Fillable FLTCIP 2.0 Full Underwriting Application (Marines)

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FLTCIP 2.0 Full Underwriting Application (Marines)

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FLTCIP 2.0 Full Underwriting Application
Valid beginning June 1, 2010
Important information to consider before you apply for coverage under
the Federal Long Term Care Insurance Program
People buy long term care insurance for many reasons. Some don’t want to use their own
assets to pay for long term care. Some buy insurance to make sure they can choose the
type of care they receive. Others don’t want their family to have to pay for care and don’t
want to rely on Medicaid. But long term care insurance can be expensive and is not right
for everyone.
Please read below for important information and questions that will help you decide if you
should apply for this coverage. You should also read the Outline of Coverage and A Shopper’s
Guide to Long-Term Care Insurance, both of which are found in the Information Kit and online
at www.LTCFEDS.com. If you have questions about whether long term care insurance is
appropriate for you, please call us at 1-800-582-3337 (TTY 1-800-843-3557).
1. Can you afford to pay the premiums for the coverage you’re considering?
If you will be paying premiums solely from your own income, a rule of thumb is that you may
not be able to afford this coverage if the premiums will be more than 7% of your income. Your
premium will be based on the benefit options you select and your age at the time we receive
your application. If you need help calculating your premium, please visit www.LTCFEDS.com
or call us at 1-800-582-3337 (TTY 1-800-843-3557).
2. Can you afford future changes to your premiums?
Your premiums may increase if:
you increase your coverage, either by accepting increases to your benefits under the
Future Purchase Option, or by requesting and being approved for an increase in your
benefits, and/or
you are among a class of enrollees whose premium is determined to be inadequate.
Effective January 2010, John Hancock raised FLTCIP 1.0 rates for enrollees with the Automatic
Compound Inflation Option who purchased coverage at age 69 or younger. While there are
no current plans to increase premium rates in the future, premiums are not guaranteed to
remain at today’s rates.
3. If you are considering the Future Purchase Option, have you considered if you can afford
increased premiums for future increases to your benefits?
If you do not plan to accept future increases, have you considered how you will pay for any
long term care that exceeds the amount your insurance will cover?
4. Do you qualify for Medicaid, or are you likely to qualify in the near future?
Medicaid may be available for persons with low income (for example, less than $20,000/
individual or $40,000/couple) and few assets (for example, less than $30,000/individual or
$50,000/couple, not counting the value of your home). Medicaid covers some long term
care services. If you have low income and few assets now, or expect to in the next 10 years,
you may want to consider whether long term care insurance is right for you. It is important
to remember that Medicaid eligibility requirements vary by state. To learn more about
Medicaid, contact your local or state Medicaid agency.
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, Boston, MA 02117,
and administered by Long Term Care Partners, LLC
2
FLTCIP 2.0 Full Underwriting Application
Valid beginning June 1, 2010
FLTCIP 2.0 Full Underwriting Application
Valid beginning June 1, 2010
Do not use this application if you are:
1
in one of the following groups:
new or newly eligible employee
spouse of a new or newly eligible employee
newly married spouse of an employee
2
and you are applying within 60 days of becoming eligible to apply.
Or, call us at 1-800-582-3337 or visit www.LTCFEDS.com/apply for the Abbreviated Underwriting Application.
Each eligible individual wishing to apply for coverage must complete a separate application.
Part A Personal information
IMPORTANT: If you received a rate quote and you are the individual named on the address label, remove the label
and place it below. If not, please fill out the information below.
Mr.
Mrs. Ms.
First name
M.I. Last name
Address 1
Address 2
City State/Territory
Country
Zip/Foreign postal code
Affix label here
Gender Male Female
Date of birth
Month Day
Year
/
/
Home phone
–
–
Work phone
–
–
Email
Social Security number
*
–
–
This application is ONLY for the groups shown. Tell us which of these makes YOU an eligible individual.
(Required: Please check only one.)
Employee or current spouse
Check here if you DO NOT have
a Social Security number
*
W
e use SSNs to obtain health information for
underwriting purposes, during the claims process, and
to process payroll and annuity/pension deductions.
Federal employee
U.S. Postal Service
(USPS) employee
Active member of the
uniformed services
Eligible D.C. government
employee
Other eligible employee
Current spouse of an
eligible employee
Annuitant or current spouse
Federal or USPS annuitant
Retired member of the
uniformed services
Eligible D.C. government
annuitant
Other eligible annuitant
Current spouse of an
eligible annuitant
Other qualified relative
Surviving spouse receiving a survivor annuity
Parent, parent-in-law, or stepparent of a living
eligible employee
Adult child of a living eligible employee or
annuitant
Same-sex domestic partner of an employee
or annuitant, other than of an active or
retired member of the uniformed services,
who has submitted (either directly or
through my partner) a form affirming this
status to my partner’s employing agency
or retirement system
If you do not see your eligible group here or are unsure which of these makes you an eligible individual, visit
www.LTCFEDS.com/eligibility or call us at the number noted below.
For assistance, call 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557) or visit www.LTCFEDS.com/apply
3
Part B Answer these questions first
1. Do you currently reside in, or has a health professional advised you to enter, a nursing
home or any type of assisted living facility?
YES NO
2. Are you currently receiving home health care services or attending adult day care?YES NO
3. 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)
YES NO
4. 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,
organic brain syndrome,
dementia
Amyotrophic lateral
sclerosis (ALS or
Lou Gehrig’s disease)
Cirrhosis (excluding
primary biliary)
Huntington’s chorea
Multiple sclerosis
Muscular dystrophy
Organ transplant
(excluding kidney,
bone marrow,
cornea transplants)
Parkinson’s disease
Paraplegia or
quadriplegia
Schizophrenia
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
YES NO
5. Do you currently use any of the following medical devices, aids, or treatments
(for any reason)?
Dialysis
Hospital bed
Motorized scooter
Multi-pronged cane
Oxygen (excluding
CPAP)
Stair lift
Walker
Wheelchair
YES NO
6. Do you currently require or receive human help or supervision with any of these activities
because of mental retardation?
Living independently
Making decisions
about your money
T
aking medications
Preparing meals
Shopping
Using transportation
Walking
YES NO
STOP
If the answer to any of questions 1–6 in Part B 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 Parts A and B are complete and mail this application. 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 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 provider(s).
For assistance, call 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557) or visit www.LTCFEDS.com/apply
4
Part C Answer these questions next
1. Do you currently have, or have you ever been diagnosed with, or treated for, any of the
following conditions?
Kidney transplant
Kidney failure
Mental retardation Paralysis of the extremities
YES
*
*
If the answer to question 1 in Part C is “YES,” you are not eligible for the unlimited benefit period in Part G
of this application.
NO
2. Do you currently require or receive human help or supervision with any of these activities?
Preparing meals
Taking medications
Using transportation
Shopping
Walking
Making decisions
about your money
YES NO
3. Do you currently use crutches, a cane, prosthetics, braces or a catheter?YES NO
4. 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?
YES NO
5. Within the last 10 years, have you had, been diagnosed with, or been treated for any of the
following conditions?
A. Stroke or cerebrovascular accident (CVA), transient ischemic attack (TIA),
carotid artery disease
YES NO
B. Peripheral vascular diseaseYES NO
C. Coronary artery disease (such as heart attack, angina), heart arrhythmia,
cardiomyopathy, congestive heart failure, aneurysm, valvular disease
YES NO
D. Diabetes (excluding gestational diabetes)YES NO
E. Cancer (excluding basal cell cancer or squamous cell cancer of the skin)YES NO
F. Chronic kidney disease (such as nephritis), incontinence, prostate disorderYES NO
G. Liver disorder (such as hepatitis), ulcerative colitis, Crohn’s diseaseYES NO
H
. Any psychiatric disorder (such as depression, bipolar disorder)YES NO
I. Disorder of the brain (such as tremor, seizure disorder, head injury,
tumor, infection), neuropathy, syncope, paralysis, any chronic or
progressive neurological disorder
YES NO
J. Chronic lung disease (such as COPD, emphysema, sarcoidosis, chronic bronchitis,
asbestosis, asthma [excluding seasonal asthma], bronchiectasis, sleep apnea)
YES NO
K. Memory lossYES NO
L. Rheumatoid arthritis, any other type of arthritis, osteoporosis, back disorder,
scoliosis, spinal stenosis, disc disease
YES NO
M. Connective tissue disorder (such as scleroderma, systemic lupus, CREST syndrome)YES NO
N. Muscle disorder (such as fibromyalgia, polymyalgia rheumatica,
chronic fatigue syndrome)
YES NO
O. Fracture, amputationYES NO
P. High blood pressureYES NO
Q. Macular degeneration, glaucoma, retinitis pigmentosa, Meniere’s diseaseYES NO
R. Anemia, polycythemia vera, thrombocytopenia, hemochromatosisYES NO
S. Alcoholism, drug dependencyYES NO
For assistance, call 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557) or visit www.LTCFEDS.com/apply
5
Part C Answer these questions next (continued)
If the answer to any of questions 1–5 is “YES,” explain below. If you need additional space, you can attach a separate
piece of paper, download a form at www.LTCFEDS.com/supplement, or call 1-800-LTC-FEDS (1-800-582-3337).
Name, address, and phone number
of treating health professional
Name
Address
Phone
Question
number
Diagnosis or disorder Date of onset
(mm/yy)
Date of last
treatment
(mm/yy)
Name
Address
Phone
Name
Address
Phone
Name
Address
Phone
Name
Address
Phone
Name
Address
Phone
For assistance, call 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557) or visit www.LTCFEDS.com/apply
6
Part C Answer these questions next (continued)
6. Have you taken any prescription medications over the past 6 months? If yes, please complete
the chart below.
YES NO
If you need additional space, you can attach a separate piece of paper, download a form at
www.LTCFEDS.com/supplement, or call 1-800-LTC-FEDS (1-800-582-3337).
Name, address, and phone number
of treating health professional
Name
Address
Phone
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
For assistance, call 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557) or visit www.LTCFEDS.com/apply
7
Part D Answer these additional questions
1. Height: feet inches Weight: pounds
2. Are you employed or engaged in any hobbies, social activities, or volunteer work?YES NO
3. Do you exercise?YES NO
4. Have you used tobacco products (cigarette, pipe, cigar, or chewing tobacco) in the
past 12 months?
YES NO
If yes, type: frequency:
5. Within the past 2 years, have you had a complete physical exam?YES NO
If yes, month: year:
Physician’s name:
6. Do you currently drink alcoholic beverages every day? YES NO
If yes, please indicate number of drinks per day: 1 2 3 4 or more
7. 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)?
YES NO
If yes, name of insurance company:
Type of insurance:
Reason:
8. Within the past 5 years, has a health professional recommended that you should have any
surgeries, tests, or procedures that have not been performed?
YES NO
9. Have you ever resided in a nursing home or any type of assisted living facility? YES NO
10. Have you ever attended adult day care or received home health care services? YES NO
11. Within the past 5 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)?
YES NO
If the answer to any of questions 8–11 is “YES,” explain below. Attach a separate piece of paper if necessary.
Name, address, and phone number
of treating health professional
Name
Address
Phone
Question
number
Diagnosis or disorder Date of onset
(mm/yy)
Date of last
treatment (mm/yy)
Name
Address
Phone
For assistance, call 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557) or visit www.LTCFEDS.com/apply
8
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 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, 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.
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 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.
To revoke this authorization I must notify Long Term Care Partners, LLC, P.O. Box 797, Greenland,
NH 03840-0797, in writing.
Applicant’s signature X
(Required)
Date signed
(Required: mm/dd/yy)
/
/
STOP
Have you signed and dated the authorization in Part E? We cannot process this
application without your signature and the date.
Part F Your primary physician information
Primary physician or health care practitioner’s first name Last name
Address
City State/Territory
Country Zip/Foreign postal code
Phone
– –
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.
For assistance, call 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557) or visit www.LTCFEDS.com/apply
click to sign
signature
click to edit
9
Part G Choose a prepackaged plan or customize a plan
You can choose either a prepackaged plan or customize your own plan. Do not choose both. If the answer to
Question 1 in Part C is “YES,” you are not eligible for 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.
Prepackaged plan
1. Choose a plan
Plan A Daily benefit amount $150
Benefit period 2 years
Plan B Daily benefit amount $150
Benefit period 3 years
Plan C Daily benefit amount $200
Benefit period 3 years
Plan D Daily benefit amount $200
Benefit period 5 years
2. Choose an inflation protection option
4% Automatic Compound Inflation Option
5% Automatic Compound Inflation Option
Future Purchase Option
or
Customized plan
1. Choose a daily benefit amount
$100 $150 $200 $250
$300 $350 $400 $450
2. Choose a benefit period
2 years 3 years 5 years Unlimited
3. Choose an inflation protection option
4% Automatic Compound Inflation Option
5% Automatic Compound Inflation Option
Future Purchase Option
STOP
Have you chosen a prepackaged plan or customized a plan? If you’ve chosen a prepackaged
plan, check only one box for your plan and one box for your inflation protection option. If
you’ve chosen a customized plan, be sure to check one box each for the daily benefit amount,
benefit period, and the inflation protection option. We cannot process this application if you
leave any of these choices blank.
Part H 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.
Are you covered under Medicaid? If you answer “YES,” you may wish to carefully consider
whether you really need long term care insurance.
YES NO
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.
Are you replacing another long term care insurance policy or certificate currently in force with
coverage 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:
YES NO
Policy number
Insurance company name
Insurance company street address
City State Zip
For assistance, call 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557) or visit www.LTCFEDS.com/apply
10
Part I Choose one billing option
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 on Part A of this application.
or
Payroll,
annuity,
or
pension
deduction
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.
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 Part A
of this application. To find a payroll/annuity office identifier, visit our website at
www.LTCFEDS.com/payroll.
Choose one:
CSRS/FERS annuity deductions
(Insert A, F, or I below and fill in the remaining 7 or 8 digits/characters)
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
(Insert A, F, or I below and fill in the remaining 7 or 8 digits/characters)
CS
All payroll or other annuity/pension deductions
Office identifier
Mr. Mrs. Ms.
Payor’s first name
M.I. Last name
Payor’s street address
City State Zip
Payor’s Social Security number
– –
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
(Required)
Date signed
(Required: mm/dd/yy)
/ /
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 3
rd
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
(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 9-digit routing number.
For assistance, call 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557) or visit www.LTCFEDS.com/apply
11
Part J Protection against an 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 M.I. Last name
Address
City State/Territory
Country Zip/Foreign postal code
Part K Agreement and acknowledgment
To complete your application you must confirm the following at the bottom of page 12 before submitting
your application:
1. That you understand the company’s right to increase premiums by checking the box on page 12.
2. That you agree to and acknowledge the terms stated in this application by signing and dating
page 12.
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 in Part A, 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 reevaluate 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.
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 fail 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.
continued
For assistance, call 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557) or visit www.LTCFEDS.com/apply
12
Part K Agreement and acknowledgment (continued)
NOTE: Your signature below also confirms the elections you made in Part G (choose a prepackaged plan or
customized plan), Part I (billing options), and Part J (protection against an unintended lapse).
If you rejected an Automatic Compound Inflation Option in Part G 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 an 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 an Automatic Compound Inflation Option under certain circumstances.
If you elected automatic bank withdrawal in Part I, 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 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 I, 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 Program 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. You can cancel your payroll or annuity/pension deduction by
contacting Long Term Care Partners to choose a different billing option.
If you did not name someone in Part J 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.
STOP
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.
Applicant’s signature X
(Required)
Date signed
(Required: mm/dd/yy)
/
/
STOP
Have you signed and dated the agreement and acknowledgment above? Have you read
the statement about the company’s right to increase premiums, and did you check the box?
You must complete these items before we can process this application.
Mail to: Long Term Care Partners, P.O. Box 797, Greenland, NH 03840-0797
or
Fax to: 1-866-921-4510
For assistance, call 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557) or visit www.LTCFEDS.com/apply
FED01578F (060110)
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FLTCIP 2.0 Full Underwriting Application (Marines)

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Completed 12 March 2022

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