Replacement

(a) Application forms shall include the following questions designed to elicit information as to whether, as of the date of the application, the applicant has another short term care or long term care policy or certificate in force or whether a short term care policy is intended to replace any other accident and sickness, short term care, or long term care policy or certificate presently in force. A supplementary application or other form to be signed by the applicant and producer, except where the coverage is sold without a producer, containing such questions may be used. (1) Do you have a long term care or another short term care insurance policy or certificate in force (including a health care service contract or health maintenance organization contract)? (2) Did you have a long term care or another short term care insurance policy or certificate in force during the last twelve (12) months? If so, with which company? If that policy lapsed, when did it lapse? (3) Are you covered by Medicaid? (4) Do you intend to replace any of your medical or health insurance coverage with this policy? (b) Agents shall list any other health insurance policies they have sold to the applicant. (1) List policies sold that are still in force. (2) List policies sold in the past five (5) years that are no longer in force. (c) Solicitations Other than Direct Response. Upon determining that a sale will involve replacement, an insurer, other than an insurer using direct response solicitation methods, or its agent shall furnish the applicant, prior to issuance or delivery of the individual short term care policy, a notice regarding replacement of accident and sickness, short term care or long term care coverage. One copy of such notice shall be retained by the applicant and an additional copy signed by the applicant shall be retained by the insurer. The required notice shall be provided in the following manner: NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND SICKNESS, SHORT TERM CARE OR LONG TERM CARE INSURANCE (Insurance company’s name and address) SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE. According to (your application) (information you have furnished), you intend to lapse or otherwise terminate existing accident and sickness, short term care or long term care insurance and replace it with an individual short term care insurance policy to be issued by (company name) Insurance Company. Your new policy provides thirty (30) days within which you may decide, without cost, whether you desire to keep the policy. 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 the new policy. You should review this new coverage carefully, comparing it with all accident and sickness, short term care or long term care insurance coverage you now have, and terminate your present coverage only if, after due consideration, you find that purchase of this short term care policy is a wise decision. STATEMENT TO APPLICANT BY AGENT (PRODUCER OR OTHER REPRESENTATIVE) (Use additional sheets, as necessary.) I have reviewed your current medical or health insurance coverage. I believe the replacement of insurance involved in this transaction materially improves your position. My conclusion has taken into account the following considerations that I call to your attention: 1. Health conditions that you may presently have (pre-existing conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay in payment of benefits under the new policy, whereas a similar claim might have been payable under your present policy. 2. State law provides that your replacement policy may not contain new pre-existing conditions or probationary periods. The insurer will waive any time periods applicable to pre-existing conditions or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy. 3. If you are replacing existing short term care or long term care insurance coverage, you may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. 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. 4. If, after due consideration, you still wish to terminate your present policy 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 your premium as though your policy had never been in force. After the application has been completed and before you sign it, reread it carefully to be certain that all information has been properly recorded. (Signature of Agent, Producer or Other Representative) (Typed Name and Address of Agent, Producer or Other Representative) The above "Notice to Applicant" was delivered to me on: (Date)____________________________________ (Applicant's Signature)_______________________ (d) Direct Response Solicitations. Insurers using direct response solicitation methods shall deliver a notice regarding replacement of accident and sickness, short term care or long term care coverage to the applicant upon issuance of the policy. The required notice shall be provided in the following manner: NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND SICKNESS, SHORT TERM CARE OR LONG TERM CARE INSURANCE (Insurance company’s name and address) SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE. According to (your application) (information you have furnished), you intend to lapse or otherwise terminate existing accident and sickness, short term care or long term care insurance and replace it with the short term care insurance policy delivered herewith issued by (company name) Insurance Company. Your new policy provides thirty (30) days within which you may decide, without cost, whether you desire to keep the policy. 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 the new policy. You should review this new coverage carefully, comparing it with all accident and sickness, short term care or long term care insurance coverage you now have, and terminate your present policy only if, after due consideration, you find that purchase of this short term care coverage is a wise decision. 1. Health conditions that you may presently have (pre-existing conditions), may not be immediately or fully covered under the new policy. This could result in denial or delay in payment of benefits under the new policy, whereas a similar claim might have been payable under your present policy. 2. State law provides that your replacement policy may not contain new pre-existing conditions or probationary periods. Your insurer will waive any time periods applicable to pre-existing conditions or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy. 3. If you are replacing existing short term care or long term care insurance coverage, you may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. 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. 4. (To be included only if the application is attached to the policy.) If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, read the copy of the application attached to your new policy and be sure that all questions are answered fully 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 thirty (30) days of receiving the policy if any information is not correct and complete, or if any past medical history has been left out of the application. (Company Name)____________________________________________ (e) Where replacement is intended, the replacing insurer shall notify, in writing, the existing insurer of the proposed replacement. The existing policy shall be identified by the name of the existing insurer, name of the insured and policy number or address including zip code. Such notice shall be made not later than five (5) working days after the date the application is received by the insurer or the date the policy is issued, whichever is sooner.