M Long-Term Care Insurance Partnership Certification Form

Section 2012.EXHIBIT M   Long-Term Care Insurance Partnership Certification Form Long-Term Care Insurance Partnership Certification Form NOTE:  This Form must be completed and submitted with each long-term care policy or certificate form for which the insurer is seeking Partnership qualification.  A separate form must be completed for each policy form and a specimen copy of the form, including all riders and endorsements, must be attached.  A long-term care insurance policy or certificate form may not be issued in Illinois as a partnership policy or certificate unless and until this form has been submitted to and approved by the Illinois Department of Insurance. Under section 1917(b)(5)(B)(iii) of the Social Security Act (42 USC 1396p(b)(5)(B)(iii)), the state insurance commissioner of a state implementing a qualified state long-term care insurance partnership ("Qualified Partnership") may certify that long-term care insurance policies (including certificates issued under a group insurance contract) covered under the Qualified Partnership meet certain consumer protection requirements, and policies so certified are deemed to satisfy those requirements.  These consumer protection requirements are set forth in section 1917(b)(5)(A) of the Social Security Act (42 USC 1396p(b)(5)(A)) and principally include certain specified provisions of the Long-Term Care Insurance Model Regulation and Long-Term Care Insurance Model Act promulgated by the National Association of Insurance Commissioners (as adopted as of October 2000) (referred to herein as the "2000 Model Regulation" and "2000 Model Act", respectively). I.          GENERAL INFORMATION A.        Name, address and telephone number of issuer: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ B.        Name, address, telephone number, and email address (if available) of an employee of issuer who will be the contact person for information relating to this form: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ C.        Policy form numbers (or other identifying information, such as certificate series) for policies covered by this Issuer Certification Form: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Specimen copies of each of the above policy forms, including any riders and endorsements, shall be provided upon request. II.        QUESTIONS REGARDING APPLICABLE PROVISIONS Please answer each of the questions below with respect to the policy forms identified in section I.C above.  For purposes of answering the questions below, any provision of the 2000 Model Regulation or 2000 Model Act listed below shall be treated as including any other provision of the 2000 Model Regulation or 2000 Model Act necessary to implement the provision. NAIC Model Regulation Requirement Identify Policy Page # and Provision OR use this space to explain if requirement is inapplicable Section 6A (relating to guaranteed renewal or noncancellability), other than paragraph (5), and the requirements of Section 6B of the 2000 Model Act relating to Section 6A Section 6B (relating to prohibitions on limitations and exclusions), other than paragraph (7) Section 6C (relating to extension of benefits) Section 6D (relating to continuation or conversion of coverage) Section 6E (relating to discontinuance and replacement of policies) Section 7 (relating to unintentional lapse) Section 8 (relating to disclosure), other than Sections 8F, 8G, 8H and 8I Section 9 (relating to required disclosure of rating practices to consumer) Section 11 (relating to prohibitions against post-claims underwriting) Section 12 (relating to minimum standards) Section 14 (relating to application forms and replacement coverage) Section 15 (relating to reporting requirements) Section 22 (relating to filing requirements for marketing) Section 23 (relating to standards for marketing), including inaccurate completion of medical histories, other than paragraphs (1), (6) and (9) of Section 23C Section 24 (relating to suitability) Section 25 (relating to prohibition against pre-existing conditions and probationary periods in replacement policies or certificates) Section 26 (relating to contingent nonforfeiture benefits, if the policyholder declines the offer of a nonforfeiture provision described in section 7702B(g)(4) of the Internal Revenue Code of 1986 (26 USC 7702B(g)(4)) Section 29 (relating to standard format outline of coverage) Section 30 (relating to requirement to deliver shopper's guide) NAIC Model Act Requirements Identify Policy Page # and Provision OR use this space to explain if requirement is inapplicable Section 6C (relating to pre-existing conditions) Section 6D (relating to prior hospitalization) Section 8 (relating to contingent nonforfeiture benefits) Section 6F (relating to right to return) Section 6G (relating to outline of coverage) Section 6H (relating to requirements for certificates under group plans) Section 6J (relating to policy summary) Section 6K (relating to monthly reports on accelerated death benefits) Section 7 (relating to incontestability period) Part III.  INFLATION PROTECTION Identify the policy provision or provide form number of endorsement or amendment form (and date of approval) for inflation protection coverage in compliance with 50 Ill. Adm. Code 2012.145(b)(1) through (b)(3). ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Part IV.  Certification I hereby certify that the answers, accompanying documents, and other information set forth herein are, to the best of my knowledge and belief, true, correct and complete and the policy [certificate] satisfies the requirements necessary for a qualified State long-term care insurance partnership policy in the State of Illinois. __________________                  _____________________________________________ Date                                              Name and Title of Officer of the Insurer ____________________________________________ Signature of Officer of the Insurer