application submission checklist to gpm life for … resources... · application submission...
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Application Submission Checklist To GPM Life For Medicare Supplement Coverage– MICHIGANTHIS APPLICATION MUST BE USED TO WRITE GPM LIFE MEDICARE SUPPLEMENT PRODUCTS
o Application 1. Complete “Plan Information” Box. 2. Refer to the Outline of Coverage for policy forms. 3. Answer all questions in full. 4. Sign and Date in all places indicated. 5. Be sure to leave all applicable forms with the proposed insured. 6. See reverse side of this page for additional detailed information.
o Collect Premium Amount • Thefullmodalpremiumiscollectedatthetimeofapplication. • Followinstructionsonpage1ofCalculate Your Premium form (T04_366) to calculate
the premium. Complete the form and return with the application. • Calculatethepremiumbasedonageatthetimeofapplication.
• TobaccoratesdonotapplyduringOpenEnrollmentorGuaranteeIssuesituations. • Thereisaone-timeapplicationfeeof$25.00(perapplicant)thatwillbecollectedwiththe initial payment.
o Provide Client with Buyer’s Guide
o Provide Client with Outline of Coverage
o Complete Producer Information page
o If applicable, complete the Authorization for Electronic Funds Transfer form (ACH/BSP form T04_367) and return with the completed application
o Provide Client with Conditional Receipt signed by agent (if applicable), and provide Client with Notice of Information Practices
o Complete, sign and provide client with copy of the Authorization To Disclose Personal Information (HIPAA form T04_363_MI_0710). This form is NOT a requirement if applying during an Open Enrollment or Guaranteed Issue Period
o Complete Replacement Notice (T04_364) and leave a copy with the applicant (if applicable)
Please provide additional information and comments in the space provided on the application.
Note: An interviewer may call to verify/confirm the information provided on the application.
P.O. Box 2679 Omaha, NE 68103-2679
T04_365_MI_1010
There are two parts to this application: One part is the general application. The other part includes necessary administrative forms that you will need at time of sale.1. Application – Agent Completes in Full: (please print)
“Plan Information” Box• PolicyForm• RequestedEffectiveDate• PremiumCollected(Amount)-Followinstructionsonpage1ofCalculateYourPremiumform(T04_366)to
calculatethepremium.CompletetheformforApplicantsA&B(ifapplying)returnwiththeapplication.• InitialMode*(A=Annual,S=Semiannual,Q=Quarterly,orACH=AutomatedClearingHouse)• RenewalPremium(Amount)• RenewalMode*(A=Annual,S=Semiannual,Q=Quarterly,orB=AutomaticFundsWithdraw) *DirectMonthlybillingnotavailableSection 1 “General Information”–• TheResidenceaddressandZIPcodeareindicated.Alternateaddressforbillingasindicated(whenapplicable).• Theapplicant’scurrentageattimeofapplication.• Theapplicant’sSocialSecuritynumberasindicatedfromapplicant’sSocialSecurityCard.• ForapplicantsalreadycoveredbyMedicare,includeapplicant’sMedicarenumberontheapplicationasindicated
fromtheapplicant’sMedicareHealthInsuranceCard.Thisnumberisrequiredforelectronicclaimprocessing.Ifthisnumberisnotavailableattimeofapplication,theapplicant/agentmustprovidethisnumberbycalling1-877-656-5424onceitisreceived.
• Theapplicant’scurrentHeightinfeetandinchesandWeightinpounds.Sections 2 and 3 “Existing Coverage Information”–• Please complete all questions in full.• IftheapplicantisnotcoveredbyMedicare,indicate“EligibilityDate”and“DateofEnrollment”.• List all individual and group health policies held by the applicant in the appropriate section of the application. • Iftheapplicantisreplacingcurrentcoveragewiththispolicy,indicatethefollowinginformation. – Name of Company – Issue Date –Policy/CertificateNumber –Termination/DisenrollmentDate – Plan – Kind of PolicyNOTE:Aninterviewermaycalltoverify/confirmtheinformationprovidedontheapplication.
2. Administrative FormsProducer/Agent Information• Be sure to include your Social Security number and commission code. NOTE: This information is necessary for the underwriting process and commission payment.• Includeyourtelephonenumber,e-mailaddressandFAXnumberforcontactpurposes.
Authorization for Electronic Funds Transfer by GPM Life Insurance Company (ACH/BSP) – If applicant chooses to pay premiums by ACH/BSP, complete this form accurately and in its entirety and return with the application.• Option A-Payallpremiums(1st&monthlyrenewals)byACH/BSP-DONOTsubmitacheckforpayment.• Option B-Pay1stmonthbypapercheck&monthlyrenewalsbyBSP-AcheckforinitialmonthlypremiumMUST
be submitted with the application• Option C-Pay1stmonthbyACH&payrenewalsbydirectbill(monthlydirectbillingisnotoffered)-
DONOTsubmitacheckforinitialpremiumpayment.Conditional Receipt and Notice of Information Practices• Completeandsignthereceipt(ifapplicable),detachentirepageandleavewithapplicant.Authorization To Disclose Personal Information (HIPAA)• If client is NOT applying during an OpenEnrollmentorGuaranteedIssuePeriod,completingtheAuthorization
ToDisclosePersonalInformationformIS a requirement. Please have the applicant readtheform,fillinrequiredinformation,sign,dateandleave a copy of the completed and signed form with applicant.
• If client IS applyingduringanOpenEnrollmentorGuaranteedIssuePeriod,completingtheAuthorization ToDisclosePersonalInformationform is NOT a requirement.
Replacement Notice – complete if applicable• Complete form including signature and date.• Leaveacopywithapplicant(ifapplicable).State – Specific Forms – complete if applicable• Be sure to include all state appropriate forms.
APPLICANT
Policy Form
APPLICANT B
Policy Form
Requested EffectiveDate RequestedEffectiveDatePremium Collected (based on age at application date)$Theinitialpremiumincludesaone-timepolicyfeeof$25.00.
Premium Collected (based on age at application date)$Theinitialpremiumincludesaone-timepolicyfeeof$25.00.
InitialMode A, S, Q, ACH InitialMode A, S, Q, ACH
Renewal$ Renewal$
RenewalMode A, S, Q, B (directmonthlynotavailable) RenewalMode A, S, Q, B (directmonthlynotavailable)
1. PLEASE READ THE FOLLOWING CAREFULLY AND ANSWER ALL QUESTIONS COMPLETELY.
NOTE: For ALL sections, ONLY complete the Applicant B information if to be insured.PLAN INFORMATION(tobecompletedbyProducer)
Applicant
Name(First/Middle/Last)
Residence Address
City
State ZIP
MailingAddress(ifdifferentfromresidenceaddress)
City
State ZIP
HomePhoneNo(_______)____________________________ (areacode)
CurrentAge_________DateofBirth___________________ mo day yr
Male Female
Social Security No
MedicareHealthInsuranceCardNumber(ifknown)
E-mailAddress
Height WeightFt________ In________ Lbs__________
/ / / /
Applicant B
Name(First/Middle/Last)
ResidenceAddress(ifdifferentfromApplicant’s)
City
State ZIP
MailingAddress(ifdifferentfromresidenceaddress)
City
State ZIP
HomePhoneNo(_______)____________________________ (areacode)
CurrentAge_________DateofBirth___________________ mo day yr
Male Female
Social Security No
MedicareHealthInsuranceCardNumber(ifknown)
E-mailAddress
Height WeightFt________ In________ Lbs__________
Application For Medicare Supplement Coverage
T04-2011-20 GPM Life Insurance Company • Administrative Office • P.O. Box 2679 • Omaha, Nebraska 68103-2679 1
1. HaveyoureceivedacopyoftheGuide to Health Insurance for People with Medicare and the Outline of Coverage?
2. Haveyouusedtobaccoinanyforminthepast12months?
To the Best of Your Knowledge:1. AreyoucoveredunderMedicarePart A? If “YES,” what is your Part A effective date?_____________ /______________________
Applicant Applicant B If “NO,” what is your eligibility date?__________________ / ______________________ Applicant Applicant B2. AreyoucoveredunderMedicarePart B? If “YES,” what is your Part B effective date?____________ /_______________________ Applicant Applicant B If“NO,”indicatedateyouplantoenroll. _______________ /_______________________ Applicant Applicant B3. Did you turn age 65 in the last six months?4. DidyouenrollinMedicarePartBinthelastsixmonths? If“YES,”indicateyoureffectivedate. _________________ /_______________________ Applicant Applicant B
Applicant Applicant B Yes No Yes No Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No Yes No Yes No
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
2. PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS.
If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issueofaMedicaresupplementinsurancepolicyorcertificate,orthatyouhadcertainrightstobuysuchapolicyorcertificate,youmaybeguaranteedacceptanceinoneormoreofourMedicaresupplementplans.Pleaseincludeacopyofthenoticefromyourpriorinsurerwithyour application. PLEASE ANSWER ALL QUESTIONS. Please mark “YES” or “NO” with an “X” to the questions below.
3. FOR YOUR PROTECTION, the National Association of Insurance Commissioners requests that we ask the following questions about insurance policies or certificates you may have.
TotheBestofYourKnowledge:1. Are you applying during a guaranteed issue period? (NOTE:Iftheansweraboveis“YES,”pleaseattachproofofeligibility.)
2. DoyouhaveanotherMedicaresupplementorMedicareselectinsurancepolicyor certificateinforce? (a) If “YES,”withwhatcompany,andwhatplandoyouhave?
(b) If“YES,”doyouintendtoreplaceyourcurrentMedicaresupplementpolicy/certificatewith this policy? (c) If“YES,”indicateterminationdate. _______________ /________________________ Applicant Applicant B (d) If “YES,” have you received a copy of the replacement notice?If you have had any other Medicare plan coverage as referenced below, not to include Medicare supplement, please complete questions (a-g) below. If not, skip to question #4.3. IfyouhadcoveragefromanyMedicareplanotherthanoriginalMedicarewithinthepast 63days(forexample,aMedicareAdvantageplan,oraMedicareHMOorPPO),fillinyour startandenddatesbelow.Ifyouarestillcoveredunderthisplan,leave“END”blank. START _____________ END____________/START____________END____________ Applicant Applicant B (a) IfyouarestillcoveredundertheMedicareplan,doyouintendtoreplaceyourcurrent coveragewiththisnewMedicaresupplementpolicy? (b) If “YES,” have you received a copy of the replacement notice? (c) Reasonfortermination/disenrollment?_______________________________ / _________________________________ Applicant Applicant B (d) Planneddateoftermination/disenrollment?_____________________________/_________________________________ Applicant Applicant B
Applicant Applicant B Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No Yes No Yes No
ApplicantName of Company
Policy/CertificateNumber
Plan
Issue Date
Applicant BName of Company
Policy/CertificateNumber
Plan
Issue Date / / / /
/ / / /
/ / / /
/ / / / / / / /
T04-2011-20 GPM Life Insurance Company • Administrative Office • P.O. Box 2679 • Omaha, Nebraska 68103-2679 2
Applicant BName of Company KindofPolicy/Certificate
(e) WasthisyourfirsttimeinthistypeofMedicareplan? (f) DidyoudropaMedicaresupplementorMedicareselectpolicy/certificatetoenrollinthis Medicareplan? (g) IsyourformerMedicaresupplementorMedicareselectpolicy/certificatestillavailable?4. Haveyouhadcoverageunderanyotherhealthinsurancewithinthepast63days? (Forexample,anemployer,union,orindividualnon-Medicaresupplementplan.) (a) If “YES,”withwhatcompanyandwhatkindofpolicy/certificate?(Listbelow.)
(b) Whatareyourdatesofcoverageundertheotherpolicy/certificate?Ifyouarestillcoveredunderthisplan,leave“END”blank. START_____________________END___________________ /START____________________END___________________ Applicant Applicant B
(c) Reasonfortermination/disenrollment? ________________________________ / ________________________________ Applicant Applicant B
(d) Planneddateoftermination/disenrollment?_____________________________ / ________________________________ Applicant Applicant B
5. AreyoucoveredformedicalassistancethroughthestateMedicaidprogram? (NOTETOAPPLICANT:Ifyouareparticipatingina“Spend-DownProgram”andhave notmetyour“ShareofCost,”pleaseanswer“NO”tothisquestion.) If“YES,”
(a) WillMedicaidpayyourpremiumsforthisMedicaresupplementpolicy? (b) DoyoureceiveanybenefitsfromMedicaidOTHERTHANpaymenttowardyour MedicarePartBpremium?6. Producersshalllistanyotherhealthinsurancepolicies/certificatestheyhavesoldtotheapplicant. (a) List policies/certificates sold which are still in force.
(b) Listpolicies/certificatessoldinthepastfive(5)yearswhicharenolongerinforce.
Applicant Applicant B Yes No Yes No
Yes No Yes No Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
/ / / / / / / /
/ / / /
ApplicantName of Company KindofPolicy/Certificate
Applicant
Name of Company
Policy/CertificateNumber
Description of Benefits
EffectiveDateofCoverage
Applicant B
Name of Company
Policy/CertificateNumber
Description of Benefits
EffectiveDateofCoverage
Applicant
Name of Company
Policy/CertificateNumber
Description of Benefits
EffectiveDateofCoverage
Applicant B
Name of Company
Policy/CertificateNumber
Description of Benefits
EffectiveDateofCoverage
T04-2011-20 GPM Life Insurance Company • Administrative Office • P.O. Box 2679 • Omaha, Nebraska 68103-2679 3
T04-2011-20 GPM Life Insurance Company • Administrative Office • P.O. Box 2679 • Omaha, Nebraska 68103-2679 4
If you are applying during Open Enrollment or a Guaranteed Issue period, SKIP SECTION 4 and GO TO SECTION 5. 4. PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS. Make sure all questions are answered by each
applicant. If either you or Applicant B answer “YES” to any of the following questions 1-14, that person is not eligible for coverage.
TotheBestofYourKnowledge: 1. Areyoucurrentlyhospitalizedorconfinedtoanursingfacility;or,areyoubedriddenor
confinedtoawheelchair? 2. Haveyoubeendiagnosedwithemphysema,ChronicObstructivePulmonaryDisease
(COPD)orotherchronicpulmonarydisorders? 3. HaveyoubeendiagnosedwithParkinson’sDisease,SystemicLupus,MyastheniaGravis,
MultipleorLateralSclerosis,Osteoporosiswithfractures,Cirrhosisorkidneydiseaserequiringdialysis?
4.HaveyoubeendiagnosedwithAlzheimer’sDisease,SenileDementia,oranyother cognitive disorder?
5.HaveyoubeendiagnosedwithortreatedforAcquiredImmuneDeficiencySyndrome(AIDS)?
6.Ifyouhavediabetes,doyouhaveanyofthefollowingconditions:diabeticretinopathy,peripheralvasculardisease,neuropathy,anyheartcondition(includinghighbloodpressure)orkidneydisease?Ifyoudonothavediabetes,thisquestionshouldbeanswered“NO”.
7.Doyouhavediabetesthathaseverrequiredmorethan50unitsofinsulindaily? 8.Withinthepasttwoyearshaveyoubeentreatedfororbeenadvisedbyaphysicianto
havetreatmentforinternalcancer,alcoholismordrugabuse,mentalornervousdisorderrequiring psychiatric care or have you had any amputation caused by disease?
9.Withinthepasttwoyearshaveyoubeentreatedfororbeenadvisedbyaphysiciantohavetreatmentforheartattack,heart,coronaryorcarotidarterydisease(notincludinghighbloodpressure),peripheralvasculardisease,congestiveheartfailureorenlargedheart,stroke,transientischemicattacks(TIA)orheartrhythmdisorders?
10.Withinthepasttwoyearshaveyoubeentreatedfordegenerativebonedisease,crippling/disabling or rheumatoid arthritis or have you been advised to have a joint replacement?
11.Haveyoubeenadvisedbyaphysicianthatsurgerymayberequiredwithinthenext12months for cataracts?
12.Haveyoubeenadvisedbyaphysiciantohavesurgery,medicaltests,treatmentortherapythat has not been performed?
13.Haveyoubeenhospitalconfinedthreeormoretimesinthelasttwoyears?14.Haveyouhadanorgantransplantorbeenadvisedbyaphysiciantohaveanorgantransplant?15.Areyoutakingorhaveyoutakenanyprescriptionorover-the-countermedicationswithin
thepast12months?If“YES,”pleaselistthedrugandtheconditioninthefollowingtable.
Applicant (pleaseattachaseparatesheetifneeded) Applicant B (pleaseattachaseparatesheetifneeded)
MedicationName(copyoffpharmacylabel)
Date Originally PrescribedFrequencyandDosageDiagnosis/Condition
MedicationName(copyoffpharmacylabel)
Date Originally PrescribedFrequencyandDosageDiagnosis/Condition
MedicationName(copyoffpharmacylabel)
Date Originally PrescribedFrequencyandDosageDiagnosis/Condition
Applicant Applicant B
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No Yes No Yes No Yes No Yes No
Yes No Yes No
IMPORTANT STATEMENTS TO BE READ BY APPLICANT YoudonotneedmorethanoneMedicaresupplementpolicy. Ifyoupurchasethispolicy,youmaywanttoevaluateyourexistinghealthcoverageanddecideifyouneedmultiplecoverage. YoumaybeeligibleforbenefitsunderMedicaidandmaynotneedaMedicaresupplementpolicy. If,afterpurchasingthepolicy,youbecomeeligibleforMedicaid,thebenefitsandpremiumsunderyourMedicaresupplementpolicycanbesuspended,ifrequested,duringyourentitlementtobenefitsunderMedicaidfor24months.Youmustrequestthissuspensionwithin90daysofbecomingeligibleforMedicaid.IfyouarenolongerentitledtoMedicaid,yoursuspendedMedicaresupplementpolicy(or,ifthatisnolongeravailable,asubstantiallyequivalentpolicy)willbereinstitutedifrequestedwithin90daysoflosingMedicaideligibility.IftheMedicaresupplementpolicyprovidedcoverageforoutpatientprescriptiondrugsandyouenrolledinMedicarePartDwhileyourpolicywassuspended,thereinstitutedpolicywillnothaveoutpatientprescriptiondrugcoverage,butwillotherwisebesubstantiallyequivalenttoyourcoveragebeforethedateofthesuspension.
Ifyouareeligiblefor,andhaveenrolledinaMedicaresupplementpolicybyreasonofdisabilityandyoulaterbecomecoveredbyanemployerorunion-basedgrouphealthplan,thebenefitsandpremiumsunderyourMedicaresupplementpolicycanbesuspended,ifrequested,whileyouarecoveredundertheemployerorunion-basedgrouphealthplan.IfyoususpendyourMedicaresupplementpolicyunderthesecircumstances,andlaterloseyouremployerorunion-basedgrouphealthplan,yoursuspendedMedicaresupplementpolicy(or,ifthatisnolongeravailable,asubstantiallyequivalentpolicy)willbereinstitutedifrequestedwithin90daysoflosingyouremployerorunion-basedgrouphealthplan.IftheMedicaresupplementpolicyprovidedcoverageforoutpatientprescriptiondrugsandyouenrolledinMedicarePartDwhileyourpolicywassuspended,thereinstitutedpolicywillnothaveoutpatientprescriptiondrugcoverage,butwillotherwisebesubstantiallyequivalenttoyourcoverage before the date of the suspension.
CounselingservicesmaybeavailableinyourstatetoprovideadviceconcerningyourpurchaseofMedicaresupplementinsuranceandconcerningmedicalassistancethroughthestateMedicaidprogram,includingbenefitsasaQualifiedMedicareBeneficiary(QMB)andaSpecifiedLow-IncomeMedicareBeneficiary(SLMB).
5. PLEASE READ AND SIGN BELOW
IwishtoapplyforaMedicaresupplementinsurancepolicy. I represent that my answers and statements on this application are trueandcomplete.Iunderstandthat,uponacceptanceofthecompletedapplication,eachapplicantwillreceiveaseparatepolicy. I understand that my policy benefitscanstartnoearlierthanmyMedicareeffectivedate,my first month’s premium has been receivedand/orprocessedandmyapplicationhasbeenapprovedbyGPMLifeInsuranceCompany.
Datedat__________________________,on__________________,_____ _________________________________________ City State Month Day Year Applicant’sSignature
Datedat__________________________,on__________________,_____ _________________________________________ City State Month Day Year ApplicantB’sSignature(ifapplying)
Premium Must Accompany ApplicationI/Wecertifythatduringaninterviewwiththeproposedapplicant,I/wehavetrulyandaccuratelyrecordedintheapplicationtheinformation supplied by the applicant.
____________________________________________________ ________________________________________________(SignatureofLicensedProducer)(Date) (SignatureofLicensedProducer)(Date)
____________________________________________________ ________________________________________________PRODUCERSTAMP PRODUCERSTAMP
T04-2011-20 GPM Life Insurance Company • Administrative Office • P.O. Box 2679 • Omaha, Nebraska 68103-2679 5
ADDITIONAL INFORMATION: PART 4 - CON’T. HEALTH /MEDICAL QUESTIONS - Question #15Applicant (pleaseattachaseparatesheetifneeded) Applicant B (pleaseattachaseparatesheetifneeded)
MedicationName(copyoffpharmacylabel)
Date Originally PrescribedFrequencyandDosageDiagnosis/Condition
MedicationName(copyoffpharmacylabel)
Date Originally PrescribedFrequencyandDosageDiagnosis/Condition
MedicationName(copyoffpharmacylabel)
Date Originally PrescribedFrequencyandDosageDiagnosis/Condition
MedicationName(copyoffpharmacylabel)
Date Originally PrescribedFrequencyandDosageDiagnosis/Condition
SECTION FOR ADDITIONAL COMMENTSApplicant (pleaseattachaseparatesheetifneeded) Applicant B (pleaseattachaseparatesheetifneeded)
T04-2011-20 GPM Life Insurance Company • Administrative Office • P.O. Box 2679 • Omaha, Nebraska 68103-2679 6
Page 1 T04_366
Complete and return with application
GPM LIFE INSURANCE COMPANY
Calculate Your PremiumMedicare Supplement
Medicare Supplement Plan _____Before you begin: If you’re not in your open enrollment or guarantee issue period, please go to page 2 to determine your eligibility for coverage.
Line Steps ExampleRate displayed is used for calculation purposes only.
Applicant’s Premium
Applicant B’s Premium
#1 PremiumWriteinyourMedsuppplan’spremiumfromthe Outline of Coverage provided.
$128.52
#2 Payment Options
Todetermineotherpaymentschedules,multiplyyourmonthlypremiumby:3topay4timesayear(quarterly)6topaytwiceayear(semiannually)12topayonceayear(annually)
$128.52monthlypayment
$385.56quarterlypayment$771.12semiannualpayment$1,542.24annualpayment
#3 Enrollment/Policy FeeThereisaone-timeapplicationfeeof$25.00. This will be collected with your initial payment and will NOT affect your renewal premium amounts.
$128.52+$25.00=$153.52
Exampleshowsinitialpayment(monthlyschedule).
Page 2 T04_366
Height and Weight ChartEligibilityTodeterminewhetheryoumaypurchasecoverage,locateyourheight,thenweightinthechartbelow.IfyourweightisintheDeclinecolumn,we’resorry,you’renoteligibleforcoverageatthistime.IfyourweightislocatedintheStandardcolumn,youmaycontinueto step 1.
Decline Standard Decline
Height Weight Weight Weight4' 2'' < 54 54 – 145 146+4' 3'' < 56 56 – 151 152+4' 4'' <58 58–157 158+4' 5'' <60 60–163 164+4' 6'' < 63 63–170 171+4'7'' < 65 65–176 177+4'8'' <67 67–182 183+4' 9'' <70 70–189 190+4'10'' <72 72–196 197+4' 11'' <75 75–202 203+5'0'' <77 77–209 210+5' 1'' <80 80–216 217+5' 2'' <83 83–224 225+5' 3'' <85 85–231 232+5' 4'' <88 88–238 239+5' 5'' < 91 91 – 246 247+5' 6'' < 93 93 – 254 255+5'7'' < 96 96 – 261 262+5'8'' < 99 99 – 269 270+5' 9'' <102 102–277 278+5'10'' <105 105–285 286+5' 11'' <108 108–293 294+6'0'' < 111 111–302 303+6' 1'' < 114 114–310 311+6' 2'' <117 117–319 320+6' 3'' < 121 121–328 329+6' 4'' < 124 124 – 336 337+6' 5'' <127 127–345 346+6' 6'' <130 130–354 355+6'7'' < 134 134 – 363 364+6'8'' <137 137–373 374+6' 9'' <140 140–382 383+6'10'' < 144 144 – 392 393+6' 11'' <147 147–401 402+7'0'' < 151 151 – 411 412+7'1'' < 155 155 – 421 422+7'2'' <158 158–431 432+7'3'' < 162 162 – 441 442+7'4'' < 166 166 – 451 452+
MedicaresupplementinsuranceisunderwrittenbyGPM Life Insurance CompanyAdministrative OfficeP.O.Box2679 Omaha,Nebraska68103-2679 www.GPMLifeMedicareSupplement.com
GPM LIFE INSURANCE COMPANY
Policy DeliveryMailpolicy/policiesto: (a) Applicant Producer
(b) ApplicantB Producer
Producer(s) Information
Producer Name_________________________________________ Social Security No____________________________
Comm. % Share ________ ProducerPhoneNo(____) ____________________ Commission Code_____________________
ProducerE-mailAddress __________________________________ @____________________________________________
ProducerFAXNumber____________________________________
Producer Name_________________________________________ Social Security No____________________________
Comm. % Share ________ ProducerPhoneNo(____) ____________________ Commission Code_____________________
ProducerE-mailAddress __________________________________ @____________________________________________
ProducerFAXNumber____________________________________
Producer To Complete Only If Premium Is To Be Paid With A Business Check/Account Initial Payment
Istheapplicant: Yes No
(a) unemployed? ..............................................................................................................................................................
(b) employed,butnotworkingforthebusinessthatispayingthepremium? ................................................................
(c) thebusinessownerorspouseofthebusinessowner? ...............................................................................................
If(a),(b),or(c)is“Yes,”thepremiumcanbepaidwithabusinesscheck/account.
Renewal Payment
Istheapplicant: Yes No
(a) unemployed? ..............................................................................................................................................................
(b) employed,butnotworkingforthebusinessthatispayingthepremium? ................................................................
(c) thebusinessownerorspouseofthebusinessowner? ...............................................................................................
If(a),(b),or(c)is“Yes,”thepremiumcanbepaidwithabusinesscheck/account.
GPM LIFE INSURANCE COMPANYAdministrative OfficeP.O.Box2679Omaha,Nebraska68103-2679
Initial Premiums Paid through Automated Clearing House (ACH)MedicaresupplementapplicationsmayhavetheirinitialpremiumsautomaticallydeductedfromtheircheckingorsavingsaccountthroughthespecificElectronicFundsTransfer(EFT)processidentifiedasAutomaticClearingHouse(ACH).Whentheydo,youmayfaxtheapplicationandrequiredformsinsteadofmailingthem.
FollowtheseeasystepstosubmitMedsuppappsusingACHforinitialpremiums:
Step 1 - Complete the Authorization for Electronic Funds Transfer (ACH/BSP) formApplicantswishingtopayelectronicallycompletetheappropriateMedsuppAuthorization for Electronic Funds Transfer form*: T04_367forGPMLifeInsuranceCompany
ToPay:• Only the initialpremiumviaEFT,completethetopportionaswellastheaccountinformationonthe MedsuppAuthorization for Electronic Funds Transfer form• Both the initial and renewalpremiumsviaEFT,completetheentireform,includingtheaccountinformation
Step 2 - Fax the following items to the dedicated line for ACH payments at 1-866-422-91391. ACHfaxtransmittalcoversheetonthebackofthisform,T04_368*2. MedsuppAuthorization for Electronic Funds Transferform,T04_367*3. Medsuppapplicationandotherrequiredforms
Tips for Submitting Initial Premiums through ACH• Donotsendasignedcheckfortheinitialpremium;clientscouldbechargedtwice• Donotfaxtheformsmorethanonce;additionalchargescouldresult• Ifyoufaxtheforms,donotmailthem,too;processingerrorsoccurandadditionalchargesresult
*Intheapplicationpackage
Forproduceruseonly.Notforusewiththegeneralpublic.
T04_368
Fax
Use to Transmit Applications with Initial Payment by ACH1-866-422-9139*
*Usethisfaxnumberonlyforapplicationsandnew-businessdocuments.Applicationsfaxedtoanyother number can cause processing delays.
Pleasecompletethefollowinginformation:
Totalnumberofpagesbeingfaxed(includingthiscoversheet)_____________
Producer Name Producer Number or SSN
Phone Number FaxNumber
Comments_________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Thiscommunicationandanyattachmentstransmittedwithitareconfidentialandaresolelyfortheuseoftheaddressee.Itmaycontainmaterialthatislegallyprivileged,proprietaryorsubjecttocopyrightbelongingtoGPMLifeInsuranceCompanyanditsaffiliates,anditmaybesubjecttoprotectionunderfederalorstatelaw.Ifyouarenottheintendedrecipient,youarenotifiedthatanyuseofthismaterialisstrictlyprohibited.Ifyoureceivedthistransmissioninerror,pleasecontactthesenderimmediatelybytelephone,collectcallsaccepted,atthenumbershownabove.WewillarrangeforyoutoreturntheoriginalmaterialtousviatheU.S.PostalService,andifrequested,wewillreimburseyouforsuchexpense.
Government Personnel Mutual Life Insurance CompanyP.O. Box 2679 Omaha, NE 68103-2679Phone 1-866-754-5716 Fax 1-866-422-9139 GPM LIFE
T04_367
Instructions for Completion of Authorization for Electronic Funds Transfer (ACH/BSP) Form
Theapplicantmayselectoneofthreepaymentoptionsindicatedonthebacksideofthisform.Instructionsforeachoptionarelistedbelow.Witheachoption,theformmustbesignedanddated.
Option A: Pay all premiums (1st month and monthly renewals) by Electronic Funds Transfer (EFT). Automatic Clearing House (ACH)isusedforinitialpaymentandBank Service Plan(BSP)isusedforrenewalpayments.WhenchoosingtopayboththeinitialandmonthlyrenewalsbyEFT,theapplicantmustcompletetheformandsubmititwiththeapplication.DONOTsubmitasignedcheckforpaymentunderthisoption.Toavoidpotentialdelaysinprocessing,submitavoidedcheckandcompletetheaccountinformation(routing/accountnumbers,nameoffinancialinstitution)ontheform.
Option B: Pay 1st month by paper check and monthly renewals by BSP WhenchoosingtopaytheinitialpremiumviapapercheckandthemonthlyrenewalsbyBSP,theapplicantmustcompletetheformandsubmititwiththeapplication.Asignedcheckfortheinitialmonthlypremiummustbesubmitted with the application.
Option C: Pay 1st month by ACH and pay renewals by direct bill (monthly direct billing is not offered) WhenchoosingtopaytheinitialpremiumsbyACHandrenewalpremiumsbydirectbilling(quarterly, semiannually,orannually),theapplicantmustcompletetheformandsubmititwiththeapplication.DONOTsubmitasignedcheckfortheinitialpremiumpaymentunderthisoption.Toavoidpotentialdelaysinprocessing,submitavoidedcheckandcompletetheaccountinformation(routing/accountnumber,nameoffinancialinstitution)ontheform.
When choosing to pay initial premiums by ACH, money will be withdrawn on the date the application is processed. This may be different from the monthly withdraw date selected for renewal premiums.
Payments cannot be postponed until a later date.Paymentfromathirdparty,includinganyfoundation,cannotbeaccepted.Allrefundswillbemadetotheapplicantintheeventofrejection,incompletesubmission,overpayment,cancellation,etc.PleasecompletetheElectronicFundsTransferformaccuratelyandinitsentirety,makingsurethatallrequiredinformationiscorrectandcompleteonyourElectronicFundsTransferformpriortosubmission.Inaddition,pleasemakesurethatthepremiumamountisfilledinontheElectronicFundsTransferformsowecaninitiateatimelyandaccuratewithdrawalfromyourclient’sbankaccount.AnexampleofhowtofindcorrectRoutingandAccountNumbersonyourclients’checksisincludedatthetopofthisform.DonotincludethechecknumberaspartofeithertheRoutingorAccountNumber.Theapplicant’sbanknameisnormallyincludedabovetheMemolineonthecheck.
John Doe Check #1234Street AddressTown, City Zip code Date: _________________
Pay to: __________________________________________________________________
___________________________________________________________________DollarsBank Name & Address
Memo _________________ Signed By: _________________________________
Account Holder Name
{ {
{ Check Number{
|:123456789:| 12345678 ||■ 1234 ||■
Bank Routing/Transfer Number
Bank Account Number
Check Number(if shown at bottom, may be
before or after the account #)
Do NOT include the check number as part of either the Routing or Account Number.
{
T04_367
Applicant A Applicant B
Please refer to instructions ontheFrontofthisform.
GPM LIFE INSURANCE COMPANY
Authorization for Electronic Funds Transfer (ACH/BSP)This form is intended as authorization to debit your account. Please complete initial and renewal premium payment information below.
Medicare Supplement Premium Payment Options: YES NO YES NO
A. Paypremiums(1stmonthandmonthlyrenewals)byElectronicFundsTransfer (ACH is used for initial payment and BSPisusedforrenewalpayments.)
B. Pay 1st premium by signed papercheckandpaymonthlyrenewalsbyBSP C. PayinitialpremiumbyACHandpayrenewalsbydirectbill (monthly direct billing is not offered)
• IfchoosingOptionsAorC,list amount of initial premium withdrawal . . . . . . . . . . . . . . . $ ________ $________
• IfchoosingOptionsAorB, select a withdrawaldateformonthlyrenewalpayments(circleone) . . . . . . . . . . . . . . . . . . 1st or 15th 1st or 15th
• Is a Business Account being used to pay premiums? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Ifyes,istheapplicant: (a)Unemployed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (b)Employed,butnotworkingforthebusinessthatispayingthepremium . . . . . . . . . . . . (c)Thebusinessownerorspouseofthebusinessowner . . . . . . . . . . . . . . . . . . . . . . . . . . . . If (A), (B), or (C) are “Yes,” premiums CAN be paid with a business account.
Applicant A Applicant B
Complete the information below. To avoid potential delays in processing, submit a copy of a voided check.Account Type (check one): Checking Savings Account Type (check one): Checking Savings
_______________________________________________ ______________________________________________NameofFinancialInstitution NameofFinancialInstitution
_______________________________________________ ______________________________________________RoutingNumber(first9digitsonlowerleftsideofcheck) RoutingNumber(first9digitsonthelowerleftsideofcheck)
_______________________________________________ ______________________________________________Account Number Account Number (DoNOTuseDebitorCreditCardaccountnumbers) (DoNOTuseDebitorCreditCardaccountnumbers)
_______________________________________________ ______________________________________________Name as Shown on Account Name as Shown on Account
IMPORTANT: Withdrawal date of the initial premium payment will occur when the application is processed and may be different than the monthly withdrawal date selected above.
IauthorizeGPMLifeInsuranceCompany(“GPMLife”)towithdrawfundsfrommyaccountformyinitialand/ormonthlyrenewalpremiumsandunderstandthattheamountsmaydiffer.IalsoauthorizeGPMLifetocollectanypremium(s)duebybankdraftwithdrawal.Premiumshortagesmayresultfromavarietyofcauses,includingunderwritingadjustments.Iauthorizeyou,myfinancialinstitution,topayfrommyaccountanychecks,draftsorpreauthorizedelectronicfundtransfersfrommyaccounttoGPMLife.Yourrightswitheachchargewillbethesameasifpersonallypaidbyme.TheauthorizationwillbeeffectiveuntilIgiveyouatleastthreebusinessdays’noticetocancelit.Ifnoticeisgivenverbally,youmayrequirewrittenconfirmationfrommewithin14daysaftermyverbalnotice.
_______________________________________________ ______________________________________________Authorized Signature as Shown on Account Authorized Signature as Shown on Account
_______________________________________________ ______________________________________________Date Date
MICHIGAN - Authorization To Disclose Personal Information To GPM Life Insurance CompanyMeanings of Terms
“Medical Persons and Entities” means: allphysicians,medicalordentalpractitioners,hospitals,clinics,pharmacies,pharmacybenefitmanagers,othermedicalcarefacilities,healthmaintenanceorganizationsandallotherprovidersofmedicalordental services.“Personal Information” means: allhealthinformation,suchasmedicalhistory,mentalandphysicalcondition,includingthepresenceofHIVinfection,AIDSorARC,prescriptiondrugrecords,drugandalcoholuseandotherinformationsuchasfinances,occupation,generalreputationandinsuranceclaimsinformationaboutme. Personal Information does not include Psychotherapy Notes.“Psychotherapy Notes” means: notes recorded by a health care provider who is a mental health professional documenting oranalyzingthecontentsofconversationduringacounselingsession,whichnotesareseparatedfromtherestoftheperson’smedicalrecord.Certaininformation,suchasthatrelatingtoprescriptions,diagnosisandfunctionalstatus,isnotincludedinthetermPsychotherapy Notes.“Specified Companies” means:
• ThegroupofcompanieswhichpresentlyincludesGPMLifeInsuranceCompanyand additional companies which may become part of this group of companies and their successors.
• Otherpersonsandentitieswhichactonbehalfofthosecompaniestoprovideservicestothem.Authorization to Disclose
IauthorizetheMedicalPersonsandEntities,theSpecifiedCompanies,employers,consumerreportingagenciesandotherinsurancecompanies to disclose Personal Information about me to GPMLifeInsuranceCompany.
PurposesThePersonalInformationwillbeusedtodeterminemyeligibilityforinsuranceandtoresolveorcontestanyissuesofincomplete,incorrect or misrepresented information on this application which may arise during the processing of my application or in connection with claims for insurance benefits.
Potential for RedisclosureIf the person or entity to whom Personal Information is disclosed is not a health care provider or health plan subject to federal privacy regulations,thePersonalInformationmaythenbesubjecttofurtherdisclosurebythatpersonorentitywithouttheprotectionsofthefederal privacy regulations.
Failure to SignIunderstandthatImayrefusetosignthisauthorization.IrealizethatifIrefusetosign,theinsuranceforwhichIamapplyingwillnotbe issued.
Expiration and RevocationUnlessrevokedearlier,thisauthorizationwillremainineffectfor24monthsfromthedateIsignit.IunderstandthatImayrevokethisauthorizationatanytime,bywrittennoticeto:
ATTN:IndividualUnderwritingGPM Life Insurance CompanyP.O.Box2679Omaha,Nebraska68103-2679
IrealizethatmyrighttorevokethisauthorizationislimitedtotheextentthatGPMLifeInsuranceCompanyhastakenactioninreliance on the authorization or the law allows GPMLifeInsuranceCompany to contest the issuance of the policy or a claim under the policy.
CopyI understand that I will receive a copy of the signed authorization. A copy of this authorization is as effective as the original.Applicantacknowledgesandagreesthatifthereismorethanoneproposedinsuredonthisapplication,allinformationprovidedmaybereviewedorsharedwiththeotherapplicant.Acompletedandsignedapplicationwillbecomepartofeachapplicant’spolicy.
Names and SignaturesName(s)usedformedicalrecords(ifdifferentthanthename(s)below):_________________________________________________
___________________________________________________________________________________________________________Applicant Applicant BPrinted Name of Proposed Applicant Printed Name of Proposed Applicant
Signature of Proposed Applicant Signature of Proposed Applicant
Date Date
T04_363_MI_0710 THIS AUTHORIZATION COMPLIES WITH HIPAA AND OTHER FEDERAL AND STATE LAWS
GPM LIFE INSURANCE COMPANYPLEASE SIGN AND RETURN THIS AUTHORIZATION WITH YOUR COMPLETED APPLICATION
Notice to Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage
Save this notice! It may be important to you in the future.Accordingtoyourapplication,youintendtoterminateexistingMedicaresupplementorMedicareAdvantageinsuranceand replace it with a policy to be issued by GPMLifeInsuranceCompany.Yournewpolicywillprovidethirty(30)dayswithinwhichyoumaydecidewithoutcostwhetheryoudesiretokeepthepolicy.Youshouldreviewthisnewcoveragecarefully.Compareitwithallaccidentandsicknesscoverageyounowhave.If,afterdueconsideration,youfindthatpurchaseofthisMedicaresupplementcoverageisawisedecision,youshouldterminateyourpresentMedicaresupplementorMedicareAdvantagecoverage.Youshouldevaluatetheneedforotheraccidentandsicknesscoverageyouhavethatmayduplicatethispolicy.Statement to Applicant by Issuer, Agent, Broker or Other Representative:Ihavereviewedyourcurrentmedicalorhealthinsurancecoverage.Tothebestofmyknowledge,thisMedicaresupplement policywillnotduplicateyourexistingMedicaresupplementor,ifapplicable,MedicareAdvantagecoveragebecauseyouintendtoterminateyourexistingMedicaresupplementcoverageorleaveyourMedicareAdvantageplan.Thereplacementpolicyisbeingpurchasedforthefollowingreason(s)(checkone):
Applicant Applicant BAdditional benefits Additional benefitsNochangeinbenefits,butlowerpremiums Nochangeinbenefits,butlowerpremiumsFewerbenefitsandlowerpremiums FewerbenefitsandlowerpremiumsMyplanhasoutpatientprescriptiondrugcoverageand I am enrolling in Part D
Myplanhasoutpatientprescriptiondrugcoverageand I am enrolling in Part D
DisenrollmentfromaMedicareAdvantagePlanPlease explain reason for disenrollment
DisenrollmentfromaMedicareAdvantagePlanPlease explain reason for disenrollment
Other(pleasespecify) Other(pleasespecify)
If you still wish to terminate your present policyorcertificateandreplaceitwithnewcoverage,becertaintotruthfullyandcompletelyanswerallquestionsontheapplicationconcerningyourmedicalandhealthhistory.Failuretoincludeallmaterialmedical information on an application may provide a basis for the Company to deny any future claims and to refund your premium as though your policyhadneverbeeninforce.Aftertheapplicationhasbeencompletedandbeforeyousignit,review it carefully to be certain that all information has been properly recorded.Do not cancel your present policy or certificate until you have received your new policy and are sure that you want to keepit.
✗ __________________________________________________Signature of Agent, Broker or Other RepresentativeGPM Life Insurance Company,P.O.Box2679,Omaha,Nebraska68103-2679
Applicant Applicant BSignature Signature
Date Date
1-HomeOfficeCopyT04_364
GPM LIFE INSURANCE COMPANY
IMPORTANT DOCUMENTS
CLIENT FORMS
Aspartoftheapplicationprocess,theapplicanthassignedmultipleforms.Applicantcopiesoftheseformsandclientnotificationsonthefollowingpagesare to be given to the applicant if applicable.
Replacement Notice(Ifreplacing,bothyouandtheapplicantmustsignthe customercopyofthereplacementnotice)
Conditional Receipt / Notice of Information Practices
Notice to Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage
Save this notice! It may be important to you in the future.Accordingtoyourapplication,youintendtoterminateexistingMedicaresupplementorMedicareAdvantageinsuranceand replace it with a policy to be issued by GPMLifeInsuranceCompany.Yournewpolicywillprovidethirty(30)dayswithinwhichyoumaydecidewithoutcostwhetheryoudesiretokeepthepolicy.Youshouldreviewthisnewcoveragecarefully.Compareitwithallaccidentandsicknesscoverageyounowhave.If,afterdueconsideration,youfindthatpurchaseofthisMedicaresupplementcoverageisawisedecision,youshouldterminateyourpresentMedicaresupplementorMedicareAdvantagecoverage.Youshouldevaluatetheneedforotheraccidentandsicknesscoverageyouhavethatmayduplicatethispolicy.Statement to Applicant by Issuer, Agent, Broker or Other Representative:Ihavereviewedyourcurrentmedicalorhealthinsurancecoverage.Tothebestofmyknowledge,thisMedicaresupplement policywillnotduplicateyourexistingMedicaresupplementor,ifapplicable,MedicareAdvantagecoveragebecauseyouintendtoterminateyourexistingMedicaresupplementcoverageorleaveyourMedicareAdvantageplan.Thereplacementpolicyisbeingpurchasedforthefollowingreason(s)(checkone):
Applicant Applicant BAdditional benefits Additional benefitsNochangeinbenefits,butlowerpremiums Nochangeinbenefits,butlowerpremiumsFewerbenefitsandlowerpremiums FewerbenefitsandlowerpremiumsMyplanhasoutpatientprescriptiondrugcoverageand I am enrolling in Part D
Myplanhasoutpatientprescriptiondrugcoverageand I am enrolling in Part D
DisenrollmentfromaMedicareAdvantagePlanPlease explain reason for disenrollment
DisenrollmentfromaMedicareAdvantagePlanPlease explain reason for disenrollment
Other(pleasespecify) Other(pleasespecify)
If you still wish to terminate your present policyorcertificateandreplaceitwithnewcoverage,becertaintotruthfullyandcompletelyanswerallquestionsontheapplicationconcerningyourmedicalandhealthhistory.Failuretoincludeallmaterialmedical information on an application may provide a basis for the Company to deny any future claims and to refund your premium as though your policyhadneverbeeninforce.Aftertheapplicationhasbeencompletedandbeforeyousignit,review it carefully to be certain that all information has been properly recorded.Do not cancel your present policy or certificate until you have received your new policy and are sure that you want to keepit.
✗ __________________________________________________Signature of Agent, Broker or Other RepresentativeGPM Life Insurance Company,P.O.Box2679,Omaha,Nebraska68103-2679
Applicant Applicant BSignature Signature
Date Date
2-ApplicantCopyT04_364
GPM LIFE INSURANCE COMPANY
GPM LIFE INSURANCE COMPANY
Conditional ReceiptCheck or Money Order ApplicationAllpremiumsmustbemadepayabletoGPMLifeInsuranceCompany.
Do not make check or money order payable to the agent or leave the payee blank.
Applicant Applicant B
Received of
this day of
,
anapplicationforForm Policy
and/orRiders and
CheckorMoneyOrderfor Dollars.
Received of
this day of
,
anapplicationforForm Policy
and/orRiders and
CheckorMoneyOrderfor Dollars. Should the Company decline to issue the insurance applied for,Iherebyagreetoreturntheabovesumtotheapplicant.
Agent
Should the Company decline to issue the insurance applied for,Iherebyagreetoreturntheabovesumtotheapplicant.
Agent
NOTICE TO APPLICANT:Eligibilityforthehealthandaccidentinsuranceappliedforisconditionaluponallof thefollowing:(a) paymentofthefull,initialpremium;(b)writtenapplication;(c)satisfyingtheCompany’sunderwritingstandards.
If you are not eligible, no insurance or temporary or interim insurance of any kind will be effective.Complete Receipt in full and leave with applicant at time of application.
GPM Life Insurance Company - Notice of Information PracticesInthecourseofproperlyunderwritingandadministeringyourinsurancecoverage,wewillrelyheavilyoninformationprovidedbyyou.Wemayalsocollectinformationfromothers,suchasmedicalprofessionalswhohavetreatedyou,hospitals,otherinsurancecompanies,andconsumerreportingagencies.Incertaincircumstances,andincompliancewithapplicablelaw,weorourreinsurersmayalsoreleaseyourpersonalorprivilegedinformationinour/theirfiles,tothirdpartieswithoutyourauthorization.Uponrequest,youhavetherighttobetoldaboutandtoseeacopyofitemsofpersonalinformationaboutyouwhichappearinourfiles,includinginformationcontainedininvestigativeconsumerreports.Youalsohavetherighttoseekcorrectionofpersonalinformation you believe to be inaccurate.Incompliancewithapplicablelaw,weorourreinsurersmayalsoreleaseinformationinour/theirfiles,includinginformationinanapplication,tootherinsurancecompaniestowhichyouapplyforlifeorhealthinsuranceortowhichaclaim is submitted.Sothattherewillbenoquestionthattheinsurancebenefitswillbepayableatthetimeaclaimismade,weurgeyoutoreview your application carefully to be sure the answers are correct and complete.THE ABOVE IS A GENERAL DESCRIPTION OF OUR INFORMATION PRACTICES. IF YOU WOULD LIKE TO RECEIVE A MORE DETAILED EXPLANATION OF THESE PRACTICES, PLEASE SEND YOUR REQUEST TO: GPM LIFE INSURANCE COMPANY, DIRECTOR OF INDIVIDUAL UNDERWRITING, P.O. BOX 2679, OMAHA, NE 68103-2679.
Give this notice to the applicant.