Fed1576os Os App

8/6/2019 Fed1576os Os App

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FLTCIP 2.0 Open Season Abbreviated Underwriting ApplicationValid April 4, 2011 through June 24, 2011

Important inormation to consider beore you apply or coverage underthe Federal Long Term Care Insurance Program

People buy long term care insurance or many reasons. Some buy insurance to make sure thecan choose the type o care they receive. Others do not want to use their own assets or havetheir amily pay or long term care. But long term care insurance can be expensive and is notright or everyone.

Please read below or important inormation and questions that may help you decide i youshould apply or this coverage. You should also read the Outline o Coverage andA ShoppersGuide to Long-Term Care Insurance, both o which are ound in the inormation kit and onlineat www.LTCFEDS.com. I you have questions about whether long term care insurance isappropriate or you, please call us at 1-800-LTC-FEDS (1-800-582-3337) TTY 1-800-843-3557.

y

1. Can you aord to pay the premiums or the coverage you are considering?

I you plan to pay premiums solely rom your own income, a rule o thumb is that you maynot be able to aord this coverage i the premium is more than 7% o your income.* Your

premium is based on the benet options you select and your age at the time we receiveyour application. I you need help calculating your premium or creating a plan that suitsyour needs, please visit www.LTCFEDS.com or call us at 1-800-LTC-FEDS (1-800-582-3337)TTY 1-800-843-3557.

2. Can you aord uture changes to your premiums?

Your premiums may increase i:

you increase your coverage, either by accepting increases to your benets under theFuture Purchase Option, or by requesting and being approved or an increase in yourbenets, and/or

you are among a group o enrollees (or example, those with the same plan design orset o benets) whose premium is determined to be inadequate.

Note: Although there are no current plans to increase premium rates in the uture, premiumsare not guaranteed to remain at todays rates. While the group policy is in eect, OPM mustapprove an increase in premium rates.

3. I you are considering the Future Purchase Option, have you looked at whether you can aordincreased premiums or uture increases to your benets?

I you do not plan to accept uture increases, have you considered how you will pay or anylong term care that exceeds the amount your insurance will cover?

4. Do you qualiy or Medicaid, or are you likely to qualiy in the near uture?

Medicaid may be available or persons with low income (or example, less than $20,000/individual or $40,000/couple) and ew assets (or example, less than $30,000/individual or

$50,000/couple, not counting the value o your home). Medicaid covers some long term careservices. I you have low income and ew assets now, or expect to in the next 10 years, youmay want to consider whether long term care insurance is right or you. It is important toremember that Medicaid eligibility requirements vary by state. To learn more about Medicaid,contact your local or state Medicaid agency.

* National Association o Insurance Commissioners.A Shoppers Guide to Long-Term Care Insurance, 2009.

The Federal Long Term Care Insurance Program issponsored by the U.S. Oice o Personnel Management,oered by John Hancock Lie & Health Insurance Company, Boston, MA 02117,and administered by Long Term Care Partners, LLC


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FLTCIP 2.0 Open Season Abbreviated Underwriting ApplicationValid April 4, 2011 through June 24, 2011

This application isonly or the members o the Federal amily noted at the bottom o this page who areparticipating in the 2011 FLTCIP Open Season. This application is only valid April 4, 2011 through June 24, 2011,unless otherwise indicated by the U.S. Oce o Personnel Management (OPM).

All other individuals cannotuse this application and must use the application appropriate to their eligibilitystatus. Current enrollees who wish to change their coverage must use a coverage change application.Call 1-800-LTC-FEDS (1-800-582-3337) TTY 1-800-843-3557 to request the appropriate application.

Each eligible individual wishing to apply or coverage must complete a separate application.

Part APart A Personal informationPersonal information

IMPORTANT: I you received a rate quote and you are the individual named on the address label,remove the label and place it below. I not, please ll out the inormation below.

Mr. Mrs. Ms.

First name M.I. Last name

Address 1

Address 2

City

Part A Personal information

State/Territory

Country Zip/Foreign postal code

Ax label here

Gender

Male Female

Home phone

Date o birth

Month

/Day

/Year

Work phone

Email

Social Security number*

Check here i you DO NOT have a Social Security number* We use SSNs to obtain health inormation or underwriting

purposes, during the claims process, and to process payrolldeductions.

This application is only or those noted below. Tell us which o these makes you an eligible individual.(Required: Please check only one.)

Federal employeeU.S. Postal Service employee

Active member o theuniormed services

Other eligible employee(or a complete listing, visitwww.LTCFEDS.com/eligibility/)

Current spouse o a: Federal employee

U.S. Postal Serviceemployee

Active member o theuniormed services

Other eligible employee

Same-sex domestic partner o a civilianworkorce member who has submitted(either directly or through theirpartner) a orm arming this status tothe partners employing agency.

I you are unsure which o these makes you an eligible individual, visit www.LTCFEDS.com/eligibility/ or call usat the number below.

For assistance, call 1-800-LTC-FEDS (1-800-582-3337) TTY 1-800-843-3557 or visit www.LTCFEDS.com/apply

I a n M H u n t e r

P S C 4 7 , B o x 9 2 3

A P O A E

U n i t e d S t a t e s 0 9 4 7 0

0 6 2 4 6 1

I A N . H U N T E R @ E U . D O D E A . E D U

1 6 3 5 8 7 0 2 8


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Part B Answer these questions rst

Spouses and same-sex domestic partners who are not eligible current employees must also answer questions8 and 9 in Part B.

1. Do you currently reside in, or has a health proessional advised you to enter, a nursinghome or any type o assisted living acility?

YES

3

NO

2. Are you currently receiving home health care services or attending adult day care?YES

Part B

NO

3. Do you currently require or receive human help or supervision with any o these activities?

Bathing Toileting (getting to and using the toilet,

completing hygiene-related unctions ater use)Dressing Continence (changing protective undergarment,Eating

managing ostomy bag and catheter, completingTranserring yoursel

hygiene-related unctions)rom bed to chair

YES NO

STOP

I the answer to any o questions 1 3 in Part B is YES, you may reapply i your conditionresolves (you are able to answer NO to questions 1, 2, and 3). You may use anabbreviated underwriting application to reapply i your condition resolves within 6 monthsater the date you became eligible to apply, and in this instance we will preserve your ageas o the date you became eligible to apply. (Indicate by checking below if you are reapplyingunder this provision.)

I am reapplying ater the end o my 60 day eligibility period (but within 6 months aterthe date I became eligible to apply). My answer to question 1, 2, and/or 3 in Part B haschanged rom YES to NO because my condition resolved.

I more than 6 months have passed since your eligibility date, you will need to submita ull underwriting application to reapply.

I the answer to any o questions 1 3 in Part B is YES or a condition that will not resolvewithin 6 months ater the date you became eligible to apply, you are not eligible or anyo the insurance options under this program. You are eligible or a non-insurance servicepackage providing access to care coordination and a discounted network o long term careproviders and services. I you would like to receive inormation about this package, makesure that Part A and questions 1 3 in Part B are complete and mail this application. Do notcomplete the rest o this application.

I the answer to each o questions 1 3 in Part B is NO, please continue with questions 4 7.

4. Do you currently have, or have you ever been diagnosed with, or ever been treated or,any o the ollowing conditions?

Alzheimers disease, organic Multiple sclerosis Stroke (cerebrovascularbrain syndrome, dementia accident): multipleMuscular dystrophy

Amyotrophic lateral sclerosis Stroke (cerebrovascularParkinsons disease(ALS or Lou Gehrigs disease) accident): with residual

Schizophrenia impairment (such as paralysis,Huntingtons chorea

Transient ischemic weakness, gait disturbance,attack (TIA): multiple vision disturbance, mental

impairment)

YES NO

5. Do you currently use any o the ollowing medical devices, aids, or treatments

(or any reason)?

Dialysis Motorized scooter Stair lit

Hospital bed Oxygen (excluding WalkerCPAP) Wheelchair

YES NO

6. Do you currently require or receive human help or supervision with any o these activitiesbecause o mental retardation?

Living independently Taking medications Shopping

Making decisions Preparing meals Using transportationabout your money Walking

YES NO


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Part B Answer these questions rst (continued)

7. Have you been diagnosed with any mental or nervous disorder or which you have beenhospitalized in the past 2 years or or which you have had 3 or more hospitalizations inthe past 10 years?

YES

4

NO

Part B

STOP

I the answer to any o questions 4, 6, or 7 in Part B is YES, you are not eligible or anyo the insurance options under this program shown in Part F o this application. You areeligible or an alternative insurance plan or a non-insurance service package providingaccess to care coordination and a discounted network o long term care providers and

services. I you would like to receive inormation about these options, make sure thatPart A and questions 17 in Part B are complete and mail this application. Do not completethe rest o this application.

I the answer to question 5 in Part B is YES, you may reapply i your condition resolves(you are able to answer NO to question 5). You may use an abbreviated underwritingapplication to reapply i your condition resolves within 6 months ater the date you becameeligible to apply, and in this instance we will preserve your age as o the date you becameeligible to apply. (Indicate by checking below if you are reapplying under this provision.)

I am reapplying ater the end o my 60 day eligibility period (but within 6 months aterthe date I became eligible) because my answer to question 5 in Part B has changed romYES to NO because my condition resolved.

I more than 6 months have passed since your eligibility date, you will need to submit a

ull underwriting application to reapply.I the answer to question 5 in Part B is YES or a condition that will not resolve within6 months ater the date you became eligible to apply, you are not eligible or any o theinsurance options under this program. You are eligible or a non-insurance service packageproviding access to care coordination and a discounted network o long term care providersand services. I you would like to receive inormation about this package, make sure thatPart A and questions 17 in Part B are complete and mail this application. Do not completethe rest o this application.

I the answer to each o questions 47 in Part B is NO, please continue with thisapplication. I you are applying as the spouse or same-sex domestic partner o an eligiblecurrent employee, complete questions 8 and 9 in Part B.

We will review your answers to determine i we can oer coverage. Certain medical

conditions, or combinations o conditions, will prevent some people rom being approvedor coverage.

For spouses and same-sex domestic partners only

I you are applying as a spouse or same-sex domestic partner, please answer questions 8 and 9.


Preparing meals Using transportation Walking

Taking medications Shopping Making decisionsabout your money

YES NO

9. Do you use crutches and/or a multi-prong cane?YES NO

I the answer to questions 8 and/or 9 is YES, please explain below. Attach a separate piece o paper inecessary. A registered nurse may call or visit you to get more inormation on your answers.


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Part C Unlimited benet period medical questions

Complete Part Conly i you are applying or the unlimited benet period. I you are applying or the 2, 3, or 5 yearbenet period, skip Part C and go to Part D.

Depending on your answers to the questions in Part C, you may receive a call rom a registered nurse to conducta telephone interview or to schedule an in-home interview. We may also request medical inormation rom yourhealth care provider(s).

1. Do you currently have, or have you ever been diagnosed with, or treated or, any o theollowing conditions?

AIDS, AIDS-related HIV Organ transplantcomplex (excluding cornea,Kidney ailure

bone marrow transplant)Cirrhosis (excluding Mental retardationprimary biliary) Paraplegia, quadriplegia

YES NO

STOP

I the answer to question 1 in Part C is YES, we cannot oer you the unlimited benetperiod. Please skip to Part D and continue.

please complete questions 26. Based onyour answers to questions 26, we will determine i you are eligible or the unlimited benetperiod. I we determine that you are eligible or coverage, but not or the unlimited benet

period, you will receive the 5 year benet period. At that time, you may change your benetperiod to the 2 year or the 3 year option, or call us i you no longer want this insurance.

I the answer to question 1 in Part C is NO,


Preparing meals Using transportation Walking

Taking medications Shopping Making decisionsabout your money

YES NO

3. Do you currently use crutches and/or a multi-prong cane?YES NO

4. Are you currently receiving disability income such as disability retirement annuity payments,VA disability compensation, workers compensation, any Federal or state disability payments,or any other type o disability payment?

YES NO

ATTENTION: I the answers to any o questions 2 4 in Part C is YES, or i you have additional detail to provide,please explain below.

Name, address, and phone numbero treating health proessional

Name

Address

Phone

Questionnumber

Diagnosis or disorder Date o onset(mm/yy)

Date o lasttreatment(mm/yy)

Name

Address

Phone

I you need additional space, you can attach a separate piece o paper, download a orm atwww.LTCFEDS.com/supplement2/, or call the number below.


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Part C Unlimited benet period medical questions (continued)

5. Within the last 10 years, have you had, been diagnosed with, or been treated or any o the ollowing conditions?

A. Stroke or cerebrovascular accident (CVA), transient ischemic attack (TIA),carotid artery disease

YES NO

B. Peripheral vascular diseaseYES NO

C. Coronary artery disease (such as heart attack, angina), heart arrhythmia, cardiomyopathy,congestive heart ailure, aneurysm, valvular disease

YES NO

D. Diabetes (excluding gestational diabetes)YES NO

E. Cancer (excluding basal cell cancer or squamous cell cancer o the skin)YES NOF. Chronic kidney disease (such as nephritis)YES NO

G. Liver disorder (such as hepatitis)YES NO

H. Any psychiatric disorder (such as depression, bipolar disorder)YES NO

I. Disorder o the brain (such as tremor, seizure disorder, head injury, tumor, inection),neuropathy, syncope, paralysis, any chronic or progressive neurological disorder

YES NO

J. Chronic lung disease (such as COPD, emphysema, sarcoidosis, chronic bronchitis,asbestosis, asthma [excluding seasonal asthma], bronchiectasis, sleep apnea)

YES NO

K. Memory lossYES NO

L. Rheumatoid arthritis, any other type o arthritis, osteoporosis, back disorder, scoliosis,spinal stenosis, disc disease

YES NO

M. Connective tissue disorder (such as scleroderma, systemic lupus, CREST syndrome)YES NO

N. Muscle disorder (such as bromyalgia, polymyalgia rheumatica, chronic atigue syndrome)YES NO

ATTENTION: I the answer to any portion o question 5 in Part C is YES, or i you have additional detail to provide,please explain below.


Name

Address

Phone

Questionnumber

Diagnosis or disorder Date o onset(mm/yy)

Date o lasttreatment(mm/yy)

Name

Address

Phone

Name

Address

Phone

I you need additional space, you can attach a separate piece o paper, download a orm atwww.LTCFEDS.com/supplement2/, or call the number noted below.


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PAPWORTH HOSPITAL NHS

THORACIC OUTPATIENT DEPARTMENT, PAPWORTH EVERAD

CAMBRIDGE CB23 3RE, UNITED KINGDOM

FROM U.S. 011-44-1480-831069

J

MILD

CYLINDRICAL

BRONCHIECTASI

S IN BOTH

MIDDLE LOBES

JULY 2008 11/2010

SEE ATTACHED

MEDICAL

RECORDS


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Part C Unlimited benet period medical questions (continued)

6. Have you taken any prescription medications over the past 6 months?I yes, please complete the chart below.

YES NO


Name

Address

Phone

Name o medicationCheck box i taking currently

Dosage(such as

10 mg)

Frequency(such as

2 x a day)

Reason prescribed

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

I you need additional space, you can attach a separate piece o paper, download a orm atwww.LTCFEDS.com/supplement2/, or call the number noted below.


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Alconbury Surgery

School Lane, Alconbury, Huntingdon, PE28 4EQ

UNITED KINGDOM

FROM UNITED STATES: 011-44-1480 890281

SALBUTAMOL

INHALER

1 PUFF X1

ASTHMA

MOMETASONE

FUROATE

1 PUFF 1X

NASAL

CONVESTION

Alconbury Surgery


UNITED KINGDOM


MONTELUKAST

SODIUM TABLETS

10 MG 1X

ASTHMA

AMOXCILLIN 500 MG X2

PROPHYLAXIS

AGAINST

INFECTION

Alconbury Surgery


UNITED KINGDOM


FOSTAIR 1 PUFF X2

ASTHMA

AUGMENTIN 625 MG 3X

ACUTE

INFECTION

ONLY


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Part D Authorization to use and disclose health inormation

Read and sign below only i the answer to question 8 or 9 in Part B is YES and/or i you are applying or theunlimited benet period and the answer to any o questions 26 in Part C is YES.

For the purposes o the Federal Long Term Care Insurance Program (including underwriting, claims, andcustomer service), I authorize any licensed health care practitioner, medical acility, employer, insurance company,or any other entity or person that has any health inormation about me to give that health inormation toLong Term Care Partners, LLC, John Hancock Lie & Health Insurance Company, their reinsurers, and/or theirsubcontractors that need to know health inormation to provide contracted services.

The health inormation I am permitting to be disclosed and used or the Federal Long Term Care InsuranceProgram includes any inormation on my medical history, and the diagnosis, prognosis, and treatment o anyphysical or mental condition. It includes the disclosure o any medical care or surgery, psychiatric or psychologicalcare or examinations, and inormation about alcohol or drug use (including any inormation otherwise protectedby Federal Regulations 42 CFR Part 2 or other applicable laws). I understand that this authorization includes myconsent to use and disclose medical inormation that relates to mental illness, HIV, AIDS, HIV-related illness,sexually transmitted diseases, or other serious communicable diseases, but only in accordance with any law orregulation that applies to any such disclosure o this inormation about me.

I understand that:

I I do not sign this authorization, my application or long term care insurance may not be processed and anyclaim or long term care insurance benets may be denied.

I may revoke this authorization at any time, except to the extent that:

action has already been taken in reliance on it beore my revocation, orLong Term Care Partners or my insurer has a right to contest my long term care insurance claim or coverage.

To revoke this authorization I must notiy Long Term Care Partners, LLC, P.O. Box 797, Greenland, NH03840-0797, in writing.

I I do revoke this authorization, I understand that my application or long term care insurance may not beprocessed and any claim or long term care insurance benets may be denied.

I I do not revoke this authorization, it will be valid or 24 months rom the date I sign it.

My health inormation may be redisclosed and no longer protected by applicable law, including ederal healthinormation privacy regulations. This can occur only i such redisclosure is required or allowed by law (orexample, in response to a subpoena).

A copy o this authorization is as valid as the original.

Applicants signature X(Required)

Date signed(Required: mm/dd/yy)

/ /

STOP

Have you signed and dated the authorization above, i required as noted in theinstructions? We cannot process this application without your signature and the date.

Part E Your primary physician inormation

Please provide the ollowing inormation only i the answer to question 8 or 9 in Part B is YES and/or i youare applying or the unlimited benet period and the answer to any o questions 26 in Part C is YES.

Primary physician or health care practitioners rst name Last name

Address

City

State/Territory


Phone Check here i you do not have a primary physician or health care practitioner

ori you have not seen the person listed above during the last two years.


06 112011

A L C O N B U R Y S U R G E R Y

S c h o o l L a n e A l c o n b u r y

H u n t i n g d o n P E 2 8 - 4 E Q


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Part F Choose a prepackaged plan orcustomize a planYou can choose eithera prepackaged plan orcustomize your own plan. Donot choose both. I the answer toQuestion 1 in Part C is YES, you are not eligible or the unlimited benet period. I you have any questionsabout options or premiums, please reer to Book 1: Program Details and Rates or call us at 1-800-LTC-FEDS(1-800-582-3337) TTY 1-800-843-3557 or visit us online at www.LTCFEDS.com/apply/.

Prepackaged plan

1. Choose a plan

Plan A Daily benet amount $150Benet period 2 years

Plan B Daily benet amount $150Benet period 3 years

Plan C Daily benet amount $200Benet period 3 years

Plan D Daily benet amount $200Benet period 5 years

2. Choose an infation protection option

4% Automatic Compound Infation Option


Future Purchase Option

or Customized plan

1. Choose a daily benet amount

$100 $150 $200 $250

$300 $350 $400 $450

2. Choose a benet period

2 years 3 years 5 years Unlimited

3. Choose an infation protection option



Future Purchase Option

STOP

Have you chosen a prepackaged plan orcustomized a plan? I you have chosen a prepackagedplan, check only one box or your plan and one box or your infation protection option. I youhave chosen a customized plan, be sure to check one box each or the daily benet amount,benet period, and the infation protection option. We cannot process this application i youleave any o these choices blank.

Part G Replacement coverage questions

Please answer the following questions about replacement of existing coverage. Federal law requires that we ask you

these questions. Your answers to these questions will NOT affect your eligibility for insurance under the Federal LongTerm Care Insurance Program. You should not replace any existing medical or health insurance coverage with theFederal Long Term Care Insurance Program. These are different types of insurance that cover different types of care.

1.Medicaid is the state/Federal program that helps pay medical costs for some people with low incomes andlimited resources. It is known as Medi-Cal in California. Please note that Medicaid is NOT the same as Medicare.

Are you covered under Medicaid? I you answer YES, you may wish to careully considerwhether you really need long term care insurance.

YES NO

2. I you currently have a long term care insurance policy or certicate, you should compare its benets and costswith the benets and costs o the Federal Long Term Care Insurance Program. It may or may not make senseor you to replace that policy or certicate with coverage under this program. You should be certain that you aremaking an inormed decision and certainly should not cancel any long term care insurance you currently haveunless/until your coverage under this program is eective.

Are you replacing another long term care insurance policy or certicate currently in orce withcoverage under the Federal Long Term Care Insurance Program? I you answer YES, we arerequired to notiy your current insurance carrier that you have applied or coverage under thisprogram. I you answer YES, please provide the ollowing inormation:

YES NO

Policy number

Insurance company name

Insurance company street address

City State Zip


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Part H Choose one billing option

Direct bill I you are approved or coverage and you do not choose a billing option or ll out this partcompletely, you will be billed directly. For assistance with completing this page, please callus at 1-800-LTC-FEDS (1-800-582-3337) TTY 1-800-843-3557.

Please send me a direct bill monthly to the address I provided in Part A o this application.

or

Payroll

deduction

Due to timing issues, please be aware that there is usually a short delay beore your payroll

deductions begin. You may receive a direct bill or any outstanding premiums resulting roma delay.

My pay: I authorize Long Term Care Partners to deduct premiums rom my pay. I haveprovided my Social Security number in Part A o this application. To nd a payroll oceidentier, visit our website at www.LTCFEDS.com/payroll/.

Payroll deduction Oce identier

or

Someone elses pay: I you are requesting that deductions be taken rom someone elsespay, that employee must complete this section and sign the authorization below.

Payroll deduction Oce identier

Mr. Mrs. Ms.

Payors rst name M.I. Last name

Payors street address

City State Zip

Payors Social Security number

I authorize Long Term Care Partners to deduct rom my pay that amount necessary to paythe premiums or the Federal Long Term Care Insurance Program coverage or this applicant.

Signature o payor X (Required)Date signed

(Required: mm/dd/yy)/ /

or

Automatic

bank

withdrawal

I authorize Long Term Care Partners (LTCP) to initiate automatic bank withdrawals romthe account number provided below. I the application is approved withdrawals will beginon the third business day ollowing the eective date and will continue on the third businessday o every month. I understand that any past due premium will be collected by withdrawingup to 2 months o unbilled premium plus unpaid billed premium rom my account untilcurrent. This authorization will remain in eect until I, my bank, or LTCP terminate(s) itby a 30-day written notice to the others. I understand that I will not receive any bills or other

notices o the withdrawals rom LTCP. I agree that i the automatic bank withdrawal isnot honored by my bank, or whatever reason, LTCP will have no liability or the payments.I understand that my insurance coverage may be terminated because o non-payment opremiums. I also understand that I will receive notice o such non-payment rom LTCPbeore my coverage is terminated.

Routing number Account number

Depositors signature X(Required)


/ /


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11/1211

Part I Protection against unintended lapse

It is a good idea to designate at least one person living outside o your household to receive notice i yourinsurance coverage is about to lapse because Long Term Care Partners did not receive your premiums.Note: this person will not be responsible or paying your premiums. The person you designate can help ndout why you stopped paying premiums. We will not contact this person until 45 days ater a premium was dueand is unpaid.

Would you like to name a person in addition to yoursel to receive notice i your insurance coverage is about tolapse because we did not receive your premiums? You must indicate Yes or No.

Yes, please contact the individual listed below. No, I reject this oer.

I YES, please provide all inormation requested.

Mr. Mrs. Ms.

First name M.I. Last name

Address

City State/Territory


Part J Agreement and acknowledgment

To complete your application you must conrm the ollowing at the bottom o page 12 beore submittingyour application:

1. That you understand the companys right to increase premiums by checking the box on page 12.

2. That you agree to and acknowledge the terms stated in this application by signing and datingpage 12.

I am applying or insurance coverage under the Federal Long Term Care Insurance Program. All o the answersand explanations I have given on this application, including my status as an eligible individual in Part A, aretrue and complete. I understand that the decision to approve my application will be based on my answers and

explanations on this application. I required, my medical records or answers to interview questions will alsobe considered.

I agree to immediately inorm Long Term Care Partners in writing i between the date I sign this application andthe date my insurance coverage is eective (1) my health changes in a way that would cause any answer I havegiven on this application to no longer be correct, or (2) I receive any medical advice or treatment rom a physicianor other health care practitioner or a condition that would aect an answer to any question on this application.I understand that Long Term Care Partners may use inormation about such health changes or medical adviceor treatment, whether provided by me or otherwise obtained, to reevaluate my application or coverage. I urtherunderstand that my coverage will not go into eect as scheduled or will be voided i the inormation, i knownpreviously, would have caused the carrier not to issue my coverage.

Active members o the uniormed services: I understand that i my application is approved, I must be onactive duty and physically able to perorm the duties o my position at least one day during the calendar weekimmediately prior to the week which contains my coverage eective date.

Other eligible current employees: I understand that i my application is approved, I must be actively at work atleast one day during the calendar week immediately beore the week which contains my coverage eective date.I must be reporting or work at an approved work location and work at least one hal o my regularly scheduledhours or that day and be able to perorm all the usual and customary duties o my employment on my regularwork schedule.

I understand I have the right to request a copy o this application at any time, but I also understand I will receiveone automatically.

continued


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E L V I R A A H U N T E R

4 B E E C H E N D , A L C O N B U R Y

H U N T I N G D O N , C A M B S

U N I T E D K I N G D O M P E 2 8 4 D Q


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Part J Agreement and acknowledgment (continued)

Caution: I you are approved or coverage, but you should not have been because one or more o your answers orexplanations is incorrect, untrue, or ails to include all material inormation requested, we may have the right todeny benets or void your insurance. This is true even i you did not knowingly misrepresent the acts as shownin your medical records. We may also void your insurance at any time i we nd that at the time o application,you misrepresented your status as a member o an eligible group.

NOTE: Your signature below also conrms the elections you made in Part F (choose a prepackaged plan orcustomize a plan), Part H (billing options), and Part I (protection against unintended lapse).

I you rejected an Automatic Compound Infation Option in Part F by choosing the Future Purchase Option,you are conrming that you reviewed the descriptions and graphs o the infation protection options in theOutline o Coverage. You also understand that i you elect an Automatic Compound Infation Option, youmay switch to the Future Purchase Option at any time. And i you elect the Future Purchase Option, you mayrequest to change rom the Future Purchase Option to the Automatic Compound Infation Option, and shouldyou make such a request:you will be required to provide, at your expense, evidence o your good health that is satisactory to us; and

the eective date o all uture automatic compound benet increases will be the anniversary o the rst dayo the month that next ollows the date o our approval o your request.

I you elected automatic bank withdrawal in Part H, you are authorizing your bank to charge your accountor such withdrawals, payable to Long Term Care Partners. This authorization will remain in eect until you,your bank, or Long Term Care Partners terminates it by a thirty (30) day written notice to the others. You will

not receive any bills or other notices o the withdrawals rom Long Term Care Partners. You agree that i theautomatic bank withdrawal is not honored by your bank, or whatever reason, Long Term Care Partners willhave no liability or the payments.

I you elected payroll deduction rom your own pay in Part H, you are authorizing Long Term Care Partners todeduct rom your pay the amount necessary to pay the premiums or the Federal Long Term Care InsuranceProgram coverage issued to you. I you elect payroll deduction, then we reserve the right to direct bill youthe amount necessary to pay the premiums upon your retirement. You can cancel your payroll deduction bycontacting Long Term Care Partners to choose a dierent billing option.

I you did not name someone in Part I to receive a notice i your coverage is about to lapse, you are conrmingthat you understand that such notices do not obligate such person in any way and are not sent until 45 daysater your premium was due but unpaid. You also understand that you may identiy a person (and/or namea dierent person) to receive notice o pending lapse at any time in the uture.

STOP

Please check the box and sign below.The companys right to increase premiums: Premiums are not guaranteed. I understandthat my premium will not change because I get older or my health changes or or anyother reason related solely to me. Premiums may only increase i I am among a groupo enrollees whose premium is determined to be inadequate. I understand that whilethe group policy is in eect, OPM must approve the change.

Note: You must check the above box to conrm that you have read and understandthe paragraph above titled The companys right to increase premiums. We cannotprocess your application i you do not check the box.

Applicants signature X(Required)


/ /

STOPHave you signed and dated the agreement and acknowledgment above? Have you readthe statement about the companys right to increase premiums, and did you check the box?

You must complete these items beore we can process this application.

Mail to:Long Term Care Partners, P.O. Box 797, Greenland, NH 03840-9803

or

Fax to:1-866-921-4510


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Fed1576os Os App

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Transcript of Fed1576os Os App