Attachment_6H-_FLTCIP_Alternative_Insurance_Plan_Supplemental_Application.pdf

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

FLTCIP Alternative Insurance Plan Supplemental Application Valid beginning August 1, 2015

Part A Personal information

Part B Replacement coverage questions

Mr. Mrs. Ms.

First name M.I. Last name

Address line 1

Address line 2

City State/Territory

Country Zip/Foreign postal code

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 FLTCIP Alternative Insurance Plan. This insurance is also not intended to replace any existing medical or health insurance coverage. 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 (for example, 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.

continued

The Federal Long Term Care Insurance Program is sponsored by the U.S. Office of Personnel Management, offered by John Hancock Life & Health Insurance Company, and administered by Long Term Care Partners, LLC.

Gender Male Female

Home phone

Work phone

Extension

Date of birth

Month Day Year

Email

Social Security number*

Please call us at the number below if you do not have a Social Security number (SSN).

* We use SSNs to obtain health information for underwriting purposes and during the claims process, verify eligibility, and process payroll deductions.

The Federal Long Term Care Insurance Plan (FLTCIP) Alternative Insurance Plan is a long term care insurance plan that offers some long term care benefits to those who applied (and were declined) for insurance coverage under the FLTCIP using the FLTCIP 2.0 Abbreviated Underwriting Application, which indicated certain medical conditions as defined below:

and were declined for standard coverage

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

Part C Protection against unintended lapse

Part B Replacement coverage questions (continued)

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 FLTCIP Alternative Insurance Plan. 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 you should not cancel any long term care insurance you currently have unless or until your coverage under the FLTCIP is effective.

Yes No Are you replacing another long term care insurance policy or certificate currently in force with coverage under the FLTCIP? 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 number

Insurance company name

Insurance company street address

Zip/Foreign postal code

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. Visit our website at www.LTCFEDS.com/payroll to find a payroll or annuity office identifier.

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 in Part A of this application.

Part D Billing options (choose one)

Direct bill

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 in Part A of this application.

Payroll or annuity/ pension deduction or

First name M.I. Last name

Address

Country Zip/Foreign postal code

Home phone Work phone Extension

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.

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

Part D Billing options (continued) or

Automatic bank withdrawal

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 two months of premium from my account until current.

Depositor’s signature X (Required) Date signed / / (Required: mm/dd/yy)

Choose one:

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 nine-digit routing number.

Part E Agreement and acknowledgment

To complete your application, you must confirm the following before submitting your application:

1. That you understand the company’s right to increase premiums by checking the box at the bottom of page 4.

2. That you agree to and acknowledge the terms stated in this application by signing and dating page 4.

I am applying for coverage under the FLTCIP Alternative Insurance Plan. My application consists of this form, along with the answers I previously gave to questions on the FLTCIP 2.0 Abbreviated Underwriting Application. All of the answers and explanations I have given on this form and on the FLTCIP 2.0 Abbreviated Underwriting Application, including my status as an eligible individual, are true and complete. I understand that the decision to approve my application will be based on my answers and explanations on these two forms. If required, my medical records or answers to interview questions will also be considered.

Choose one CSRS/FERS annuity deductions CS

All payroll or other annuity/pension deductions

Office identifier or

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:

CSRS/FERS annuity deductions CS

All payroll or other annuity/pension deductions

Office identifier

(Insert A, F, or I below and fill in the remaining seven or eight characters)

(Insert A, F, or I below and fill in the remaining seven or eight characters)

Payroll or annuity/ pension deduction (continued)

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

Payor’s signature X (Required) Date signed / / (Required: mm/dd/yy)

Payor’s first name M.I. Last name

Payor’s Social Security number

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

Part E Agreement and acknowledgment

Applicant’s signature X Date signed / / (Required) (Required: mm/dd/yy)

FLTCIP009431 v. 2 0815

Please check the box and sign below.

The company’s right to increase premiums: Premiums are not guaranteed. I understand that my premium will not change because I get older or my health changes or for any other reason related solely to me. Premiums may only increase if I am among a group of enrollees whose premium is determined to be inadequate. I understand that while the group policy is in effect, OPM must approve the change.

Note: You must check the above box to confirm that you have read and understand the paragraph above titled, “The company’s right to increase premiums.” We cannot process your application if you do not check the box.

Mail to: Long Term Care Partners, P.O. Box 797, Greenland, NH 03840-0797 or Fax to: 1-866-921-4510

I agree to immediately inform Long Term Care Partners in writing if between the date I submitted information on the FLTCIP 2.0 Abbreviated Underwriting Application and the date my insurance coverage is effective: (1) my health changes in a way that would cause any answer I have given on my 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 these two forms. I understand that the conditions and provisions of my coverage may not be waived, changed, or otherwise affected unless I am notified in writing by Long Term Care Partners, and that the U.S. Office of Personnel Management (OPM) must agree to any change affecting benefits and premiums.

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 at least one day during the calendar week immediately prior to the week that contains my coverage effective date.

Other eligible current employees: I understand that if my application is approved, I must be actively at work at least one day during the calendar week immediately before the week that contains my coverage effective date.

I must be reporting for work at an approved work location, work at least one-half of my regularly scheduled hours for that day, and be able to perform all the usual and customary duties of my employment on my regular work schedule.

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 should not have been because one or more of your answers or explanations are incorrect or untrue, or fails to include all material information requested, we may have the right to deny benefits or void your insurance. This is true even if you did not knowingly misrepresent the facts as shown in your medical records. We may also void your insurance at any time if we find that at the time of application, you misrepresented your status as a member of an eligible group.

Note: Your signature below also confirms the elections you made in Part C: Protection Against Unintended Lapse and Part D: Billing Options.

If you did not name someone in Part C 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.

If you elected automatic bank withdrawal in Part D, 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 you, your bank, or Long Term Care Partners terminates it by a 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 D, you are authorizing Long Term Care Partners to deduct from your pay or annuity/pension the amount necessary to pay the premiums for the FLTCIP Alternative Insurance Plan 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 on your retirement. You can cancel your payroll or annuity/pension deduction by contacting Long Term Care Partners to choose a different billing option.