Attachment_6K_-_Coverage_Increase_Application_for_FLTCIP_2.0_Enrollees.pdf

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

This application is only for people who are currently enrolled in FLTCIP 2.0 and wish to apply for an increase in coverage or reactivate the future purchase option offer.

If you are currently enrolled in FLTCIP 1.0 and want to apply for an increase in coverage, you must use the Coverage Increase Application for FLTCIP 1.0 Enrollees.

If you are not currently enrolled and wish to apply for coverage, you cannot use this application. Call us at 1-800-LTC-FEDS (1-800-582-3337) TTY 1-800-843-3557 or visit www.LTCFEDS.com/apply for a full or abbreviated underwriting application.

Each enrollee wishing to apply for an increase in coverage must complete a separate application.

Part A Personal information

Coverage Increase Application for FLTCIP 2.0 Enrollees

Mr. Mrs. Ms.

First name M.I. Last name

Address line 1

Address line 2

City State/Territory

Country Zip/Foreign postal code

FLTCIP account number

U or 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 or annuity/pension deductions.

Gender Male Female

Home phone

Work phone

Extension

Date of birth

Month Day Year

Email

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.

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

Coverage increase options Please review your current coverage as outlined below in the column labeled Your FLTCIP 2.0 coverage.

To request an increase in your coverage, you must make a selection for plan features 2, 4, and 6 in the Modify my FLTCIP 2.0 coverage column.

Make your selection for plan features 2, 4, and 6.

Plan features Your FLTCIP 2.0 coverage Modify my FLTCIP 2.0 coverage

1. Coverage type Comprehensive Comprehensive

2. Daily benefit amount (DBA)

$ DBA

as of

Month Day Year

$100 $150

$200 $250

$300 $350

$400 $450

Keep current DBA

3. Benefit type Daily Daily

4. Benefit period 2 years 3 years

5 years Unlimited

2 years 3 years

5 years Unlimited

5. Waiting period 90 calendar days 90 calendar days

6. Inflation protection option Future purchase option

4% Automatic compound inflation option

5% Automatic compound inflation option

Future purchase option

4% Automatic compound inflation option

5% Automatic compound inflation option

Part A Personal information (continued)

Part B Health questions (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

Dressing

Eating

Transferring yourself from bed to chair

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

Continence (changing protective undergarment, managing ostomy bag and catheter, completing hygiene-related functions)

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

Part B Health questions (continued)

If the answer to any of questions 1–6 in Part B is “Yes,” you are not eligible for an increase in coverage under the Federal Long Term Care Insurance Program (FLTCIP). Do not complete the rest of this application.

If the answer to each of questions 1–6 in Part B 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 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 practitioner(s).

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, HIV

Alzheimer’s disease, cognitive impairment, dementia

Amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease)

Cirrhosis (excluding primary biliary)

(excluding kidney, bone marrow, cornea transplants)

Stroke (cerebrovascular accident): multiple

Stroke (cerebrovascular accident): with residual impairment (such as paralysis, weakness, gait disturbance, vision disturbance, mental impairment)

Transient ischemic attack (TIA): multiple

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

CPAP)

6. Yes No Do you currently require or receive human help or supervision with any of these activities because of intellectual disability (formerly referred to as mental retardation)?

about your money

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

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

Intellectual disability (formerly referred to as mental retardation)

Paralysis of the extremities

* If the answer to question 1 in Part C is “Yes,” you are not eligible for an increase from the two-, three-, or five-year benefit period to the unlimited benefit period.

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

about your money

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?

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, TIA, carotid artery disease

B. Yes No Peripheral vascular disease

C. Yes No Coronary artery disease (such as 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 (such as nephritis), incontinence, prostate disorder

G. Yes No Liver disorder (such as hepatitis), ulcerative colitis, Crohn’s disease

H. Yes No Any psychiatric disorder (such as depression, bipolar disorder)

I. Yes No Disorder of the brain (such as tremor, seizure disorder, head injury, tumor, infection), neuropathy, syncope, paralysis, any chronic or progressive neurological disorder

J. Yes No Chronic lung disease (such as 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 (such as scleroderma, systemic lupus, CREST syndrome)

N. Yes No Muscle disorder (such as 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

Part C Health questions (answer these questions next)

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

Part C Health questions (answer these questions next)

If the answer to any of questions 1–5 is “Yes,” or if you have additional detail to provide, please explain below.

Name, address, and phone number of treating health professional

Question number

Diagnosis or disorder Date of onset (mm/yyyy)

Date of last treatment (mm/yyyy)

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

If you need additional space, you can attach a separate piece of paper, download a form at www.LTCFEDS.com/supplement, or call the number below.

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

Part C Health questions (continued)

6. Yes No Have you taken any prescription medications over the past six months?

If yes, please complete the chart below.

Name, address, and phone number of treating health professional

Name of medication Check box if taking currently

Dosage (such as

10 mg)

Frequency (such as

2 x a day)

Reason prescribed

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

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

Part D Additional health questions

1. Height: feet inches Weight: pounds

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 past 12 months?

If yes, type: frequency:

5. Yes No Within the past two 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 past five 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 past five years, have you ever been hospitalized or have you ever 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,” or if you have additional detail to provide, please explain below.

Name, address, and phone number of treating health professional

Question number

Diagnosis or disorder Date of onset (mm/yyyy)

Date of last treatment (mm/yyyy)

Name

Address

Phone

Name

Address

Phone

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

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 & Health 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 FLTCIP 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, 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 an increase in long term care insurance may not be processed and any claim for long term care insurance benefits may be denied.

or coverage.

To revoke this authorization, I must notify Long Term Care Partners, LLC, P.O. Box 797, Greenland, NH

03840-0797, in writing.

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

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 above in Part E? We cannot process this application without your signature and the date.

Part F Primary care physician’s or health care practitioner’s information

Primary care physician’s or health care practitioner’s first name Last name

Address

City State/Territory

Country Zip/Foreign postal code

Phone

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

To complete your application, you must confirm the following on page 10 before submitting your application:

1. That you understand the company’s right to increase premiums by checking the box on page 10.

2. That you agree to and acknowledge the terms stated in this application by signing and dating on page 10.

I am applying for an increase in insurance coverage under the FLTCIP. All of the answers and explanations I have given on this application are true and complete. I understand that the decision to approve my coverage increase 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 increase in coverage is effective (1) my health changes in a way that would cause any answer I have 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 reevaluate 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 I have the right to request a copy of this application at any time, but I also understand I will receive one automatically.

I understand that my benefits and/or premiums for those benefits may change based on the change(s) that I selected.

If my request for an increase in coverage is approved, I understand that within 30 days after I receive the new FLTCIP 2.0 Benefit Booklet, I may cancel the change in my coverage and return to my original coverage.

If I have applied to reactivate my future purchase option (FPO) offers, this reinstates the FPO rules outlined in the FLTCIP 1.0 Benefit Booklet.

I understand that if my request for an increase in coverage is approved, my increased coverage will be effective on the first day of the month following my approval.

Caution: If you are approved for an increase in coverage, but you should not have been because one or more of your answers or explanations is incorrect, untrue, or fails to include all material information requested, we may have the right to deny increased coverage benefits or void 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 application indicate that the answers you provided on your original application were incorrect or untrue at that time, or that your original application failed to include all material requested, we may have the right to void your current coverage in accordance with the provisions stated in the “Statements Made by You Relating to Insurability” section in the Benefit Booklet.

I understand that if my request for an increase in coverage is denied, my original coverage will remain in effect so long as I continue to pay applicable premiums for that coverage.

continued

Part G Agreement and acknowledgment

For assistance, call 1-800-LTC-FEDS (1-800-582-3337) TTY 1-800-843-3557

If you rejected an automatic compound inflation option (ACIO) in Part A by choosing the FPO, you are confirming that you reviewed the descriptions and graphs of the inflation protection options in the FLTCIP 2.0 Outline of Coverage. You also understand that if you elect an ACIO, you may switch to the FPO at any time. And if you elect the FPO, you may request to change from the FPO to the ACIO, and should you make such a request:

you will be required to provide, at your expense, evidence of your good health that is satisfactory to us; and the effective date of all future automatic compound benefit increases will be the anniversary of the first day of the month that next follows the date of our approval of your request.

Part G Agreement and acknowledgment (continued)

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

Note: We may request medical records from your primary care physician or health care practitioner. We will advise you by letter if this request is necessary. If we have any questions regarding the answers on your application, an associate with Long Term Care Partners or one of our affiliated entities may reach out to you for additional information either in writing or by phone.

Some of our affiliated entities may request that you provide them with a separate authorization for physician information in addition to the one in this application.

If any of our associates or affiliated entities need to reach out to you regarding any aspect of your application, they will identify themselves as contacting you on behalf of Long Term Care Partners.

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, LLC, P.O. Box 797, Greenland, NH 03840-0797 or

Fax to: 1-866-921-4510

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