Attachment 6K - Coverage Change Application.pdf

Day 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

Coverage Change Application Valid beginning March 1, 2008

This application is ONLY for persons who are currently enrolled in the Federal Long Term Care Insurance Program and wish to apply for a change in coverage. All other eligible individuals applying for coverage CANNOT use this application and must use the Full Underwriting Application or the Abbreviated Underwriting Application, depending on eligibility. Call us at 1-800-582-3337 or visit www.LTCFEDS.com/apply for a Full or Abbreviated Underwriting Application.

▲ (AFFIX LABEL HERE) ▲

Part A Personal Information Each enrollee wishing to apply for a change in current coverage must complete a separate application.

Coverage Change Options Please indicate the change(s) in coverage that you wish to make. If you do not indicate a change in a plan feature, your current coverage for that plan feature will remain in effect. For example, if you only want to change your Plan type, complete item #1, and leave #2-6 blank. If any single change you request is an increase in coverage, your request will be subject to medical underwriting.

Date of Birth / /

Social Security Number or ID# We Gave You

(Required)

Month

Home Phone ( _________ ) __________________________________

Work Phone ( _________ ) __________________________________

E-mail ________________________________________________________________

Mr. Mrs. Ms.

First Name

Street Address

M.I. Last Name

City

State/Territory

Country

ZIP/Foreign Postal Code

Change My Coverage to: You are applying for an increase in coverage if:

1. Plan Type Facilities-Only Comprehensive You currently have Facilities-Only and want to change to Comprehensive.

2. Daily Benefit Amount (DBA) $50 $75 $150 $175 $250 $275

$100 $125 $200 $225 $300

You choose a DBA higher than your current amount.

3. Daily or Weekly Benefit Daily Weekly You currently have a Daily Benefit and want to change to a Weekly Benefit.

4. Benefit Period 3 Years

Unlimited

5 Years You currently have 3 Years and want to change to 5 Years or Unlimited OR you currently have 5 Years and want to change to Unlimited.

5. Waiting Period 90 Days 30 Days You currently have 90 Days and want to change to 30 Days.

6. Inflation Protection Option Future Purchase Option

Automatic Compound Inflation Option

You currently have Future Purchase Option and want to change to Automatic Compound Inflation Option.

If you are applying for: Any increase in coverage, complete Parts B through G.

Only a decrease in coverage, go directly to Part G. Do not complete Parts B through F.

You may also call us at the number below to decrease your coverage.

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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Part B Answer These Questions First

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

YES1. 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?

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

• AIDS, AIDS-related Complex or HIV

• Multiple Sclerosis • Stroke (Cerebrovascular

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

• Muscular Dystrophy

• Alzheimer’s Disease, Organic

Brain Syndrome, or Dementia

• Organ Transplant (excluding kidney, bone marrow or cornea transplants) • Amyotrophic Lateral Sclerosis

(ALS or Lou Gehrig’s Disease) • Parkinson’s Disease

• Cirrhosis (excluding

Primary Biliary)

• Schizophrenia • Transient Ischemic Attack

(TIA): multiple

• Paraplegia or Quadriplegia

• Diabetes with amputation or ongoing complication affecting the kidney

• Stroke (Cerebrovascular Accident): multiple

• Transient Ischemic Attack (TIA): within 3 years

• Stroke (Cerebrovascular Accident): within 5 years • Huntington’s Chorea

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 • Multi-prong cane

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

If the answer to any of questions 1-6 above is “YES,” you are NOT eligible for an increase in coverage under this Program. Do not complete the rest of this application.

If the answer to each of questions 1-6 above is “NO,” please continue with this application. We will review your answers to determine if we can offer an increase in coverage. Certain medical conditions, or combinations of conditions, will prevent some people from being approved for an increase in coverage.

Depending on the answers to the questions in this application, 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?

Part C Answer These Questions Next

• Kidney transplant • Kidney failure • Mental retardation • Paralysis of the extremities

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, a cane, prosthetics, braces, or a catheter?

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?

* If the answer to question 1 in Part C is “YES,” you are not eligible to increase your coverage to the Unlimited Benefit Period.

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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), Incontinence, Prostate Disorder

G. YES NO Liver Disorder (e.g., hepatitis, Ulcerative Colitis, Crohn’s Disease)

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

I. YES NO Disorder of the Brain (e.g., 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)

O. YES NO Fracture or Amputation

P. YES NO High Blood Pressure

Q. YES NO Macular Degeneration, Glaucoma, Retinitis Pigmentosa, Meniere’s Disease

R. YES NO Anemia, Polycythemia Vera, Thrombocytopenia, Hemochromatosis

S. YES NO Alcoholism, Drug Dependency

If the answer to any of questions 1-5 is “YES,” explain below. If you need additional space, you can download a form from our website at www.LTCFEDS.com/supplement, 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

Question # Diagnosis or Disorder Date of Onset (mm/yy)

Date of Last Treatment (mm/yy)

Name

Address

Phone ( _________ )

Name

Address

Phone ( _________ )

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/supplement, call us at 1-800-LTC-FEDS (1-800-582-3337) or attach a separate piece of paper.

Name and Address of Prescribing Health Professional

Name of Medication Check box if taking currently

Dosage (e.g., 10 mg)

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

Reason Prescribed

Name

Address

Name

Address

FED02060(0307) Page 3

Part D Answer These Additional Questions

1. Height: _________ feet _________ inches Weight: _________ lbs.

2. YES NO Are you employed or engaged in any hobbies, social activities, or volunteer work?

3. YES NO Do you exercise?

4. YES NO Have you used tobacco products (cigarette, pipe, cigar, or chewing tobacco) in the last 12 months?

If yes: Type: ____________________________________ Frequency:

5. YES NO Within the past 2 years, have you had a complete physical exam?

If yes: Month: __________ Year: __________ Physician’s Name:

6. YES NO Do you currently drink alcoholic beverages every day?

If yes, please indicate number of drinks per day: ■ 1 ■ 2 ■ 3 ■ 4 or more

7. YES NO Have you ever had an application for Life, Health, Disability, or Long Term Care Insurance declined, postponed, modified or rated (offered insurance at a higher premium rate than the standard premium rate)?

If yes: Name of Insurance Company: _____________________ Type of Insurance: ____________________

Reason:

8. YES NO Within the last 5 years, has a health professional recommended that you should have any surgeries, tests, or procedures that have not been performed?

9. YES NO Have you ever resided in a nursing home or any type of assisted living facility?

10. YES NO Have you ever attended adult day care or received home health care services?

11. YES NO Within the last 5 years, have you ever been hospitalized, consulted with, or received treatment from a health professional for any disease or condition not previously identified in any section of this application (excluding childbirth without complications, the common cold or flu)?

If the answer to any of questions 8-11 is “YES,” explain below. If you need additional space, you can download a form from our website at www.LTCFEDS.com/supplement, call us at 1-800-LTC-FEDS (1-800-582-3337) or attach a separate piece of paper.

Health Care Facility or Treating Health Care Professional

Question # Diagnosis or Disorder Date of Onset (mm/yy)

Date of Last Treatment (mm/yy)

Name

Address

Phone ( _________ )

Name

Address

Phone ( _________ )

FED02060(0307)

Part E Authorization to Use and Disclose Health Information

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 Coverage Change Application for long term care insurance may not be processed and any claim for additional 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 Coverage Change Application for long term care insurance may not be processed. In addition, if the authorization I signed as part of my original application has not yet expired, it will also be considered revoked (subject to the exceptions stated in the second bullet), 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 privacy 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.

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

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

Part F 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 Last Name

Street Address

City Country

State/Territory ZIP/Foreign Postal Code

FED02060(0307)

Part G Agreement and Acknowledgement

For coverage increases:

I am applying for an increase in insurance coverage under the Federal Long Term Care Insurance Program. All of the answers and explanations I’ve given on this Coverage Change Application are true and complete. I understand that the decision whether to approve my coverage increase will be based on my answers and explanations on this coverage change 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 Coverage Change Application and the date my increase in 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 an increase in coverage. I further understand that my increase in 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 increase in coverage.

I understand that if my request for an increase in coverage is approved, my increased coverage becomes effective on the first day of the month after the month in which Long Term Care Partners approves my Coverage Change Application. (For example, if my Coverage Change Application is approved on April 15, my increased coverage becomes effective May 1.)

Caution: If you are approved for an increase in 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 increased coverage benefits or rescind your increase in coverage even if you did not knowingly misrepresent the facts as shown in your medical records. Additionally, if your answers on this Coverage Change Application indicate that the answers you provided on your original application are incorrect, untrue, or fails to include all material information requested, Long Term Care Partners may have the right to rescind your current coverage in accordance with the provisions stated in the Statements Made by You Relating to Insurability in the Benefit Booklet.

For coverage decreases:

I am requesting a decrease in insurance coverage under the Federal Long Term Care Insurance Program. I understand my new (decreased) level of coverage becomes effective on the first day of the month after the date Long Term Care Partners receives my application.

If I am now rejecting Automatic Compound Inflation Protection by changing to the Future Purchase Option, I am confirming that I reviewed the descriptions and graphs of the inflation protection options in the Outline of Coverage. I also understand that I may switch back to Automatic Compound Inflation Protection under certain circumstances.

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

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

Have you signed and dated the Agreement and Acknowledgement in Part G above? We cannot process this Coverage Change Application without your signature and the 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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