69O-156.106. Certification Form Required

It shall be the responsibility of each agent directly soliciting a policy of Medicare supplemental insurance to complete a form as indicated by Exhibit “A” herein. Substantially equivalent forms may be adopted with the prior approval of the Director. The original copy of such form shall be furnished to the applicant upon the taking of the application and a copy shall be maintained in the files of the company for a period of three years. “EXHIBIT A” CERTIFICATION I, the undersigned insurance agent certify: THAT, I have taken an application for Policy Form No. ________ offered by the ________ (Name of Insurance Company) to ________ (Applicant). THAT, I have explained the provisions of the policy being applied for, including specifically, all the different benefits, exceptions and limitations of the plan. THAT, I am a licensed agent of this insurance company and have given a company receipt for an initial premium in the amount of $________ (Insert zero if no premium received) which has been paid to me by () Check () Cash () Money Order (Check appropriate method of payment). THAT, I have clearly explained any benefits of this plan are a supplement to any benefits that the applicant may be entitled to receive from the Medicare Program of the Federal Government. THAT, I have not made any representation to the applicant that there is any endorsement whatsoever by the Social Security Administration or the Health Care Financing Administration of the Federal Government in connection with this insurance policy being applied for. ________ ____________________________ Date Signature of Agent ________________________________ ____________________________ I, the undersigned Name of Agency applicant, have received a copy of this form ____________________________ Address of Agent or Agency ________________________________ ________ Applicant’s Phone No. signature Rulemaking Authority 624.308(1), 626.9611, 626.9641 FS. Law Implemented 624.307(1), 626.830, 626.9541(1), (2), (3), (5), (11), (12), 626.9641(1)(a), (c), (e), (h) FS. History–New 7-1-79, Formerly 4-46.04, 4-46.004, 4-156.106.