[Please mark Yes or No below with an "X"]
To the best of your knowledge,
Yes_____ No_____
Yes_____ No_____
[NOTE TO APPLICANT: If you are participating in a "Spend-Down Program" and have not met your "Share of Cost," please answer NO to this question.]
Yes_____ No_____
Yes_____ No_____
Yes_____ No_____
START __/__/__ END __/__/__
Yes_____ No_____
Yes_____ No_____
Yes_____ No_____
Yes_____ No_____
_____________________________________________________________________
Yes_____ No_____
Yes_____ No_____
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
START __/__/__ END __/__/__
(If you are still covered under the other policy, leave "END" blank.)
NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE OR MEDICARE ADVANTAGE
[Insurance company's name and address]
SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE.
According to [your application] [information you have furnished], you intend to terminate existing Medicare supplement or Medicare Advantage insurance and replace it with a policy to be issued by [Company Name] Insurance Company. Your new policy will provide thirty (30) days within which you may decide without cost whether you desire to keep the policy.
You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should terminate your present Medicare supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy.
STATEMENT TO APPLICANT BY ISSUER, AGENT [BROKER OR OTHER REPRESENTATIVE]:
I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason (check one):
____ Additional benefits.
____ No change in benefits, but lower premiums.
____ Fewer benefits and lower premiums.
____ My plan has outpatient prescription drug coverage and I am enrolling in Part D.
____ Disenrollment from a Medicare Advantage plan. Please explain reason for disenrollment. [optional only for Direct Mailers.]
_____________________________________________________________________________
_____________________________________________________________________________
____ Other. (please specify)___________________________________________________________
Do not cancel your present policy until you have received your new policy and are sure that you want to keep it.
______________________________________________________ (Signature of Agent, Broker or Other Representative)*
[Typed Name and Address of Issuer, Agent or Broker]
______________________________________________________ (Applicant's Signature)
_______________________ (Date)
*Signature not required for direct response sales.
N.H. Admin. Code § Ins 1905.20
#5390, eff 7-1-92; ss by #5656, eff 7-1-93; ss by #6406, eff 1-1-97; ss by #7174, eff 12-22-99; ss by #8051, eff 3-1-04; ss by #8363, eff 9-8-05; ss by #9559, eff 10-13-09 (from Ins 1905.18 )