Important Legal Information

Please read the information below carefully. Your application for insurance coverage under the Federal Long Term Care Insurance Program - received either online or via downloading, completing, and mailing a paper application - confirms that you've read and understand the information below.

• Applying and Underwriting
• Authorization to Use and Disclose Health Information
• Authorization for Automatic Bank Withdrawal or Payroll / Annuity Deduction
• Agreement and Acknowledgement
• Online Application Consent (online applications only)
   

Applying and Underwriting

You (the applicant) understand that applying for long term care insurance coverage under the Federal Long Term Care Insurance Program (FLTCIP) does not automatically guarantee you will be approved for that coverage and enrolled.

Further, you understand the FLTCIP is medically underwritten and certain medical conditions, or combinations of conditions, will prevent some people from being approved for coverage. You must apply and pass a medical screening to be enrolled.

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Authorization to Use and Disclose Health Information

Upon signing in the section titled "Authorization to Disclose Health Information", for the purposes of the Federal Long Term Care Insurance Program (including underwriting, claims, and customer service), you (the applicant) are authorizing any licensed health care practitioner, medical facility, employer, insurance company, or any other entity or person that has any health information about you to give that health information to Long Term Care Partners, LLC, John Hancock Life Insurance Company, Metropolitan Life Insurance Company, their re-insurers, and their subcontractors that need to know health information to provide contracted services.

The health information you are permitting to be disclosed and used for the Federal Long Term Care Insurance Program includes any information on your medical history, and the diagnosis, prognosis and treatment of any physical or mental condition. It includes the disclosure of any medical care or surgery, psychiatric or psychological care or examinations, and information about alcohol or drug use (including any information otherwise protected by Federal Regulations 42 CFR Part 2 or other applicable laws). You understand that this authorization includes your consent to use and disclose medical information that relates to mental illness, HIV, AIDS, HIV-related illness and sexually transmitted diseases or other serious communicable diseases, but only in accordance with any law or regulation that applies to any such disclosure of this information about you.

You understand that:

• If you do not sign this authorization on the application, your application for Long Term Care Insurance may not be processed and any claim for long term care insurance benefits may be denied.
   
• You may revoke this authorization at any time, except to the extent that:
  – action has already been taken in reliance on it before your revocation, or
  – Long Term Care Partners or your insurer has a right to contest your long term care insurance claim or coverage.
   
• If you do revoke this authorization, you understand that your application for long term care insurance may not be processed and any claim for long term care insurance benefits may be denied.
   
• To revoke this authorization you must notify Long Term Care Partners, LLC, P.O. Box 797, Greenland, NH 03840-0797, in writing.
   
• If you do not revoke this authorization, it will be valid for 24 months from the date you sign it.
   
• Your health information may be redisclosed and no longer protected by applicable law, including federal health information privacy regulations. This can occur only if such redisclosure is required or allowed by law (for example, in response to a subpoena).
   
• A copy of this authorization is as valid as the original.

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Authorization for Automatic Bank Withdrawal or Payroll / Annuity Deduction

If you select Automatic Bank Withdrawal as your payment method, by signing the "Automatic Bank Withdrawal" portion of the section titled "Choose One Billing Option" on the application, you authorize Long Term Care Partners to initiate automatic bank withdrawals from the account number provided on your voided check or savings deposit slip. Withdrawals begin the month after you are approved and continue on third business day of every month. You further understand that any past due premium is collected by withdrawing up to 2 months of premium from your account until your premium payments are current.

If you select someone else's pay or annuity/pension as your payment method, you understand that person (the payor) must sign the "Someone Else's Pay or Annuity/Pension" portion in the section titled "Choose One Billing Option" on the application. Further, you confirm the signature is the payor's signature. By their signature, the payor authorizes Long Term Care Partners to deduct from their pay or annuity/pension that amount necessary to pay the FLTCIP premiums for this applicant.

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Agreement and Acknowledgement

By signing the section titled "Agreement and Acknowledgement" on your application, you acknowledge you are applying for insurance coverage under the Federal Long Term Care Insurance Program. You confirm all of the answers and explanations you give on your application, including your status as an eligible individual on page 1, are true and complete.

Further, you understand the decision to approve your application will be based on your answers and explanations on the application. If required, your medical records or answers to interview questions will also be considered.

You agree to inform Long Term Care Partners, in writing, if between the date you sign your application and the date your insurance coverage is effective: (1) your health changes in a way that would cause any answer you’ve given on your application to no longer be correct, or (2) you receive any medical advice or treatment from a physician or other health care practitioner for a condition that would affect an answer to any question on this application.

Further, you understand you have the right to request a copy of your application at any time, but you also understand you will receive one automatically.

Caution: If you are approved for coverage, but you shouldn’t have been because one or more of your answers or explanations are not true, we may have the right to deny benefits or rescind your insurance even if you did not knowingly misrepresent the facts as shown in your medical records.

In addition, by signing the section titled "Agreement and Acknowledgement" on your application, you are confirming the elections you made in the sections titled "Choose a Pre-Packaged Plan or Customize a Plan", "Choose One Billing Option", and "Protection Against Unintended Lapse".

• If you reject Automatic Compound Inflation Protection in the section titled "Choose a Pre-Packaged Plan or Customize a Plan" by choosing the Future Purchase Option, you are confirming that you reviewed the descriptions and graphs of the inflation protection options in the Outline of Coverage. You also understand that if you elect the Automatic Compound Inflation Option you may switch to the Future Purchase Option at any time, and if you elect the Future Purchase Option you may switch to the Automatic Compound Inflation Option under certain circumstances.
   
• If you elect Automatic Bank Withdrawal, you are authorizing your bank to charge your account for such withdrawals, payable to Long Term Care Partners. This authorization will remain in effect until either you, your bank or Long Term Care Partners terminates it by a thirty (30) day written notice to the others. You will not receive any bills or other notices of the withdrawals from Long Term Care Partners. You agree that if the automatic bank withdrawal is not honored by your bank, for whatever reason, Long Term Care Partners will have no liability for the payments.
   
• If you elect Payroll or Annuity/Pension Deduction from your own pay or annuity/pension, you are authorizing Long Term Care Partners to deduct from your pay or annuity/pension the amount necessary to pay the premiums for the Federal Long Term Care Insurance coverage issued to you. If you elect Payroll Deduction then we reserve the right to deduct from your annuity/pension or direct bill you the amount necessary to pay the premiums upon your retirement. Your Payroll or Annuity/Pension Deduction may be cancelled by notice to Long Term Care Partners.
   
• If you did not name someone to receive a notice if your coverage is about to lapse, by signing you are confirming that you understand that such notices do not obligate such person in any way and are not sent until 45 days after your premium was due but unpaid. You also understand that you may identify a person (and/or name a different person) to receive notice of pending lapse at any time in the future.

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Online Application Consent (Online Applications Only)

If you intend on using the online application available at this website, you understand ONLY those eligible for Abbreviated Underwriting can use the online application process.

Further, you understand the online application process takes place over the Internet using secure technologies to safeguard the transmission of your personal information through this website. You also understand you have the option of submitting an application through regular postal mail. To get an application to complete and mail to us, go to the Apply section of this website.

You also understand and confirm that you've read the important information made available to you in connection with your application in our Information Kit. If you would like a paper copy of this information, please use our Information Kit request form and one will be mailed to you.

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