. How is the interview conducted? Within a few days, you will receive a call from a representative of LifePlans. LifePlans personnel conduct your interview on State Life s behalf. When you receive this initial call, you may do the interview immediately or you may schedule a time that is more convenient. The sooner the interview is conducted, the sooner your application for Asset-Care can be reviewed. The interview is estimated to take minutes. What will the interviewer ask? You will be asked questions about your medical history and health status, such as: Your physicians Medications you are taking Health conditions and medical diagnoses You will be asked to perform verbal exercises to assist in evaluation of your cognitive status. You will also be asked questions about your: Employment status Residence and living arrangements Hobbies and activities Social habits How does State Life Insurance Company protect your privacy and the information you provide? State Life and LifePlans will protect your privacy and safeguard the information you provide. Please refer to our Privacy Practice Notice C and Notice of Insurance Information Practices I for details. What happens after my telephone interview? State Life s underwriting staff will evaluate the information that you have provided along with information available through Medical Information Bureau. You will be notified of the results of this evaluation whether you are approved or declined for the issuance of an Asset-Care policy. Your policy will not be issued until all of State Life s requirements, including receiving the premium, have been met. If you are not approved, then your insurance advisor will provide you with other potential options that will meet your needs, if any are available. Asset-Care is whole life insurance that allows prepayment of the death benefit for qualifying long-term care expenses. It is medically underwritten and issued by The State Life Insurance Company, Indianapolis, Indiana. Policy Forms: L301, SA31 and R501. Not available in all states or may vary by state. Page 1 of 5 I /13/09
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3 TO PREPARE TO ANSWER THE INTERVIEW, PLEASE TAKE THE TIME TO RECORD THE INFORMATION BELOW. You may wish to contact your health care professional for assistance with completing this form. This form is used only to assist you in providing medical information during the interview. It does not need to be returned to us. (Please use a separate form for each proposed insured) MEDICAL HISTORY List any medical conditions, diseases or injuries that you have or have been diagnosed with or treated for in the last 10 years. Condition Date of Diagnosis Types of Treatments and Dates If diagnosed with coronary heart disease, please provide: Number of vessels, if you have undergone bypass surgery: Date of angioplasty, if applicable: Date(s) of any heart attacks: Date/results of most recent cardiac testing: If there has been a diagnosis of cancer, please provide the following information: Site: Type: Grade: Stage: Number of lymph nodes involved: Results of most recent blood tests: If diagnosed with diabetes, please provide the following information: Age/date of diagnosis: Date/results of most recent A1c: Please provide the results of any recent tests, such as bone density T-scores, EKGs, blood tests or latest blood pressure reading: Page 2 of 5 I /13/09
4 Physicians Date/Reason Doctor's Name Street Address City, State, Zip Phone Number Last Seen Current Medications: Please list all medications you are currently taking Medication Name Dosage Frequency Why are you taking this medication? Copy One First Insured Copy Two Second Insured (optional) Page 3 of 5 I /13/09
5 TO PREPARE TO ANSWER THE INTERVIEW, PLEASE TAKE THE TIME TO RECORD THE INFORMATION BELOW. You may wish to contact your health care professional for assistance with completing this form. This form is used only to assist you in providing medical information during the interview. It does not need to be returned to us. (Please use a separate form for each proposed insured) MEDICAL HISTORY List any medical conditions, diseases or injuries that you have or have been diagnosed with or treated for in the last 10 years. Condition Date of Diagnosis Types of Treatments and Dates If diagnosed with coronary heart disease, please provide: Number of vessels, if you have undergone bypass surgery: Date of angioplasty, if applicable: Date(s) of any heart attacks: Date/results of most recent cardiac testing: If there has been a diagnosis of cancer, please provide the following information: Site: Type: Grade: Stage: Number of lymph nodes involved: Results of most recent blood tests: If diagnosed with diabetes, please provide the following information: Age/date of diagnosis: Date/results of most recent A1c: Please provide the results of any recent tests, such as bone density T-scores, EKGs, blood tests or latest blood pressure reading: Page 4 of 5 I /13/09
6 Physicians Date/Reason Doctor's Name Street Address City, State, Zip Phone Number Last Seen Current Medications: Please list all medications you are currently taking Medication Name Dosage Frequency Why are you taking this medication? Copy One First Insured Copy Two Second Insured (optional) Page 5 of 5 I /13/09
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