Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Appendix 6

Current through June 24, 2024
NOTICE TO APPLICANT REGARDING REPLACEMENT OF INDIVIDUAL
				ACCIDENT AND SICKNESS OR LONG-TERM CARE INSURANCE
[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 lapse or otherwise terminate existing accident and
				sickness or long-term care insurance and replace it with an individual
				long-term care insurance policy to be issued by [company name] Insurance
				Company. Your new policy provides thirty (30) days within which you may decide,
				without cost, whether you desire to keep the policy. For your own information
				and protection, you should be aware of and seriously consider certain factors
				that may affect the insurance protection available to you under the new
				policy.
You should review this new coverage carefully, comparing it
				with all accident and sickness or long-term care insurance coverage you now
				have, and terminate your present policy only if, after due consideration, you
				find that purchase of this long-term care coverage is a wise decision.
STATEMENT TO APPLICANT BY AGENT [BROKER OR OTHER
				REPRESENTATIVE]:
(Use additional sheets, as necessary.)
I have reviewed your current medical or health insurance
				coverage. I believe the replacement of insurance involved in this transaction
				materially improves your position. My conclusion has taken into account the
				following considerations, which I call to your attention:
1. Health conditions that you may presently have (preexisting
				conditions), may not be immediately or fully covered under the new policy. This
				could result in denial or delay in payment of benefits under the new policy,
				whereas a similar claim might have been payable under your present
				policy.
2. State law provides that your replacement policy or
				certificate may not contain new preexisting conditions or probationary periods.
				The insurer will waive any time periods applicable to preexisting conditions or
				probationary periods in the new policy (or coverage) for similar benefits to
				the extent such time was spent (depleted) under the original policy.
3. If you are replacing existing long-term care insurance
				coverage, you may wish to secure the advice of your present insurer or its
				agent regarding the proposed replacement of your present policy. This is not
				only your right, but it is also in your best interest to make sure you
				understand all the relevant factors involved in replacing your present
				coverage.
4. If, after due consideration, you still wish to terminate
				your present policy and replace it with new coverage, be certain to truthfully
				and completely answer all questions on the application concerning your medical
				health history. Failure to include all material medical information on an
				application may provide a basis for the company to deny any future claims and
				to refund your premium as though your policy had never been in force. After the
				application has been completed and before your sign it, reread it carefully to
				be certain that all information has been properly recorded.
______________________________________________________
(Signature of Agent, Broker or Other Representative)
[Typed Name and Address of Agent or Broker]
The above "Notice to Applicant" was delivered to me on:
______________________________________
				__________________________
(Applicant's Signature) (Date)