Form Gr-68004-4 - Aetna Individual Medicare Supplement Plan Application (Page 8 of 8) in pdf

Form Gr-68004-4 - Aetna Individual Medicare Supplement Plan Application Page 8

Applicant’s Name

Social Security Number

NOTICE OF COMPENSATION

[Producers (Brokers, Agents, Consultants): Licensed and appointed producers may earn compensation in the form of a

commission on the sale of this product. The amount of compensation varies depending on a number of factors, including

customer segment and the products selected. Aetna offers additional bonus programs to its producers, which may also apply.

Please consult your broker for additional information concerning his/her compensation for this sale, including commission and

any applicable bonus programs. The producer is prohibited by law from altering the amount of compensation received from

Aetna based in whole or in part on the sale.]

[Salaried Aetna Employees: Salaried employees may earn compensation on the sale of Aetna products based on the services

they provide, including providing quotes on, and explanations of, Aetna products. The compensation varies depending on a

number of factors, including customer segment and products selected. Combining all factors, and excluding limited-benefit

plans, compensation for each product quoted averages less than [0.80]% of the total first year annual premium. Aetna offers

additional bonus programs, which may also apply. Neither Aetna nor the employee has material ownership interests in the

other. The employee may not alter the amount of compensation received from Aetna. You may obtain additional information

about the compensation expected to be received by eligible employees, based in whole or in part on the sale of an Aetna

product, or alternative options presented, by contacting Aetna at https://

us/forms/employer/transparency.html

]

PLEASE MAKE A COPY FOR YOUR RECORDS

Page 8 of 8

GR-68004-4 (4-11) NY

[C]

Form Gr-68004-4 - Aetna Individual Medicare Supplement Plan Application Page 8