Group Coverage Application Form (Page 3 of 4) in pdf

7. Have you had coverage under any other health insurance within the past 63 days

(for example, an employer, union, or individual plan)? .........................................................................................

Yes

■

If yes, Insurance Company name: ____________________________ Insurance Company ID #: _______________

Group #: ________________________________ What kind of policy? ________________________________

Start Date: ________________________________ End Date: _____________________________________

8. To all Producers: Producers shall list other health insurance policies they have sold to the applicant.

Following Policies are still in force: ______________________________________________________________________________

Following Policies are not in force: ______________________________________________________________________________

_________________________________________________________

Signature of Producer

IMPORTANT — PLEASE READ CAREFULLY

You do not need more than one Medicare supplement policy.

If you purchase this policy, you may want to evaluate your existing health coverge and decide if you need multiple coverages.

You may be eligible for benefits under Medicaid and may not need a Medicare supplement policy.

If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare supplement policy can

be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within

90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare supplement policy or, if

the Medicare supplement policy is no longer available, a substantially equivalent policy will be reinstituted if requested within 90 days

of losing Medicaid eligibility. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in

Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will

otherwise be substantially equivalent to your coverage before the date of suspension.

If you are eligible for, and have enrolled in a Medicare supplement policy by reason of disability and you later become covered by an

employer or union-based group health plan, the benefits and premiums under your Medicare supplement policy can be suspended, if

requested, while you are covered under the employer or union-based group health plan. If you suspend your Medicare supplement policy

under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare supplement policy

(or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing your employer

or union-based group health plan. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled

in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will

otherwise be substantially equivalent to your coverage before the date of suspension.

Counseling services may be available in your state to provide advice concerning your purchase of Medicare supplement insurance and

concerning medical assistance through the state Medicaid program, including benefits as a Qualified Medicare Beneficiary (QMB) and a

Specified Low-Income Medicare Beneficiary (SLMB).

Group Coverage Application Form Page 3