thank you for taking the time to explore our final expense...
TRANSCRIPT
Final Expense Program Letter 04-2017
Thank you for taking the time to explore our Final Expense program!
Liberty Bankers/The Capitol Life Insurance Companies (LBL) offers Final Expense life insurance
through our Independent IMO distribution channel. For over a decade, LBL has been helping Agents
and their clients with quality products and timely service. LBL strives each day to continually provide
our field force with the cutting-edge final expense program and tools required to offer solutions for your
clients’ end-of-life needs while assisting you in growing your business. I am excited to introduce LBL’s
Final Expense portfolio of products and services that provide Agents solutions focused on the baby
boomer and senior market life insurance needs. In addition, we believe in adding value to our most
important asset, our agents, by providing more than just commission! I invite you to compare our Final
Expense Program and see how LBL can fit your organization!
Our portfolio was developed to provide solutions-driven products to fit the Final Expense needs
of our ever increasing population of seniors! We offer two outstanding immediate death benefit
plans (SIMPL) with optional Children’s and Grandchildren’s Term Insurance riders, along with an
Accidental Death & Dismemberment rider. Of course, all SIMPL plans automatically include our
Accelerated Death Benefit rider (ADBR) AT NO COST! The ADBR provides your client the option to
access their death benefit in the event they are diagnosed with a terminal or chronic illness. LBL offers
a portfolio for clients who pay premiums with their Direct Express debit card. In addition, Agents
marketing final expense via Telesales will find our process simple and easy.
Is your marketing technology keeping you on the cutting edge for ease of doing
business and personal profitability?
Ease of Doing Business: Managing your life insurance career takes time. How this time is spent will
directly affect the rewards and income from your practice. Our paperless application process and instant
underwriting decision through our point of sale telephone interview will save time and improve accuracy
for your sales processing. In addition, our Agent website is on the cutting edge for providing Agents
and Agencies management tools for service and profitability!
Agent Value Added Programs: LBL offers more than just a commission contract. Our rewards include
renewal commission bonuses, lead re-imbursement program, and exotic conventions around the world.
Agent quality business performance is well rewarded at LBL! Please take a few moments to review the
information provided herein. You’re going to like what you see!
Best Regards,
Mark A. Aremia Mark A. Aremia, CLU
Vice President Sales
#1 Log on to our website:
www.libertybankerslife.com
Liberty Bankers/The Capitol Life Insurance Companies Agent Website
How to Access Calculators, Rate Books, Product Details, Supplies, and Training Videos!
#2 To access the Life Insurance portal for
Agents: Click on the top right corner
#3 To log on to the Life Dashboard page:
User Name: life Password: agent
User ID & Password are lower case sensitive
Now you’re in the Dashboard page:
• Forms, including rate books
• Products and Training Videos
• Final Expense Paperless Worksheet
Once you receive your agent number: You will now have your own “Agent File Cabinet” portal. In order to access,
please use the first 5 digits of your agent number and last 4 digits of your tax ID. (all lower case) You will be asked to
change and personalize your password the first time you log on with your new credentials. PLEASE KEEP FORYOUR RECORDS. Your “File Cabinet” will store all your policies, statements, and reports to manage your business!
Final Expense Intro Letter 05-2017
Date: 3/1/2017 Subject: Rate Book & Calculators GREAT NEWS! We’ve now made it extremely easy for you to access our rates! After logging into the LBL Agent Portal simply navigate to the “Quick Links” section and download/print the “SIMPL Rate Book” or if you prefer just select the appropriate rate calculator for your device. You can also search and download the rate calculator directly from the App Store on your Apple device or Google Play Store on Android devices.
CALCULATOR PASSWORD – rates4life (case sensitive)
LBL
PORTAL
APPLE
DEVICE
ANDROID
DEVICE
Business Quality and Bonus Guidelines for Agents
Liberty Bankers/The Capitol Life Insurance Companies (LBL) recognizes and appreciates our field
force for the value their services they bring to communities across our land. Our Final Expense
program as a whole is one of the best in our industry today! Business quality is an important
factor for LBL’s financial health and product integrity. Policyholders want their Insurance
Company to be financially strong and stable while our Agents demand reliable products and
services. In order to achieve these objectives, LBL monitors the quality of Agents business which
drives the goals of our partnership. Agent’s business quality is measured by their persistency,
placement ratio, and excessive death claims, Our Agent Bonus Incentive Package rewards those
Agents who achieve certain business quality expectations! Please review the information below.
Persistency: Minimum 60% 13-month Projected
4-month: 80% 7-month: 71% 13-month: 60%
Placement: Minimum 65% Paid to Submit Ratio.
Persistency: Measuring for persistency is based on issued policy count. Any agent with a 13-
month projected persistency less than 60% (59.9% or less) will be inactivated once they reach
more than 15 policies issued and placed. LBL calculates the results for 4th, 7th, and 13th months
for an Agent’s overall performance and is listed under the Projected column on the report.
Placement: Calculated by the number of policies that are placed (issued and paid for) versus
the number of declines, cancellations and NTOs. This ratio is calculated over a rolling 12-month
period and should be 60% or greater. Agents who fail to meet the minimum standard will be
inactivated. Additional Agent factors may be considered prior to any action from LBL.
AGENT BONUS INCENTIVES
Agent Level Persistency/Placement Requirement Renewal Bonus * Lead Bonus Program Incentive Trips
Platinum 75% > 13-month
60% > 25-month
65% > Placement
175%
YES
YES
Gold 70% > 13-month
65% > Placement
150% YES YES
Silver 60% - < 70% 13-month
65% > Placement
100% NO YES
Renewal Bonus: The writing Agent and Up-Line 2nd, 3rd, and 4th year renewal commission are bonused according to status. Please refer to your Commission Schedule.
Date: January 16, 2017 To: All Contracted Liberty Bankers / Capitol Life Agents From: Mark Aremia, Vice President – Ordinary Life Division
Re: Enhanced Agent Lead Bonus Program
As has been communicated to you previously, Liberty Bankers/The Capitol Life Insurance Companies make available to Gold agents a lead bonus program designed to help reimburse the cost of obtaining leads. Effective February 1, 2017, we are enhancing the existing program to make available DOUBLE the lead reimbursement credits, subject to the following program rules.
Qualification: • Agent must be GOLD status during the bonus period.
o Gold status = agent persistency of 70% or higher as reported on your persistency report. • Agent must have issued a minimum 10 net policies for the month in order to qualify.
o Net policies means the number of policies issued minus those not taken. o Example: in a particular month, a gold agent issues 16 policies, but has 2 policies not-taken. As
a result, the gold agent has 14 net issued policies for that month.
Bonus: • For each net issued policy for the month, we will credit you with $30 of lead reimbursement credits.
Obtaining Reimbursement: • You must have had a minimum of 10 net policies issued for the month, and must be classified as a Gold
agent to obtain reimbursement. • Lead reimbursement credits can be redeemed by submitting:
o Proof of purchase for leads from any lead vendor (including your IMO), or o Proof of purchase for advertising (newspaper, direct mail, TV, and radio) and client seminars
• Submit receipts to our Agency Department via fax (469-522-4430), email attachment ([email protected]), or mail (1605 LBJ Freeway, Dallas, TX 75234).
• Lead reimbursement credits expire after 90 days of remaining unclaimed.
Earning Gold Agent Status Has Other Benefits: • Earn a 50% on 2nd, 3rd, and 4th year renewal commissions! • Receive 60% convention roll-over for any unused premium!
2018 INCENTIVE
TRIP SPAINLiberty Bankers Insurance Group 2018 Agent Incentive TripHotel Wellington | Madrid, SpainQualification Period: January 1 – December 31, 2017Trip Dates: June 17 – 22, 2018
QUALIFICATIONMust meet the definition of Qualified Agent.
Net Issued Premium during the qualification period thattotals $75,000 or greater of paid annualized premiumand a minimum 13 month projected persistency of 65%.
Roll-Over Credit: Agents will receive roll-over credit fortheir Net Issued 2016 business based on the followingguidelines:
1. Agents registered for the 2016 trip will not carry-over any credits into 2017.
2. Otherwise, production will roll-over at the followingpercentages:a. Platinum Agent: 75%b. Gold Agent: 50%c. Silver Agent: 40%
QUALIFICATION TERMSQualified Agent means an appointed & licensed agentwho is active with the company and who has placed atleast five policies in the quarter preceding the trip andwho does not have a debit balance with the Company.
Net Issued Premium includes all issued and paidannualized premium less those not-taken and cancelled.
Important: Any deviation from the conference programis at the qualifier’s expense and subject to availability. Alladditional travel expenses must be paid in full by theparticipant prior to the conference. The Home Officemay, if necessary, amend the rules governingqualification requirements for the 2018 Agent IncentiveTrip during the qualification period, including the triplocation. All Home Office decisions are final.
CITYSCAPE OF TOLEDO, SPAIN,ONE OF OUR PLANNED TRIP TOURS
ORDINARY LIFEDIVISION AGENTS
Date: February 10, 2017
To: All Liberty Bankers / The Capitol Life Insurance Company Agents From: Mark Aremia, Vice President – Ordinary Life Division
Re: Revised guidelines for re-dating new business and/or lapsed policies In order for agents to conserve business, LBL offers a streamlined process designed to ease the financial burden that traditional reinstatement causes (specifically, the requirement to pay back-premium).
This easy process, called “re-dating” works for two different types of situations: 1. Newly issued policies where the first premium has never been paid, or 2. Policies in-force which have lapsed due to non-payment of premium
Both practices have proven success in helping agents conserve business, thus improving persistency. However, after studying this practice, we have concluded that after we allow two or more re-dates, there is a very high likelihood that the customer never successfully maintains a pattern of payment.
Going forward, a LBL policy may be re-dated only once for issue or re-instatement purposes. Once this option is exhausted, the policyholder will not be eligible to apply for any more coverage with LBL. It will be the agent’s responsibility to verify if a prospect has had a LBL policy issued previously prior to making the POSTI phone call.
Here are some additional tips about how this process works, and how it impacts your business:
New Policy Application: When a new business application is submitted and approved, the first premium is due. Usually the initial premium is drafted from a bank account or direct express account either immediately or on a specified future date. If the first premium is returned for Non-Sufficient Funds (NSF) the policy is considered Not-Taken and goes against an agent’s placement ratio. LBL will allow a one-time re-date for the issued policy and attempt another draft for the initial premium. If the second attempt is unsuccessful, the policy will be cancelled and the insured will not be approved to apply again. Hence the one time except to re-date a new policy for issue.
In-force Policy Lapse: If a policyholder were to lapse their policy, in order to put their life insurance protection back inforce, they would be required to apply for re-instatement and pay all back premiums. This is the traditional way of processing a re-instatement and could require several months of unpaid premiums. In many cases, an insured could not afford to do. LBL has an easy re-instate by re-date paperless app process that allows for a lapsed policy to be re-dated currently and the policyholder just continues to pay premiums going forward. LBL will allow a one-time opportunity re-date for re-instatement purposes. However, after the one-time re-date option is exhausted, the policyholder may re-instate by paying all back premiums.
Please review LBL’s easy reinstate by re-date process found on the website. If you have any further questions, please contact your up-line manager or IMO office.
Agent Product/Service Information Reinstating Business
Good Persistency Pays
At Liberty Bankers Life we are committed to providing our Agents with quality products, excellent service, and lucrative compensation. In return, LBL relies on our Agents to produce quality and persistent business. Business persistency is one of the key components for product pricing, commission, and most of all, profitability for both LBL and our Agents. This is important in order to have a successful partnership. By maintaining 70% or better 13 month persistency, you qualify for a 50% bonus on your 2nd, 3rd, and 4th year renewal commission! PLUS: You are eligible for our Lead Bonus Program!
Reinstate by Re-date The easiest way is to re-instate lapsed policies is to Re-instate by Re-date. This procedure makes it economically painless for your client to put their life insurance back in force! Simply follow the procedures listed and watch your income increase! LBL requires a minimum of 60% 13-month persistency on business written by Agents.
Email: [email protected]
Reinstatement
Procedures
1. Contact your lapsed policyholder to conserve the policy.
2. Use the Re-instatement worksheet to verify that your policyholder is still insurable.
3. Obtain and verify new Banking/Direct Express information for the first premium.
4. Call DIMA in order to complete the Telephone I n t e r v i e w , I n s t a n t Underwriting decision, AND, paperless application ( i n c l u d i n g H I P A A , Disclosures, and Banking forms!).
5. Once approved, your client’s policy will be back in-force when the required premium is received.
The Business that Stays,
Is the Business that Pays!
Mark A. Aremia, CLU
VP Sales - Ordinary Life Division
APPLICATION FOR REINSTATEMENT
LIBERTY BANKERS LIFE INSURANCE COMPANY
P O Box 224 Brownwood, Texas 76804
Name _____________________________________________________ Date of Birth _____________________________
Address ________________________ City _______________ State _____ Zip _________ Policy No._______________
The above numbered policy having lapsed, I hereby apply for reinstatement of said policy. In order to obtain such reinstatement, I make the following statements:
Yes No
1. Are all persons insured under the policy in good health & free from impairment? If no, explain in #7 ............ □ □ 2. Since the date of issue of the policy, or within the past 5 years if less, has any person covered by the policy:
(a) Had a change of health due to injury or sickness?. ................................................................................... □ □
(b) Consulted, been examined, or been treated by any physician or practitioner? ......................................... □ □
(c) Changed occupation, aviation status or participated in hazardous sports or hobbies? .............................. □ □
(d) Had life insurance with any other company declined, modified, cancelled or been refused reinstatement?. .......................................................................................................................................... □ □
(e) Been diagnosed or treated by a member of the medical profession for Acquired Immune Deficiency Syndrome AIDS) or AIDS Related Complex (ARC) or tested positive for the antibodies to the AIDS virus? ........................................................................................................................................................
□ □
3. Do you currently smoke cigarettes or have you smoked any cigarettes during the last 12 months? .................. □ □
4. What is your present occupation?_______________________________ Annual Income?______________
5. How much life insurance do you have in force or applied for on your life, not including this policy? ________________ 6. Please list the names of all persons covered by this policy including heights and weights: Name Height Weight Applicant Child Rider 7. Give details of all "Yes" answers to questions 2 A-E above, including dates, persons affected, names and addresses of attending physicians: _________________________________________________________________________________________________________________________
To the best of my/our knowledge and belief, the answers to the above questions are true and complete. Except as noted in question 1 and 2 A-E above, I and any other person insured under this policy or any attached rider are in good health. I/we understand that: (1) reinstatement will not begin until the monthly policy anniversary date on or after the date the Company approves the application for reinstatement and all past due amounts have been paid during the continued good health of my lifetime; and (2) if this application is not approved, all money paid will be returned to and accepted by me without interest. I/we agree that this reinstatement shall be contestable for a period of two years from the date of approval. I/we have received and read a copy of the Company's Notices about the Fair Credit Reporting Act, the MIB, Inc.and the Notice of Information Practices. Liberty Bankers Life Insurance Company is authorized to obtain an investigative consumer report on me/us. (continued on the reverse)
L- APP-REINSTATE(0806)
-------------------------------------------------------------------------------------------------------------------------------------- PRE-NOTICE TO APPLICANTS
Pre-Notice: MIB, Inc. Information regarding your insurability will be treated as confidential. Liberty Bankers Life Insurance Company or its reinsurer may, however, make a brief report of my protected health information to the MIB, Inc., a not for profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB, Inc. member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, the MIB, Inc., upon request, will supply such company with the information in its file. Upon receipt of a request from you, the MIB, Inc. will arrange disclosure of any information it may have in your file. If you question the accuracy of information in the MIB’s file, you may contact the MIB, Inc. and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Report Act. The address of the MIB's information office is 50 Braintree Hill, Suite 400, Braintree, Massachusetts, 02184, telephone 1-866-692-6901, web address: www.mib.com. Liberty Bankers Life Insurance Company, or its reinsurer, may also release information in its file to other life insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. Pre-Notice: Investigative Consumer Report Federal Law requires that notice of investigation be given to persons applying for insurance. In making this application for insurance to Liberty Bankers Life Insurance Company, it is understood that an investigative consumer report may be prepared whereby information is obtained through personal interviews with your neighbors, friends, or others with whom you are acquainted. This inquiry includes information as to your character, general reputation, personal characteristics and mode of living. You have the right to make a written request within a reasonable period of time to receive additional information about the nature and scope of this investigation.
AUTHORIZATION For the Release of Information To: Any licensed physician, medical practitioner, hospital, clinic, pharmacy benefit manager, or other medically related facility, insurance company or the MIB, Inc., or other organization, institution, or person. So that eligibility for life insurance can be determined, I authorize you to give Liberty Bankers Life Insurance Company and, through it, to its reinsurers and the MIB, Inc., any data or records you may have about me or my mental or physical health. This also applies to any child proposed for insurance in the application. This authorization also includes information about pharmacy prescription drugs, drugs, or alcoholism or any other non-health (non-medical) history information. This authorization is valid until two and one half years after the effective date of any contract issued in connection with the authorization. A photo of this form will be as valid as the original. (The person who signs this form may have a copy of it upon request.)
Application Made at: ______________________________________ Date:_______________________________
(City and State) (Month and Day)
________________________________________________________ ___________________________________ Insured Owner Agent/Witness ___________________________________________
LBL-ABC-2010-09-01 Please attach a VOIDED CHECK to this form.
P.O. Box 224 Brownwood, TX 76804 1 (888) 525-4467
Premium Payments as Easy as ABC (Automatic Bank Checking)
Save the Hassle. With ABC, you let LBL/CLIC and your financial institution handle your premium payments. Select the ABC option, and your future premiums will be withdrawn directly from your account and sent to us for timely processing.
Authorization to Pay Future Monthly Premiums by ABC (Automatic Bank Checking)
I authorize my Financial Institution to pay my insurance or annuity premiums through monthly checks, share drafts or electronic account debits drawn by and payable to Liberty Bankers/The Capitol Life Insurance Company. As my Financial Institution, you will be fully protected in honoring these payments until you receive written notice from me canceling this request.
Scheduled Payment Amount $ Scheduled Payment Dates:
Account Name: □ Checking □ Savings Transit Number: Account Number: Financial Institution Name & Address:
I have paid the initial premium by check, please draft future payments on the scheduled payment date shown above after policy approval. Signature: Date:
***********************************************************************************
Only complete this bottom section if NO premium has been collected!
FIRST PREMIUM BY BANK DRAFT (Select one option to initiate your first premium draft)
1. ________ Bank Draft my account IMMEDIATELY upon receipt of this pending application, (initial here) and then on the scheduled payment date shown above after policy approval.
2. ________ Bank Draft my account only when the policy is APPROVED for issue and (initial here) thereafter on the scheduled payment date shown above.
3. ________ WAIT to Bank Draft my account on the FIRST Scheduled Payment Date (initial here) listed above following the policy approval. Signature Date
NEW 09/01/2010
Automatic Bank Draft
LBL-HIPAA-2012-08-23
Administrative Office: P O Box 224 Brownwood, Texas 76804 1-800-604-8002
AUTHORIZATION TO OBTAIN, RELEASE AND DISCLOSE MEDICAL INFORMATION
I hereby authorize any: medical practitioner, physician, hospital, clinic, pharmacy benefit manager, or other medical related facility, insurance company, insurance support organization, business partner, pharmacy, government agency, group policy holder, employer, benefit plan administrator, the MIB, Inc., the Department of Motor Vehicle Registration, and paramedical facility to provide to LIBERTY BANKERS LIFE INSURANCE COMPANY/THE CAPITOL LIFE INSURANCE COMPANY, or to any agent, attorney, consumer reporting agency or independent administrator, including medical record retrieval services or pharmaceutical services, acting on LIBERTY BANKERS LIFE INSURANCE COMPANY/THE CAPITOL LIFE INSURANCE COMPANY, or its reinsurers’ behalf, information concerning advice, care, or treatment sought by or provided to me and/or any other applicant for coverage, including information relating to medical history, medical conditions, treatment, hospitalizations or confinements, ailments, pharmacy prescription drugs, and/or drug, alcohol or tobacco usage of the applicant(s). It is understood that LIBERTY BANKERS LIFE INSURANCE COMPANY/THE CAPITOL LIFE INSURANCE COMPANY’s underwriters, claim examiners, reinsurers, attorneys, or the medical director may disclose such health information to the aforementioned parties for purposes of underwriting, compliance, record clarification or explanation, or in response to litigation, summons, or subpoenas. I understand that after this information is disclosed, the recipient may re-disclose it resulting in loss of protection by federal regulations. I authorize LIBERTY BANKERS LIFE INSURANCE COMPANY/THE CAPITOL LIFE INSURANCE COMPANY, or its reinsurers, to make a brief report of my protected health information to the MIB, Inc. I understand that: • such information will be used by LIBERTY BANKERS LIFE INSURANCE COMPANY/THE CAPITOL LIFE
INSURANCE COMPANY for underwriting and insurability determinations; • I may refuse to sign this authorization and that my refusal to sign will affect my ability to obtain life insurance coverage; • a picture copy or photocopy of this authorization shall be as valid as the original; and • any authorized representative of the proposed insured is entitled to receive a copy of this authorization upon request. This authorization is valid from the date signed for a duration of 24 months. I understand I may revoke the authorization at any time, except to the extent that action has been taken in reliance on this authorization, by sending written notice to the Life Underwriting Department of LIBERTY BANKERS LIFE INSURANCE COMPANY/THE CAPITOL LIFE INSURANCE COMPANY, P. O. Box 224, Brownwood, Texas 76804. I may inspect or copy any information used or disclosed under this authorization, if signed. Date
Proposed Insured (Please print)
Signature of Proposed Insured (or parent if Proposed Insured is under age 16)
Birthdate
Additional Proposed Insured (Please print)
Signature of Additional Person Proposed for Insurance
Birthdate
Personal Representative designated by signature above is hereby authorized to execute this instrument based on: power of attorney, guardian-in-fact, guardian, payee, representative, other (Circle one)
Final Expense Paperless Application Process Instructions
Agents will no longer be required to fill out an application, HIPAA and Disclosure Forms, Bank Draft or Direct
Express Forms and submit these to new business! It’s EZ as 1 - 2 – 3!
1. The Agent makes the final expense sale with client. Using the application worksheet,Child/Grandchild Supplemental Application, along with the Disclosure Form, the Agent should:
a. Pre-Qualify the client, and Children and/or Grandchildren (if applicable), for the correct plan
using the health questions as a guideline.
b. Gather important client personal and Bank account information.
c. Have all the required disclosures, including HIPAA, to read and give the client in one easy
detached form. Included is a conditional receipt should you collect the first premium!
2. Once worksheet is completed and disclosures read, the Agent will make the call to DIMA (800-
604-6844) to initiate the Point of Sale Telephone Interview (POSTI) for instant underwriting decision
AND application paperwork completion! Information from the worksheet, and Child//Grandchild Supp
App (if applicable) will be required during this interview from the agent. Complete and accurate datawill make the call smooth and timely.
Please Note: By eliminating the need to fill out and then send in all paperwork, the time will more than offset the few additional minutes required in the paperless process. The worksheet will allow an agent to have important client and bank information readily available for the Telephone Interview.
DIMA will begin the process as follows:
a. Ask the Agent client personal and Bank information.
b. Speak with your client to obtain, verify, and underwrite the sale. This includes:
i. Verify disclosures have been read or given to client, including MIB and HIPAA.
ii. Obtain voice signatures for disclosures and application.
iii. Verify health questions (same as worksheet).
iv. Complete Application and all required Forms.
v. Give the Agent an instant underwriting decision before you hang up!
vi. Instruct DIMA where the policy should be sent: To the Agent or Client.
3. The Agent retains the worksheet for their record……..NO need to send in anything and the client’s
policy will be issued. EXCEPT FOR THE FOLLOWING:
a. If the sale is a replacement: The proper state required replacement form(s) must
be completed and signed prior to the call to DIMA.
b. Alabama: Alabama Arbitration Disclosure Form (#CLIC-ARB-AL)
c. California: Medical Eligibility Disclosure (#7404.4-0505) Home Meeting Disclosure
for 65 & Over (7404.2-0505) Financial Product Disclosure 65 & Over (7404.3-0505)
d. Pennsylvania: Disclosure Statement (LBL PA DIS (0806)
Agent must note POSTI reference # on the upper right corner for any required form and fax to new
business @888-525-5002. Failure to do so will delay policy issue and commissions paid.
09-2017
PO Box 224 Brownwood, Texas 76804-0224 ● 1-888-525-4467 ● FAX 1-888-525-5002 ● E-Mail: [email protected]
FOR AGENTS USE ONLY!
Check Appropriate
Company
Proposed Insured Full Name:
Date of Birth Present Age
Sex Height Weight
State of Birth Country of Birth
Social Security No. or ITIN
Have you used tobacco, nicotine, or e-cigarettes in any
form in the past 12 months? □ YES □ NO
Name and City of Doctor:________________________
Are You Currently Disabled? □ YES □ NO
If Yes, Please provide details::____________________
*****************************************Street Address
City, State, Zip
Home/Cell Phone
Work Phone
OWNER OF POLICY IF NOT INSURED:
Relationship
Social Security No.
Address
Home/Cell Phone
Final Expense
Pre-Qualifying Worksheet
SIMPL WORKSHEET 09-2017
This worksheet is necessary to initiate underwriting. Please complete all information before you call DIMA. Once form is completed, please call 800-604-6844 for the application and approval completion process. Agent, Insured, (Owner and/or Payor, if different) must be on the phone at the time of the call. This worksheet contains sensitive
information and should be kept secured for your records or destroyed. Do not send in this form.
Plan- Riders Applied For:
Face Amount $_____________________________
__ SIMPL Preferred __SIMPL Standard ___MWL
__ AD&D ___(units) CTIR ___Grandchild Rider
Premium Amount $ Premium Mode:
□ Monthly Bank Draft OR □ Direct Express Card
□ Quarterly □ Semi-Annual
□ Annual Amount Paid with Application
$
Primary Beneficiary
Relationship
Home/Cell Phone
Contingent Beneficiary
Relationship
Home/Cell Phone
Agent: Agent Number Date:________________
POSTI Reference #: Issue State: Telesales application □ YES □ NO
□ Check here to draft first premium
Direct Express OR Bank Draft Date Each Month
1st of Month 3rd of Month
2nd Wednesday 3rd Wednesday
4th Wednesday Other Date:_________
Name as it Appears on Bank Acct:
____________________
Acct. # ____________
Routing #: ____________
Final Expense Pre-Qualifying Worksheet
Bank Information Name of Financial Institution:
_______________________________________
City: ______
State: ___________________
Use the following health questions to decide which Final Expense plan to offer
If the applicant answers “Yes” to any question in Part 1, DO NOT PROCEED with the application.
Part 1 YES NO Have you ever been diagnosed have you been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for: 1. Congestive heart failure (CHF), cardiomyopathy, memory loss, Alzheimer’s, senile dementia, dementia,
heart defibrillator implant, two or more instances of internal cancer(s) or terminal illness (terminal illness means a disease or illness that is expected to result in death within 24 months)? ................................. □ □
2. Organ transplant (other than corneal), untreated Hepatitis C, kidney failure or dialysis, amputation due todiabetic complications, multiple sclerosis, muscular dystrophy, mental retardation, amyotrophic lateral sclerosis (ALS) or Lou Gehrig’s disease, Downs’s syndrome, cystic fibrosis or Huntington’s disease? ........................ □ □
3. Diabetes at age 9 or younger? ........................................................................................................................................... □ □4. AIDS, AIDS Related Complex, tested positive for HIV virus or any other disorder of the immune system? ................. □ □Within last 2 years, have you been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for: 5. Uncontrolled diabetes or uncontrolled high blood pressure? ............................................................................................ □ □Within the last year have you: 6. Been confined to a hospital, been advised by a member of the medical profession to have surgery or
hospitalization, used oxygen due to a medical condition, been unable to care for yourself or been prescribedbed rest by a member of the medical profession at home or in a nursing home, hospice, long-term care or assistedliving facility? Definition of assisted living: requires help in at least one area of skills considered necessary forliving and caring for oneself (feeding, dressing or bathing)………………………………..……………………………□ □
If all “No” answers in Part 1, complete Part 2.
Part 2 Complete all questions and circle the condition(s) to which each “Yes” answer, if any, applies. YES NO
Within the past 2 years have you been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for:
(a) Angina (chest pain), any type of heart or circulatory surgery, heart attack, or received a pacemaker or stent? . □ □(b) Stroke, Transient Ischemic Attack (TIA/mini-stroke) or paralysis? ................................................................... □ □(c) Cancer or received or been advised to receive chemotherapy or radiation for cancer
(the term “cancer” includes melanoma, but excludes basal cell skin cancer)? ................................................... □ □(d) Aneurysm, brain tumor or sickle cell anemia? ................................................................................................... □ □ (e) Complications of diabetes such as nephropathy (kidney), neuropathy (nerve, circulatory), retinopathy (eye)
diabetic coma or insulin shock? ......................................................................................................................... □ □ (f) Alcohol or drug abuse, have you used illegal drugs or been convicted of felony or on parole? ........................ □ □(g) Used a walker, wheelchair or electric scooter due to chronic illness or disease? ............................................... □ □
If all “No” answers in Part 2, complete Part 3. Otherwise, select MWL & check for state availability.
Part 3 Complete all questions and circle the condition(s) to which each “Yes” answer, if any, applies. YES NO
Have you ever been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for:
(a) Chronic Obstructive Pulmonary Disease (COPD), chronic bronchitis, emphysema, peripheral vascular disease or peripheral artery disease? ................................................................................... □ □
(b) Chronic hepatitis, Hepatitis C, cirrhosis of the liver, chronic pancreatitis, liver disease or kidney disease? ............................................................................................................................................................. □ □
(c) Insulin use before age 25? ................................................................................................................................. □ □(d) Irregular heartbeat, atrial fibrillation, Systemic Lupus (SLE), epileptic seizures, Parkinson’s disease? ........... □ □
If all ‘No” answers in Part 3, select SIMPL Preferred. Otherwise, select SIMPL Standard.
AGENT NOTES:
Replacement Information: (Replacement not allowed for tele-sales) YES NO 1. Does proposed Insured have existing life insurance policies or annuity contracts? .......................................... □ □2. Will this insurance replace or change any other insurance policies or annuity contracts? .................................. □ □If “Yes” to either question, please provide details of the insurance, including Amount, Company & Plan of Insurance and appropriate Replacement Form, if required:
Application to Liberty Bankers Life Insurance Supplemental Application for: P.O. Box 224 Brownwood, TX 76804 Children or Grandchild Rider
1. Supplement to Application on : Check Appropriate Rider Proposed Insured: Application
Date: Policy # (When adding existing rider)
Child Rider # of units
Grandchild Rider $7,500
Address City State Zip Code
2. Children/Grandchild Proposed for Insurance (Please Print)
Name all natural-born children, stepchildren and legally adopted children or grandchildren for grandchild rider of Primary Proposed Insured who have not attained age 18. Insurance will not be provided on newborn children less than 15 days of age or grandchildren if grandchild riders applied for. (Attach another sheet if necessary):
Full Name of Proposed Insured Child/Grandchild
Age Last Birthday
Sex Date of Birth Relationship to Proposed Insured
Height Weight
A. B. C.
3. Health Information1. Has any Proposed Insured Child/Grandchild ever had, been diagnosed or treated for cancer, diabetes, heart or circulatory
disorder, mental or nervous disorder, mental retardation, cerebral palsy, muscular dystrophy, spina bifida, cystic fibrosis,un-operated heart defects, epilepsy, asthma, disorders of the muscles or bones, anemia or other disorders of the blood,bladder, kidneys, liver or lungs?.............................................................................................................. DYes DNo
2. Has any Proposed Insured Child/Grandchild ever had, been diagnosed or treated by a member of the medical professionfor an Immune Deficiency Disorder, Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)or tested positive for the Human Immunodeficiency Virus (HIV) ?........................................................ DYes DNo
3. Has any Proposed Insured Child/Grandchild ever used or received treatment, advice or counseling from a physician orother practitioner relating to the usage of alcohol, heroin, cocaine, narcotics, hallucinogens, tranquilizers, barbiturates,amphetamines, or other similar drugs except as prescribed by a physician?............................................. DYes DNo
Please provide details to any “Yes” answer to Question 1-3 (Attach another sheet if necessary): Proposed Insured Child/Grandchild
Condition & Treatment Date Name & Address of Physician or Hospital
Beneficiary Designation: Any proceeds payable under this rider will be paid to the Owner, if living. Otherwise, per the beneficiary provision of the rider.
1. Does Proposed Insured Child/Grandchild have existing life insurance policies or annuity contracts?.... o YES o NO 2. Will this insurance replace or change any other insurance policies or annuity contracts? ………………o YES o NO If “YES” to either question, please provide details of the insurance, including Amount, Company & Plan of Insurance and appropriate Replacement Form, if required:
I declare and represent that the foregoing statements and answers have been correctly recorded and that they are full, complete and true to the best of my knowledge and belief and shall constitute a part of the application Dated at , on this day of , .
Signature of Grandparent/Parent Guardian (e-signed)
The electronic signature(s) above fully comply with the Federal Electronic Signature status, Title 15, U.S.C., Chap. 96, Sec. 7001, et seq., and is therefore fully legal and valid as an original signature.
Agent Statement:
1. Does the Proposed Insured have any existing life insurance policies or annuity contracts?.................... o YES o NO 2. Is replacement of existing insurance involved in this application? If yes: Have you submitted
the appropriate replacement forms?........................................................................................................ o YES o NO
Signature of Agent: (e-signed) Agent Number
LBL-SUPP-APP-0310
DISCLOSURES for PAPERLESS APPLICATION PROCESS – GENERIC
Included are the three required disclosures (Fair Credit, MIB, and HIPAA) that must be read and given to your applicant prior to the point of sale telephone interview (POSTI). For SIMPL Standard and Preferred plans only, an Accelerated Death Benefit disclosure must also be read and given to the applicant prior to the point of sale telephone interview. Your client will be asked to verify that these were read to them. In addition, the states of Alabama, California, and Pennsylvania require state specific disclosures that must be completed, signed, and faxed to New Business prior to issuing a policy. These state required forms may be obtained from the website in the Forms Portal. Agent must note POSTI reference # on the upper right corner for any required form and fax to new business @888-525-5002.
In addition, included is a conditional receipt should you collect the correct first premium mode. --------------------------------------------------------------------------------------------------------------------------------------------------
This Notice Must be Given to Proposed Insured
FAIR CREDIT REPORTING ACT PRE-NOTIFICATION FORM. Thank you for considering Liberty Bankers/The Capitol Life Insurance Company as your insurance carrier. Your application will be processed as quickly as possible. Public Law 91-5088 requires that we advise you that an investigative consumer report may be made in connection with this application which will provide applicable information concerning character, general reputation, personal characteristics and mode of living. The information for this report may be obtained through personal interviews with friends, neighbors, and associates. You are entitled to be interviewed in connection with an investigative consumer report; and, you have the right to receive a copy of any investigative consumer report by making a written request within a reasonable period of time.
NOTICE TO APPLICANTS FOR INSURANCE. Information regarding your insurability will be treated as confidential. Liberty Bankers/The Capitol Life Insurance Company, or its reinsurer(s), may, however, make a brief report of my protected health information to the MIB, Inc., a not for profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB, Inc. member company for life and health insurance coverage, or a claim for benefits is submitted to such a company, the MIB, Inc., upon request from you, will arrange disclosure of any information it may have in your file. If you question the accuracy of information in the MIB's file, you may contact the MIB, Inc. and seek a correction in accordance with the procedure set forth in the Federal Fair Credit Reporting Act. The address of the MIB's information office is 50 Braintree Hill, Suite 400, Braintree, Massachusetts, 02184, telephone 1-866-692-6901, web address: www.mib.com. Liberty Bankers/The Capitol Life Insurance Company, or its reinsurer(s), may also release information in its file to other life insurance companies to whom you may also apply for life or health insurance, or to whom a claim for benefits may be submitted.
---------------------------------------------------------------------------------------------------------------------------------------------------
CONDITIONAL RECEIPT – (Cross through if payment is NOT received).
NO INSURANCE WILL BECOME EFFECTIVE PRIOR TO DELIVERY, UNLESS THE FOLLOWING CONDITIONS HAVE BEEN FULFILLED EXACTLY: INSURANCE ISSUED BASED ON THE APPLICATION WILL TAKE EFFECT ONLY IF THESE CONDITIONS ARE MET: 1. That on the effective date the Proposed Insured is insurable as a standard risk under the Company’s rules for the plan amount andpremium rate applied for.2. That the sum paid is equal to the FULL FIRST PREMIUM for the policy applied for.
INSURANCE ISSUED BASED ON THE APPLICATION WILL TAKE EFFECT ON THE LATEST OF: (a) date of the application; or (b) date requested in the application; or(c) date of the last of any medical examinations or tests required under the rules and practices of the Company.The total amount of insurance which may become effective prior to delivery of the policy to the Owner shall not exceed $25,000.This amount includes LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS then IN FORCE or APPLIED FOR with thisCompany. LIBERTY BANKERS/THE CAPTIOL LIFE INSURANCE COMPANY has received $for Applicant
XAgent’s Signature Date
THE PREMIUM CHECK MUST BE MADE PAYABLE TO LIBERTY BANKERS/THE CAPITOL LIFE INSURANCE COMPANY. DO NOT MAKE THE CHECK PAYABLE TO THE AGENT OR LEAVE THE PAYEE BLANK.
Administrative Office: P O Box 224 Brownwood, Texas 76804 1-800-604-8002
AUTHORIZATION TO OBTAIN, RELEASE AND DISCLOSE MEDICAL INFORMATION
I hereby authorize any: medical practitioner, physician, hospital, clinic, pharmacy benefit manager, or other medical related facility, insurance company, insurance support organization, business partner, pharmacy, government agency, group policy holder, employer, benefit plan administrator, the MIB, Inc., the Department of Motor Vehicle Registration, and paramedical facility to provide to LIBERTY BANKERS LIFE INSURANCE COMPANY, or to any agent, attorney, consumer reporting agency or independent administrator, including medical record retrieval services or pharmaceutical services, acting on LIBERTY BANKERS LIFE INSURANCE COMPANY’S or its reinsurers’ behalf, information concerning advice, care, or treatment sought by or provided to me and/or any other applicant for coverage, including information relating to medical history, medical conditions, treatment, hospitalizations or confinements, ailments, pharmacy prescription drugs, and/or drug, alcohol or tobacco usage of the applicant(s). It is understood that LIBERTY BANKERS LIFE underwriters, claim examiners, reinsurers, attorneys, or the medical director may disclose such health information to the aforementioned parties for purposes of underwriting, compliance, record clarification or explanation, or in response to litigation, summons, or subpoenas. I understand that after this information is disclosed, the recipient may re-disclose it resulting in loss of protection by federal regulations. I authorize LIBERTY BANKERS LIFE INSURANCE COMPANY, or its reinsurers, to make a brief report of my protected health information to the MIB, Inc.
I understand that: • such information will be used by LIBERTY BANKERS LIFE INSURANCE COMPANY for underwriting and
insurability determinations;• I may refuse to sign this authorization and that my refusal to sign will affect my ability to obtain life insurance coverage;• a picture copy or photocopy of this authorization shall be as valid as the original; and• any authorized representative of the proposed insured is entitled to receive a copy of this authorization upon request.
This authorization is valid from the date signed for a duration of 24 months. I understand I may revoke the authorization at any time, except to the extent that action has been taken in reliance on this authorization, by sending written notice to the Life Underwriting Department of LIBERTY BANKERS LIFE INSURANCE COMPANY, P. O. Box 224, Brownwood, Texas 76804. I may inspect or copy any information used or disclosed under this authorization, if signed.
Date
Proposed Insured (Please print) Signature of Proposed Insured (or parent if Proposed Insured is under age 16)
Birthdate
Additional Proposed Insured (Please print) Signature of Additional Person Proposed for Insurance
Birthdate
Personal Representative designated by signature above is hereby authorized to execute this instrument based on: power of attorney, guardian-in-fact, guardian, payee, representative, other (Circle one)
LBL-HIPAA-2012-08-23
Liberty Bankers Life Insurance Company
ACCELERATED DEATH BENEFIT PAYMENT RIDER DISCLOSURE
PREMIUMS There is no premium charge for the accelerated death benefit rider.
EFFECT ON POLICY VALUES
After payment of the accelerated death benefit, the death benefit of the policy will be reduced by the amount of accelerated death benefit. Any premium payments, cash values, and other obligations and benefits under this policy, excluding that for riders, will be reduced proportionately. Upon a request to accelerate benefits under this rider, the owner and any irrevocable beneficiary will be given a statement demonstrating the effect of the acceleration of benefits on the cash value, death benefit, premium charges, and policy loans.
AMENDED POLICY SCHEDULE
An amended policy schedule will be sent to you, the owner, and any irrevocable beneficiary upon a request to accelerate benefits and upon payment of this benefit. The schedule will show the reduced death benefit, cash value and premium amounts.
ACCELERATED BENEFIT A benefit that may be requested by the owner if the insured is terminally ill, or if the insured is chronically ill. Terminal Illness and Chronic Illness are defined below.
MAXIMUM ACCELERATED DEATH BENEFIT
The sum of all accelerated benefit payments may not exceed the smaller of $250,000 or 80% of the face amount.
CONDITION OF PAYMENT We will pay an amount up to the maximum accelerated death benefit if we receive proof that the insured (a) has been diagnosed with a terminal illness; or (b) is chronically ill. An administrative expense charge and an interest charge may apply at the time of acceleration.
DEFINITION OF TERMINAL ILLNESS Terminal illness is considered a disease or illness that is expected to result in the death of the insured within twelve (12) months.
DEFINITION OF CHRONIC ILLNESS
Chronic illness is considered a disease or illness such that the insured is unable to perform at least two activities of daily living or requires substantial supervision as protections from threats to health or safety.
ICC16-LBL-CLL-ADBDISC 1 (02-2017)
NOTICE: Death benefits, premium payments, and cash surrender values will be reduced upon payment of an accelerated benefit. The accelerated benefits offered under this rider do not and are not intended to qualify as long-term care insurance. The accelerated benefits offered under this rider are intended to qualify for favorable tax treatment under the Internal Revenue Code of 1986. Whether such benefits qualify depends on factors such as your life expectancy at the time benefits are accelerated or whether you use the benefits to pay for necessary long-term care expenses, such as nursing home care. If the acceleration of benefits qualifies for favorable tax treatment, the benefits will be excluded from your income and not subject to federal taxation. However, accelerated benefit payments may be taxable by your state. Tax laws relating to accelerated benefits are complex. You should consult a qualified tax advisor for specific information. Receipt of an accelerated benefit payment may adversely affect your, your spouse’s or your family’s eligibility for medical assistance (Medicaid), Aid to Families with Dependent Children (AFDC), supplementary social security income (SSI), and drug assistance or other public assistance programs. You should consult with a qualified advisor and with social services agencies regarding how receipt of such payment may affect
eligibility for such programs.
CERTIFICATION OF PHYSICIAN The certification by a physician must include documentation supported by clinical, radiological, histological, or laboratory evidence of the condition.
PHYSICIAN OF OUR CHOICE
We may require an additional examination by a physician of our choice, and at our expense. If there is a conflict of medical opinion as to the life expectancy of the insured, a third medical opinion that is provided by a physician that is mutually acceptable to the insured and the company will govern.
I have received a copy of this disclosure.
X X
Applicant Date Agent Date
ICC16-LBL-CLL- ADBDISC 2 (02-2017)
BANK DRAFT OPTION DATES: 1st – 28th also 2nd, 3rd, or 4th Wednesdays. If a
Wednesday draft is needed to correlate with a social security deposit, please choose
which Wednesday is needed at the time of the POSTI.
PAPERLESS APPLICATION: The Point of Sale Telephone Interview (POSTI) includes
completing the application and underwriting decision all in one process. For a smooth and
efficient call, please complete the worksheet to gather all client data, including banking
information, while pre-qualifying your client before you call!
Final Expense Build Chart and Helpful Information
Maximum Acceptable UNISEX Build Chart for Final Expense
HEIGHTSIMPL PREF
SIMPL STD
MOD WL HEIGHT
SIMPL PREF
SIMPL STD
MODWL
4’8” 212 220 260 5’8” 304 321 391
4’9” 219 228 271 5’9” 312 330 403
4’10” 226 236 282 5’10” 320 339 415
4’11” 233 244 293 5’11” 328 349 426
5’ 240 252 304 6’ 337 359 437
5’1” 248 260 315 6’1” 346 369 448
5’2” 256 268 326 6’2” 355 379 459
5’3” 264 276 337 6’3” 364 389 470
5’4” 272 285 347 6’4” 374 399 481
5’5” 280 294 356 6’5” 384 409 492
5’6” 288 303 366 6’6” 394 419 503
5’7” 296 312 378 6’7” 404 429 515
LBL-FPDG-11-07-2016 1
Field Prescription Drug GuideThe following Guide is designed to assist you when writing a SIMPL Preferred,SIMPL Standard or Modified Whole Life application. It discloses the most widely used prescriptions and usage. It is not uncommon for applicants to be on medication or multiple medications and this is an underwritingconsideration.
Prescribed medications “obtained or increased in the last 2 years”are used in the underwriting process for SIMPL Preferred, SIMPL Standard OR MWL.
PLEASE NOTE:
When multiple Rxs are used for one disorder it may be a sign that the disease/illness may be at an uninsurable stage and this can be reason for a decline. Please call or check with Underwriter.
LBL/CLICO may investigate any medication (or combination of) which may suggest treatment for a condition that may be life threatening.
If you see an unlisted drug or have any questions, please call our Underwriting Department at 1-800-731-4300 prior to submitting the application.
BPH = Benign prostate hypertrophy HTN = Hypertension or High Blood PressureCHF = Congestive Heart Failure MS = Multiple SclerosisCOPD= Chronic Obstructive RA = Rheumatoid Arthritis
Pulmonary Disease RLS = Restless Leg Syndrome(dot) = “Yes” approved for plan
List of Medications SIMPL PREF.
SIMPL STD. MWL Medical Condition Underwriting Decision
3TC HIV treatmentAbarelix Prostate cancer Accupril HTN/CHF/Renal failure Yes if for HTN only Adcirca Pulmonary Hypertension
Aggrenox Circulatory disorders/Stroke/TIA Stroke/TIA MWL only Akineton Parkinson's DiseaseAldactone HTN/CHF/Renal Failure prevention Yes if for HTN only
Aldesleukin Cancer treatment Alglucerase Gaucher's genetic disease
Alkeran Cancer Altace HTN/CHF/Kidney Failure prevention Yes if for HTN only
Altretamine Cancer treatment Amantadine Severe Parkinson's Disease Ambrisentan Pulmonary HTN/CHF
Amicar Anemia/Cirrhosis SIMPL Std if Cirrhosis only
LBL-FPDG-11-07-2016 2
List of Medications SIMPL PREF.
SIMPL STD. MWL Medical Condition Underwriting Decision
Amiodarone CHF/Irregular heart beat
Amlodipine Besylate
HTN/CHF/Kidney Failure prevention Yes if for HTN only
Anakinra Rheumatoid Arthritis Anastrozole Cancer treatment Yes Testosterone only
Aplenzin Major Depression/Depression Aromasin Breast cancer Arimidex Breast cancer Aricept Dementia, Alzheimer’s Dementia
Atenolol HTN/Migraines Atripla AIDS, HIV treatment Avinza Moderate to Severe pain Avastin Chemotherapy for cancer treatment Avonex Multiple Sclerosis (MS) Azasan Anti-rejection for organ transplant
Azathioprine Anti-rejection for organ transplant AZT HIV/AIDS treatment
Baclofen Anti-spasmodic/MS/Nerve Damage Benztropine Severe Parkinson's Disease Betaseron Multiple Sclerosis (MS)
Bicalutamide Cancer treatment BiDil Angina/Heart Disease
Bocerevir Hepatitis C Brilinta Heart / Stroke
Bumetanide CHF/Kidney disease Bumex CHF/Kidney disease
Buprenex Moderate to severe chronic pain Buprenorphine Moderate to severe chronic pain
Butrans Moderate to severe chronic pain Byetta Diabetes Only if controlled Caduet HTN/CHF/Kidney Failure prevention Yes if for HTN only
Calcitriol Kidney Dialysis Campral Alcohol Addiction Captopril HTN/CHF Yes if for HTN only
Carbidopa RLS / Severe Parkinson's Disease Standard for RLS only Carboplatin Cancer
Cardizem HTN/Angina/Abnormal Heart Yes if for HTN only Carvedilol Heart failure/Hypertension Yes if for HTN only Casodex Cancer Cellcept Anti-rejection for organ transplant
Certolizumab pegol Crohn’s/Rheumatoid,Psoriatic Cilostazol Claudication/Clogged arteries
Cimzia Crohn’s/Rheumatoid,Psoriatic Cognex Dementia/Alzheimer's Dementia
Combivent COPD/Emphysema Copaxone Multiple Sclerosis (MS) Cordarone CHF/ Heart failure
LBL-FPDG-11-07-2016 3
List of Medications SIMPL PREF.
SIMPL STD. MWL Medical Condition Underwriting Decision
Coreg Heart failure/Hypertension Yes if for HTN only Coumadin Blood thinner If for Stroke MWL only
Cozaar HTN Creon Pancreatic insufficiency
Cyclosporine Autoimmune disorders Cymbalta Depression DALIResp Severe Respiratory disorder(s)
Dicalutimide Cancer Digoxin Irregular heart beat Dilaudid Moderate to severe pain
Diltiazem HTN/Angina/Cardiac Yes if for HTN only Dimethyl fumarate Multiple Sclerosis/Brain Lesions
Disulfiram Alcoholism Donepezil Alzheimer's dementia Dopamine Circulatory problems
Dopar Severe Parkinson's Disease Dronabinol Cancer, AIDS treatment
Dronedarone Anti-arrhythmic Droperidol Tranquilizer, sedative, anti-nausea
Droxia Leukemia/Cancer/Sickle Cell Anemia Dynacirc CR HTN/High Blood Pressure
Effient CAD/stent - angioplasty history If current use only MWL Enalapril HTN/Hypertension/CHF Yes if for HTN only Eldepryl Severe Parkinson's Disease Entresto Chronic heart failure Eliquis Blood thinner Enbrel Arthritis/Ankylosing Spondylitis Emcyt Cancer
Entacapone Severe Parkinson’s Disease Enzalutamide Cancer
Erbitux Cancer treatment Ergoloid Dementia
Erythropoietin Anemia of Renal or Kidney origin Etanercept Arthritis/Ankylosing Spondylitis Etopophos Cancer
Eulexin Cancer Evzio Narcotic overdose
Exelon Dementia Exemestane Breast cancer
Extavia Multiple Sclerosis (MS) Femara Cancer Fentanyl Severe Pain
Fentanyl Patch Severe Pain Flecainide Arrhythmias/Abnormal Heart No CHF,Cardiomyopathy
Fluphenazine Psychotic Disorders Formoterol COPD Furosemide Fluid/HTN/CHF Yes if for HTN only Gabapentin Pain/Neuropathy SMP Pref or Std < 900 mg
LBL-FPDG-11-07-2016 4
List of Medications SIMPL PREF.
SIMPL STD. MWL Medical Condition Underwriting Decision
Galantamine Alzheimer's dementia Glatiramer Multiple Sclerosis (MS)
Gleevec Cancer Goserelin Cancer Gilenya Multiple Sclerosis (MS)
HCTZ Fluid/HTN/CHF/Kidney failure Yes if for HTN only Hectoral Kidney Disorder Hexalen Cancer
Hydergine Alzheimer's dementia Hydrea Leukemia (CLL)
Hydromorphone Moderate to severe pain Hydroxychloroquine Autoimmune disorders
Hydroxyurea Leukemia (CLL) Humira Rheumatoid
Idarubicin Leukemia Ifosfamide Cancer
Imatinib Cancer Imdur Angina/Heart disease
Imuran Organ transplant/blood disorders Incivek Hepatitis C Inderal Tremor/HTN/Angina Yes if for HTN only Insulin Diabetes Only if controlled
Interferon Cancer, HIV/AIDS, Hepatitis C Yes if Hepatitis C only Isosorbide Angina/Heart disease
Jakafi Organ transplant/blood disorders Kemadrin Severe Parkinson's Disease
Kineret Rheumatoid Arthritis Lamivudine HIV/AIDS treatment
Lanoxin Heart/A Fib If used for CHF, decline Lantus Diabetes Only if controlled Lasix Fluid/HTN/CHF Yes if for HTN only
Letrozole Cancer/Breast Cancer Levodopa RLS / Severe Parkinson's Disease Standard for RLS only
Lisinopril HTN/Heart Yes if for HTN only Lloperidone Schizophrenia Lopressor HTN/Heart Yes if for HTN only Lopinavir HIV/AIDS treatment Lupron Cancer Megace Cancer/HIV/AIDS treatment MWL only if for appetite
Megestrol Cancer/HIV/AIDS treatment MWL only if for appetite Memantine Alzheimer's dementia
Mercaptopurine Leukemia Mesna Cancer
Methadone Severe pain/Drug addiction Methotrexate Cancer/MS/Rheumatoid Arthritis MWL if for Cancer
Metoprolol HTN/Angina/Heart Yes if for HTN only Mitomycin Cancer
LBL-FPDG-11-07-2016 5
List of Medications SIMPL PREF.
SIMPL STD. MWL Medical Condition Underwriting Decision
Modafinil Daytime sleepiness/Narcolepsy/OSA Morphine Moderate to Severe pain
Mycophenolate Anti-rejection Organ transplant Multaq Anti-arrhythmic
Naloxone Narcotic overdose Naltrexone Drug Addiction Namenda Alzheimer's dementia
Narcan Narcotic overdose Neurontin Pain/Neuropathy SMP if < 900 mg daily dose Nifedipine HTN/Angina/Heart SMP PREF for HTN only Nitrobid Angina/chest pains/Heart
Nitroglycerine Angina/chest pains/Heart Nitroquick Angina/chest pains/Heart Nivolumab Advanced Cancer Norfloxacin Infections
Norvir HIV/AIDS treatment Nucynta Pain/Neuropathy Nuvigil Narcolepsy, Excessive sleepiness
Octreotide Cancer treatment Olysio Hepatitis C Opdivo Advanced Cancer Opana Severe pain
Oxycontin Severe pain Oxymorphone Severe pain
Paclitaxel Cancer Parlodel Severe Parkinson's Disease Permex Severe Parkinson's Disease
Plaquenil Autoimmune disorders, Lupus Plavix Blood thinner
Pradaxa Blood thinner Pramipexole RLS/Mild Parkinson's Disease
Prasugrel CAD/stent - angioplasty history If current use only MWL Procrit Kidney Disorder
Procylidine Severe Parkinson's Disease Prograf Organ transplant rejection Provigil Excessive sleepiness/Narcolepsy/OSA Ranexa Chronic Angina
Ranolazine Chronic Angina Rasagiline Severe Parkinson's Disease Renagel Kidney Dialysis
Remeron Depression/Tremors/Panic disorder Remicade Rheumatoid Reminyl Alzheimer's/Dementia Requip Parkinson's/Restless Leg Syndrome SMPL Pref./Std if RLS only
Ribavirin Hepatitis C Rifaximin Liver Failure Ritonavir HIV/AIDS treatment
Rivastigmine Alzheimer's/Dementia
LBL-FPDG-11-07-2016 6
List of Medications SIMPL PREF.
SIMPL STD. MWL Medical Condition Underwriting Decision
Ropinirole RLS/Parkinson's Disease Ruxolitinib Organ transplant/blood disorders
Sandostatin Cancer treatment Selegiline RLS/Dementia SMP Pref./STD If RLS only
Simeprevir Hepatitis C Sinemet Parkinson’s Disease Spiriva COPD/Emphysema
Spironolactone Fluid/HTN/CHF Yes if for HTN only < 100mg Szofosburvir Hepatitis C
Solvadi Hepatitis C Stalevo Severe Parkinson's Disease Stribild HIV/AIDS treatment
Suboxone Drug and Alcohol treatment Sunitinib Malate Advanced Renal Cancer & GIST
Sutent Advanced Renal Cancer & GIST Symmetrel Parkinson's Disease Tacrolimus Organ transplant rejection Tamoxifen Breast cancer
Taiazac HTN/Angina Yes if for HTN only Tapentadol Pain/Neuropathy Tecfidera Multiple Sclerosis/Brain Lesions Telaprevir Hepatitis C Tenofovir HIV treatment Tizanidine MS/Spinal cord disorders No, if for MS Thorazine Psychotic Disorders Tolcapone Parkinson's Disease
Toprol HTN/Angina/Heart Yes if for HTN only Torsemide CHF/Kidney or Liver Disease Toremifene Cancer Triamterene Fluid/HTN/CHF Yes if for HTN only
Trifluoperazone Psychotic Disorders Trihexyphenidyl Parkinson's Disease
Vasotec HTN/Angina/CHF SMPL for HTN only Viread HIV treatment Vicodin Chronic Pain Victrelis Hepatitis C Warfarin Blood thinner Xarelto Blood thinner SMPL STD if no longer
taking or for Afib only Xifaxan Brain function loss Xtandi Cancer
ZDV HIV treatment Zenpep Pancreatic insufficiency
Zidovudine HIV treatment Zoladex Cancer Zometa Cancer/Multiple Myeloma Zytiga Prostate Cancer