2. State law provides that your replacement policy or certificate, may not contain new preexisting conditions, waiting periods, elimination periods or probationary periods. The insurer will waive any time periods applicable to preexisting conditions, waiting periods, elimination periods, or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was satisfied under the Medicare supplement policy.
3. If, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all requested material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all requested information has been properly reported. [If the policy or certificate is guaranteed issue, this paragraph need not appear.]
Do not cancel your present policy until you have received your new policy and are sure you want to keep it.
__________________________________________
(Signature of Agent, Broker or Other Representative)*
[Typed Name and Address of Issuer, Agent or Broker]
__________________________________________
(Applicant's Signature)
_____________________
(Date)
* Signature not required for direct response sales.
Ins 3.39 APPENDIX 10
DISCLOSURE STATEMENTS
(a) [For policies that reimburse expenses incurred for specified disease(s) or other specified impairment(s). This includes expense incurred cancer, specified disease and other types of health insurance policies that limit reimbursement to named medical conditions.]
-
See PDF for table 
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for one of the specific diseases or health conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it pays:
○ hospital or medical expenses up to the maximum stated in the policy.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
○ hospitalization
○ physician services
○ hospice
○ [outpatient prescription drugs if you are enrolled in Medicare
Part D]
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the “Wisconsin Guide to Health Insurance for People with Medicare," available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
(b) [Alternative disclosure statement for policies that reimburse expenses incurred for specified diseases or other specified impairments. This includes expense-incurred cancer, specified disease and other types of health insurance policies that limit reimbursement to named medical conditions.]
-
See PDF for table
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy. Medicare generally pays for most or all of these expenses.
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for one of the specific diseases or health conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
○ hospitalization
○ physician services
○ hospice
○ [outpatient prescription drugs if you are enrolled in Medicare
Part D]
○ other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
- See PDF for table
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the Wisconsin Guide to Health Insurance for People with Medicare, available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
(c) [For policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy.]
-
See PDF for table
This is not Medicare Supplement Insurance
This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one of the specific diseases or health conditions named in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits because Medicare generally pays for most of the expenses for the diagnosis and treatment of the specific conditions or diagnoses named in the policy.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
○ hospitalization
○ physician services
○ hospice
○ [outpatient prescription drugs if you are enrolled in Medicare
Part D]
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the “Wisconsin Guide to Health Insurance for People with Medicare," available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
(d) [Alternative disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy.]
-
See PDF for table
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one of the specific diseases or health conditions named in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
○ hospitalization
○ physician services
○ hospice
○ [outpatient prescription drugs if you are enrolled in Medicare
Part D]
○ other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
- See PDF for table
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the Wisconsin Guide to Health Insurance for People with Medicare, available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
(e) [For indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies.]
-
See PDF for table
This is not Medicare Supplement Insurance
This insurance pays a fixed amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when:
○ any expenses or services covered by the policy are also covered by Medicare.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
○ hospitalization
○ physician services
○ hospice
○ [outpatient prescription drugs if you are enrolled in Medicare
Part D]
√ Check the coverage in all health insurance policies you already have.
√ For more information about Medicare and Medicare Supplement insurance, review the “Wisconsin Guide to Health Insurance for People with Medicare," available from the insurance company.
√ For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
(f) [Alternative disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies.]
-
See PDF for table
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
○ hospitalization
○ physician services
○ hospice
○ [outpatient prescription drugs if you are enrolled in Medicare
Part D]
