Application for Medicare Supplement Insurance

Underwritten by

Aetna Health

Insurance Company

AHCMS05602NJ

101519

Application

Medicare Supplement Insurance

New Jersey

aetnaseniorproducts.com

AHCMS05602NJ

101519

Aetna Health

Insurance Company

P.O. Box 14399

Lexington, KY 40512

1. Applicant A information

Full name of proposed insured First, M.I., Last

▪

Address Phone

▪ ▪

City State Zip

▪ ▪ ▪

E-mail Social Security Number

▪ ▪

Birth date mm/dd/yyyy Age

▪ ▪

○ Male

○ Female

Are you a legal resident of the United States? ○ Yes ○ No

Medicare card number

▪

Date enrolled in: Medicare Part A Medicare Part B

▪ ▪

Application for Medicare Supplement Insurance

from Aetna Health Insurance Company

Page 1 of 11

• Print clearly and use blue or black ink.

• If only one applicant, just complete Applicant A information.

• Complete all required sections of the application. Any incomplete or missing

information could delay processing of your application.

Write the name as stated on the

Medicare card. Provide a copy of the

Medicare card with the application

if possible.

Write the date of birth that is on the

birth certificate.

Include any letters associated with

the Medicare number and in the

appropriate position. If applicant

has not received a Medicare card

yet, put "No Medicare number yet".

Check if application is for:

Applicant A

○ Open Enrollment

○ Guaranteed Issue

Applicant B

○ Open Enrollment

○ Guaranteed Issue

Deliver policy(ies) to:

○ Agent

○ Applicant(s)

○ Electronically

Applicant B information

Full name of proposed insured First, M.I., Last

▪

Address Phone

▪ ▪

City State Zip

▪ ▪ ▪

E-mail Social Security Number

▪ ▪

Birth date mm/dd/yyyy Age

▪ ▪

○ Male

○ Female

Are you a legal resident of the United States? ○ Yes ○ No

Medicare card number

▪

Date enrolled in: Medicare Part A Medicare Part B

▪ ▪

Review instructions above before

completing.

For agent use only

2. Plan and premium information

Underage Coverage: Plans C* and D are available for qualified consumers aged 50 – 64 who are eligible

for Medicare by reason of disability.

Open Enrollment: You are eligible for Guaranteed Acceptance in Plan C if your Medicare Part B effective

date is prior to 1/1/2020 and you apply:

▪ within six months of enrollment in Medicare Part B; or

▪ within six months beginning with the month in which a retroactive determination of Medicare is made.

*Plan C is available for applicants newly eligible for Medicare prior to January 1, 2020.

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101519

Payment method

○ Check ○ EFT

○ List Bill billing file identifier

Payment method

○ Check ○ EFT

○ List Bill billing file identifier

Application for Medicare Supplement Insurance

Page 2 of 11 Applicant A Initials........................................................ Applicant B Initials........................................................

Plan and premium information continued

You have a choice among several

payment options or modes for

paying your premium (annual,

semi-annual, quarterly and

monthly electronic funds transfer).

If applying for household discount:

provide the discounted and non-

discounted premium amounts.

HOUSEHOLD PREMIUM DISCOUNT INFORMATION

In order to be eligible for the household discount under an Aetna Company Medicare

supplement plan, you must apply for a Medicare supplement plan at the same time as another

Medicare eligible adult or the other Medicare eligible adult must currently be covered

by an Aetna Company Medicare Supplement policy issued in New Jersey. The Medicare

eligible adult must be either: (a) your spouse; (b) someone with whom you are in a civil

union partnership; and (c) someone with whom you have continuously resided for the past

12 months. The household discount will only be applicable if a policy for each applicant is

issued. The discounted rates will be 7 percent lower than the individual rates and will apply

as long as both policies remain in force.

PAYMENT MODES

Each payment mode, other than annual and monthly electronic funds transfer, results in higher total

yearly premium costs. Reasons for higher costs include added collection and administrative costs, time

value of money considerations and lapse rates. The annual and monthly electronic funds transfer modes

have the same and lowest total yearly premium costs. As a result, there is a time value of money

advantage to you for paying monthly versus annually. However, there may be other advantages to you

for choosing an annual payment based on your preferences. Your agent can explain the differences in

modes and help you decide which is best for you. You may change your payment mode, among the modes

available, during the life of your policy.

Household premium discount

eligibility information

To be eligible for the household

discount as outlined below, please

answer the applicable eligibility

questions in this section.

1) Is the other Medicare eligible

adult applying either:

a. your spouse; or

b. someone with whom you are in a

civil union partnership; and

c. someone with whom you have

continuously resided for the past 12

months?

Applicant A ○ Yes ○ No

Applicant B ○ Yes ○ No

If both answered "yes", and

purchase this policy, you will

qualify for the household premium

discount.

2) Or, does the other Medicare

eligible adult already have Medicare

supplement coverage with the

same or another Aetna Company

that also has available a household

discount and is either

a. your spouse; or

b. someone with whom you are in a

civil union partnership; and

c. someone with whom you have

continuously resided with for the

past 12 months?

Applicant B ○ Yes ○ No

If yes, please provide the following

information:

Name: ...........................................................................................................

Address: ....................................................................................................

........................................................................................................................................

Policy Number: ........................................................................

Upon verification of eligibility, and

approval of your application, you

and the existing policyholder will

qualify for the discount.

Applicant A Plan selected Requested Medicare Supplement effective date: mm/dd/yyyy

▪ ▪

Modal premium:

Modal premium with discount:

Application fee:

Total initial premium collected/draft:

Applicant B Plan selected Requested Medicare Supplement effective date: mm/dd/yyyy

▪ ▪

Modal premium:

Modal premium with discount:

Application fee:

Total initial premium collected/draft:

Initial premium:

○ Draft initial premium upon policy approval

○ Draft initial premium on policy effective date

Initial premium:

○ Draft initial premium upon policy approval

○ Draft initial premium on policy effective date

Payment mode

○

Annually ○ Quarterly

○ Semi-Annually ○ Monthly EFT (Electronic Funds Transfer)

Payment mode

○

Annually ○ Quarterly

○ Semi-Annually ○ Monthly EFT (Electronic Funds Transfer)

You are eligible for Guaranteed Acceptance in Plan D if:

▪ your Medicare Part B effective date is prior to 1/1/2020 and you apply within six months of enrollment

in Medicare Part B and you are not covered by any other Medicare Supplement Plan; or

▪ your Medicare Part B effective date is on or after 1/1/2020 and you apply within 12 months of enrollment

in Medicare Part B.

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101519

Application for Medicare Supplement Insurance

Page 3 of 11 Applicant A Initials........................................................ Applicant B Initials........................................................

3. Eligibility questions

Please answer all questions.

NOTE: If you are participating in

a "Spend-Down Program" and have

not met your "Share of Cost," please

answer NO to question 2.

If you lost or are losing other health

insurance coverage and received a

notice from your prior insurer saying

you were eligible for guaranteed

issue of a Medicare Supplement

insurance policy, or that you had

certain rights to buy such a policy,

you may be guaranteed acceptance

in one or more of our Medicare

Supplement plans. Please include a

copy of the notice from your prior

insurer with your application.

To the best of your knowledge: Applicant: A B

1. Did you turn age 65 in the last 6 months? ○Y ○N ○Y ○N

A. Did you enroll in Medicare Part B in the last 6 months? ○Y ○N ○Y ○N

B. If yes, what is the effective date?

Applicant A effective date

▪

Applicant B effective date

▪

2. Are you covered for medical assistance through the state Medicaid program? ○Y ○N ○Y ○N

A. If yes: Will Medicaid pay your premiums for this Medicare Supplement policy? ○Y ○N ○Y ○N

B. Do you receive any benefits from Medicaid other than payments toward ○Y ○N ○Y ○N

your Medicare Part B premium?

3. If you had coverage from any Medicare plan other than original Medicare within

the past 63 days (for example, a Medicare Advantage plan, or a Medicare HMO

or PPO), fill in your start and end dates below. If you are still covered under this

plan, leave "End" blank.

Applicant A start date End date

▪ ▪

Applicant B start date End date

▪ ▪

A. If you are still covered under the Medicare plan, do you intend to replace your ○Y ○N ○Y ○N

current coverage with this new Medicare Supplement policy?

B. Was this your first time in this type of Medicare plan? ○Y ○N ○Y ○N

C. Did you drop a Medicare Supplement policy to enroll in the Medicare plan? ○Y ○N ○Y ○N

4. Do you have another Medicare Supplement policy inforce? ○Y ○N ○Y ○N

A. If so for Applicant A, with what company, and what plan do you have?

Company Plan

▪

If so for Applicant B, with what company, and what plan do you have?

Company Plan

▪

B. If so, do you intend to replace your current Medicare Supplement policy with this

○Y ○N ○Y ○N

policy?

5. Have you had coverage under any other health insurance within the past 63 days? ○Y ○N ○Y ○N

(For example, an employer, union, or individual plan)

A. If so for Applicant A, with what company, and what kind of policy?

Company Plan

▪ ▪

B. What are your start and end dates of coverage under the other policy?

(If you are still covered under the other policy, leave "End" blank.)

Start date End date

▪ ▪

A. If so for Applicant B, with what company, and what kind of policy?

Company Plan

▪ ▪

B. What are your start and end dates of coverage under the other policy?

(If you are still covered under the other policy, leave "End" blank.)

Start date End date

▪ ▪

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101519

Application for Medicare Supplement Insurance

Page 4 of 11 Applicant A Initials........................................................ Applicant B Initials........................................................

4. Health questions

If the health questions are answered

for an Open Enrollment or

Guaranteed Issue application, the

application cannot be processed and

will be returned.

If this is an Open Enrollment or

Guaranteed Issue application, do not

answer questions in this section.

1. Are you dependent on a wheelchair or any motorized mobility device? ○Y ○N ○Y ○N

2. Have you used any tobacco products in the past 12 months ○Y ○N ○Y ○N

3. Do any of the following apply to you?

Currently hospitalized, confined to a bed, in a nursing facility or assisted living ○Y ○N ○Y ○N

facility, receiving home health care or physical therapy

4. At any time, have you been medically diagnosed, treated, or had surgery for any

of the following?

A. congestive heart failure, unoperated aneurysm, defibrillator ○Y ○N ○Y ○N

B. leukemia, lymphoma, multiple myeloma, cirrhosis ○Y ○N ○Y ○N

C. Parkinson's Disease, Lou Gehrig's Disease, Alzheimer's Disease, dementia, ○Y ○N ○Y ○N

multiple sclerosis, muscular dystrophy, cerebral palsy

D. chronic kidney disease, kidney failure, kidney disease requiring dialysis, ○Y ○N ○Y ○N

renal insufficiency, Addison's Disease

E. any condition requiring a bone marrow transplant or stem cell transplant, any ○Y ○N ○Y ○N

condition requiring an organ transplant

F. Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), ○Y ○N ○Y ○N

tested positive for the Human Immunodeficiency Virus (HIV)

5. Do you have diabetes?

A. that requires use of insulin ○Y ○N ○Y ○N

B. with complications including retinopathy, neuropathy, ○Y ○N ○Y ○N

peripheral vascular or arterial disease or heart artery blockage

C. with history of heart attack or stroke (at any time) ○Y ○N ○Y ○N

D. treated with medication that has been changed or adjusted in the past 12 ○Y ○N ○Y ○N

months because of uncontrolled blood sugar

6. Within the past 36 months, have you been medically diagnosed, treated, or had

surgery for any of the following?

A. alcoholism, drug abuse ○Y ○N ○Y ○N

B. cardiomyopathy, atrial fibrillation, anemia requiring repeated blood transfusions, ○Y ○N ○Y ○N

any other blood disorder

C. internal cancer, melanoma, Hodgkin's Disease ○Y ○N ○Y ○N

D. hepatitis, disorder of the pancreas ○Y ○N ○Y ○N

7. Within the past 24 months, have you been medically diagnosed, treated, or had

surgery for any of the following?

A. enlarged heart, transient ischemic attack (TIA), stroke, peripheral vascular or ○Y ○N ○Y ○N

arterial disease, neuropathy, amputation caused by disease

B. myasthenia gravis, systemic lupus or connective tissue disorder ○Y ○N ○Y ○N

C. osteoporosis with fractures, Paget's Disease, arthritis that restricts mobility or ○Y ○N ○Y ○N

the activities of daily living

D. any lung or respiratory disorder requiring the use of a nebulizer or oxygen, ○Y ○N ○Y ○N

or 3 or more medications for lung or respiratory disorder

E. any lung or respiratory disorder and currently use tobacco products ○Y ○N ○Y ○N

8. Within the past 12 months, have you been advised by a medical professional to ○Y ○N ○Y ○N

have treatment, further evaluation, diagnostic testing, surgery that has not been

performed or any pending test results?

9. Within the past 12 months, have you been medically diagnosed or, treated, or ○Y ○N ○Y ○N

had surgery for a heart attack, artery blockage, or heart valve disorder?

Within the past 12 months, have you been medically diagnosed with wet macular ○Y ○N ○Y ○N

degeneration and have taken or are currently receiving injections?

Applicant: A B

10.

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101519

Application for Medicare Supplement Insurance

Page 5 of 11 Applicant A Initials........................................................ Applicant B Initials........................................................

Use an additional sheet of paper if

needed for explanation.

1. Within the past 24 months if you have been medically diagnosed, treated, or had surgery for any

brain, mental or nervous disorder, provide reason and diagnosis:

2. Within the past ﬁve years if you have been hospitalized, treated at an outpatient facility, or

emergency room, provide reason and diagnosis:

3. Prescribed medications Reason for medications (diagnosis)

▪ ▪

If this is an Open Enrollment or

Guaranteed Issue application, do

not answer questions in this section.

5. Applicant A health history

Health questions continued

Use an additional sheet of paper if

needed for explanation.

1. Within the past 24 months if you have been medically diagnosed, treated, or had surgery for any

brain, mental or nervous disorder, provide reason and diagnosis:

2. Within the past ﬁve years if you have been hospitalized, treated at an outpatient facility, or

emergency room, provide reason and diagnosis:

3. Prescribed medications Reason for medications (diagnosis)

▪ ▪

If this is an Open Enrollment or

Guaranteed Issue application, do

not answer questions in this section.

Applicant B health history

Applicant: A B

Within the past 12 months, do any of the following apply to you?

A. had a pacemaker implanted ○Y ○N ○Y ○N

B. had a PSA blood test greater than 4.5, under age 70, with no history of ○Y ○N ○Y ○N

prostate cancer

C. had a PSA blood test greater than 6.5, age 70 or older, with no history of ○Y ○N ○Y ○N

prostate cancer

D. had a seizure ○Y ○N ○Y ○N

Was your last blood pressure reading higher than 175 Systolic or higher than ○Y ○N ○Y ○N

100 Diastolic?

Height Feet and inches Weight Pounds

Applicant A Applicant A

Applicant B Applicant B

Systolic is the upper number and

Diastolic is the bottom number of

a blood pressure reading.

13.

12.

11.

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101519

Application for Medicare Supplement Insurance

Page 6 of 11 Applicant A Initials........................................................ Applicant B Initials........................................................

Your primary physician Phone

▪ ▪

Physician's office name

▪

City State

▪ ▪

Specialist seen in the past 24 months Specialty

▪ ▪

Reason for seeing (diagnosis)

▪

Specialist seen in the past 24 months Specialty

▪ ▪

Reason for seeing (diagnosis)

▪

Specialist seen in the past 24 months Specialty

▪ ▪

Reason for seeing (diagnosis)

▪

Have you seen any additional physicians other than those listed above in the past ○ Y ○ N

24 months?

6. Applicant A physician information

Your primary physician Phone

▪ ▪

Physician's office name

▪

City State

▪ ▪

Specialist seen in the past 24 months Specialty

▪ ▪

Reason for seeing (diagnosis)

▪

Specialist seen in the past 24 months Specialty

▪ ▪

Reason for seeing (diagnosis)

▪

Specialist seen in the past 24 months Specialty

▪ ▪

Reason for seeing (diagnosis)

▪

Have you seen any additional physicians other than those listed above in the past ○ Y ○ N

24 months?

Applicant B physician information

If this is an Open Enrollment or

Guaranteed Issue application, do

not answer questions in this section.

If this is an Open Enrollment or

Guaranteed Issue application, do

not answer questions in this section.

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101519

Application for Medicare Supplement Insurance

Page 7 of 11 Applicant A Initials........................................................ Applicant B Initials........................................................

7. Important statements

1. You do not need more than one Medicare Supplement policy.

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

need multiple coverages.

3. You may be eligible for beneﬁts under Medicaid and may not need a Medicare Supplement policy.

4. If, after purchasing this policy, you become eligible for Medicaid, the beneﬁts and premiums under

your Medicare Supplement policy can be suspended, if requested, during your entitlement to beneﬁts

under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible

for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare Supplement policy

(or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested

within 90 days of losing Medicaid eligibility. If the Medicare Supplement policy provided coverage for

outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended,

the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be

substantially equivalent to your coverage before the date of the suspension.

5. If you are eligible for, and have enrolled in a Medicare Supplement policy by reason of disability and

you later become covered by an employer or union-based group health plan, the beneﬁts and premiums

under your Medicare Supplement policy can be suspended, if requested, while you are covered under

the employer or union-based group health plan. If you suspend your Medicare Supplement policy under

these circumstances, and later lose your employer or union-based group health plan, your suspended

Medicare Supplement policy (or, if that is no longer available, a substantially equivalent policy) will be

reinstituted if requested within 90 days of losing your employer or union-based group health plan. If

the Medicare Supplement policy provided coverage for outpatient prescription drugs and you enrolled

in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient

prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the

date of suspension.

6. Counseling services may be available in your state to provide advice concerning your purchase of

Medicare Supplement insurance and concerning medical assistance through the state Medicaid

program, including beneﬁts as a Qualiﬁed Medicare Beneﬁciary (QMB) and a Speciﬁed Low-Income

Medicare Beneﬁciary (SLMB).

8. Privacy notice

Although your application is our initial source of information, we may collect information, including health

history and medical records, from persons other than you and we may conduct a telephone interview with

you. Aetna Health Insurance Company, its afﬁliates, or its reinsurer(s) may also in certain circumstances

release information collected by us to third parties without authorization from you. Upon written request,

we will provide you with the information contained in your ﬁle. Medical information will be disclosed

to you only through the medical professional you designate. Should you wish to request correction,

amendment or deletion of any information in your ﬁle, which you believe inaccurate, please contact us

and we will advise you of the necessary procedures.

9. Producer compensation

When you purchase insurance from us, we pay compensation to the licensed agent, who represents us for

such limited purposes as taking your insurance application, collecting your initial premiums and delivering

your policy, and to any intermediaries through which the licensed agent works. This compensation may

include commissions when a policy is purchased or renewed, and fees for marketing and administrative

services and educational opportunities. The compensation may vary by the type of insurance purchased,

or the particular features included with your policy. Additionally, some licensed agents and/or their

intermediaries may also receive discounts on their own policy premiums and bonuses, and incentive

trips or prizes associated with sales contests based on sales criteria, such as the overall sales volume

of an agent or intermediary with our companies, or for the percentage of completed sales. (Generally,

this will not be the case for registered variable insurance products or for ﬁxed products sold through

banks or broker-dealers.) Intermediaries may also pay compensation directly to the licensed agent. If the

licensed insurance agent can sell insurance policies from other insurance carriers, those carriers may pay

compensation that differs from ours.

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Application for Medicare Supplement Insurance

Page 8 of 11 Applicant A Initials........................................................ Applicant B Initials........................................................

10. Applicant(s) agreement

I hereby apply to Aetna Health Insurance Company for a policy to be issued in reliance on my written

answers to the questions on this application. I have read and understand all statements and answers

and certify that to the best of my knowledge and belief, they are true, complete and correctly recorded. I

acknowledge that I have received an outline of coverage for the policy applied for and A Guide to Health

Insurance for People with Medicare.

I understand that I will receive a copy of the signed application and that a copy is as effective as the original.

I acknowledge and agree that if there is more than one applicant on this application, all information

provided may be reviewed or shared with the other applicant. I understand that upon acceptance of

the completed application, each applicant will receive a separate policy with a copy of this application

attached.

I agree (1) this application and any policy issued will constitute the entire contract of insurance and the

Company will not be bound in any way by any statements, promises or information made or given by or

to any agent or other person at any time unless the same is in writing and submitted to the Company at

its Home Ofﬁce and made a part of such contract. Only a Company Ofﬁcer can make, modify or discharge

contracts or waive any of the Company's rights or requirements and then only in writing; and (2) this

application shall not be approved until the ﬁrst premium is paid, there has been no change in my health

as stated in the application and a policy has been issued by the Company.

I understand and agree that, if I choose to pay my premium by electronic funds transfer (EFT) from my

checking or savings account, I am accepting the terms and conditions of the EFT authorization attached

to this application.

I understand that if any answers on this application are incorrect, incomplete or untrue,

Aetna Health Insurance Company has the right to adjust my premium, reduce my beneﬁts or

rescind the policy.

Any person who includes any false or misleading information on an application for an insurance policy,

is subject to criminal and civil penalties.

Applicant A signature Date signed

Applicant B signature Date signed

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Application for Medicare Supplement Insurance

Page 9 of 11 Applicant A Initials........................................................ Applicant B Initials........................................................

11. Applicant A account information

Complete this section if you are

requesting electronic funds transfer

(EFT) for premium payment.

Include a voided check with the

application.

Name

▪

Account owner name, if different than proposed insured's

▪

Account owner ○ Business owned ○ Living trust ○ Employer

relationship to

by proposed insured

○ Power of Attorney ○ Conservator/guardian

proposed insured:

○ Family member; specify

Financial institution name

▪

○ Checking ○ Savings

Routing number

▪

Account number

▪

Draft date if different from effective date

▪

This is an example of a personal

check. A business check may be

different.

For checks with an

ACH RT (Automated

Clearing House

Routing) number,

please use this

number.

The account number

is up to 17 characters

long and appears next

to the

◾

symbol at

the bottom of the

check and usually to

the right of the bank

routing number.

For all other checks,

use the nine-

character bank

routing number,

which appears

between the

◾

symbols, usually

at the bottom left

corner of the check.

Complete this section if you are

requesting electronic funds transfer

(EFT) for premium payment.

Include a voided check with the

application.

Name

▪

Account owner name, if different than proposed insured's

▪

Account owner ○ Business owned ○ Living trust ○ Employer

relationship to

by proposed insured

○ Power of Attorney ○ Conservator/guardian

proposed insured:

○ Family member; specify

Financial institution name

▪

○ Checking ○ Savings

Routing number

▪

Account number

▪

Draft date if different from effective date

▪

Applicant B account information

Draft date cannot be on the

29th, 30th or 31st of the month.

Requesting to have a draft date

more than 15 days greater than the

policy's paid to date will draft a

month in advance.

Draft date cannot be on the

29th, 30th or 31st of the month.

Requesting to have a draft date

more than 15 days greater than the

policy's paid to date will draft a

month in advance.

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Application for Medicare Supplement Insurance

Page 10 of 11 Applicant A Initials........................................................ Applicant B Initials........................................................

13. Agent

Please list any other medical or health insurance policies sold to Applicant A.

1) List policies sold which are still in force

▪

2) List policies sold in the past 5 years which are no longer in force

▪

Please list any other medical or health insurance policies sold to Applicant B.

1) List policies sold which are still in force

▪

2) List policies sold in the past 5 years which are no longer in force

▪

I certify that:

1. I have accurately recorded the information supplied by the applicant(s).

2. The application was provided to the applicant(s) to review and the applicant(s) has been advised that

any false statement or misrepresentation in the application may result in an adjustment of premium,

reduction of beneﬁts or rescission of the policy(ies).

3. I have provided an outline of coverage for the policy(ies) applied for and A Guide to Health Insurance

for People with Medicare to applicant(s) prior to completing the application.

Agent name Printed Writing number (agent or company)

▪ ▪

Agent signature State license ID number (for FL only)

X ▪

Phone

E-mail

▪ ▪

All information must be completed.

The writing number reflects where

commissions will be paid.

12. Electronic funds transfer (EFT) authorization

Signature only required if the

account owner is different than the

proposed insured.

I understand and accept these terms and conditions:

•

We are authorized to withdraw funds periodically from your account to pay insurance premiums for the insured.

•

If your ﬁnancial institution does not honor an EFT request, we will NOT consider your premium paid.

•

If your ﬁnancial institution does not honor an EFT request, we may make a second attempt within ﬁve

business days.

•

We have the right to end EFT payments at any time and bill you directly either quarterly or less frequently

for premiums due.

•

Information as to each EFT charge will be provided by entry on your account statement or by any other

means provided by your ﬁnancial institution. You will not receive premium notices from us.

•

If you want to cancel or change this authorization, you must contact us at least three business days

before a scheduled withdrawal.

•

Any refund of unearned premium will be made to the policy owner or the policy owner's estate.

Signature of account owner for Applicant A Date

X ▪

Signature of account owner for Applicant B Date

X ▪

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Application for Medicare Supplement Insurance

Page 11 of 11 Applicant A Initials........................................................ Applicant B Initials........................................................

14. Agent request to split commissions

If this application results in an issued policy through Aetna Health Insurance Company (AHIC), the

agents listed below have agreed to split the commissions earned on the policy.

▪

Both agents must be properly licensed and appointed with AHC in the policy’s state of issue.

▪

Split commissions are calculated as a percentage of commissionable premium and will apply while the

policy remains inforce.

▪ The percentage of the premium split can be for any amount but must be stated in whole numbers and

total 100%. (For example, the percentage for the premium split can be from 1% to 99% but cannot be

0% or 100%.

)

▪

Calculation of each agent’s commissions are based on their respective AHC commission schedule.

Agent Information Print

Writing Agent Percentage

▪ ▪ %

Secondary Agent Writing number Percentage

▪ ▪ ▪ %

Writing Agent Signature

This section must be completed

with this application in order to split

commissions.

By signing this form, the writing agent

agrees to split his/her commission with

the secondary agent as indicated above.

AHCMS05602NJ

101519

Applicant A name Printed Date of application

▪ ▪

Initial payment collected (if applicable)

○ Check ○ Money order

EFT draft amount

EFT draft date

▪

Applicant B name Printed Date of application

▪ ▪

Initial payment collected (if applicable)

○ Check ○ Money order

EFT draft amount

EFT draft date

▪

This acknowledges receipt of your application for an Aetna Health Insurance Company Medicare

Supplement insurance policy.

Agent name Printed Phone

▪ ▪

Signature of agent

•

Payment will be refunded for any coverage not issued.

•

All premium payments must be made payable to Aetna Health Insurance Company.

•

DO NOT make any check payable to the agent and do not leave the payee blank on the check.

•

A recorded interview may be required as part of the underwriting on your application

for insurance.

Medicare Supplement Insurance - A. If this payment equals the full, initial premium for the mode

of premium payment selected by the applicant(s); and B. if the answers are true and correct in the

application and if Aetna Health Insurance Company issues a Medicare Supplement policy according

to its rules, limits, and standards for the plan and amount applied for by the applicant(s); then this

payment shall be applied to the payment of the first premium of the issued Medicare Supplement

policy. No Medicare Supplement policy shall be effective until it has actually been issued by Aetna

Health Insurance Company.

Thank you for choosing Aetna Health Insurance Company!

Receipt

from Aetna Health Insurance Company

Page 1 of 1

• Print clearly and use blue or black ink.

• Applicant(s) keeps this receipt for their records.

• If only one applicant, just complete Applicant A information.

Aetna Health

Insurance Company

P.O. Box 14399

Lexington, KY 40512

800-264-4000

aetnaseniorproducts.com

oce hours 7:00 a.m. - 7:00 p.m. CST