Attachment 6I - Abbreviated Underwriting Application.pdf

Thank you for your interest in the Federal Long Term Care Insurance Program (FLTCIP). As you consider submitting an application for coverage, it is important for you to know that the FLTCIP may be undergoing some changes.

The U.S. Office of Personnel Management (OPM) currently contracts with John Hancock Life Insurance Company and Metropolitan Life Insurance Company, as the insurers for the FLTCIP.

Long Term Care Partners, a joint venture of John Hancock and MetLife, administers the Program.

The current contract ends on April 30, 2009.

OPM is in the process of selecting the insurer(s) for the next contract period. Under the next contract, benefits and/or premiums may change from what is outlined in the Information and Application Kit. Until the next contract is awarded, information about the next insurer(s) or changes in benefits and/or premiums will not be available. This may affect your decision to apply now.

What should I consider before I apply?

In addition to your own specific financial, family, and health situation, you should consider the following:

Your premiums may change under the next contract, whether you apply now or later.

If your application is approved, you would be charged at the current premium rates through at least April 30, 2009.

The next contract may offer different benefits or other options. OPM will provide sufficient information about any differences after contract award, so you can make an informed decision, should any decision be necessary.

There could be a different insurance company or companies providing the insurance under the next contract.

Premiums are based on your age when you submit your application. If you submit an application after your next birthday, your premiums will be based on that higher age.

Applications are underwritten. That means that certain medical conditions or combinations of conditions will prevent some people from being approved for coverage. If you are currently in good health, waiting to apply always carries the risk of developing a condition that may make you uninsurable.

If you are eligible to apply with abbreviated underwriting now, keep in mind your opportunity ends 60 days after your hire/eligibility date. If you want to apply after those 60 days and before the end of the current contract, you will have to apply with full underwriting, which requires you to answer more questions about your health status. The availability of any other opportunities to apply with abbreviated underwriting and the underwriting standards under the next contract will not be known until the next contract is awarded.

Important Notice

FOR APPLICANTS—PLEASE READ

Year

Sponsored by the U.S. Office of Personnel Management Administered by Long Term Care Partners, LLC Offered by John Hancock Life Insurance Company, Boston, MA Metropolitan Life Insurance Company, New York, NY

Abbreviated Underwriting Application Valid beginning March 1, 2007

This application is ONLY for persons who (1) are in the following groups AND (2) are applying WITHIN 60 days of becoming eligible for this Program.

• New/newly eligible current Employee • Spouse of a new/newly eligible current Employee • Newly married spouse of an eligible current Employee

All other eligible individuals CANNOT use this application and must use the Full Underwriting Application. Call us at 1-800-582-3337 or visit www.LTCFEDS.com/apply for the Full Underwriting Application.

Each eligible individual wishing to apply for coverage must complete a separate application.

For assistance, call 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557) or visit www.LTCFEDS.com/apply

New or newly eligible current Employee or current spouse Employee became eligible on ____/____/____ (date required)

(mm/dd/yy) Federal employee U.S. Postal Service employee Active member of the uniformed services D.C. Courts employee Other eligible employee (as specified on the Application Guide) Current spouse of a newly eligible Employee

Newly married spouse

Newly married spouse of an eligible current Employee.

I married on ____/____/____ (date required) (mm/dd/yy)

Note: Spouses who are also eligible current Employees can only use this application if they are newly eligible based on their own employment status.

This application is ONLY for the groups shown. Tell us which of these makes YOU an eligible individual and the date you became eligible. (Required: Please check only one.)

If you are unsure which of these makes YOU an eligible individual, please see the Application Guide for additional details. You can also contact us at the number below or visit us online at www.LTCFEDS.com/eligibility.

Gender Male Female Date of Birth / /

Social Security Number* – –

Check here if you DO NOT have a Social Security Number

* We use SSNs to obtain health information for underwriting purposes, during the claims process, and to process Payroll and Annuity/Pension deductions.

Home Phone ( _________ ) __________________________________

Work Phone ( _________ ) __________________________________

E-mail ________________________________________________________________

Mr. Mrs. Ms.

First Name

Street Address

Month Day

IMPORTANT: If you are the individual named on the address label affixed to the Rate Quote, remove the address label and place it below. If you do not have the label or if you are another eligible individual, please fill out the information below.

▲ (AFFIX LABEL HERE) ▲

M.I. Last Name

City

State/Territory

Country

ZIP/Foreign Postal Code

Personal InformationPart A

FED02061(0307) Page 1

Part B Answer These Questions First

1. YES NO Do you currently reside in, or has a health professional advised you to enter, a nursing home or any type of assisted living facility?

2. YES NO Are you currently receiving home health care services or attending adult day care?

3. YES NO Do you currently require or receive human help or supervision with any of these activities?

• Bathing • Toileting (getting to and using the toilet, completing hygiene-related functions after use) • Dressing

• Eating • Continence (changing protective undergarment, managing ostomy bag and catheter, completing hygiene-related functions) • Transferring yourself from bed to chair

Spouses who are not current Employees must also answer questions 8 and 9 in Part B.

If the answer to any of questions 1-3 above is “YES,” you are NOT eligible for any of the insurance options under this Program. You are eligible for a non-insurance service package providing access to care coordination and a discounted network of long term care providers and services. If you would like to receive information about this package, make sure that Part A and questions 1-3 in Part B are complete and mail this application.

Do not complete the rest of this application.

If the answer to each of questions 1-3 above is “NO,” please continue with questions 4-7 below.

4. YES NO Do you currently have, or have you ever been diagnosed with, or ever been treated for, any of the following conditions?

• Alzheimer’s Disease, Organic Brain Syndrome, or Dementia

• Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s Disease)

• Diabetes with amputation or ongoing complication affecting the kidney

• Multiple Sclerosis

• Muscular Dystrophy

• Parkinson’s Disease

• Schizophrenia

• Stroke (Cerebrovascular Accident): with residual impairment (e.g., paralysis, weakness, gait disturbance, vision disturbance, mental impairment)

• Stroke (Cerebrovascular Accident): multiple

• Stroke (Cerebrovascular Accident): within 5 years

• Transient Ischemic Attack (TIA): multiple

• Transient Ischemic Attack (TIA): within 3 years

5. YES NO Do you currently use any of the following medical devices, aids, or treatments (for any reason)?

• Hospital bed • Motorized scooter • Oxygen (excluding CPAP) • Stair lift

• Dialysis • Wheelchair • Walker

6. YES NO Do you currently require or receive human help or supervision with any of these activities because of mental retardation?

• Living independently • Taking medications • Shopping • Making decisions about your money • Preparing meals • Using transportation • Walking

7. YES NO Have you been diagnosed with any mental or nervous disorder for which you have been hospitalized in the past 2 years or for which you have had 3 or more hospitalizations in the past 10 years?

If the answer to any of questions 4-7 above is “YES,” you are NOT eligible for any of the insurance options under this Program shown in Part F of this application. You are eligible for an alternative insurance plan or a non-insurance service package providing access to care coordination and a discounted network of long term care providers and services. If you would like to receive information about these options, make sure that Part A and questions 1-7 in Part B are complete and mail this application. Do not complete the rest of this application.

If the answer to each of questions 4-7 above is “NO,” please continue with this application. If you are applying as the spouse of an eligible current Employee, complete questions 8 and 9 on the top of page 3.

We will review your answers to determine if we can offer coverage. Certain medical conditions, or combinations of conditions, will prevent some people from being approved for coverage.

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For Spouses Only If you are applying as the spouse of an eligible current Employee, please answer questions 8 and 9.

8. YES NO Do you currently require or receive human help or supervision with any of these activities?

• Preparing meals •Taking medications • Shopping

• Making decisions about your money •Using transportation • Walking

9. YES NO Do you use crutches and/or a multi-prong cane?

If the answer to questions 8 and/or 9 is “YES,” please explain below. Attach a separate piece of paper if necessary.

A registered nurse may call or visit you to get more information on your answers.

Part C Unlimited Benefit Period Medical Questions

Complete Part C ONLY if you are applying for the Unlimited Benefit Period. If you are applying for the Three Year or Five Year Benefit Periods, skip Part C and go to Part D.

Depending on your answers to the questions in Part C, you may receive a call from a registered nurse to conduct a telephone interview or to schedule an in-home interview. We may also request medical information from your health care provider(s).

1. YES NO Do you currently have, or have you ever been diagnosed with, or treated for, any of the following conditions?

• AIDS or AIDS-related complex • Cirrhosis (excluding Primary Biliary) • HIV

• Kidney failure • Mental retardation • Paraplegia or Quadriplegia

• Organ transplant (excluding cornea or bone marrow transplant)

If the answer to question 1 is “YES,” we cannot offer you the Comprehensive 150+ plan or the Unlimited Benefit Period. Please skip to Part D and continue.

If the answer to question 1 is “NO,” please complete questions 2-6. Based on your answers to questions 2-6, we will determine if you are eligible for the Unlimited Benefit Period. If we determine you are eligible for coverage, but not the Unlimited Benefit Period, you will receive the Five Year Benefit Period. If you wish to change your Benefit Period to the Three Year option or no longer want this insurance, please call us.

5. Within the last 10 years, have you had, been diagnosed with or been treated for any of the following conditions?

A. YES NO Stroke or Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Carotid Artery Disease

B. YES NO Peripheral Vascular Disease

C. YES NO Coronary Artery Disease (e.g., heart attack, angina), Heart Arrhythmia, Cardiomyopathy, Congestive Heart Failure, Aneurysm, Valvular Disease

D. YES NO Diabetes (excluding gestational diabetes)

E. YES NO Cancer (excluding basal cell cancer or squamous cell cancer of the skin)

F. YES NO Chronic Kidney Disease (e.g., nephritis)

G. YES NO Liver Disorder (e.g., hepatitis)

H. YES NO Any Psychiatric Disorder (e.g., depression, bipolar disorder)

2. YES NO Do you currently require or receive human help or supervision with any of these activities?

• Preparing meals • Taking medications • Shopping

• Making decisions about your money • Using transportation • Walking

3. YES NO Do you currently use crutches and/or a multi-prong cane?

4. YES NO Are you currently receiving disability income such as disability retirement annuity payments, VA disability compensation, workers’ compensation, any Federal or state disability payments, or any other type of disability payment?

FED02061(0307) Page 3

I. YES NO Disorder of the Brain (e.g., Huntington’s Chorea, tremor, seizure disorder, head injury, tumor, infection), Neuropathy, Syncope, Paralysis, any Chronic or Progressive Neurological Disorder

J. YES NO Chronic Lung Disease (e.g., COPD, emphysema, sarcoidosis, chronic bronchitis, asbestosis, asthma [excluding seasonal asthma], bronchiectasis, sleep apnea)

K. YES NO Memory Loss

L. YES NO Rheumatoid Arthritis, any other type of Arthritis, Osteoporosis, Back Disorder, Scoliosis, Spinal Stenosis, Disc Disease

M. YES NO Connective Tissue Disorder (e.g., scleroderma, systemic lupus, CREST syndrome)

N. YES NO Muscle Disorder (e.g., fibromyalgia, polymyalgia rheumatica, chronic fatigue syndrome)

If the answer to any of questions 2-5 is “YES,” explain below. If you need additional space, you can download a form from our website at www.LTCFEDS.com/supplement2, call us at 1-800-LTC-FEDS (1-800-582-3337) or attach a separate piece of paper.

Name, Address and Phone Number of Treating Health Professional

Date of Onset (mm/yy)

Date of Last Treatment (mm/yy)

Question # Diagnosis or Disorder

Phone ( _________ ) ________________________

Name ____________________________________

Address __________________________________

Phone ( _________ ) ________________________

Name ____________________________________

Address __________________________________

➧ 6. ■ ■ YES ■ ■ NO Have you taken any prescription medications over the past 6 months? If yes, please complete the “Medications” chart below.

Medications: List all prescription medications taken over the past 6 months. If you need additional space, you can download a form from our website at www.LTCFEDS.com/supplement2, call us at 1-800-LTC-FEDS (1-800-582-3337) or attach a separate piece of paper.

Name, Address and Phone Number of Prescribing Health Professional

Name of Medication Check box if taking currently

Dosage (e.g., 10 mg)

Frequency (e.g., 2 x a day)

Reason

Prescribed

Phone ( _________ ) ________________________

Name ____________________________________

Address __________________________________

Phone ( _________ ) ________________________

Name ____________________________________

Address __________________________________

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Part D Authorization to Use and Disclose Health Information

Applicant’s Signature X _______________________________________________ Date Signed _______ / _______ / _______ (Required) (Required mm/dd/yy)

Read and sign below only if the answer to question 8 or 9 in Part B is “YES” and/or if you are applying for the Comprehensive 150+ plan or the Unlimited Benefit Period and the answer to any of questions 2-6 in Part C is “YES.”

For the purposes of the Federal Long Term Care Insurance Program (including underwriting, claims, and customer service), I authorize any licensed health care practitioner, medical facility, employer, insurance company, or any other entity or person that has any health information about me to give that health information to Long Term Care Partners, LLC, John Hancock Life Insurance Company, Metropolitan Life Insurance Company, their reinsurers, and/or their subcontractors that need to know health information to provide contracted services.

The health information I am permitting to be disclosed and used for the Federal Long Term Care Insurance Program includes any information on my medical history, and the diagnosis, prognosis and treatment of any physical or mental condition. It includes the disclosure of any medical care or surgery, psychiatric or psychological care or examinations, and information about alcohol or drug use (including any information otherwise protected by Federal Regulations 42 CFR Part 2 or other applicable laws). I understand that this authorization includes my consent to use and disclose medical information that relates to mental illness, HIV, AIDS, HIV-related illness and sexually transmitted diseases or other serious communicable diseases, but only in accordance with any law or regulation that applies to any such disclosure of this information about me.

I understand that:

• If I do not sign this authorization, my application for long term care insurance may not be processed and any claim for long term care insurance benefits may be denied.

• I may revoke this authorization at any time, except to the extent that:

– action has already been taken in reliance on it before my revocation, or

– Long Term Care Partners or my insurer has a right to contest my long term care insurance claim or coverage.

• To revoke this authorization I must notify Long Term Care Partners, LLC, P.O. Box 797, Greenland, NH 03840-9803, in writing.

• If I do revoke this authorization, I understand that my application for long term care insurance may not be processed and any claim for long term care insurance benefits may be denied.

• If I do not revoke this authorization, it will be valid for 24 months from the date I sign it.

• My health information may be redisclosed and no longer protected by applicable law, including federal health information priva cy regulations. This can occur only if such redisclosure is required or allowed by law (for example, in response to a subpoena).

• A copy of this authorization is as valid as the original.

Have you signed and dated the authorization in Part D above, if required as noted in the instructions above? We cannot process this application without your signature and date.

Part E Your Primary Physician Information

Check here if you do not have a Primary Physician or Health Care Practitioner OR if you have NOT seen the person listed above during the last two years.

Phone ( _______________ ) _______________________________________

Primary Physician or Health Care Practitioner’s First Name

Please provide the following information only if the answer to question 8 or 9 in Part B is “YES” and/or if you are applying for the Unlimited Benefit Period or the Comprehensive 150+ Plan and the answer to any of questions 2-6 in Part C is “YES.”

Last Name

Street Address

City Country

State/Territory ZIP/Foreign Postal Code

FED02061(0307)

Optional Weekly Benefit — Check here if you have selected the Comprehensive Option in Question 1 above, and would prefer a weekly benefit equal to (7x) the Daily Benefit Amount. This feature is available at an additional cost.

Part F Choose a Pre-packaged Plan OR Customize a Plan You can choose EITHER a pre-packaged plan OR customize your own plan. Do NOT choose both. If you choose the Comprehensive 150+ plan or the Unlimited Benefit Period, please make sure you complete Parts C and D. If the answer to Question 1 in Part C is “YES,” you are not eligible for the Comprehensive 150+ plan or the Unlimited Benefit Period. If you have any questions about options or premiums, please refer to Book 1– Program Details and Rates or call us at 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557) or visit us online at www.LTCFEDS.com/apply.

Choose a Pre-packaged Plan OR Customize a Plan

1. Choose a Pre-packaged Plan

Facilities 100 Daily Benefit Amount: $100 Benefit Period: 3 Years Waiting Period: 90 Days

Comprehensive 100 Daily Benefit Amount: $100 Benefit Period: 3 Years Waiting Period: 90 Days

Comprehensive 150 Daily Benefit Amount: $150 Benefit Period: 5 Years Waiting Period: 90 Days

Comprehensive 150+ Daily Benefit Amount: $150 Benefit Period: Unlimited Waiting Period: 90 Days

2. Choose an Inflation Protection Option

Automatic Compound Inflation Option

Future Purchase Option

1. Choose a Plan Type Comprehensive Facilities-Only

2. Choose a Daily Benefit Amount

$50 $75 $100 $125 $150 $175

$200 $225 $250 $275 $300

3. Choose a Benefit Period

3 Years 5 Years Unlimited

4. Choose a Waiting Period

30 Days 90 Days

5. Choose an Inflation Protection Option

Automatic Compound Inflation Option

Future Purchase Option

Have you chosen a pre-packaged plan OR customized a plan? Have you chosen an Inflation Protection Option even if you chose a pre-packaged plan? If you customized a plan, have you answered all five sections?

We cannot process this application if you leave any of these answers blank.

Part G Replacement Coverage Questions

Please answer the following questions about replacement of existing coverage. Federal law requires that we ask you these questions. Your answers to these questions will NOT affect your eligibility for insurance under the Federal Long Term Care Insurance Program. You should not replace any existing medical or health insurance coverage with the Federal Long Term Care Insurance Program. These are different types of insurance that cover different types of care.

1. Medicaid is the state/Federal program that helps pay medical costs for some people with low incomes and limited resources. It is known as Medi-Cal in California. Please note that Medicaid is NOT the same as Medicare.

YES NO Are you covered under Medicaid? If you answer “YES,” you may wish to carefully consider whether you really need long term care insurance.

2. If you currently have a long term care insurance policy or certificate, you should compare its benefits and costs with the benefits and costs of the Federal Long Term Care Insurance Program. It may or may not make sense for you to replace that policy or certificate with coverage under this Program. You should be certain that you are making an informed decision, and certainly should not cancel any long term care insurance you currently have unless/until your coverage under this Program is effective.

YES NO Are you replacing another long term care insurance policy or certificate currently in force with cover age under the Federal Long Term Care Insurance Program? If you answer “yes,” we are required to notify your current insurance carrier that you have applied for coverage under this Program. If you answer “YES,” please provide the following information:

Policy #

Insurance Company Name

Insurance Company Street Address

City, State and Zip Code

Page 6 FED02061(0307)

Part H Choose One Billing Option

Someone Else’s Pay or Annuity/Pension — If you are requesting that deductions be taken from someone else’s pay or annuity/pension, that Employee or Annuitant must complete this section and sign the authorization below:

Choose One:

Office Identifier 2 4 9 0 0 0 0 2

Choose One:

(Insert A, F or I below and fill in the remaining 7 or 8 digits/characters) Choose One:

Office Identifier 2 4 9 0 0 0 0 2

My Pay or Annuity/Pension — I authorize Long Term Care Partners to deduct premiums from my pay or annuity/pension. I have provided my Social Security Number on page 1 of this application.

OR

OR

OR

If you are approved for coverage and you do not choose a billing option or fill out this Part completely, you will be billed directly.

For assistance with completing this page, please call us at 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557).

Please send me a direct bill monthly to the address I provided on page 1 of this application.

DIRECT BILL

CSRS/FERS Annuity Deductions: CS , All Payroll or other Annuity/Pension Deductions: Office Identifier (4-8 Digits/Characters)

(Insert A, F or I below and fill in the remaining 7 or 8 digits/characters)

I authorize Long Term Care Partners to deduct from my pay or annuity/pension that amount necessary to pay the premiums for the Federal Long Term Care Insurance Program coverage for this applicant.

Signature of Payor X ____________________________________________________ Date Signed _____ / /

(Required) (Required mm/dd/yy)

A.

B.

C. Payor’s Social Security Number – –

Payor’s First Name, Middle Initial, Last Name

Payor’s Street Address

City, State and Zip Code OR Country and Foreign Postal Code

Mr. Mrs. Ms.

CSRS/FERS Annuity Deductions: CS , All Payroll or other Annuity/Pension Deductions: Office Identifier (4-8 Digits/Characters)

PAYROLL OR ANNUITY/PENSION DEDUCTION

You can find Annuity/Pension or Payroll Office Identifiers on the Application Guide, online at www.LTCFEDS.com/payroll or by calling 1-800-LTC-FEDS (1-800-582-3337). Due to timing issues, please be aware that there is usually a short delay before your payroll or annuity/pension deductions begin. You may receive a direct bill for any outstanding premiums resulting from a delay.

I authorize Long Term Care Partners to initiate automatic bank withdrawals from the account number provided on my voided check or savings deposit slip. Withdrawals will begin the month after I am approved and will continue on the third business day of every month. I understand that any past due premium will be collected by withdrawing up to 2 months of premium from my account until current.

Depositor’s Signature X __________________________________________________ Date Signed ____ / / (Required) (Required mm/dd/yy)

CHECKING: You must attach a Voided Check (Do not attach a checking deposit slip). We do not accept money market accounts.

SAVINGS: You must attach a Voided Savings Deposit Slip that lists a 9-digit routing number.

AUTOMATIC BANK WITHDRAWAL

FED02061(0307) Page 7

Part J Agreement and Acknowledgement

Applicant’s Signature X _______________________________________________ Date Signed _______ / _______ / _______ (Required) (Required mm/dd/yy)

Part I Protection Against Unintended Lapse It is a good idea to designate at least one person living outside of your household to receive notice if your insurance coverage is about to lapse because Long Term Care Partners did not receive your premiums. Note: This person will NOT be responsible for paying your premiums. The person you designate can help find out why you stopped paying premiums. We will not contact this person until 45 days after a premium was due and is unpaid. Would you like to name a person in addition to yourself to receive notice if your insurance coverage is about to lapse because we did not receive your premiums? You must indicate Yes or No.

Yes, please contact the individual listed below. No, I reject this offer.

If “YES,” please provide all information requested.

Mr. Mrs. Ms.

First Name Last Name

Street Address

City Country

State/Territory ZIP/Foreign Postal Code

Phone ( _______________ ) _______________________________________

I am applying for insurance coverage under the Federal Long Term Care Insurance Program. All of the answers and explanations I’ve given on this application, including my status as an eligible individual on page 1, are true and complete. I understand that the decision to approve my application will be based on my answers and explanations on this application. If required, my medical records or answers to interview questions will also be considered.

I agree to immediately inform Long Term Care Partners, in writing, if between the date I sign this application and the date my insurance coverage is effective: (1) my health changes in a way that would cause any answer I've given on this application to no longer be correct, or (2) I receive any medical advice or treatment from a physician or other health care practitioner for a condition that would affect an answer to any question on this application.

I understand that Long Term Care Partners may use information about such health changes or medical advice or treatment, whether provided by me or otherwise obtained, to re-evaluate my application for coverage. I further understand that my coverage will not go into effect as scheduled or will be voided if the information, if known previously, would have caused the carrier not to issue my coverage.

Active members of the uniformed services: I understand that if my application is approved, I must be on active duty and physically able to perform the duties of my position on the effective date of my insurance coverage for it to take effect.

Other eligible current Employees: I understand that if my application is approved, I must be actively at work for at least one-half of my regularly scheduled hours on the effective date of my insurance coverage for it to take effect.

I understand I have the right to request a copy of this application at any time, but I also understand I will receive one automatically.

Caution: If you are approved for coverage, but you shouldn’t have been because one or more of your answers or explanations are incorrect, untrue, or fails to include all material information requested, we may have the right to deny benefits or rescind your insurance even if you did not knowingly misrepresent the facts as shown in your medical records.

NOTE: Your signature below also confirms the elections you made in Part F (Inflation Protection), Part H (Billing Options) and Part I (Protection Against Unintended Lapse).

• If you rejected Automatic Compound Inflation Protection in Part F by choosing the Future Purchase Option, you are confirming that you reviewed the descriptions and graphs of the Inflation Protection Options in the Outline of Coverage. You also understand that if you elect the Automatic Compound Inflation Option, you may switch to the Future Purchase Option at any time, and if you elect the Future Purchase Option, you may switch to the Automatic Compound Inflation Option under certain circumstances.

• If you elected Automatic Bank Withdrawal in Part H, you are authorizing your bank to charge your account for such withdrawals, payable to Long Term Care Partners. This authorization will remain in effect until either you, your bank or Long Term Care Partners terminates it by a thirty (30) day written notice to the others. You will not receive any bills or other notices of the withdrawals from Long Term Care Partners. You agree that if the automatic bank withdrawal is not honored by your bank, for whatever reason, Long Term Care Partners will have no liability for the payments.

• If you elected Payroll or Annuity/Pension Deduction from your own pay or annuity/pension in Part H, you are authorizing Long Term Care Partners to deduct from your pay or annuity/pension the amount necessary to pay the premiums for the Federal Long Term Care Insurance coverage issued to you. If you elect Payroll Deduction, then we reserve the right to deduct from your annuity/pension or direct bill you the amount necessary to pay the premiums upon your retirement. Your Payroll or Annuity/Pension Deduction may be cancelled by notice to Long Term Care Partners.

• If you did not name someone in Part I to receive a notice if your coverage is about to lapse, you are confirming that you understand that such notices do not obligate such person in any way and are not sent until 45 days after your premium was due but unpaid. You also understand that you may identify a person (and/or name a different person) to receive notice of pending lapse at any time in the future.

Have you signed and dated the Agreement and Acknowledgement in Part J above? We cannot process this application without your signature and date.

MAIL TO: Long Term Care Partners, P.O. Box 797, Greenland, NH 03840-9803 For assistance, call 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557) or visit www.LTCFEDS.com/apply

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