A Policy Checklist

Section 2008.APPENDIX A  Policy Checklist Applicant's Name Policy Number Name of Existing Insurer Expiration Date of Existing Insurance SERVICE BENEFIT MEDICARE PAYS EXISTING COVERAGE SUPPLEMENT PAYS YOU PAY Hospital Inpatient First 60 Days All But ($        ) 61 st to 90 th Day All But ($        ) a Day 91 st to 150 th Day (Lifetime Reserve) ($        ) a Day Beyond 150 Days Nothing Skilled Nursing Home Care First 20 Days Additional 80 Days 100% of Cost All But ($        ) A Day Beyond 100 Days Nothing Medical Expense Physician's Services in hospital, office or home, inpatient and out-patient medical services and supplies at a hospital, physical and speech therapy and ambulance 80% of Medicare Determined allowable charges after ($              ) Deductible Prescription Drugs Inpatient Prescription Drugs.  80% of allowable charges for immunosuppressive drugs during the first year following a covered transplant. This policy does/does not comply with the minimum standards set forth in Section 363 of the Illinois Insurance Code. DATE SIGNATURE OF APPLICANT SIGNATURE OF INSURANCE PRODUCER