Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Appendix 7

Current through June 24, 2024
NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE
				SUPPLEMENT, MEDICARE COST, MEDICARE SELECT, MEDICARE ADVANTAGE OR EXISTING
				ACCIDENT AND SICKNESS 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 terminate existing Medicare supplement, Medicare
				cost, Medicare select 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 the purchase of this Medicare supplement, Medicare cost, Medicare
				select or Medicare Advantage coverage is a wise decision, you should terminate
				your present Medicare supplement, Medicare cost, Medicare select, 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, Medicare cost,
				Medicare select or Medicare Advantage policy will not duplicate your existing
				Medicare supplement, Medicare cost, Medicare select or, if applicable, Medicare
				Advantage coverage because you intend to terminate your existing Medicare
				supplement, Medicare cost, Medicare select coverage or leave your Medicare
				Advantage plan. The replacement policy is being purchased for the following
				reason(s):
______Additional benefits.
______No change in benefits, but lower premiums.
______Fewer benefits and lower premiums.
______My plan has prescription drug coverage and I am enrolling
				in Medicare Part D. ______Disenrollment from a Medicare Advantage plan. Please
				explain reason for disenrollment. [optional only for Direct Mailers.]
______________________________________________________________________________________________________________________________________________________________________________________________
Other. (please specify)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
1. Note: If the issuer of the Medicare supplement policy being
				applied for does not, or is otherwise prohibited from imposing pre-existing
				condition limitations, please skip to statement 2 below. Health conditions that
				you may presently have (pre-existing conditions) may not be immediately or
				fully covered under the new policy. This could result in denial or delay of a
				claim for 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 condition waiting periods. The
				insurer will waive any time periods applicable to preexisting conditions
				waiting periods in the new policy (or coverage) for similar benefits to the
				extent such time was satisfied under the Medicare supplement policy.
3. If, 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 and health history.
				Failure to include all requested 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 you sign it, review it carefully to
				be certain that all requested information has been properly reported. [If the
				policy or certificate is guaranteed issue, this paragraph need not
				appear.]
Do not cancel your present policy until you have received your
				new policy and are sure 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.