United Wrld Life Insurance Cmpany A Mutual f Omaha Cmpany P.O. Bx 3608 Omaha, Nebraska 68103-3608 APPLICATION fr MEDICARE SUPPLEMENT INSURANCE PENNSYLVANIA MAP535_PA
United Wrld Life Insurance Cmpany A Mutual f Omaha Cmpany P.O. Bx 3608 Omaha, Nebraska 68103-3608 Applicatin Submissin Checklist T United Wrld Fr Medicare Supplement Cverage PENNSYLVANIA THIS APPLICATION MUST BE USED TO WRITE UNITED WORLD MEDICARE SUPPLEMENT PRODUCTS Applicatin 1. Cmplete Plan Infrmatin Bx. 2. Refer t the Outline f Cverage fr plicy frms. 3. Answer all questins in full. 4. PLAN N: If yu have an applicant applying fr Plan N, skip Part III. If the applicant is nt in an Open Enrllment r a Guaranteed Issue perid, answer nly Sectin III #3 f the applicatin. Fr mre clarificatin, please see yur Underwriting Guide. 5. Sign and Date in all places indicated. 6. Be sure t leave all applicable frms with the prpsed insured. 7. See reverse side f this page fr additinal detailed infrmatin. Cllect Premium Amunt The full mdal premium is cllected at the time f applicatin. Calculate the premium based n age at time f applicatin. Tbacc rates d nt apply during Open Enrllment r Guarantee Issue situatins. Prvide Client with Buyer s Guide Prvide Client with Outline f Cverage Cmplete Prducer Infrmatin page If applicable, cmplete the Authrizatin fr Electrnic Funds Transfer frm (ACH/BSP frm M26238_0409) and return with the cmpleted applicatin. Prvide Client with Cnditinal Receipt signed by Agent (if applicable), and prvide Client with Ntice f Infrmatin Practices Cmplete, sign and prvide Client with cpy f the Authrizatin T Disclse Persnal Infrmatin (HIPAA frm W24903_0709). This frm is NOT a requirement if applying during an Open Enrllment r Guaranteed Issue Perid. Cmplete Replacement Ntice (W24680_0605) and leave a cpy with the applicant (if applicable) Prvide Client with PA-Guaranteed Issue and Open Enrllment Ntice (W26254) Please prvide additinal infrmatin and cmments in the space prvided n the applicatin. Nte: An interviewer may call t verify/cnfirm the infrmatin prvided n the applicatin. BROKERAGE ONLY Please list yur cmmissin cde in the bx n the first page f the applicatin. This will help avid delay in cmmissin payment.
There are tw parts t this applicatin: One part is the general applicatin. The ther part includes necessary administrative frms that yu will need at time f sale. 1. Applicatin Agent Cmpletes in Full: (please print) Plan Infrmatin Bx Plicy Frm Requested Effective Date Premium Cllected (Amunt) Initial Mde* (A=Annual, S=Semiannual, Q=Quarterly, r B=Autmatic Funds Withdraw) Renewal Premium (Amunt) Renewal Mde* (A=Annual, S=Semiannual, Q=Quarterly, r B=Autmatic Funds Withdraw) *Direct Mnthly billing nt available Part I General Infrmatin The Residence address and ZIP cde are indicated. Alternate address fr billing as indicated (when applicable). The applicant s current age at time f applicatin. The applicant s Scial Security number as indicated frm applicant s Scial Security Card. Fr applicants already cvered by Medicare, include applicant s Medicare number n the applicatin as indicated frm the applicant s Medicare Health Insurance Card. This number is required fr electrnic claim prcessing. If this number is nt available at time f applicatin, the applicant/agent must prvide this number by calling 1-877-617-5587 nce it is received. Part II Existing Cverage Infrmatin Please cmplete all questins in full. If the applicant is nt cvered by Medicare, indicate Eligibility Date and Date f Enrllment. List all individual and grup health plicies held by the applicant in the apprpriate sectin f the applicatin. If the applicant is replacing current cverage with this plicy, indicate the fllwing infrmatin. Name f Cmpany Issue Date Plicy/Certificate Number Terminatin/Disenrllment Date Plan Kind f Plicy Nte: An interviewer may call t verify/cnfirm the infrmatin prvided n the applicatin. 2. Administrative Frms Prducer/Agent Infrmatin Be sure t include yur Scial Security number and cmmissin cde. NOTE: This infrmatin is necessary fr the underwriting prcess and cmmissin payment. Include yur telephne number, e-mail address and FAX number fr cntact purpses. Authrizatin fr Electrnic Funds Transfer by United Wrld Life Insurance Cmpany (ACH/BSP) If applicant chses t pay premium by ACH/BSP, cmplete this frm accurately and in its entirety and return with the applicatin. Optin A - Pay all premiums (1st & mnthly renewals) by ACH/BSP - DO NOT submit a check fr payment. Optin B - Pay 1st mnth by paper check & mnthly renewals by BSP - A check fr initial mnthly premium MUST be submitted with the applicatin. Optin C - Pay 1st mnth by ACH & pay renewals by direct bill (mnthly direct billing is nt ffered) - DO NOT submit a check fr initial premium payment. Cnditinal Receipt and Ntice f Infrmatin Practices Cmplete and sign the receipt (if applicable), detach entire page and leave with applicant. Authrizatin T Disclse Persnal Infrmatin (HIPAA) If client is NOT applying during an Open Enrllment r Guaranteed Issue Perid, cmpleting the Authrizatin T Disclse Persnal Infrmatin frm IS a requirement. Please have the applicant read the frm, fill in required infrmatin, sign, date and leave a cpy f the cmpleted and signed frm with applicant. If client IS applying during an Open Enrllment r Guaranteed Issue Perid, cmpleting the Authrizatin T Disclse Persnal Infrmatin frm is NOT a requirement. Replacement Ntice cmplete if applicable Cmplete frm including signature and date. Leave a cpy with applicant (if applicable). State Specific Frms cmplete if applicable Be sure t include all state apprpriate frms.
United Wrld Life Insurance Cmpany Grup number (if applicable): Mgr./Cmmissin Cde (Required Field Fr Brkerage) District Sales Manager/Assc. Marketer Applicatin Reviewed By: PLAN INFORMATION (t be cmpleted by Prducer) Plicy Frm Plan A Plan C Plan F Plan M Plan B Plan D Plan G Plan N Requested Effective Date: Spuse applying fr cverage (different applicatin)? Yes N Premium Cllected $ Initial Mde A, S, Q r B Renewal $ Renewal Mde A, S, Q r B (mnthly nt allwed) Applicatin T United Wrld Life Insurance Cmpany Fr Medicare Supplement Cverage PART I. GENERAL INFORMATION 1. Print Name Hme Phne N ( ) (Title) (First) (Middle) (Last) (Area Cde) 2. Residence Address (N and Street and Apt N) (City) (State) (ZIP Cde) 3. Mailing Address (N and Street and Apt N) (City) (State) (ZIP Cde) 4. Birth Date Age Sex M F M Day Yr (current age) 5. Scial Security N E-mail Address 6. Have yu received a cpy f the Guide t Health Insurance fr Peple with Medicare and the Outline f Cverage?... Yes N PART II. EXISTING COVERAGE INFORMATION (COMPLETE IN FULL) T the best f yur knwledge: 1. Are yu cvered under Medicare?... Part A Yes N Part B Yes N If Yes, give yur Medicare card number If N, when will yu becme eligible? / / M Day Yr 2. Did yu turn age 65 in the last six mnths?...yes N 3. Did yu enrll in Medicare Part B in the last 6 mnths?... Yes N If Yes, indicate yur effective date. / / If N, indicate date yu plan t enrll. / / M Day Yr M Day Yr 4. Are yu applying during a guaranteed issue perid?... Yes N (Refer t Frm W26254 t determine the definitin f a guarantee issue perid. NOTE: If the answer abve is Yes please attach prf f eligibility.) If yu lst r are lsing ther health insurance cverage and received a ntice frm yur prir insurer saying yu were eligible fr guaranteed issue f a Medicare supplement insurance plicy, r that yu had certain rights t buy such a plicy, yu may be guaranteed acceptance in ne r mre f ur Medicare supplement plans. Please include a cpy f the ntice frm yur prir insurer with yur applicatin. PLEASE ANSWER ALL QUESTIONS. Please mark Yes r N with an X t the questins belw. 5. (a) If yu had cverage frm any Medicare plan ther than riginal Medicare within the past 63 days (fr example, a Medicare Advantage plan, r a Medicare HMO r PPO), fill in yur start and end dates belw. If yu are still cvered under this plan, leave END blank. START END_ / / / / (b) If yu are still cvered under the Medicare plan, d yu intend t replace yur current cverage with this new Medicare supplement plicy?... Yes N (c) If yes, have yu received a cpy f the replacement ntice?... Yes N (d) Reasn fr terminatin/disenrllment? (e) Planned date f terminatin/disenrllment / / (f) Was this yur first time in this type f Medicare plan?... Yes N (g) Did yu drp a Medicare supplement plicy t enrll in this Medicare plan?... Yes N 6. Have yu had cverage under any ther health insurance within the past 63 days? (Fr example, an emplyer, unin, r individual plan)... Yes N (a) If s, with what cmpany and what kind f plicy? Name f Cmpany Kind f Plicy WA5893-36 Rev 01-10 United Wrld Life Insurance Cmpany P.O. Bx 3608 Omaha, Nebraska 68103-3608 1
(b) What are yur dates f cverage under the ther plicy? If yu are still cvered under this plan, leave END blank. START / / END / / (c) Reasn fr terminatin/disenrllment? (d) Date f terminatin/disenrllment. / / 7. (a) D yu have anther Medicare supplement insurance plicy in frce?... Yes N (b) If s, with what cmpany, and what plan d yu have? Name f Cmpany Plicy/Certificate Number Plan Issue Date (c) If s, d yu intend t replace yur current Medicare supplement plicy with this plicy?... Yes (d) If Yes, indicate terminatin date. / / Have yu received a cpy f the Replacement Ntice?... Yes M Day Yr 8. Are yu cvered fr medical assistance thrugh the state Medicaid prgram? NOTE TO APPLICANT: If yu are participating in a Spend-Dwn Prgram and have nt met yur Share f Cst, please answer NO t this questin... Yes If yes, (a) Will Medicaid pay yur premiums fr this Medicare supplement plicy?... Yes (b) D yu receive any benefits frm Medicaid OTHER THAN payment tward yur Medicare Part B premium?... Yes 9. Prducers shall list any ther health insurance plicies they have sld t the applicant. (a) List plicies sld which are still in frce. Name f Cmpany Plicy/Certificate Number Descriptin f Benefits Effective Date f Cverage N N N N N (b) List plicies sld in the past five (5) years which are n lnger in frce. Name f Cmpany Plicy/Certificate Number Descriptin f Benefits Effective Date f Cverage PART III. HEALTH /MEDICAL QUESTIONS (COMPLETE IN FULL) 1. If the answer is Yes t any f the fllwing health questins 1(a)-1(n) r 3(a), yu are nt eligible fr cverage. (If yu are applying fr cverage during an pen enrllment r guaranteed issue perid, d nt answer questins 1-3 in Part III. If yu are applying fr Plan N utside f an pen enrllment r guaranteed issue perid, nly answer questins 3(a) and 3(b) in Part III. If yu are applying fr any plan ther than Plan N and yu are utside f an pen enrllment r guaranteed issue perid, answer questins 1 & 2 in Part III.) Yes N (a) Are yu currently hspitalized r cnfined t a nursing facility; r, are yu bedridden r cnfined t a wheelchair?... (b) Have yu been diagnsed by a member f the medical prfessin with emphysema, Chrnic Obstructive Pulmnary Disease (COPD) r ther chrnic pulmnary disrders?... (c) Have yu been diagnsed by a member f the medical prfessin with Parkinsn s Disease r Multiple r Lateral Sclersis, steprsis with fractures, r kidney disease requiring dialysis?... (d) Have yu been diagnsed by a member f the medical prfessin with Alzheimer s Disease, senile dementia, rganic brain disrder, r any ther senility disrder?... (e) Have yu been diagnsed with r medically treated fr Acquired Immune Deficiency Syndrme (AIDS) r AIDS Related Cmplex (ARC)?... (f) Have yu been diagnsed by a member f the medical prfessin with diabetes in additin t any f the fllwing: diabetic retinpathy, peripheral vascular disease, neurpathy, any heart cnditin (including high bld pressure) r kidney disease?... (g) D yu have diabetes that has ever required mre than 50 units f insulin daily?... (h) Within the past tw years have yu been treated fr r been advised by a physician t have treatment fr internal cancer, alchlism r drug abuse; cirrhsis; mental r nervus disrder requiring psychiatric care; r have yu had any amputatin caused by disease?... (i) Within the past tw years have yu been treated fr r been advised by a physician t have treatment fr heart attack, heart, crnary r cartid artery disease (nt including high bld pressure); peripheral vascular disease; cngestive heart failure r enlarged heart; strke; transient ischemic attacks (TIA), r heart rhythm disrders?... (j) Within the past tw years have yu been treated fr r medically diagnsed with degenerative bne disease, crippling/disabling r rheumatid arthritis, r have yu been advised by a member f the medical prfessin t have a jint replacement?... (k) Have yu been advised by a physician that surgery may be required within the next 12 mnths fr cataracts?... (l) Have yu been advised by a physician t have surgery, medical tests, treatment r therapy that has nt been perfrmed?... (m) Have yu been hspital cnfined three r mre times in the last tw years?... (n) Have yu had an rgan transplant r been advised by a physician t have an rgan transplant?... () Have yu used tbacc in any frm in the past 12 mnths?... WA5893-36 Rev 01-10 United Wrld Life Insurance Cmpany P.O. Bx 3608 Omaha, Nebraska 68103-3608 2
2. Are yu taking r have yu taken any prescriptin r ver-the-cunter medicatins within the past 12 mnths?... Yes N If Yes, please list the drug and the cnditin. (Use page 4 f applicatin, if mre space is necessary.) Medicatin Name (cpy ff pharmacy label) Date Originally Prescribed Frequency and Dsage Diagnsis/Cnditin 3. IF APPLYING FOR PLAN N OUTSIDE OF AN OPEN ENROLLMENT OR A GUARANTEED ISSUE PERIOD - Please answer these REQUIRED questins: (a) D yu have End Stage Renal Disease (ESRD) r have yu been treated fr r been diagnsed with chrnic renal failure, with r withut dialysis?...yes N (b) Have yu used tbacc in any frm in the past 12 mnths?...yes N NOTE: Please verify the cmpleteness and accuracy f the abve statements as they may impact claim payment. PART IV. IMPORTANT STATEMENTS TO BE READ BY APPLICANT (a) Yu d nt need mre than ne Medicare supplement plicy. (b) If yu purchase this plicy, yu may want t evaluate yur existing health cverages and decide if yu need multiple cverage. (c) Yu may be eligible fr benefits under Medicaid and may nt need a Medicare supplement plicy. (d) If, after purchasing the plicy, yu becme eligible fr Medicaid, the benefits and premiums under yur Medicare supplement plicy can be suspended, if requested, during yur entitlement t benefits under Medicaid fr 24 mnths. Yu must request this suspensin within 90 days f becming eligible fr Medicaid. If yu are n lnger entitled t Medicaid, yur suspended Medicare supplement plicy (r, if that is n lnger available, a substantially equivalent plicy) will be reinstituted if requested within 90 days f lsing Medicaid eligibility. If the Medicare supplement plicy prvided cverage fr utpatient prescriptin drugs and yu enrlled in Medicare Part D while yur plicy was suspended, the reinstituted plicy will nt have utpatient prescriptin drug cverage, but will therwise be substantially equivalent t yur cverage befre the date f the suspensin. (e) If yu are eligible fr, and have enrlled in a Medicare supplement plicy by reasn f disability and yu later becme cvered by an emplyer r unin-based grup health plan, the benefits and premiums under yur Medicare supplement plicy can be suspended, if requested, while yu are cvered under the emplyer r unin-based grup health plan. If yu suspend yur Medicare supplement plicy under these circumstances, and later lse yur emplyer r unin-based grup health plan, yur suspended Medicare supplement plicy (r, if that is n lnger available, a substantially equivalent plicy) will be reinstituted if requested within 90 days f lsing yur emplyer r unin-based grup health plan. If the Medicare supplement plicy prvided cverage fr utpatient prescriptin drugs and yu enrlled in Medicare Part D while yur plicy was suspended, the reinstituted plicy will nt have utpatient prescriptin drug cverage, but will therwise be substantially equivalent t yur cverage befre the date f the suspensin. (f) Cunseling services may be available in yur state t prvide advice cncerning yur purchase f Medicare supplement insurance and cncerning medical assistance thrugh the state Medicaid prgram, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Lw-Incme Medicare Beneficiary (SLMB). (g) Yur signature is an acknwledgement and agreement t the plan infrmatin and premium ptin selected n page ne n this applicatin. I represent that my answers and statements are true and cmplete and agree that n insurance will be effective unless a plicy is issued. Any persn wh knwingly and with intent t defraud any insurance cmpany r ther persn files an applicatin fr insurance r statement f claim cntaining any materially false infrmatin r cnceals fr the purpse f misleading, infrmatin cncerning any fact material theret cmmits a fraudulent insurance act, which is a crime and subjects such persn t criminal and civil penalties. Dated at, n, (City) (State) (Mnth) (Day) (Year) (Signature f Applicant) Premium Must Accmpany Applicatin I/We certify that during an interview with the prpsed applicant, I/we have truly and accurately recrded in the applicatin the infrmatin supplied by the applicant. (Signature f Licensed Prducer) (Date) (Signature f Licensed Prducer) (Date) PRODUCER STAMP PRODUCER STAMP WA5893-36 Rev 01-10 United Wrld Life Insurance Cmpany P.O. Bx 3608 Omaha, Nebraska 68103-3608 3
ADDITIONAL INFORMATION: PART III - CON T. HEALTH /MEDICAL QUESTIONS - Questin #2. Medicatin Name (cpy ff pharmacy label) Date Originally Prescribed Frequency and Dsage Diagnsis/Cnditin SECTION FOR ADDITIONAL COMMENTS: WA5893-36 Rev 01-10 United Wrld Life Insurance Cmpany P.O. Bx 3608 Omaha, Nebraska 68103-3608 4
United Wrld Life Insurance Cmpany A Mutual f Omaha Cmpany Plicy Delivery Mail plicy t: Applicant Prducer Prducer(s) Infrmatin Prducer Name Scial Security N Cmm. % Share Prducer Phne N ( ) Cmmissin Cde Prducer E-mail Address @ Prducer FAX Number Prducer Name Scial Security N Cmm. % Share Prducer Phne N ( ) Cmmissin Cde Prducer E-mail Address @ Prducer FAX Number (Nte: Prducers must be under the same cmmissin cde t share r split cmmissins.) Prducer T Cmplete Only If Premium Is T Be Paid With A Business Check/Accunt Initial Payment Is the applicant: Yes N (a) unemplyed?... (b) emplyed, but nt wrking fr the business that is paying the premium?... (c) the business wner r spuse f the business wner?... If (a), (b), r (c) is Yes, the premium can be paid with a business check/accunt. Renewal Payment Is the applicant: Yes N (a) unemplyed?... (b) emplyed, but nt wrking fr the business that is paying the premium?... (c) the business wner r spuse f the business wner?... If (a), (b), r (c) is Yes, the premium can be paid with a business check/accunt.
Instructins fr Cmpletin f Authrizatin fr Electrnic Funds Transfer (ACH/BSP) Frm Accunt Hlder Name { Check Number { Jhn De Check #1234 Street Address Twn, City Zip cde Date: Pay t: Dllars Bank Name & Address Mem :123456789: 12345678 1234 Signed By: { { Bank Ruting/ Transfer Number Bank Accunt Number { Check Number (if shwn at bttm, may be befre r after the accunt #) D NOT include the check number as part f either the Ruting r Accunt Number. The applicant may select ne f three payment ptins indicated n the back side f this frm. Instructins fr each ptin are listed belw. With each ptin, the frm must be signed and dated. Optin A: Pay premiums (1st mnth and mnthly renewals) by Electrnic Funds Transfer (EFT). Autmated Clearing Huse (ACH) is used fr initial payment and Bank Service Plan (BSP) is used fr renewal payments. When chsing t pay bth the initial and mnthly renewals by EFT, the applicant must cmplete the frm and submit it with the applicatin. DO NOT submit a signed check fr payment under this ptin. T avid ptential delays in prcessing, submit a vided check and cmplete the accunt infrmatin (ruting/accunt numbers, name f financial institutin) n the frm. Optin B: Pay 1st mnth by paper check and mnthly renewals by BSP When chsing t pay the initial premium via paper check and the mnthly renewals by BSP, the applicant must cmplete the frm and submit it with the applicatin. A signed check fr the initial mnthly premium must be submitted with the applicatin. Optin C: Pay 1st mnth by ACH and pay renewals by direct bill (mnthly direct billing is nt ffered) When chsing t pay the initial premium by ACH and renewal premiums by direct billing (annually, semiannually, r quarterly), the applicant must cmplete the frm and submit it with the applicatin. DO NOT submit a signed check fr the initial premium payment under this ptin. T avid ptential delays in prcessing, submit a vided check and cmplete the accunt infrmatin (ruting/accunt number, name f financial institutin) n the frm. When chsing t pay initial premium by ACH, mney will be withdrawn n the date the applicatin is prcessed. This may be different frm the mnthly withdraw date selected fr renewal premiums. Payments cannt be pstpned until a later date. Payment frm a third party, including any fundatin, cannt be accepted. All refunds will be made t the applicant in the event f rejectin, incmplete submissin, verpayment, cancellatin, etc. Please cmplete the ACH/BSP frm accurately and in its entirety, making sure that all required infrmatin is crrect and cmplete n yur ACH/BSP frm prir t submissin. In additin, please make sure that the premium amunt is filled in n the ACH/BSP frm, s we can initiate a timely and accurate withdrawal frm yur client s bank accunt. An example f hw t find crrect Ruting and Accunt Numbers n yur clients checks is included at the tp f this frm. D nt include the check number as part f either the Ruting r Accunt Number. The applicant s bank name is nrmally included abve the Mem line n the check. M26238_0409
Mutual f Omaha Insurance Cmpany r United Wrld Life Insurance Cmpany Please refer t instructins n the Frnt f this frm. Authrizatin fr Electrnic Funds Transfer (ACH/BSP) This frm is intended as authrizatin t debit yur accunt. Please cmplete initial and renewal premium payment infrmatin belw. Medicare Supplement Premium Payment Optins: YES NO A. Pay premiums (1st mnth and mnthly renewals) by Electrnic Funds Transfer... (ACH is used fr initial payment and BSP is used fr renewal payments.) B. Pay initial premium by signed paper check and pay mnthly renewals by BSP... C. Pay initial premium by ACH and pay renewals by direct bill (mnthly direct billing is nt ffered)... If chsing Optins A r C, list amunt f initial premium withdrawal, if applicable...$ If chsing Optins A r B, select a withdrawal date fr mnthly BSP renewal payments (circle ne)... 1st r 15th Is a business accunt being used t pay premiums?... If yes, is the applicant: (a) Unemplyed... (b) Emplyed, but nt wrking fr the business that is paying the premium... (c) The business wner r spuse f the business wner... If (a), (b), r (c) are Yes, premiums CAN be paid with a business accunt. Accunt Type (check ne): Checking Savings Cmplete infrmatin belw. T avid ptential delays in prcessing, submit a cpy f a vided check. Name f Financial Institutin Ruting Number (first 9 digits n lwer left side f check) Accunt Number (D NOT use Debit r Credit Card accunt numbers) Name as Shwn n Accunt IMPORTANT: Withdrawal date f the initial premium payment will ccur when the applicatin is prcessed and may be different than the mnthly withdrawal date selected abve. I authrize Mutual f Omaha and/r United Wrld Life Insurance Cmpany t withdraw funds frm my accunt fr my initial and/r mnthly renewal premiums and understand that the amunts may differ. I als authrize Mutual f Omaha and/r United Wrld Life Insurance Cmpany t cllect any premium(s) due by bank draft withdrawal. Premium shrtages may result frm a variety f causes, including underwriting adjustments. I authrize yu, my financial institutin, t pay frm my accunt any checks, drafts r preauthrized electrnic fund transfers frm my accunt t Mutual f Omaha and/ r United Wrld Life Insurance Cmpany. Yur rights with each charge will be the same as if persnally paid by me. The authrizatin will be effective until I give yu at least three business days ntice t cancel it. If ntice is given verbally, yu may require written cnfirmatin frm me within 14 days after my verbal ntice. Authrized Signature as Shwn n Accunt Date M26238_0409
United Wrld Life Insurance Cmpany A Mutual f Omaha Cmpany Authrizatin T Disclse Persnal Infrmatin T United Wrld Life Insurance Cmpany Meanings f Terms Medical Persns and Entities means: all physicians, medical r dental practitiners, hspitals, clinics, pharmacies, pharmacy benefit managers, ther medical care facilities, health maintenance rganizatins and all ther prviders f medical r dental services. Persnal Infrmatin means: all health infrmatin, such as medical histry, mental and physical cnditin, prescriptin drug recrds, drug and alchl use and ther infrmatin such as finances, ccupatin, general reputatin and insurance claims infrmatin abut me. Persnal Infrmatin des nt include Psychtherapy Ntes. Psychtherapy Ntes means: ntes recrded by a health care prvider wh is a mental health prfessinal dcumenting r analyzing the cntents f cnversatin during a cunseling sessin, which ntes are separated frm the rest f the persn s medical recrd. Certain infrmatin, such as that relating t prescriptins, diagnsis and functinal status, is nt included in the term Psychtherapy Ntes. Specified Cmpanies means: The grup f cmpanies which presently includes Mutual f Omaha Insurance Cmpany, United f Omaha Life Insurance Cmpany, United Wrld Life Insurance Cmpany, Cmpanin Life Insurance Cmpany, additinal cmpanies which may becme part f this grup f cmpanies and their successrs. Other persns and entities which act n behalf f thse cmpanies t prvide services t them. Authrizatin t Disclse I authrize the Medical Persns and Entities, the Specified Cmpanies, emplyers, cnsumer reprting agencies and ther insurance cmpanies t disclse Persnal Infrmatin abut me t United Wrld Life Insurance Cmpany. Purpses The Persnal Infrmatin will be used t determine my eligibility fr insurance and t reslve r cntest any issues f incmplete, incrrect r misrepresented infrmatin n my applicatin which may arise during the prcessing f my applicatin r in cnnectin with claims fr insurance benefits. Ptential fr Redisclsure If the persn r entity t whm Persnal Infrmatin is disclsed is nt a health care prvider r health plan subject t federal privacy regulatins, the Persnal Infrmatin may then be subject t further disclsure by that persn r entity withut the prtectins f the federal privacy regulatins. Failure t Sign I understand that I may refuse t sign this authrizatin. I realize that if I refuse t sign, the insurance fr which I am applying will nt be issued. Expiratin and Revcatin Unless revked earlier, this authrizatin will remain in effect fr 24 mnths frm the date I sign it. I understand that I may revke this authrizatin at any time, by written ntice t: ATTN: Individual Underwriting United Wrld Life Insurance Cmpany Mutual f Omaha Plaza Omaha, NE 68175-0001 I realize that my right t revke this authrizatin is limited t the extent that United Wrld Life Insurance Cmpany has taken actin in reliance n the authrizatin r the law allws United Wrld Life Insurance Cmpany t cntest the issuance f the plicy r a claim under the plicy. Cpy I understand that I will receive a cpy f the signed authrizatin. A cpy f this authrizatin is as effective as the riginal. Names and Signatures Name(s) used fr medical recrds (if different than the name(s) belw): Applicant Printed Name f Prpsed Applicant Applicant B Printed Name f Prpsed Applicant Signature f Prpsed Applicant Date Signature f Prpsed Applicant Date W24903_0709 THIS AUTHORIZATION COMPLIES WITH HIPAA AND OTHER FEDERAL AND STATE LAWS
United Wrld Life Insurance Cmpany A Mutual f Omaha Cmpany Ntice t Applicant Regarding Replacement f Medicare Supplement Insurance r Medicare Advantage Save this ntice! It may be imprtant t yu in the future. Accrding t yur applicatin, yu intend t terminate existing Medicare supplement r Medicare Advantage insurance and replace it with a plicy t be issued by United Wrld Life Insurance Cmpany. Yur new plicy will prvide thirty (30) days within which yu may decide withut cst whether yu desire t keep the plicy. Yu shuld review this new cverage carefully. Cmpare it with all accident and sickness cverage yu nw have. If, after due cnsideratin, yu find that purchase f this Medicare supplement cverage is a wise decisin, yu shuld terminate yur present Medicare supplement r Medicare Advantage cverage. Yu shuld evaluate the need fr ther accident and sickness cverage yu have that may duplicate this plicy. Statement t Applicant by Issuer, Agent, Brker r Other Representative: I have reviewed yur current medical r health insurance cverage. T the best f my knwledge, this Medicare supplement plicy will nt duplicate yur existing Medicare supplement r, if applicable, Medicare Advantage cverage because yu intend t terminate yur existing Medicare supplement cverage r leave yur Medicare Advantage plan. The replacement plicy is being purchased fr the fllwing reasn(s) (check ne): Additinal benefits N change in benefits, but lwer premiums Fewer benefits and lwer premiums My plan has utpatient prescriptin drug cverage and I am enrlling in Part D Disenrllment frm a Medicare Advantage Plan. Please explain reasn fr disenrllment Other (please specify) If, yu still wish t terminate yur present plicy r certificate and replace it with new cverage, be certain t truthfully and cmpletely answer all questins n the applicatin cncerning yur medical and health histry. Failure t include all material medical infrmatin n an applicatin may prvide a basis fr the Cmpany t deny any future claims and t refund yur premium as thugh yur plicy had never been in frce. After the applicatin has been cmpleted and befre yu sign it, review it carefully t be certain that all infrmatin has been prperly recrded. D nt cancel yur present plicy r certificate until yu have received yur new plicy and are sure that yu want t keep it. Signature f Agent, Brker r Other Representative* United Wrld Life Insurance Cmpany, Mutual f Omaha Plaza, Omaha, NE 68175 (Applicant s Signature) *Signature nt required fr direct respnse sales. (Date) 1 - Hme Office Cpy W24680_0605
IMPORTANT DOCUMENTS CLIENT FORMS As part f the applicatin prcess, the applicant has signed multiple frms. Applicant cpies f these frms and client ntificatins n the fllwing pages are t be given t the applicant if applicable. Replacement Ntice Cnditinal Receipt / Ntice f Infrmatin Practices Guaranteed Issue and Open Enrllment Ntice
United Wrld Life Insurance Cmpany A Mutual f Omaha Cmpany Ntice t Applicant Regarding Replacement f Medicare Supplement Insurance r Medicare Advantage Save this ntice! It may be imprtant t yu in the future. Accrding t yur applicatin, yu intend t terminate existing Medicare supplement r Medicare Advantage insurance and replace it with a plicy t be issued by United Wrld Life Insurance Cmpany. Yur new plicy will prvide thirty (30) days within which yu may decide withut cst whether yu desire t keep the plicy. Yu shuld review this new cverage carefully. Cmpare it with all accident and sickness cverage yu nw have. If, after due cnsideratin, yu find that purchase f this Medicare supplement cverage is a wise decisin, yu shuld terminate yur present Medicare supplement r Medicare Advantage cverage. Yu shuld evaluate the need fr ther accident and sickness cverage yu have that may duplicate this plicy. Statement t Applicant by Issuer, Agent, Brker r Other Representative: I have reviewed yur current medical r health insurance cverage. T the best f my knwledge, this Medicare supplement plicy will nt duplicate yur existing Medicare supplement r, if applicable, Medicare Advantage cverage because yu intend t terminate yur existing Medicare supplement cverage r leave yur Medicare Advantage plan. The replacement plicy is being purchased fr the fllwing reasn(s) (check ne): Additinal benefits N change in benefits, but lwer premiums Fewer benefits and lwer premiums My plan has utpatient prescriptin drug cverage and I am enrlling in Part D Disenrllment frm a Medicare Advantage Plan. Please explain reasn fr disenrllment Other (please specify) If, yu still wish t terminate yur present plicy r certificate and replace it with new cverage, be certain t truthfully and cmpletely answer all questins n the applicatin cncerning yur medical and health histry. Failure t include all material medical infrmatin n an applicatin may prvide a basis fr the Cmpany t deny any future claims and t refund yur premium as thugh yur plicy had never been in frce. After the applicatin has been cmpleted and befre yu sign it, review it carefully t be certain that all infrmatin has been prperly recrded. D nt cancel yur present plicy r certificate until yu have received yur new plicy and are sure that yu want t keep it. Signature f Agent, Brker r Other Representative* United Wrld Life Insurance Cmpany, Mutual f Omaha Plaza, Omaha, NE 68175 (Applicant s Signature) *Signature nt required fr direct respnse sales. (Date) 2 - Applicant Cpy W24680_0605
United Wrld Life Insurance Cmpany A Mutual f Omaha Cmpany Cnditinal Receipt Check r Mney Order Applicatin All premiums must be made payable t the United Wrld Life Insurance Cmpany. D nt make check r mney rder payable t the agent r leave the payee blank. Received f this day f, an applicatin fr a Frm Plicy and Riders and Check r Mney Order fr Dllars. Shuld the Cmpany decline t issue the insurance applied fr, I hereby agree t return the abve sum t the applicant. Agent NOTICE TO APPLICANT: Eligibility fr the health and accident insurance applied fr is cnditinal upn all f the fllwing: (a) payment f the full, initial premium; (b) written applicatin; (c) satisfying the Cmpany s underwriting standards. If yu are nt eligible, n insurance r temprary r interim insurance f any kind will be effective. Cmplete Receipt in full and leave with applicant at time f applicatin. United Wrld Life Insurance Cmpany - Ntice f Infrmatin Practices In the curse f prperly underwriting and administering yur insurance cverage, we will rely heavily n infrmatin prvided by yu. We may als cllect infrmatin frm thers, such as medical prfessinals wh have treated yu, hspitals, ther insurance cmpanies, and cnsumer reprting agencies. In certain circumstances, and in cmpliance with applicable law, we r ur reinsurers may als release yur persnal r privileged infrmatin in ur/their files, t third parties withut yur authrizatin. Upn request, yu have the right t be tld abut and t see a cpy f items f persnal infrmatin abut yu which appear in ur files, including infrmatin cntained in investigative cnsumer reprts. Yu als have the right t seek crrectin f persnal infrmatin yu believe t be inaccurate. In cmpliance with applicable law, we r ur reinsurers may als release infrmatin in ur/their files, including infrmatin in an applicatin, t ther insurance cmpanies t which yu apply fr life r health insurance r t which a claim is submitted. S that there will be n questin that the insurance benefits will be payable at the time a claim is made, we urge yu t review yur applicatin carefully t be sure the answers are crrect and cmplete. THE ABOVE IS A GENERAL DESCRIPTION OF OUR INFORMATION PRACTICES. IF YOU WOULD LIKE TO RECEIVE A MORE DETAILED EXPLANATION OF THESE PRACTICES, PLEASE SEND YOUR REQUEST TO: UNITED WORLD LIFE INSURANCE COMPANY, DIRECTOR OF INDIVIDUAL UNDERWRITING, MUTUAL OF OMAHA PLAZA, OMAHA, NE 68175. Give this ntice t the applicant.
United Wrld Life Insurance Cmpany A Mutual f Omaha Cmpany Guaranteed Issue and Open Enrllment Ntice The fllwing are definitins f the categries f the individuals wh are eligible fr Guaranteed Issue: (a) Enrlled under an emplyee welfare benefit plan and the plan terminates r ceases t prvide benefits r the individual is n lnger eligible fr the plan; (b) Enrlled in a Medicare Advantage plan r 65 years f age r lder and enrlled with a Prgram f All-Inclusive Care fr the Elderly (PACE) and the rganizatin's certificatin r plan is terminated r the individual has been ntified f an impending terminatin f certificatin r the rganizatin has terminated r therwise discntinued prviding the plan in the area in which the individual resides r the individual is n lnger eligible t elect the plan because f change in circumstances, r the plan is terminated fr all individuals within a residence area; r the rganizatin substantially vilated a material plicy prvisin, r a material misrepresentatin was made t the individual; r (c) Enrlled in a Medicare risk cntract, health care prepayment plan, cst cntract r Medicare Select Plan, r similar rganizatin, and the rganizatin's certificatin r plan is terminated r specific circumstances permit discntinuance including, but nt limited t a change in residence f the individual, the plan is terminated within a residence area, the rganizatin substantially vilated a material plicy prvisin, r a material misrepresentatin was made t the individual; r (d) Enrlled in a Medicare supplement plicy and cverage discntinues due t inslvency, bankruptcy r ther invluntary terminatin f cverage, substantial vilatin f a material plicy prvisin, r material misrepresentatin; r (e) Enrlled under a Medicare supplement plicy and terminates enrllment and subsequently enrlls, fr the first time, with any Medicare Advantage rganizatin under a Medicare Advantage plan under Part C f Medicare, any eligible rganizatin under a cntract under sectin 1876 f the Scial Security Act (Medicare cst ) (42 U.S.C.A. 1935mm), any similar rganizatin perating under demnstratin prject authrity, any PACE prvider under sectin 1894 f the Scial Security Act, r any Medicare Select plicy and the subsequent enrllment under this paragraph is terminated by the enrllee during the first 12 mnths f the subsequent enrllment (during which the enrllee is permitted t terminate the subsequent enrllment under sectin 1851 (e) f the Scial Security Act), r (f) Upn first becming eligible fr benefits under Part A and enrlled in Part B, if eligible, f Medicare, enrlls in a Medicare Advantage plan under Part C f Medicare, r with a PACE prvider under sectin 1894 f the Scial Security Act, and disenrlls frm the plan r prgram within 12 mnths after the effective date f enrllment. (g) Enrlls in a Medicare Part D plan during the initial enrllment perid and, at the time f enrllment in Part D, was enrlled under a Medicare supplement plicy that cvers utpatient prescriptin drugs and the Insured Persn terminates enrllment in the Medicare supplement plicy and submits evidence f enrllment in Medicare Part D alng with the applicatin fr a plicy that is classified as a Plan A, B, C, F (including F with a high deductible), K r L, and that is ffered and is available fr issuance t new enrllees by the same issuer that issued the individual's Medicare supplement plicy with utpatient prescriptin drug cverage. If any f the definitins apply t yu, please cmplete the Applicatin fr Medicare supplement Insurance and submit evidence f the date f terminatin r disenrllment. Applicatin must be made fr cverage n later than 63 days f terminatin r disenrllment. Open Enrllment An issuer may nt deny r cnditin the issuance r effectiveness f a Medicare supplement plicy r certificate available fr sale in this Cmmnwealth, nr discriminate in the pricing f a plicy r certificate because f the health status, claims experience, receipt f health care r medical cnditin f an applicant in the case f an applicatin fr a plicy r certificate that is submitted prir t r during the 6-mnth perid beginning with the first day f the first mnth in which an individual enrlled fr benefits under Medicare Part B. Each Medicare supplement plicy and certificate currently available frm an issuer shall be made available t applicants wh qualify under this sectin withut regard t age. In the case f grup plicies, an issuer may cnditin issuance n whether an applicant is a member r is eligible fr membership in the insured grup. W26254 Give This Cpy T The Applicant