Medicare Supplement Underwriting Guidelines

T04_412_1211

Table of Contents

Contacts ............................................................................................................................................................ Page 1• AddressesforMailingandDeliveryReceipts• OnlineForms• ImportantPhoneNumbers

Introduction ..................................................................................................................................................... Page 2

Policy Issue Guidelines .............................................................................................................................. Page 3• OpenEnrollment• StateswithUnderAge65Requirements• SelectiveIssue• ApplicationDates• CoverageEffectiveDates• Replacements• Reinstatements• TelephoneInterviews• PharmaceuticalInformation• PolicyDeliveryReceipt• GuaranteeIssueRules

−GuaranteedIssueRightsforVoluntaryTerminationofGroupHealthPlan− AdditionalStateSpecificRights− GuaranteedIssueRightsforLossofMedicaidQualification

Medicare Advantage (MA) ......................................................................................................................... Page 8• MedicareAdvantage(MA)AnnualElectionPeriod• MedicareAdvantage(MA)ProofofDisenrollment• GuaranteeIssueRights

Premium .......................................................................................................................................................... Page 10• CalculatingPremium• TypesofMedicarePolicyRatings• HeightandWeightChart• CompletingthePremiumontheMethodofPaymentForm• CollectionofPremium• BusinessChecks• PremiumReceiptandNoticeofInformationPractices• Shortages• Refunds• GeneralAdministrativeRule–12MonthRate

Application ..................................................................................................................................................... Page 14• Application Sections

− Section A – Plan Information Section− Section B – Applicant Information− Section C – Medicare Information− Section D – Previous or Existing Coverage Information− Section E – Please answer all of the following questions− Section F – Health Information− Section G – Medication Information− Section H – Agreement and Authorization− Section J – To be Completed by Producer

Health Questions ......................................................................................................................................... Page15• UninsurableHealthConditions• PartialListofMedicationsAssociatedwithUninsurableHealthConditions

Mailing Applications to Prospects ....................................................................................................... Page 18• TheFacts• TheProcess

Required Forms ........................................................................................................................................... Page 21• Application• ProducerInformationPage• MethodofPaymentForm• PremiumReceiptandNoticeofInformationPractices• ReplacementForm• AgentorWitnessCertificationforNon-EnglishSpeakingand/orReadingApplicants

State Special Forms ................................................................................................................................... Page 22• Arkansas–DocumentationofSolicitationofMedicareRelatedProductsform• Colorado–CommissionDisclosureForm –GuaranteeIssueforEligiblePersons• Florida–FloridaCertificationForm• Illinois–MedicareSupplementChecklist• Iowa–ImportantNoticeBeforeYouBuyHealthInsurance• Kentucky–MedicareSupplementComparisonStatement• Louisiana–YourRightsRegardingtheReleaseandUseofGeneticInformation• Maryland–EligiblePersonsforGuaranteeIssueandOpenEnrollment• Minnesota–AgentInformationForm• Nebraska–SeniorHealthCounselingNotice• Ohio–SolicitationandSaleDisclosure• Pennsylvania–GuaranteeIssueandOpenEnrollmentNotice• SouthCarolina–DuplicationofInsuranceForm• Texas–DefinitionofEligiblePersonforGuaranteedIssueNotice• Wisconsin–DisclosureofOtherHealthInsuranceSoldtoApplicantbyAgent

CONTACTS

Addresses for Mailing New Business and Delivery ReceiptsWhenmailingorshippingyournewbusinessapplications,besuretousethepreaddressedenvelopes.

Administrative Office Mailing InformationMailing Address Overnight/Express AddressGPMLife GPMLifeP.O.Box2679 Records/MailingProcessingCenterOmaha,NE68103-2679 9330StateHighway133 Blair,NE68008-6179

FAX Number for New Business - Automated Bank Account Withdrawal Applications1-866-422-9139

Online Forms, General and State Specifichttp://www.GPMLifeMedicareSupplement.com • Enterusernameandpassword USER NAME: gpmlife PASSWORD: medsupp

Important Phone NumbersArea Phone NumberUnderwriting 1-866-453-4993SalesSupport 1-866-754-5716Licensing 1-866-701-5271CompensationSupportCenter 1-866-387-4401CustomerCallCenter,Service 1-866-242-7573CustomerCallCenter,Claims 1-866-865-7631

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INTRODUCTION

ThisguideprovidesinformationabouttheevaluationprocessusedintheunderwritingandissuingofMedicaresupplementinsurancepolicies.Ourgoalistoprocesseachapplicationasquicklyandefficientlyaspossiblewhileassuringproperevaluationofeachrisk.Toensureweaccomplishthisgoal,theproducerorapplicantwillbecontacteddirectlybyunderwritingifthereareanyproblemswithanapplication.

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POLICY ISSUE GUIDELINES

AllapplicantsmustbecoveredunderMedicarePartA&BinMichigan,TexasandWashington;inallotherstates,onlyPartAisrequired.Policyissueisstatespecific.Theapplicant’sstateofresidencecontrolstheapplication,forms,premiumandpolicyissue.Ifanapplicanthasmorethanoneresidence,thestatewheretaxesarefiledshouldbeconsideredasthestateofresidence.Pleaserefertoyourintroductorymaterialsforrequiredformsspecifictoyourstate.

Open EnrollmentTobeeligibleforopenenrollment,anapplicantmustbeatleast64½yearsofage(inmoststates)andbewithinsixmonthsofhis/herenrollmentinMedicarePartB.

ApplicantscoveredunderMedicarePartBpriortoage65areeligibleforasix-monthopenenrollmentperioduponreachingage65.

Additional Open Enrollment periods for Residents of the following state:

Connecticut–Year-roundopenenrollment.

Maine – OnemonthOpenEnrollmentperiodeveryyearinJuneforPlanA.IndividualswhohavehadaMedicaresupplementplanoranotherhealthplanthatsupplementsbenefitsprovidedbyMedicarewithin90daysareeligibleforaplanthatprovidesequalorlesserbenefits.PleaseincludedocumentationverifyingthePlaninformationorthebenefitsofthecoveragebeingreplaced.Alsobesuretoincludedocumentationshowingthecurrentcoverageisinforceorwasinforcewithinthelast90days.

Applicantsreplacingacurrent1990Standardizedplanwitha2010Modernizedplan,mayapplyfora2010ModernizedMedicaresupplementplanofequalorlesserbenefitsandwouldnotbesubjecttounderwritingguidelines.

Missouri–IndividualsthatterminateaMedicaresupplementpolicywithin30daysoftheannualpolicyanniversarydatemayobtainthesameplanonaguaranteeissuebasisfromanyissuerthatoffersthatplan.PleaseincludedocumentationverifyingthePlaninformation,paid-to-dateandthepolicyanniversaryofthecurrentcoverage. Forpolicieswithaneffectivedateof6/1/2010orafter,individualswithexistingplansE,H,IandJcanconverttooneofthefollowingplans:A,B,C,F,KorL.

Vermont–Year-roundopenenrollment.

Washington – IndividualswhocurrentlyhaveastandardizedMedicaresupplementplanmayreplacetheplanasindicatedbelowonanOpenEnrollmentbasis.

• PersonswithaPlanAmayonlymovetoanotherPlanA.• PersonswithaPlanB,C,DE,F,G,MorNmaymovetoanyotherPlanB,C,D,F(includinghigh deductible),G,MorN.(Whetherhigherorlowerinbenefitscomparedtocurrentplan.)• Personswitha“Standardized”PlanH,I,orJmaymovetoanotherlesscomprehensivePlanB,C,D,F,G,M orN..• PleaseincludedocumentationverifyingthePlaninformationandpaid-to-dateofthecurrentcoverage.

Note:PlansE,H,I,andJwillnolongerbeavailablefornewbusinessasofJune1,2010.

States with Under Age 65 RequirementsColorado Allplansavailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.Connecticut PlanAandCareavailable.

Delaware AllplansareavailableonlyforindividualsonMedicareduetoend-stagerenaldisease.Openenrollmentifwithin6monthsofPartBenrollment.

Florida Allplansavailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.

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Georgia Allplansavailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.

Illinois Allplansavailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.

Kansas Allplansavailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.

Kentucky Allplansareavailable.Noopenenrollment.Allapplicationsareunderwritten.

Louisiana Allplansavailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.

Maine Allplansavailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.

Maryland PlansA&Cavailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.Minnesota Allplansandridersavailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.

Mississippi Allplansavailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.

Missouri Allplansavailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.

New Hampshire Allplansavailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.

North Carolina PlansA&Favailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.

Oklahoma PlanAisavailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.

Oregon Allplansavailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.

Pennsylvania Allplansavailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.

Tennessee Allplansavailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.

Texas PlanAisavailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.

South Dakota Allplansavailable.OpenenrollmentifappliedforwithinsixmonthsofPartBenrollment.

Vermont Allplansareavailable.Notavailableforindividualswithend-stagerenaldisease.

Wisconsin Basepolicyandridersareavailable.Openenrollmentifwithin6monthsofPartBenrollment.

Selective IssueApplicantsovertheageof65,orunderage65inthestateslistedabove,andatleastsixmonthsbeyondenrollmentinMedicarePartBwillbeselectivelyunderwritten,exceptinConnecticutandVermont,whichareyear-roundopenenrollmentstates.Allhealthquestionsmustbeanswered.Theanswerstothehealthquestionsontheapplicationwilldeterminetheeligibilityforcoverage.Ifanyhealthquestionsareanswered“Yes,”theapplicantisnoteligibleforcoverage.Applicantswillbeacceptedordeclined.Eliminationendorsementswillnotbeused.Inadditiontothehealthquestions,theapplicant’sheightandweightwillbetakenintoconsiderationwhendeterminingeligibilityforcoverage.Coveragewillbedeclinedforthoseapplicantswhoareoutsidetheestablishedheightandweightguidelines,exceptforapplicantsinConnecticutandVermont.Healthinformation,includinganswerstohealthquestionsonapplicationsandclaimsinformation,isconfidentialandisprotectedbystateandfederalprivacylaws.Accordingly,GPMLifeInsuranceCompanydoesnotdisclosehealthinformationtoanynon-affiliatedinsurancecompany.

Application Dates• OpenEnrollment–Uptosixmonthspriortothemonththeapplicantturnsage65• UnderwrittenCases–Upto60dayspriortotherequestedcoverageeffectivedate• ConnecticutandVermont–Year-roundopenenrollment.Appscanbetakenupto60dayspriortotherequested coverageeffectivedate.• WestVirginia–Applicationsmaybetakenupto30dayspriortothemonththeapplicantturnsage65• Wisconsin–Applicationsmaybetakenupto90dayspriortothemonththeapplicantturnsage65.

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Coverage Effective DatesCoveragewillbemadeeffectiveasindicatedbelow:

1. Betweenage64½and65–Thefirstofthemonththeindividualturnsage65.2. AllOthers–Applicationdateordateofterminationofothercoverage,whicheverislater.

ReplacementsA“replacement”takesplacewhenanapplicantterminatesanexistingMedicaresupplement/SelectpolicyandreplacesitwithanewMedicaresupplementpolicy.GPMLiferequiresafullycompletedapplicationwhenapplyingforareplacementpolicy(bothinternalandexternalreplacements).

Apolicyownerwantingtoapplyforanontobaccoplanmustcompleteanewapplicationandqualifyforcoverage.

IfanapplicanthashadaMedicaresupplementpolicyissuedbyGPMLifewithinthelast60days,anynewapplicationswillbeconsideredtobeareplacementapplication.Ifmorethan60dayshaselapsedsincepriorcoveragewasinforce,thenapplicationswillfollownormalunderwritingrules.

AllreplacementsinvolvingaMedicaresupplement,MedicareSelectorMedicareAdvantageplanmustincludeacompletedReplacementNotice.Onecopyistobeleftwiththeapplicant;onecopyshouldaccompanytheapplication.Thereplacementcannotbeappliedforontheexactsamecoverageandexactsamecompany.

ThereplacementMedicaresupplementpolicycannotbeissuedinadditiontoanyotherexistingMedicaresupplement,SelectorMedicareAdvantageplan.

ReinstatementsWhenaMedicaresupplementpolicyhaslapsedanditiswithin90daysofthelastpaidtodate,coveragemaybereinstated,baseduponmeetingtheunderwritingrequirements.WhenaMedicaresupplementpolicyhaslapsedanditismorethan90daysbeyondthelastpaidtodate,thecoveragecannotbereinstated.Theclientmay,however,applyfornewcoverage.Allunderwritingrequirementsmustbemetbeforeanewpolicycanbeissued.

Telephone InterviewsRandomtelephoneinterviewswithapplicantswillbeconductedonunderwrittencases.Pleasebesuretoadviseyourclientsthatwemaybecallingtoverifytheinformationontheirapplication.InWisconsin,telephoneinterviewswillbeconductedwithapplicantsage75andoveronunderwrittencases.

Pharmaceutical InformationGPMLifehasimplementedaprocesstosupportthecollectionofpharmaceuticalinformationforunderwrittenMedicaresupplementapplications.The“AuthorizationtoDisclosePersonalInformation(HIPAA)”isincludedintheAgreementandAuthorizationsectionoftheapplication.Prescriptioninformationnotedontheapplicationwillbecomparedtotheadditionalpharmaceuticalinformationreceived.Thisadditionalinformationwillnotbesolelyusedtodeclinecoverage.

Policy Delivery ReceiptDeliveryreceiptsarerequiredonallpoliciesissuedinLouisiana,SouthDakotaandWestVirginia.Twocopiesofthedeliveryreceiptwillbeincludedinthepolicypackage.Onecopyistobeleftwiththeclient.ThesecondcopymustbereturnedtoGPMLifeinthepostage-paidenvelopewhichisalsoincludedinthepolicypackage.

InKentuckyandNebraskathepolicyisallowedtobemaileddirectlytotheinsured.Ifthisoptioniselected,thedeliveryreceiptdoesnotneedtobeincludedinthepolicypackage;Ifthepolicyisnotmaileddirectlytotheinsuredadeliveryreceiptwillneedtobeincludedinthepolicypackage.

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Guarantee Issue RightsThesituationslistedbelowarebaseduponscenariosfoundintheGuidetoHealthInsurance.Guarantee Issue Situation Client has the right to buy. . .ClientisintheoriginalMedicarePlanandhasan employergrouphealthplan(includingretireeorCOBRAcoverage)orunioncoveragethatpaysafterMedicarepays.Thatcoverageisending.

Note:Inthissituation,statelawsmayvary.

MedigapPlanA,B,C,F,KorLthatissoldinclient’sstatebyanyinsurancecompany.

IfclienthasCOBRAcoverage,clientcaneitherbuyaMedigappolicy/certificaterightawayorwaituntiltheCOBRAcoverageends.

ClientisintheoriginalMedicarePlanandhasa MedicareSELECTpolicy/certificate.ClientmovesoutoftheMedicareSELECTplan’sservicearea.

ClientcankeeptheMedigappolicy/certificateorhe/shemaywanttoswitchtoanotherMedigappolicy/certificate.

MedigapPlanA,B,C,F,KorLthatissoldbyanyinsur-ancecompanyinclient’sstateorthestatehe/sheismovingto.

Client’sMedigapinsurancecompanygoesbankruptandtheclientlosescoverage,orclient’sMedigappolicy/certificatecoverageotherwiseendsthroughnofaultofclient.

MedigapPlanA,B,C,F,KorLthatissoldinclient’sstatebyanyinsurancecompany.

Group Health Plan Proof of TerminationProofofInvoluntaryTermination:IfapplyingforMedicaresupplement,UnderwritingcannotissuecoverageasGuaranteeIssuewithoutproofthatanindividual’semployercoverageisnolongeroffered.Thefollowingisrequired:• CompletetheOtherHealthInsurancesectionontheMedicaresupplementapplication;and• Provideacopyoftheterminationletter,showingdateofandreasonfortermination,fromtheemployerorgroupcarrier

ProofofVoluntaryTermination:Underthestatespecificvoluntaryterminationsscenarios,thefollowingproofoftermincationisrequiredalongwithcompletingtheOtherHealthInsurancesectionontheMedicaresupplementapplication:

• CertificateofGroupHealthPlanCoverage.• InIA,OK,VAandWV,provideproofofchangeinbenefitsfromemployerorgroupcarrier.

Guaranteed Issue Rights for Voluntary Termination of Group Health Plan

State Qualifies for Guaranteed Issue...CO,KS,ID,IL,IN,ME,OH,PA,TX,VT

iftheemployersponsoredplanisprimarytoMedicare.

AR,FL,MO,LA Noconditions-alwaysqualifies.

IAiftheemployersponsoredplan’sbenefitsarereduced,butdoesnotincludeadefinedthresh-old.

OK,VA,WV iftheemployersponsoredplan’sbenefitsarereducedsubstantially.

WIiftheannualizedpremiumfortheemployersponsoredplanwouldbegreaterthan125%oftheBasicAnnualPremiumfortheapplicant’sage,genderandtobacco,thentheapplicantwouldqualifyforGIeligibility.

ForpurposesofdeterminingGIeligibilityduetoaVoluntaryTerminationofanemployersponsoredgroupwelfareplan,areductioninbenefitswillbedefinedasanyincreaseintheinsured’sdeductibleamountortheircoinsurancerequirements(flatdollarco-paysorcoinsurance%).Apremiumincreasewithoutanincreaseinthedeductibleorcoinsurance

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requirementwillnotqualifyforGIeligibility.ThisdefinitionwillbeusedtosatisfyIA,OK,VAandWVrequirements.Proofofcoverageterminationisrequired.

Additional State Specific Guarantee Issue RightsConnecticut All plans available for all Guarantee Issue situations.

Maine All plans available for all Guarantee Issue situations.

Minnesota Basic Plan and any combination of these riders: Part A Deductible, Part B Deductible, and Part B Excess for all Guarantee Issue situations.

Vermont All plans available for all Guarantee Issue situations.

Wisconsin All plans and riders available for all Guarantee Issue situations.

Guarantee Issue Rights for Loss of Medicaid Qualification

State Guarantee Issue Situation Client has the right to buy. . .KS ClientloseseligibilityforhealthbenefitsunderMedicaid.

GuaranteedIssuebeginningwithnoticeofterminationandending63daysaftertheterminationdate.

anyMedigapplanofferedbyanyissuer.

ME ClientiseligibleforMedicarePartBandisenrolledinMedicaid,andenrollmentinMedicaidceasesbecausetheindividualisnolongereligible.GuaranteedIssuebegin-ningwithnoticeofterminationandending90daysaftertheterminationdate.

anyMedigapplanofferedbyanyissuer.

OR ClientisenrolledinanemployeewelfarebenefitplanorastateMedicaidplanthatprovideshealthbenefitsthatsupple-mentthebenefitsunderMedicare,andtheplanterminatesortheplanceasestoprovideallsuchsupplementalhealthbenefits.GuaranteedIssuebeginningwithnoticeoftermina-tionandending63daysaftertheterminationdate.

MedigapPlanA,B,C,F(includingFwithahighdeductible),KorLofferedbyanyissuer.

TN ClientisenrolledunderMedicaidandtheenrollmentinvol-untarilyceasesandtheindividualiseligibleforandenrolledinMedicarePartB.GuaranteedIssuebeginningwithnoticeofterminationandending63daysaftertheterminationdate.

MedigapPlanA,B,C,F(includingFwithahighdeductible),KorLofferedbyanyissuer.

TX ClientloseseligibilityforhealthbenefitsunderMedicaid.GuaranteedIssuebeginningwithnoticeofterminationandending63daysaftertheterminationdate.

MedigapPlanA,B,C,F(includingFwithahighdeductible),KorLofferedbyanyissuer;exceptthatforpersonsunder65yearsofage,itisapolicywhichhasabenefitpackageclas-sifiedasPlanA.

UT ClientisenrolledinMedicaidandisinvoluntarilyterminated.GuaranteedIssuebeginningwithnoticeofterminationandending63daysaftertheterminationdate.

MedigapPlanA,B,C,F(includingFwithahighdeductible),KorLofferedbyanyissuer.

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WI ClientiseligibleforbenefitsunderMedicarePartsAandBandiscoveredunderthemedicalassistanceprogramandsub-sequentlyloseseligibilityinthemedicalassistanceprogram.GuaranteedIssuebeginningwithnoticeofterminationandending63daysaftertheterminationdate.

Wisconsin’sBasicMedicaresupplementpolicyorcertificate,alongwithanyofferedrider.

MEDICARE ADVANTAGE (MA)

Medicare Advantage (MA) Annual Election Period

General Election Periods for Medicare Advantage (MA)

Timeframe Allows for…

AnnualElectionPeriod(AEP)Oct.15th–Dec.7th ofeveryyear

•EnrollmentselectionforaMAplan•DisenrollfromacurrentMAplan•EnrollmentselectionforMedicarePartD

MedicareAdvantageDisenrollmentPeriod(MADP)

Jan.1st–Feb.14th ofeveryyear

• MAenrolleestodisenrollfromanyMAplanandreturntoOriginalMedicare

TheMADPdoesnotprovideanoppourtunityto:• SwitchfromoriginalMedicaretoaMedicareAd-vantagePlan

• SwitchfromoneMedicareAdvantagePlantoanother

• SwitchfromoneMedicarePrescriptionDrugPlantoanother

• Join,switchordropaMedicareMedicalSavingsAccountPlan

Therearemanytypesofelectionperiodsotherthantheoneslistedabove.IfthereisaquestionastowhetherornottheMAclientcandisenroll,pleaserefertheclienttothelocalSHIPofficefordirection.

Medicare Advantage (MA) Proof of DisenrollmentIfapplyingforaMedicaresupplement,Underwritingcannotissuecoveragewithoutproofofdisenrollment.IfamemberdisenrollsfromMedicare,theMAplanmustnotifythememberofhis/herMedicaresupplementguaranteeissuerights.

Disenroll during AEP and MADP CompletetheMAsectionontheMedicaresupplementapplication;and

1. SendONEofthefollowingwiththeapplication a.Acopyoftheapplicant’sMAplan’sterminationnotice

b. ImageofinsuranceIDcard(onlyallowedifMAplanisbeingterminated)

If an individual is disenrolling outside AEP/MADP1. CompletetheMAsectionontheMedicaresupplementapplication;and

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2. Sendacopyoftheapplicant’sMAplan’sdisenrollmentnoticewiththeapplication.

ForanyquestionsregardingMAdisenrollmenteligibility,contactyourStateHealthInsuranceAssistanceProgram(SHIP)officeorcall1-800-MEDICARE,aseachsituationpresentsitsownuniquesetofcircumstances.TheSHIPofficewillhelptheclientdisenrollandreturntoMedicare.

Guarantee Issue Rights

ThesituationslistedbelowarebaseduponscenariosfoundintheGuidetoHealthInsurance.

Guarantee Issue Situation Client has the right to…Client’sMAplanisleavingtheMedicareprogram, stopsgivingcareinhis/herarea,orclientmovesoutoftheplan’sservicearea.

buyaMedigapPlanA,B,C,F,KorLthatissoldintheclient’sstatebyanyinsurancecarrier.ClientmustswitchtooriginalMedicarePlan.

ClientjoinedanMAplanwhenfirsteligiblefor MedicarePartAatage65andwithinthefirstyearofjoin-ing,decidedtoswitchbacktooriginalMedicare.

buyanyMedigapplanthatissoldinyourstatebyanyinsurancecompany.

Clientdroppedhis/herMedigappolicy/certificatetojoinanMAPlanforthefirsttime,havebeenintheplanlessthanayearandwanttoswitchback.

obtainclient’sMedigappolicy/certificatebackifthatcarrierstillsellsit.Ifhis/herformerMedigappolicy/certificateisnotavailable,theclientcanbuyaMedigapPlanA,B,C,F,KorLthatissoldinhis/herstatebyanyinsurancecom-pany.

ClientleavesanMAplanbecausethecompanyhasnotfol-lowedtherulesorhasmisledtheclient.

buyMedigapplanA,B,C,F,KorLthatissoldinthecli-ent’sstatebyanyinsurancecompany.

Client’sgrouphealthplanendedandtheclientjoinedaMAPlanforthefirsttime,hasbeenintheplanlessthanayear,andwantstoswitchbacktoOriginalMedicare.(Wisconsin only)

buyanyMedigapplanandriders

Ifyoubelieveanothersituationexists,pleasecontacttheclient’slocalSHIPoffice.

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PREMIUM

Calculating PremiumUtilize Outline of Coverage

• DetermineZIPcodewheretheclientresidesandfindthecorrectratepageforthatZIPcode• DeterminePlan• Determineifnon-tobaccoortobacco• FindAge/Gender-Verifythattheageanddateofbirtharetheexactageasoftheapplicationdate• Thiswillbeyourbasemonthlypremium

Tobacco rates do not apply during Open Enrollment or Guarantee Issue situations in the following states:Arkansas OhioColorado PennsylvaniaConnecticut TennesseeIllinois UtahIowa VermontKentucky VirginiaLouisiana WashingtonMaryland WisconsinMichiganMissouriNewHampshireNorthCarolinaNorthDakota

Utilizing the Calculate Your Premium Form (excluding Connecticut)• Enterthebasepremiumonline#1andproceedwiththeinstructionsthatfollow.

Types of Medicare Policy Ratings

• Community Rated-ThesamemonthlypremiumischargedtoeveryonewhohastheMedicarepolicy,regardlessofage.Premiumsarethesamenomatterhowoldtheapplicantis.Premiumsmaygoupbecauseofinflationandotherfactors,butnotbasedonage.

• Issue-age Rated–ThepremiumisbasedontheagetheapplicantiswhentheMedicarepolicyisbought.Premiumsarelowerforapplicantswhobuyatayoungerage,andwon’tchangeastheygetolder.Premiumsmaygoupbecauseofinflationandotherfactors,butnotbecauseofapplicant’sage.

• Attained-age Rated–Thepremiumisbasedontheapplicant’scurrentagesothepremiumgoesupastheapplicantgetsolder.Premiumsarelowforyoungerbuyers,butgoupastheygetolder.Inadditiontochangeinage,premiumsmayalsogoupbecauseofinflationandotherfactors.

Note: Ifapremiumispaidbyabusinessaccount,refertothe“BusinessChecks”sectionofthisguidetodetermineifac-ceptable.

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Rate Type Available by State

State Tobacco / Non-Tobacco Rates

Gender Rates

Attained, Issue, or Community Rated

Tobacco Rates During Open Enrollment

Enrollment/Policy Fee

AL Y Y A Y YAR Y N C N NAZ Y Y I Y YCO Y Y A N YCT N N C N YDE Y Y A Y YFL Y Y I Y YGA Y Y I Y YIA Y Y A N YID Y N I Y YIL Y Y A N YIN Y Y A Y YKS Y Y A Y YKY Y Y A N YLA Y Y A N YMD Y Y A N YME Y N C Y NMI Y Y A N YMN Y N C Y NMO Y Y I N YMS Y Y A Y YNE Y Y A Y YNC Y Y A N YND Y Y A N YNH Y Y I N YOH Y Y A N YOK Y Y A Y YOR Y Y A Y YPA Y Y A N YRI Y N A Y YSC Y Y A Y YSD Y Y A Y YTN Y Y A N YTX Y Y A Y YUT Y Y A N YVA Y Y A N YVT N N C N YWA N N C N NWI Y Y A N YWV Y Y A Y NWY Y Y A Y Y

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Height and Weight Chart

Eligibility (excluding Connecticut)Todeterminewhetheryoumaypurchasecoverage,locateyourheight,thenweightinthechartbelow.IfyourweightisintheDeclinecolumn,we’resorry,you’renoteligibleforcoverageatthistime.IfyourweightislocatedintheStandardcolumn,youmaycontinuetostep1.

Decline Standard Decline

Height Weight Weight Weight4' 2'' <54 54–145 146+4' 3'' <56 56–151 152+4' 4'' <58 58–157 158+4'5'' <60 60–163 164+4'6'' <63 63–170 171+4'7'' <65 65–176 177+4' 8'' <67 67–182 183+4'9'' <70 70–189 190+4' 10'' <72 72–196 197+4' 11'' <75 75–202 203+5'0'' <77 77–209 210+5'1'' < 80 80–216 217+5'2'' < 83 83–224 225+5'3'' <85 85–231 232+5'4'' < 88 88–238 239+5'5'' <91 91–246 247+5'6'' <93 93–254 255+5'7'' <96 96–261 262+5'8'' <99 99–269 270+5'9'' < 102 102–277 278+5'10'' <105 105–285 286+5'11'' < 108 108–293 294+6'0'' < 111 111–302 303+6'1'' < 114 114–310 311+6'2'' <117 117–319 320+6'3'' < 121 121–328 329+6'4'' < 124 124–336 337+6'5'' <127 127–345 346+6'6'' < 130 130–354 355+6'7'' < 134 134–363 364+6'8'' <137 137–373 374+6'9'' < 140 140–382 383+6'10'' < 144 144–392 393+6'11'' <147 147–401 402+7'0'' <151 151–411 412+7'1'' <155 155–421 422+7'2'' <158 158–431 432+7'3'' <162 162–441 442+7'4'' <166 166–451 452+

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Enrollment/Policy FeeTherewillbeaone-timeapplicationfeeof$25.00($6.00inMississippi)thatwillbecollectedwitheachapplicant’sinitialpayment.Forahusbandandwifewrittenonthesameapplication,$50.00infeesmustbecollected.Thiswillnotaffecttherenewalpremiums.TheapplicationfeedoesnotapplyinArkansas,Maine,Minnesota,WashingtonandWestVirginia.

Completing the Method of Payment Form

Premiums are calculated based upon the applicants exact age at the time of application, not their age as of the requested coverage effective date.

Initial Premium • TheamountdeterminedfromtheCalculateYourPremiumFormwillbetheamountyouenterontheInitial

PremiumAmountbox.• Marktheappropriatemodefortheinitialpayment.Ongoing Premium Payments• Determinehowtheclientwantstobebilledgoingforward(renewal)andselecttheappropriate modeontheOngoingPremiumPaymentssection.• Monthly billing is not allowed.

Collection of PremiumAtleastonemonth’spremiummustbesubmittedwiththeapplication.Ifamodeotherthanmonthlyisselected,thenthefullmodalpremiummustbesubmittedwiththeapplication.• Moneyorders,cashier’schecksandcounterchecksareonlyacceptableifobtainedbytheapplicant.Thirdpartypay-

orscannotobtainamoneyorderorcashier’scheckonbehalfoftheapplicant.

NOTE:GPMLife doesnotacceptpost-datedchecksorpaymentsfromThirdParties,includinganyFoundationsaspremiumforMedicaresupplement.

Business ChecksBusinesschecksareonlyacceptableiftheyaresubmittedforthebusinessownerortheowner’sspouse.Ifsubmittedforthebusinessownerorspouse,completetheinformationlocatedonthePayorInformationsection(PartII)oftheMethodofPaymentForm.

Premium Receipt and Notice of Information PracticesLeavethePremiumReceiptandtheNoticeofInformationPracticeswiththeapplicant.ThePremiumReceiptmustbecompletedwhenprovidedtoapplicantifpremiumiscollected.NOTE: Do notmailacopyofthereceiptwiththeapplication.

ShortagesGPMLifewillcommunicatewiththeproducerbytelephone,e-mailorFAXintheeventofapremiumshortage.Theapplicationwillbeheldinpendinguntilthebalanceofthepremiumisreceived.ProducersmaycommunicatewithUnderwritingbycalling1-866-453-4993orbyFAXat1-402-997-1980.

RefundsGPMLifewillmakeallrefundstotheapplicantintheeventofrejection,incompletesubmission,overpayment,cancellations,etc.

Our General Administrative Rule – 12 Month RateOurcurrentadministrativepracticeisnottoadjustratesfor12monthsfromtheeffectivedateofcoverage.

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APPLICATIONProperlycompletedapplicationsshouldbefinalizedwithin5-7daysofreceiptatGPMLife’sadministrativeoffice.Theidealturnaroundtimeprovidedtotheproduceris11-14days,includingmailtime.

Application SectionsTheapplicationmustbecompletedinit’sentirety.Pleasebesuretoreviewyourapplicationsforthefollowinginformationbeforesubmitting.

Administrative Information• AgentWritingNumber• EnteryouragentwritingnumberorSocialSecuritynumber.Note:YoudoNOTneedtocompletetheFAVKeyfield.

Section A — Plan Information Section• EntireSectionmustbecompleted.• Thissectionshouldindicatetheplanorpolicyformselected,requestedeffectivedateandthepolicydelivery option.

Section B — Applicant Information• Pleasecompletetheapplicant’sresidenceaddressinfull.Ifpremiumnoticesaretobemailedtoanaddressother thantheapplicant’sresidenceaddress,pleasecompletethemailingaddressinfull.• AgeandDateofBirtharetheexact ageasoftheapplication date.• Height/Weight—Thesearerequiredonunderwrittencases.• Answerthetobaccoquestion.(RefertotheCalculatingPremiumsectionofthisGuideforalistofstateswhere Tobaccoratesdonotapplyduringopenenrollmentorguaranteedissuesituations).

Section C — Medicare Information• MedicareClaimnumber,alsoreferredtoastheHealthInsuranceClaim(HIC)number,isvitalforelectronic claimspayment.• PleaseindicateiftheapplicantiscoveredunderPartsAandBofMedicare.

Section D — Previous or Existing Coverage Information• Verifyiftheapplicantiscoveredthroughhis/herstateMedicaidprogram.IfMedicaidispayingforbenefits

beyondtheapplicant’sPartBpremiumortheMedicaresupplementpremiumforthispolicy,thentheapplicantisnoteligibleforcoverage.

• IftheapplicantisreplacinganotherMedicaresupplementpolicy,completequestion2andincludethereplacement notice.• IftheapplicantisleavingaMedicareAdvantageplan,completequestion3andincludethereplacementnotice.• Iftheapplicanthashadanyotherhealthinsurancecoverageinthepast63days,includingcoveragethrougha unionplan,employergrouphealthplan,orothernon-Medicaresupplementcoverage,completequestion4.

Section E — Please answer all of the following questions• Iftheapplicantisapplyingduringaguaranteedissueperiod,besuretoincludeproofofeligibility.• IfeitherApplicantAorBanswered“YES”toquestion5ORBOTHquestions6and7inSectionE,theycanskip toSectionH—AgreementandAuthorization.

Section F — Health Information• Iftheapplicantisapplyingduringanopenenrollmentoraguaranteedissueperiod,donotanswerthehealth

questions.• Ifapplicantisnotconsideredtobeinopenenrollmentoraguaranteedissuesituation,allhealthquestionsmustbe

answered.NOTE: Inordertobeconsideredeligibleforcoverage,allhealthquestionsmustbeanswered“No.”Forquestionsonhowtoansweraparticularhealthquestion,seetheHealth QuestionssectionofthisGuideforclarification.

Section G — Medication Information• Iftheapplicantisapplyingduringanopenenrollmentoraguaranteedissueperiod,donotanswerthemedication

informationsection.

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• Ifapplicantisnotconsideredtobeinopenenrollmentoraguaranteedissuesituation,allmedicationinformationmustbelistedasindicated.

Section H — Agreement and Authorization• ApplicantacknowledgesreceivingtheGuidetoHealthInsuranceandOutlineofCoverage.Itisrequiredtoleave thesetwodocumentswiththeclientatthetimetheapplicationiscompleted.• ApplicantagreestotheAuthorizationtoDisclosePersonalInformation.• Signaturesanddates:requiredbyapplicant(s).• Ifsomeoneotherthantheapplicantissigningtheapplication(i.e.,PowerofAttorney),pleaseincludecopiesof thepapersappointingthatpersonasthelegalrepresentative.

Section J — To be Completed by Producer• Theproducer(s)mustcertifythattheyhave:

• providedtheapplicantwithacopyofthereplacementnoticeifapplicable,• accuratelyrecordedintheapplicationtheinformationsuppliedbytheapplicant,• andhaveinterviewedtheproposedapplicant.

(Note:Applicationswillonlybeacceptedwithananswerof“No”iftheproducerhassubmittedthesalesprocessforreviewandreceivedwrittenpriorapproval.)• Signaturesanddates:requiredbyproducer(s).• Theproducermustbeappointedinthestatewheretheapplicationissigned.• IfanapplicationistakenonaKansasresident,theproducermustbeappointedinKansasandinthestatewhere

theapplicationissigned. NOTE:Applicant’ssignaturemustmatchnameofapplicantontheapplication.Inrarecaseswhereapplicant cannotsignhis/hername,amark(“X”)isacceptable.Fortheirownprotection,producersareadvised againstactingassolewitness.

HEALTH QUESTIONSUnlessanapplicationiscompletedduringopenenrollmentoraguaranteeissueperiod,allhealthquestions,includingtheques-tionregardingprescriptionmedications,mustbeanswered.OurgeneralunderwritingphilosophyistodenyMedicaresupple-mentcoverageifanyofthehealthquestionsareanswered“Yes”.Foralistofuninsurableconditionsandtherelatedmedicationsassociatedwiththeseconditions,pleaserefertothenexttwosectionsinthisguide.

Theremay,however,besituationswhereanapplicanthasbeenreceivingmedicaltreatmentortakingprescriptionmedica-tionforalong-standingandcontrolledhealthcondition.Thoseconditionsarelistedinhealthquestions12and14.

Aconditionisconsideredtobecontrollediftherehavebeennochangesintreatmentormedicationsforatleasttwoyears.Ifthissituationexistsandyouwouldlikeconsiderationtobegiventotheapplication,answertheappropriatequestion“Yes,”andattachanexplanationstatinghowlongtheconditionhasexistedandhowitisbeingcontrolled.Besuretoincludethenamesanddosagesofallprescriptionmedications.

Ifyouhavequestionsabouttheinterpretationofhealthquestion12ontheapplication,pleaseseetheinformationbelow.

Peoplewithdiabetes(insulindependentortreatedwithoralmedications)whoalsohaveoneormoreofthecomplicatingconditionslistedinquestion12ontheapplication,arenoteligibleforcoverage.Forpurposesofthisquestion,hyperten-sion(highbloodpressure)isconsideredaheartcondition.Someadditionalquestionstoaskyourclienttodetermineifhe/shedoeshaveacomplicationinclude:1. Doeshe/shehaveeye/visionproblems?2. Doeshe/shehavenumbnessortinglinginthetoesorfeet?3. Doeshe/shehaveproblemswithcirculation?Paininthelegs?Considerationforcoveragemaybegiventothosepersonswithwell-controlledcasesofhypertensionanddiabetes.Acaseisconsideredtobewellcontrolledifthepersonistakingnomorethantwooralmedicationsfordiabetesandnomorethantwomedicationsforhypertension.Acombinationofinsulinandoneoralmedicationwouldbethesameastwooralmedicationsifthediabeteswerewellcontrolled.Ingeneral,toverifystability,thereshouldbenochangesinthedosagesormedicationsforatleasttwoyears.Individualconsiderationwillbegivenwheredeemedappropriate.Weconsiderhypertensiontobestableifrecentaveragebloodpressurereadingsare150/85orlower.

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Uninsurable Health ConditionsApplicationsshouldnotbesubmittedifapplicanthasthefollowingconditions:

AIDS Diabetes (MN and WI only)

Alzheimer’s Disease Emphysema

ARC Kidney disease requiring dialysis

Any cardio-pulmonary disorder requiring oxygen Chronic kidney disease

Cirrhosis Kidney failure

Chronic hepatitis Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease)

Chronic Obstructive Pulmonary Disease (COPD) Lupus - Systemic

Other chronic pulmonary disorders to include: Multiple Sclerosis

Chronic bronchitis Myasthenia Gravis

Chronic obstructive lung disease (COLD) Organ transplant

Chronic asthma Osteoporosis with fracture

Chronic interstitial lung disease Parkinson’s Disease

Chronic pulmonary fibrosis Senile Dementia

Cystic fibrosis Other cognitive disorders to include:

Sarcoidosis Mild cognitive impairment (MCI)

Bronchiectasis Delirium

Scleroderma Organic brain disorder

Inadditiontotheaboveconditions,thefollowingwillalsoleadtoadecline:• Implantablecardiacdefibrillator• Useofsupplementaloxygen• Useofanebulizer• Asthmarequiringcontinuoususeofthreeormoremedicationsincludinginhalers• Takinganymedicationthatmustbeadministeredinaphysician’soffice• Advisedtohavesurgery,medicaltests,furtherdiagnosticevaluation,treatmentortherapy• Ifapplicant’sheight/weightisinthedeclinecolumnonthechart

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17*CoveragenotavailableforindividualswithdiabetesinMNandWI.

Partial List of Medications Associated with Uninsurable Health Conditions This list is not all-inclusive. An application should not be submitted if a client is taking any of the following medications:3TC AIDS *Insulin (MN and WI only) DiabetesAcetate Prostate Cancer Interferon AIDS, Cancer, HepatitisAlkeran Cancer Indinavir AIDSAmantadine Parkinson’s Disease Invega SchizophreniaApokyn Parkinson’s Disease Invirase AIDSAptivus HIV Kaletra HIVAricept Dementia Kemadrin Parkinson’s DiseaseArtane Parkinson’s Disease Lasix / Furosemide

(>60 mg/day) Heart DiseaseAtripla HIVAvonex Multiple Sclerosis L-Dopa Parkinson’s DiseaseAzilect Parkinson’s Disease Letairis Pulmonary HypertensionAZT AIDS Leukeran

Cancer,Immunosupression,Severe Arthritis

Baclofen Multiple SclerosisBCG Bladder CancerBetaseron Multiple Sclerosis Leuprolide Prostate CancerBicalutamide Prostate Cancer Levodopa Parkinson’s DiseaseCarbidopa Parkinson’s Disease Lexiva HIVCasodex Prostate Cancer Lioresal Multiple SclerosisCerefolin Dementia Lomustine CancerCogentin Parkinson’s Disease Lupron CancerCognex Dementia Megace CancerCombivir HIV Megestrol CancerComtan Parkinson’s Disease Mellaril PsychosisCopaxone Multiple Sclerosis Melphalan CancerCrixivan HIV Memantine Alzheimer’s Disease

Cytoxan

Cancer, Severe Arthritis,Immunosupression

Methotrexate (>25mg/wk) Rheumatoid ArthritisMetrifonate Dementia

D4T AIDS Mirapex Parkinson’s DiseaseDDC AIDS Myleran CancerDDI AIDS Namenda Alzheimer’s DiseaseDES Cancer Natrecor CHFDuoNeb COPD Navane PsychosisEldepryl Parkinson’s Disease Nelfinavir AIDSEmbrel Rheumatoid Arthritis Neoral

Immunosupression,Severe ArthritisEmtriva HIV

Epivir HIV Neupro Parkinson’s DiseaseEpogen Kidney Failure, AIDS Norvir HIVErgoloid Dementia Novatrone Multiple SclerosisExelon Dementia Paraplatin CancerFuzeon HIV Parlodel Parkinson’s DiseaseGalantamine Dementia Permax Parkinson’s DiseaseGeodon Schizophrenia Prednisone (>10 mg/day) Rheumatoid Arthritis, COPDGold Rheumatoid Arthritis Prezista HIVHaldol Psychosis Procrit Kidney Failure, AIDSHerceptin Cancer Prolixin PsychosisHydergine Dementia Razadyne DementiaHydrea Cancer Remicade Rheumatoid Arthritis

Hydroxyurea

Melanoma, Leukemia,Cancer

Reminyl DementiaRemodulin Pulmonary Hypertension

Imuran

Immunosupression,Severe Arthritis

Requip Parkinson’s DiseaseRescriptor HIV

MAILING APPLICATIONS TO PROSPECTSMailingacompletedapplicationaddsafewstepstothenormalsalesprocess.Belowisadescriptionofthenecessarysteps.The Facts When Face-to-face Interviews Aren’t Possible Face-to-faceinterviewsarealwayspreferable,however,therewillbetimeswhenyoucannotmeetwithprospectsinperson. Whennecessary,andwiththeprospect’sconsent,youmayconducttheinterviewoverthephoneandmailthecompleted applicationtotheprospect.* Thisoptionistobeusedonlywithpeoplewhohaverespondedtolead-generationmaterialorwithwhomyouhaveongoing clientrelationships.Itisnotappropriateforcoldcallingasnationalandcorporatedo-not-callrulesandothercompliance requirementsapply. The Sales Process

ThemethodforsellingMedicaresupplementsdoesn’tchange:Callalead,reviewcoverage,askforthesale,completeandsigntheapplication,submitthebusiness,deliverthepolicy.Thedifferenceisthatpartsofthesalesprocessmaybeconductedviathetelephoneinsteadofface-to-face.Consequently,thereareafewmoresteps,outlinedonthenexttwopages,tocompletethesale.

Improve Time Service Submittingcompleteandaccurateinformationensuresquicktimeservice.Otherfactorsare: • Youmustbelicensedtosellinthestatewheretheprospectisatthetimeofsolicitation;thatisthestatewherehe/sheis locatedwhenyouaskthequestionsontheapplication

• IfanapplicationistakenonaKansasresident,theproducermustbeappointedinKansasandinthestatewheretheapplicationissigned

• Theproducerwhosolicitsthebusinessmustsignthecorrespondingapplication • Youcannotsignblankapplications • Itisnotacceptabletomailblankapplications,brochuresandoutlinesasprospectingmaterial Spot Check for Customer Satisfaction ToensurethatcustomerswhocompleteMedicaresupplementapplicationsoverthephoneperceivethisprocessaspositive andthatit’sfollowedcorrectly,GPMLifewillcallaportionoftheseapplicantsto: • Verifythecontentandaccuracyoftheinformationsubmitted • Determinetheiroverallsatisfactionlevel • Confirmthatproducersfollowedthisprocess*AppliesonlytoGPMLifeMedicaresupplementproductsanddoesnotchangethecurrentunderwritingrequirementsforotherGPMLifeproducts.

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Partial List of Medications Associated with Uninsurable Health Conditions (continued)Retrovir AIDS Trelstar-LA Prostate CancerRebif Multiple Sclerosis Triptorelin Prostate CancerReyataz HIV Trizivir HIVRilutek Amyotrophic Lateral Sclerosis Truvada HIVRiluzole ALS Tysabri Multiple SclerosisRisperdal Psychosis Valycte CMV HIVRitonavir AIDS VePesid Cancer

SandimmuneImmunosupression,Severe Arthritis

Videx HIVVincristine Cancer

Selzentry HIV Viracept HIVSinemet Parkinson’s Disease Viramune AIDSStalevo Parkinson’s Disease Viread HIVStelazine Psychosis Zanosar CancerSustiva AIDS Zelapar Parkinson’s DiseaseSymmetrel Parkinson’s Disease Zerit HIVTacrine Dementia Ziagen HIVTasmar Parkinson’s Disease Ziprasidone SchizophreniaTeslac Cancer Zoladex CancerThiotepa Cancer Zometa Hypercalcemia in CancerThorazine Psychosis

The ProcessPleasecompletethefollowingstepswhenyouconducttheMedicaresupplementsalesinterviewover thephoneandmailthecompletedapplicationtotheprospect:

Step Action

1 Call the prospect who responded to a lead. Whenyoureceivealead,telephonethepersontodiscussthebenefits,ratesandanswerquestions. Attempttoscheduleaface-to-faceappointmenttoreviewdetails,askforthesaleandapplyforcoverage.

Iftheprospectpreferstocontinuethesalesprocessonthephone,continuetoStep2. Note:Youmustbelicensedtosellinthestatewheretheprospectisatthetimeofsolicitation;thatisthestatewherehe/sheislocatedwhenaskedthequestionsontheapplication.

2 Communicate the process. Iftheprospectwantscoverageandpreferstoapplyforapolicyoverthephoneinsteadofin person,explaintheprocessbeforeproceedingtoStep3: 1.Produceraskstheprospectthequestionsontheapplicationandrequiredforms. 2.Producermailsthecompletedapplicationandformstotheprospectforreviewandhis/hersignature. 3.Prospectcarefullyreviewstheapplicationandformsforcompletenessandaccuracyandsignsthem. 4.Prospectreturnstheapplication,formsandpremiumintheprovidedpostage-paidenvelope. 5.Producerverifiesalltherequiredformsarecompletedandsigned. 6.Producersubmitstheapplicationthroughyourusualchannel. 7.Whenissued,theproducerdeliversthepolicyaccordingtocurrentpolicydeliveryguidelines.

3 Complete the required forms over the telephone. Asktheprospectallthequestionsontheapplication,replacementnoticeandstatespecialforms (ifneeded)andprinttheanswers.Considerrepeatinghis/herresponsesforaccuracy.

Note:Privacyrequirementsprohibitdiscussingeligibilityforotherproductsoverthetelephone.

4 Mail forms to the prospect.

Placethefollowinginanenvelopeandmailtotheprospect:•Coverletter(attachyourbusinesscard): -Indicatingwhichformstosignandwhattoreturntoyou -Askingtheprospecttoverifyallinformationincludinghis/herMedicarecardnumber, tomakenecessarycorrectionsandinitialchanges -Invitingtheprospecttocontactyouwithanyquestions •Applicationandforms(replacementnoticeandstatespecialforms,ifneeded)withsignatureareasandpremiumhighlighted •OutlineofCoverage,Guide to Health Insurance for People with Medicare •Postage-paidaddressedenvelope

Note:Planavailabilityandpremiumratesarebasedonwhentheapplicationissigned.TheproducermustcommunicatechangesinplanavailabilityorpremiumtotheprospectbeforesubmittingtheformstoGPMLife.

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5 Prospect reviews and signs forms.

Oncetheprospectreceivestheapplicationandforms,he/she:•Verifiestheresponsesandinitialsanycorrections •Signstheapplicationandformsashighlighted •Returnstheapplicationandformstotheproducerintheprovidedenvelope

6 Verify and sign forms.

Whenyoureceivetheenvelopefromtheprospect,you: •Checkthatyouhavethefirstpremiumpaymentandthecompletedandsignedapplicationandforms •Verifythattheprospectinitialedanychanges •Signtherequireditems •SendthePremiumReceipttotheapplicant

Note:Theproducerwhosolicitedthebusinessmustsigntheapplication.

7 Submit for processing.

Submitthebusiness(applicationandforms)intheusualmanner.

8 Deliver the policy according to current policy delivery guidelines.

Questions? CallSalesSupport,1-866-754-5716.

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REQUIRED FORMSApplicationOnlycurrentMedicaresupplementapplicationsmaybeusedinapplyingforcoverage.Acopyofthecompletedapplica-tionwillbemadebyGPMLifeandattachedtothepolicytomakeitpartofthecontract.

TheagentisresponsibleforsubmittingcompletedapplicationstoGPMLife’sadministrativeoffice.

Producer Information PageProducers must include their name and Agent Writing Number or Social Security number. A maximum of two producers are allowed and they should indicate the commission percentage shares, which must total 100%. Commission Code is required only if the producer is not appointed or licensed or is changing bro-kerage firms.

Method of Payment FormComplete this required form regarding payment options and submit with all applications.

Premium Receipt and Notice of Information PracticesReceiptmustbecompletedandprovidedtoapplicantasreceiptforpremiumcollected.Noticemustbeprovidedtoap-plicant.

Replacement FormThereplacementformmustbesignedandsubmittedwiththeapplicationwhenreplacinganyMedicaresupplementorMedicareAdvantageapplication.Asignedreplacementnoticemustbeleftwiththeapplicant;asecondsignedreplace-mentnoticemustbesubmittedwiththeapplication.

InWisconsin,thereplacementformmustalsobecompletedwhenreplacinganyotherhealthinsurance. Agent or Witness Certification for Non-English Speaking and/or Reading ApplicantsIftheapplicantdoesnotspeakEnglish,thisformistobecompletedbytheagentifagentistranslatingorawitnessifawit-nessistranslating.Acopymustbesubmittedwiththeapplicationandacopyleftwiththeapplicant.

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STATE SPECIAL FORMS Formsspecificallymandatedbystatestoaccompanypointofsalematerial.

ArkansasDocumentation of Solicitation of Medicare Related Products form–Formmustbecompletedandretainedinagent’sfilefortheapplicant.ColoradoCommission Disclosure Form–ThisformistobecompletedbytheAgent,thensignedbytheAgentandApplicant.LeaveacopywiththeApplicantandretainacopyintheagent’sfilefortheapplicant.Guarantee Issue for Eligible Persons–ThisformistobeleftwiththeApplicant.FloridaFlorida Certification Form–ThisformistobecompletedbytheAgent,thensignedbytheAgentandApplicant.AcopymustbesubmittedwiththeapplicationandacopyleftwiththeApplicant.IllinoisMedicare Supplement Checklist–TheChecklistmustbecompletedandsubmittedwiththeapplicationandacopyleftwiththeapplicant.IowaImportant Notice before You Buy Health Insurance – TobeleftwiththeApplicant.KentuckyMedicare Supplement Comparison Statement–FormshouldbecompletedwhenreplacingaMedicaresupplementorMedicareAdvantageplanandsubmittedwiththeapplication.LouisianaYour Rights Regarding the Release and Use of Genetic Information–ThisformistobeleftwiththeApplicant.MarylandEligible Persons for Guarantee Issue and Open Enrollment–TobeleftwiththeApplicant.MinnesotaAgent Information Form–ThisformisbecompletedandsignedbytheAgentandleftwiththeapplicant.NebraskaSenior Health Counseling Notice–ThisformistobeleftwiththeApplicant.OhioSolicitation and Sale Disclosure–ThisformistobeleftwiththeApplicant.Pennsylvania Guarantee Issue and Open Enrollment Notice–TobeleftwiththeApplicant.South CarolinaDuplication of Insurance–FormshouldbecompletedandsubmittedwiththeapplicationwhenduplicatingMedicaresupplementinsurancewithotherhealthinsurance.TexasDefinition of Eligible Person for Guaranteed Issue Notice–Thisnoticemustbeprovidedtotheclient.WisconsinDisclosure of Other Health Insurance Sold to Applicant by Agent–TobecompletedandsignedbytheAgent,thensubmittedwiththeapplication.

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