Form LTC-1 "Notice to Applicant Regarding Replacement of Individual Accident and Sickness or Long-Term Care Insurance" - Missouri

What Is Form LTC-1?

This is a legal form that was released by the Missouri Department of Commerce and Insurance - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 15, 2007;
  • The latest edition provided by the Missouri Department of Commerce and Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form LTC-1 by clicking the link below or browse more documents and templates provided by the Missouri Department of Commerce and Insurance.

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Download Form LTC-1 "Notice to Applicant Regarding Replacement of Individual Accident and Sickness or Long-Term Care Insurance" - Missouri

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NOTICE TO APPLICANT REGARDING REPLACEMENT OF INDIVIDUAL
ACCIDENT AND SICKNESS OR LONG-TERM CARE INSURANCE
[Insurance company’s name and address]
SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE.
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 an individual long-term care
insurance policy to be 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.
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.
STATEMENT TO APPLICANT BY PRODUCER [OR OTHER REPRESENTATIVE]:
(Use additional sheets, as necessary.)
I have reviewed your current medical or health insurance coverage. I believe the replacement of insurance
involved in this transaction materially improves your position. My conclusion has taken into account the
following considerations, which I call to your attention:
1. Health conditions that 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.
2. State law provides that your replacement policy or certificate may not contain new preexisting conditions
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.
3. If you are replacing existing long-term care insurance coverage, you may wish to secure the advice of
your present insurer or its producer 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.
4. If, after due consideration, 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
health history. Failure to include all 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, reread it carefully to be certain that all
information has been properly recorded.
____________________________________
(Signature of Producer or
Other Representative)
[Typed Name and Address of Producer]
The above “Notice to Applicant” was delivered to me on:
____________________________________
(Applicant’s Signature)
____________________________________
(Date)
Form LTC-1
(Rev 11/15/2007)
NOTICE TO APPLICANT REGARDING REPLACEMENT OF INDIVIDUAL
ACCIDENT AND SICKNESS OR LONG-TERM CARE INSURANCE
[Insurance company’s name and address]
SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE.
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 an individual long-term care
insurance policy to be 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.
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.
STATEMENT TO APPLICANT BY PRODUCER [OR OTHER REPRESENTATIVE]:
(Use additional sheets, as necessary.)
I have reviewed your current medical or health insurance coverage. I believe the replacement of insurance
involved in this transaction materially improves your position. My conclusion has taken into account the
following considerations, which I call to your attention:
1. Health conditions that 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.
2. State law provides that your replacement policy or certificate may not contain new preexisting conditions
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.
3. If you are replacing existing long-term care insurance coverage, you may wish to secure the advice of
your present insurer or its producer 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.
4. If, after due consideration, 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
health history. Failure to include all 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, reread it carefully to be certain that all
information has been properly recorded.
____________________________________
(Signature of Producer or
Other Representative)
[Typed Name and Address of Producer]
The above “Notice to Applicant” was delivered to me on:
____________________________________
(Applicant’s Signature)
____________________________________
(Date)
Form LTC-1
(Rev 11/15/2007)