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«FOR USE WITH EFFECTIVE DATES OF 1/1/2013 OR LATER 1717 W. Broadway–P.O. Box 8190 Madison, WI 53708-8190 MEDICARE SUPPLEMENT ...»

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FOR USE WITH EFFECTIVE DATES OF 1/1/2013 OR LATER

1717 W. Broadway–P.O. Box 8190

Madison, WI 53708-8190

www.wpsic.com

MEDICARE SUPPLEMENT ENROLLMENT APPLICATION

INSTRUCTIONS: YOU MAY NOT APPLY MORE THAN THREE (3) MONTHS PRIOR TO BECOMING ELIGIBLE FOR

COVERAGE. PLEASE COMPLETE ALL INFORMATION REQUESTED ON APPLICATION, AND MAIL THIS ENTIRE FORM

IN THE POSTAGE-PAID ENVELOPE ENCLOSED. IF APPLICATION IS BEING COMPLETED THROUGH AN AGENCY, THE

AGENT MUST COMPLETE AND SUBMIT THE AGENCY FORM FOR MEDICARE SUPPLEMENT ENROLLMENT.

Reason for Application: q Initial Application q Adding Benefit Riders q Removing Benefit Riders q Adding Dental How did you learn about this WPS plan?

1. APPLICANT INFORMATION (YOU MUST HAVE MEDICARE PARTS A AND B TO ENROLL.)

Last Name First Middle Date of Birth Sex Street Address City County State Zip Code Telephone No. (Home) ( ) E-Mail Address Social Security No. Medicare No.

Medicare Part A Effective Date: Medicare Part B Effective Date:

Is anyone who resides in your household* already enrolled or currently applying for a WPS Medicare Supplement? q Yes q No If yes, that person’s full name Social Security No. Effective date of policy Where would you like your policy delivered? q Applicant q Agent

2. EFFECTIVE DATE

If WPS approves you for coverage under this Medicare Supplement policy, the policy’s effective date will be the latest of:

A. The first day of the calendar month in which you become enrolled in Medicare Part B, or B. The first day of the calendar month following the date of WPS approval; or C. Requested effective date /01/ (must be the first of the month) Please see below if adding Foreign Travel after the initial effective date.

3.SELECT A BASIC OR A COST-SHARING PLAN BELOW

q BASIC PLAN ONLY COST-SHARING PLAN

q BASIC PLAN PLUS RIDERS YOU’RE REQUESTING (When adding or q 50% COST-SHARING PLAN

removing optional riders, choose all of the benefits you are electing to keep.) q Optional Rider:

q Medicare 100% Part A Deductible OR q Medicare 50% Part A Deductible Additonal Home Health Care q Medicare Part B Deductible OR q Medicare Part B Copayment or Coinsurance

–  –  –

*Household: Two or more individuals who reside together in the same dwelling. For purposes of this definition, “dwelling” means a single home, condominium unit, or apartment unit within an apartment. This does not apply to the dental option.

–  –  –

4. ELIGIBILITY/IMPORTANT INFORMATION/HEALTH QUESTIONS

A. You are automatically accepted for coverage, and no health questions are required to be answered if:

• You are applying three calendar months before you enroll in Medicare Part B.

• You are applying in the calendar month in which you enroll in Medicare Part B.

• You are applying within six calendar months immediately following the month you enroll in Medicare Part B.

• You are applying within six calendar months beginning with the month of your 65th birthday if you’re currently enrolled in Medicare Part B.

• You are currently insured by WPS, are losing eligibility and applying for this coverage at least 30 days prior to your coverage termination.

• You are eligible for guaranteed issue. Guaranteed issue applies when you lose or terminate health coverage under certain circumstances, providing you apply within 63 days of the termination date of your prior health plan. You must provide a copy of the termination notice you received from your prior plan along with your application. This notice must verify the circumstances of your prior plan’s termination and also describe your right to guaranteed issue of Medicare supplement insurance.

B. IMPORTANT INFORMATION

NOTE: If you have other Medicare supplement insurance that you don’t intend to cancel, you aren’t eligible for this WPS Medicare Supplement Policy.

1. You do not need more than one Medicare supplement, Medicare cost or Medicare select policy.

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

3. If you are eligible for benefits under Medicaid, you may not need a Medicare supplement, Medicare cost or Medicare select policy.

4. If after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare supplement, Medicare cost or Medicare select 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, Medicare cost or Medicare select policy, or, if that is no longer available, a substantially equivalent policy, will be reinstituted if requested within 90 days of losing Medicaid eligibility. If the Medicare supplement, Medicare cost or Medicare select 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.





5. If you are eligible for and have enrolled in a Medicare supplement or Medicare cost, 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 or Medicare cost 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 or Medicare cost policy under these circumstances, and later lose your employer or unionbased group health plan, your suspended Medicare supplement or Medicare cost policy or, if that is not 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 or Medicare cost 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.

6. Counseling services may be available in your state to provide advice concerning your purchase of Medicare supplement or Medicare cost 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). Please see the booklet entitled “Wisconsin Guide to Health Insurance for People with Medicare” which you received at the time you were solicited to purchase this policy.

25656-051-1212 2 C. Health questions are required to be answered if you are applying at any other time other than stated in A. above.

(1) In the past two years (a) Have you been hospitalized (more than 24 hours) three times or more, or been recommended to have inpatient surgery that hasn’t yet been performed?

(b) Have you been hospitalized for the treatment of mental or nervous disorders including alcohol or drug abuse?

(c) Have you had or been told by your physician you had a heart attack, congestive heart failure, heart valve disorder, heart rhythm disorder, enlarged heart, coronary artery disease (hardening or narrowing of the artery or arterial blockage), carotid artery disease, stroke, aneurysm, or peripheral vascular disease?................. q Yes q No (d) Have you had or been told by your physician you had diabetes that requires insulin; liver disease; or broken bones due to osteoporosis?

(e) Have you had or received treatment for End Stage Renal Disease (ESRD) kidney disease, or have you received kidney dialysis?

(2) In the past five years (a) Have you had or received treatment or surgery for cancer (except for non-melanoma skin cancer), Hodgkin’s Disease, melanoma or leukemia?

(b) Have you had, or been recommended to have any organ transplant other than of the cornea?

(3) Have you ever been diagnosed with Multiple Sclerosis, Muscular Dystrophy, Cerebral Palsy, Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease or ALS), Parkinson’s Disease, Alzheimer’s Disease, Systemic Lupus, Myasthenia Gravis, Hemophilia, Sickle Cell Anemia, Emphysema, or Cystic Fibrosis?

(4) Are you currently confined to a nursing facility?

5. PREMIUM/PAYMENT OPTIONS

Please check the mode of payment you’re requesting in either A., B., or C. below).

A. AUTOMATIC WITHDRAWAL. We electronically transfer your premium directly from your bank account at the frequency you request. (If you select this option, please complete Automatic Withdrawal Payment Authorization Form.) q Monthly q Quarterly q Semiannually q Annually With this option your first premium payment can be drafted from your bank account.

B. DIRECT BILL. We send a premium notice directly to your home at the frequency you request. You return payment to WPS by the premium due date.

q Monthly q Quarterly q Semiannually q Annually C. CREDIT/DEBIT CARD. (If you select this option, please complete Credit/Debit Card Authorization Form.) q Initial Premium Deposit q Monthly q Quarterly q Semiannually q Annually With this option your first premium payment can be charged to your credit card.

–  –  –

Questions about Medicare replacement coverage C. (1) If you had coverage from any Medicare plan other than original Medicare within the past 63 days (for example, a Medicare Advantage plan, or a Medicare health maintenance organization or preferred provider organization), fill in your start and end dates below. If you are still covered under this plan, leave “END” blank.

–  –  –

(3) If so, do you intend to replace your current Medicare supplement policy with this policy?

–  –  –

25656-051-1212 4 7. ACCEPTANCE/AGREEMENT NOTE: Signature on this agreement does not authorize disclosure of information prohibited under Section 631.90, Wisconsin Statutes.

By my signature below, I understand and agree that all statements and answers I’ve given are complete and true to he best of my knowledge and that the policy for which I’m applying will be effective only after WPS approves this application. Evidence of such approval will be issuance of the policy.

I hereby authorize any licensed physician, medical practitioner, health care provider, hospital, clinic, or other medical or medically related facility, insurance or reinsuring company, Medical Information Bureau, Inc. (“MIB”), consumer reporting agency, or other organization, institution, or person that has any record or knowledge of me to give to Wisconsin Physicians Service Insurance Corporation (“WPS”) or its legal representative, reinsurers, authorized agents or designees, any and all information in any form (excluding psychotherapy notes) about me concerning diagnosis, treatment and prognosis for any physical or mental condition, history or character, general reputation, personal traits, and mode of living, including, but not limited to, all medical and health care records. The information authorized for release shall not include whether the individual has obtained a test for the presence of HIV, antigen or nonantigenic products of HIV or an antibody to HIV or the results of such a test, if obtained by the individual.

I understand the information obtained by this authorization will be used by WPS to determine eligibility for coverage under this Medicare supplement policy and that my failure to authorize the release of said information might result in a refusal to issue or provide coverage. I agree that WPS may release said information to MIB or to WPS’ reinsuring companies, representative(s) or other person(s) performing business or legal services in connection with this application or as may be permitted or required by law, or as I may further authorize from time to time.

I understand that I may revoke this authorization by providing advance written notice of termination to WPS at its office in Madison, Wisconsin, and that any information released in reliance upon this authorization and prior to such revocation cannot be retrieved. In such case, WPS, its directors, officers, employees and agents shall not be held responsible or liable for such release. I understand this authorization will remain valid for 30 months from the date I execute this authorization unless revoked by me in writing prior to the end of that 30-month period.

I understand that I should retain a copy of this completed authorization for my own records, and that a photographic copy shall be as valid as the original. I understand that once information is disclosed pursuant to this authorization, federal privacy laws may no longer protect it and the person or entity that receives the information may re-disclose it.

I understand that an insurance agent or broker cannot modify or waive the terms, conditions, or provisions of the insurance policy, application or requirement imposed by WPS, nor bind coverage or guarantee approval of coverage.

I further understand that WPS, its directors, officers, employees and agents shall not be liable for any injury, damage or expense (including attorneys’ fees), I suffer as a result of any improper advice, action or omission on the part of any health care provider.



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