“THE NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND SICKNESS OR LONG TERM CARE INSURANCE”
According to (your application) (information you have furnished), you intend to lapse or otherwise terminate existing accident and sickness or Long Term Care Insurance and replace it with Long Term Care Insurance coverage to be issued by (company name) Insurance Company. Your new coverage provides thirty (30) days within which you may decide, without cost, whether you desire to keep the coverage. For your own information and protection, you should be aware of and seriously consider certain factors that may affect the insurance protection available to you under new coverage.
(1) Health conditions which you may presently have (pre-existing conditions), may not be immediately or fully covered under the new coverage. This could result in denial or delay in payment of benefits under the new coverage, whereas a similar claim might have been payable under your present coverage.
(2) You may wish to secure the advise of your present insurer or its agent regarding the, proposed replacement of your present coverage. This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage.
(3) If, after due consideration, you still wish to terminate your present coverage and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund you premium as though your coverage had never been in force. After the application has been completed and before you sign it, reread it carefully to be certain that all the information has been properly recorded. The above “Notice to Applicant” was delivered to me on:
Date _______________Applicant’s Signature _______________________________________________
COMPARISON TO YOUR CURRENT COVERAGE:
I have reviewed your current long term care coverage. To the best of my knowledge, the replacement of insurance involved in this transaction materially improves your position for the following reasons:
Additional or different benefits (please specify)
______No change in benefits, but lower premiums
______Fewer benefits and lower premiums
______Other (please specify)
__________________________________ _______________________________________________
Signature of Agent and Name of Insurer Signature of Applicant
Date_____________
For group coverage not subject to the 30-day return provision, the notice shall be modified to reflect the appropriate time period in which the policy may be resumed and premium refunded.
The commissioner shall define inappropriate replacement of Long Term Care Insurance in consultation with other interested parties.
Insurers using direct response solicitation methods shall deliver a notice regarding replacement of accident and sickness or long term care coverage to the applicant upon issuance of the policy or certificate. The required notice shall be provided in the following form:
“THE NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND SICKNESS OR LONG TERM CARE INSURANCE”
According to (your application) (information you have famished), intend to lapse or otherwise terminate existing accident and sickness or Long Term Care Insurance and replace it with Long Term Care Insurance coverage delivered herewith issued by (company name) Insurance Company. Your new coverage provides thirty (30) days within which you may decide, without cost, whether you desire to keep the coverage. For your own information and protection, you should be aware of and seriously consider certain factors that may affect the insurance protection available to you under new coverage.
(1) Health conditions which you may presently have (pre-existing conditions), may not be immediately or fully covered under the new coverage. This could results in denial or delay in payment of benefits under the new coverage, whereas a similar claim might have been payable under your present coverage.
(2) You may wish to secure the advise of your present insurer or its agent regarding the, proposed replacement of your present coverage. This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage.
(3) (To be included only if the application is attached to the policy or certificate) If, after due consideration, you still wish to terminate your present coverage and replace it with new coverage, read the copy of the application attached to your new coverage and be sure that all questions are answered truthfully and correctly. Omissions or misstatements in the application could cause an otherwise valid claim to be denied. Carefully check the application and write to (company name and address) within 30 days if any information is not correct and complete, or if any past medical history has been left out of the application.
Company Name