<html xmlns="http://www.w3.org/1999/xhtml"><head><meta charset="UTF-8" /><title></title><meta name="Generator" content="PowerTools for Open XML" /><style>span { white-space: pre-wrap; } p.s631b9173-6d5d-4eef-be03-9a470a61e04cNormal { font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-left: 0; margin-right: 0; margin-bottom: .001pt; } span.s631b9173-6d5d-4eef-be03-9a470a61e04c000000 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001 { text-align: center; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-left: 0; margin-right: 0; margin-bottom: .001pt; } span.s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } 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} p.s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000007 { text-align: right; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-left: 0; margin-right: 0; margin-bottom: .001pt; } p.s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000008 { font-family: Times; font-size: 10pt; line-height: 108%; margin-top: 0; margin-left: 0; margin-right: 0; margin-bottom: .001pt; } span.s631b9173-6d5d-4eef-be03-9a470a61e04c000009 { font-size: 10pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </style></head><body><div><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">DEPARTMENT OF LABOR AND REGULATION</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">DIVISION OF INSURANCE</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">REPLACEMENT OF ACCIDENT AND SICKNESS</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">OR LONG-TERM CARE COVERAGE</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">Chapter 20:</span><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">06:21</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">APPENDIX C</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">SEE: §</span><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont-000002"> </span><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">20:06:21:29</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">    </span><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont-000003">Source:</span><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont"> 22 SDR 97, effective </span><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">December 18, 1995.</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont-000004"><br />&#x200e;</span><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont-000003">Appendix C</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">NOTICE TO APPLICANT REGARDING REPLACEMENT OF</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">ACCIDENT AND SICKNESS OR LONG-TERM CARE INSURANCE</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">(Insurance Company's Name and Address)</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont-000003">SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE.</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000001"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000005"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">According to (your application) (information you have furnished), you intend to lapse or otherwise terminate existing accident and sickness or long-term care insurance and replace it with the long-term care insurance policy delivered herewith issued by (company name) Insurance Company. Your new policy provides thirty (30) days within which you may decide, without cost, whether you desire to keep the policy. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new policy.</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000005"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000005"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">You should review this new coverage carefully, comparing it with all accident and sickness or long-term care insurance coverage you now have, and terminate your present policy only if, after due consideration, you find that purchase of this long-term care coverage is a wise decision.</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000005"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000006"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">1)    Health conditions which you may presently have (preexisting conditions), may not be immediately or fully covered under the new policy. This could result in denial or delay in payment of benefits under the new policy, whereas a similar claim might have been payable under your present policy.</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000006"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000006"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">2)    State law provides that your replacement policy or certificate may not contain new preexisting or probationary periods. The insurer will waive any time periods applicable to preexisting conditions or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy.</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000006"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000006"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">3)    If you are replacing existing long-term care insurance coverage, you may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage.</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000006"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000006"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">4)    (To be included only if the application is attached to the policy.) If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, read the copy of the application attached to your new policy and be sure that all questions are answered fully and correctly. Omissions or misstatements in the application could cause an otherwise valid claim to be denied. Carefully check the application and write to (company name and address) within thirty (30) days if any information is not correct and complete, or if any past medical history has been left out of the application.</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000006"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000006"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000000"> </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000007"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">__________________________</span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000007"><span class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont">(Company Name)</span><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04cDefaultParagraphFont-000002">         </span></p><p dir="ltr" class="s631b9173-6d5d-4eef-be03-9a470a61e04cNormal-000008"><span xml:space="preserve" class="s631b9173-6d5d-4eef-be03-9a470a61e04c000009"> </span></p></div></body></html>