, FL 33766-4659 (877) 492-5870 age · 01-WA age 1 f 7 hought e 0710 ON) TE: n ed. 1 . T n C G e ) C G e il P o d r l $ l m $ de i-y y EFT T B an C G ip e P) C G e d r l $ l m $ de

* Plan F also has an option called a high deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,070 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,070. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.

This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan “A” available. Some plans may not be available in your state. Plans E, H, I and J are no longer available for sale. Basic Benefits: Hospitalization: : Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses), or copayment for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B coinsurance or copayments. Blood: First three pints of blood each year. Hospice: Part A coinsurance.

A B C D F F* G

Basic, including

100% Part B coinsurance

Basic, including


Basic, including


Basic, including


Basic, including


Basic, including


Skilled Nursing Facility

coinsurance


coinsurance


coinsurance


coinsurance

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part B Deductible

Part B Deductible

Part B Excess (100%)

Part B Excess (100%)

Foreign Travel Emergency




K L M N

Hospitalization and preventive care paid at

100%; other basic benefits paid at 50%

Hospitalization and preventive care paid at

100%; other basic benefits paid at 75%

Basic, Including 100%

Part B coinsurance

Basic, including 100%Part B coinsurance,

except up to $20copayment for

office visit, and up to$50 copayment for ER

50% Skilled Nursing Facility

coinsurance

75% Skilled Nursing Facility

coinsurance


coinsurance


coinsurance

50% Part A Deductible



Part A Deductible



Out-of-Pocket limit $4660

paid at 100% after limit reached

Out-of-Pocket limit $2330;

paid at 100% after limit reached

MSOC10-01-WA 1 ©2012 Forethought 0112

Forethought Life Insurance Company Administrative Office P.O. Box 14659, Clearwater, FL 33766-4659 (877) 492-5870Outline of Medicare Supplement Coverage – Cover Page

Benefit Plans A, C, F, G and N Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010

PREMIUM INFORMATION We, Forethought Life Insurance Company, can only raise Your premium if We raise the premium for all policies like yours in this state. DISCLOSURES Use this Outline to compare benefits and premiums among policies. This outline shows benefits and premiums of policies sold for effective dates on or after June 1, 2010. Policies sold for effective dates prior to June 1, 2010 have different benefits and premiums. Plans, E, H, I and J are no longer available for sale.

READ YOUR POLICY VERY CAREFULLY This is only an Outline, describing your Policy’s most important features. The Policy is your insurance contract. You must read the Policy itself to understand all of the rights and duties of both you and Forethought Life Insurance Company.

RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to Forethought Life Insurance Company, P.O. Box 14659, Clearwater, FL 33766-4659. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your premiums. POLICY REPLACEMENT If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. NOTICE This policy may not fully cover all of your medical costs. Neither Forethought Life Insurance Company nor its agents are connected with Medicare. This Outline of Coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare and You for more details. COMPLETE ANSWERS ARE VERY IMPORTANT When you fill out the application for the new Policy, be sure to answer truthfully and completely all questions about your medical and health history. The Company may cancel your Policy and refuse to pay any claims if you leave out or falsify important medical information. Review the application carefully before you sign it. Be certain that all information has been properly recorded.

MSOC10-01-WA 2 0112

MSOC10-01-WA 3 0112

ForEthouGht LiFE iNSurANCE CoMPANy - Monthly rates *These rates apply to ZIP codes starting with: ALL

* To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, or 3, respectively

Issue Age

Male and Female

Plan A Plan C Plan F Plan G Plan N

All Ages 65 and Older $142.60 $193.25 $194.92 $160.52 $145.83

Standard Plans - Nonsmoker and Smoker

* A benefit period begins on the first day You receive service as an inpatient in a hospital and ends after You have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

**NotiCE: When Your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing You for the balance based on any difference between its billed charges and the amount Medicare would have paid.

SErViCES MEDiCArE PAyS PLAN PAyS you PAyHOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days61st thru 90th day91st day and after:

• While using 60 lifetime reserve days • Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days

All but $1,156All but $289 a day

All but $578 a day

$0 $0

$0$289 a day

$578 a day

100% of Medicare Eligible Expenses $0

$1,156 (Part A Deductible)$0

$0

$0** All Costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days 21st thru 100th day 101st day and after

All approved amounts All but $144.50 a day $0

$0 $0 $0

$0 Up to $144.50 a day All Costs

BLOODFirst 3 pintsAdditional amounts

$0100%

3 pints$0

$0$0

HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance $0

PLAN AMEDiCArE (PArt A) – hoSPitAL SErViCES – PEr BENEFit PErioD

MSOC10-01-WA 4 0112

PLAN AMEDiCArE (PArt B) – MEDiCAL SErViCES – PEr CALENDAr yEAr

MSOC10-01-WA 5 0112

* Once You have been billed $140 of Medicare-approved amounts for covered services (which are noted with an asterisk), Your Part B Deductible will have been met for the calendar year.

SErViCES MEDiCArE PAyS PLAN PAyS you PAyMEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $140 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0Generally 80%

$0Generally 20%

$140 (Part B Deductible)$0

Part B Excess Charges (Above Medicare-approved amounts)

$0

$0

All costs

BLOODFirst 3 pintsNext $140 of Medicare-approved amounts*Remainder of Medicare-approved amounts

$0$080%

All costs$020%

$0$140 (Part B Deductible)$0

CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

HOME HEALTH CARE MEDICARE-APPROVED SERVICES• Medically necessary skilled care services and medical supplies • Durable medical equipment First $140 of Medicare-approved amounts* Remainder of Medicare-approved amounts

100%

$080%

$0

$020%

$0


PArtS A & B

MSOC10-01-WA 6 0112

PLAN CMEDiCArE (PArt A) – hoSPitAL SErViCES – PEr BENEFit PErioD

SErViCES MEDiCArE PAyS PLAN PAyS you PAyHOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: • While using 60 lifetime reserve days • Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days


All but $578 a day

$0 $0

$1,156 (Part A Deductible)$289 a day

$578 a day

100% of Medicare Eligible Expenses $0

$0$0

$0

$0** All Costs


All approved amountsAll but $144.50 a day$0

$0Up to $144.50 a day$0

$0$0All Costs


$0100%

3 pints$0

$0$0



Medicare copayment / coinsurance $0

**NotiCE: When Your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the Policy’s “Core Benefits.” During this time the hospital is prohibited from billing You for the balance based on any difference between its billed charges and the amount Medicare would have paid.

MSOC10-01-WA 7 0112

PLAN CMEDiCArE (PArt B) – MEDiCAL SErViCES – PEr CALENDAr yEAr


SErViCES MEDiCArE PAyS PLAN PAyS you PAyMEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. First $140 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0Generally 80%

$140 (Part B Deducticble)Generally 20%

$0$0


$0

$0

All costs


$0$080%

All Costs$140 (Part B Deducticble)20%

$0$0$0


100%

$0

$0

HOME HEALTH CARE MEDICARE-APPROVED SERVICES• Medically necessary skilled care services and medical supplies• Durable medical equipment First $140 of Medicare-approved amounts* Remainder of Medicare-approved amounts

100%

$0 80%

$0

$140 (Part B Deducticble) 20%

$0

$0 $0

ForEiGN trAVEL – Not CoVErED By MEDiCArEMedically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of charges

$0$0

$080% to a lifetime maximum benefit of $50,000

$25020% and amounts over the $50,000 lifetime maximum

PArtS A & B

othEr BENEFitS – Not CoVErED By MEDiCArE

MSOC10-01-WA 8 0112

PLAN FMEDiCArE (PArt A) – hoSPitAL SErViCES – PEr BENEFit PErioD





All but $578 a day

$0$0


$578 a day

100% of Medicare Eligible Expenses$0

$0 $0

$0

$0**All Costs



$0Up to $144.50 a day$0

$0$0All Costs


$0100%

3 pints$0

$0$0



Medicare copayment / coinsurance

$0

MSOC10-01-WA 9 0112

PLAN FMEDiCArE (PArt B) – MEDiCAL SErViCES – PEr CALENDAr yEAr

* Once You have been billed $140 of Medicare-approved amounts for covered services (which are noted with an asterisk), Your Part B Deductible will have been met for the calendar year


$0Generally 80%

$140 (Part B Deducticble)Generally 20%

$0$0


$0

100%

$0


$0$080%

All Costs$140 (Part B Deducticble)20%

$0$0$0


100%

$0

$0

HOME HEALTH CARE MEDICARE-APPROVED SERVICES • Medically necessary skilled care services and medical supplies • Durable medical equipment First $140 of Medicare-approved amounts* Remainder of Medicare-approved amounts

100% $080%

$0 $140 (Part B Deducticble)20%

$0 $0$0

FOREIGN TRAVEL – NOT COVERED BY MEDICAREMedically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of charges

$0$0



PArtS A & B


MSOC10-01-WA 10 0112

PLAN GMEDiCArE (PArt A) – hoSPitAL SErViCES – PEr BENEFit PErioD




All but $1,156 All but $289 a day

All but $578 a day

$0$0


$578 a day


$0 $0

$0

$0**All Costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital. First 20 days 21st thru 100th day 101st day and after


$0Up to $144.50 a day$0

$0$0All Costs

BLooDFirst 3 pintsAdditional amounts

$0100%

3 pints$0

$0$0




$0

MSOC10-01-WA 11 0112

PLAN GMEDiCArE (PArt B) – MEDiCAL SErViCES – PEr CALENDAr yEAr



$0Generally 80%

$0Generally 20%



$0

100%

$0


$0$080%

All costs$020%



100%

$0

$0


100%

$080%

$0

$020%

$0


FOREIGN TRAVEL - NOT COVERED BY MEDICAREMedically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of charges

$0$0



PArtS A & B


MSOC10-01-WA 12 0112

PLAN NMEDiCArE (PArt A) – hoSPitAL SErViCES – PEr BENEFit PErioD


**NotiCE: When Your Medicare Part A hospital benefits are exhausted, the insurer stands in place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing You for the balance based on any difference between its billed charges and the amount Medicare would have paid



All but $578 a day

$0$0


$578 a day


$0 $0

$0

$0**All Costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital. First 20 days 21st thru 100th day 101st day and after


$0Up to $144.50 a day$0

$0$0All Costs

BLooDFirst 3 pintsAdditional amounts

$0100%

3 pints$0

$0$0




$0

MSOC10-01-WA 13 0112

PLAN NMEDiCArE (PArt B) – MEDiCAL SErViCES – PEr CALENDAr yEAr


SErViCES MEDiCArE PAyS PLAN PAyS you PAyMEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUT-PATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. First $140 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0Generally 80%

$0Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense

$140 (Part B Deductible)Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.


$0

$0

All Costs


$0$080%

All Costs$020%



100%

$0

$0

MSOC10-01-WA 14 0112

PLAN N


100% $080%

$0 $020%

$0 $140 (Part B Deducticble)$0

FOREIGN TRAVEL – NOT COVERED BY MEDICAREMedically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of charges

$0$0




PArtS A & B

This packet contains the following form

s needed to complete an Application For M

edicare Supplement Insurance. Please tear

out the application and all pages marked “rEturN to

CoM

PANy” and leave the remaining pages w

ith the applicant(s). Please review

the following inform

ation carefully and complete all needed form

s:

❑

Application For Medicare Supplem

ent Insurance (Form M

SAP1000-01 or MSAPC1000-01)

■

Medicare Supplem

ent – If the applicant(s) is applying during Open Enrollm

ent or a Guaranteed Issue period,

Section 4 is not required to be com

pleted.

■ Section 5 should be com

pleted only if the applicant(s) would like his/her paym

ents to be deducted automatically from

his/her checking/savings account. This option applies only if prem

iums are paid m

onthly.

❑

Agent Certification (Form AGTCRT10-01) – This form

must be signed by the agent and by the applicant(s).

❑

Calculate your premium

– This form is used in coordination w

ith the Outline of Coverage, to calculate the correct

(M

edicare Supplement prem

ium). This form

must be returned w

ith the application. ❑

Fax Transmittal – Follow

the instructions on this form only if the applicant(s) elects to pay prem

iums using ACH and you are

subm

itting the underwriting docum

ents via fax instead of regular mail.

❑

Authorization to Release Confidential Medical Inform

ation (Form M

S-HIPAA10-01) – Must be com

pleted only if applying

outside Open Enrollm

ent or a Guaranteed Issue period for Medicare Supplem

ent. If both spouses are applying for

coverage on the same application, then both m

ust sign the form.

❑

Notice to Applicant regarding replacement of M

edicare Supplement insurance or M

edicare Advantage (Form M

S-RN10-01-WA)

– This form

must be com

pleted if replacement of an existing M

edicare Supplement policy is involved. O

ne signed copy

must be returned to the Adm

inistrative Offi

ce and the other signed copy must be left w

ith the applicant(s). ❑

Investigative Consumer Report Notice to Applicant, M

edical Information Bureau Disclosure Notice and M

edicare

Supplem

ent/Select Initial Premium

Receipt (MSREC-01) – The Initial/Prem

ium Receipt m

ust be left with the applicant(s)

and the full m

odal premium

is required with all applications.

Please note, you are also required to provide the applicant(s) with the follow

ing items:

❑

Guide to Health Insurance for People with M

edicare ❑

Outline of Coverage (Form

MSO

C10-01-WA)

Premium

s and policy fee Utilize the O

utline of Coverage to determine M

edicare Supplement prem

iums.

■

Determine ZIP code w

here the client resides and find the correct rate page for that ZIP code

■ Determ

ine Plan

■ Determ

ine if tobacco or non-tobacco use

■ Find age/gender – Verify that the age and date of birth are the exact age as of the application date, this w

ill be your

base m

onthly premium

■ Use the Calculate your prem

ium form

to adjust the monthly prem

ium for different m

odes and to add the policy fee

■ A voided check needs to be subm

itted with the Application for EFT

Agent checklist for completing the

Medicare Supplem

ent Application

Mailing A

ddress Forethought Life Insurance Com

pany A

dministrative offi

ce P.O

. Box 14659 Clearw

ater, FL 33766-4659

overnight/Express A

ddress Forethought Life Insurance Com

pany A

dministrative offi

ce 2650 M

cCormick D

rive Clearw

ater, FL 33759

FAX

Num

ber for New

Business - EFt Applications 1-855-808-0944

© 2012 Forethought 0512

MS4000-03-W

A

THIS PA

GE LEFT IN

TENTIO

NA

LLY BLAN

k

A

PPLICATIO

N FO

R MED

ICARE SU

PPLEMEN

T

INSU

RAN

CE Forethought Life Insurance C

ompany

Administrative O

ffice: O

ne Forethought Center

P. O. Box 14659

Batesville, Indiana 47006 C

learwater, FL 33766-4659

MS

AP

1000-01-WA

P

age 1 of 7 ©2010 Forethought

0710

MED

ICARE SU

PPLEMEN

T PLAN

INFO

RMA

TION

(To be completed by Producer)

NO

TE: For ALL sections, complete the Applicant B inform

ation ON

LY if Applicant B is to be insured.

SECTION

1 – PLEASE A

NSW

ER ALL Q

UESTIO

NS CO

MPLETELY.

APPLICA

NT

Medicare Supplem

ent Standard Plan

A C

F

G

N

Medicare Supplem

ent Select Plan (not available in all states)

C

F G

N

Requested Effective Date

Mail Policy To

Insured Producer

Initial Premium

Collected $

Renewal Prem

ium $

Renewal Prem

ium M

ode Annual

Semi-Annual

Quarterly

Monthly EFT

APPLICA

NT B

Medicare Supplem

ent Standard Plan

A C

F

G

N

Medicare Supplem

ent Select Plan (not available in all states)

C

F G

N

Requested Effective Date

Mail Policy To

Insured Producer

Initial Premium

Collected $

Renewal Prem

ium $

Renewal Prem

ium M

ode Annual

Semi-Annual

Quarterly

Monthly EFT

APPLICA

NT

Last Nam

e First

M.I.

Mailing Address

Residential Address (if different from M

ailing Address)

City

State Zip

Age D

ate of Birth State of Birth

M

ale Fem

ale

Hom

e Phone # ( ) - E-M

ail Address

Social Security Num

ber H

eight Weight

Medicare H

ealth Insurance Card N

umber (if know

n)

Have you used tobacco in any form

in the past 12 months?

Yes N

o

APPLICA

NT B

Last Nam

e First

M.I.

Mailing Address

Residential Address (if different from M

ailing Address)

City

State Zip

Age D

ate of Birth State of Birth

M

ale Fem

ale

Hom

e Phone # ( ) - E-M

ail Address

Social Security Num

ber H

eight Weight

Medicare H

ealth Insurance Card N

umber (if know

n)

Have you used tobacco in any form

in the past 12 months?

Yes N

o

THIS PA

GE LEFT IN

TENTIO

NA

LLY BLAN

k

MS

AP

1000-01-WA

Page 2 of 7 0710

SECTION

2 –PLEASE A

NSW

ER ALL O

F THE FO

LLOW

ING

QU

ESTION

S.

SECTION

3 – FOR YO

UR PRO

TECTION

, THE N

ATIO

NA

L ASSO

CIATIO

N O

F INSU

RAN

CE COM

MISSIO

NERS REQ

UESTS

THA

T WE A

SK TH

E FOLLO

WIN

G Q

UESTIO

NS A

BOU

T INSU

RAN

CE POLICIES O

R CERTIFICATES YO

U M

AY H

AV

E.

1. H

ave you received a copy of the Guide to H

ealth Insurance for People with

Medicare and the O

utline of Coverage?

APPLICA

NT

Yes

No

APPLICA

NT B

Yes

No

To the Best of Your Know

ledge:

1.

Are you covered under Medicare Part A: If “YES,” w

hat is your Part A effective date? _____________/______________ A

pplicant Applicant B

If “NO

,” what is your eligibility date? _____________/______________

Applicant A

pplicant B

Yes

No

Yes

No

2. Are you covered under M

edicare Part B? If “YES,” what is your Part B effective

date? _____________/______________ A


If “NO

,” indicate date you plan to enroll. _____________/______________ A


3. D

id you turn age 65 in the last six months?

4. D

id you enroll in Medicare Part B in the last six m

onths? 5.

If “YES,” indicate your effective date. _____________/______________ A


Yes

No

Yes

No

Yes N

o Yes

No

Yes

No

Yes

No

Yes N

o Yes

No

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 Supplem

ent Insurance policy or certificate, or that you had certain rights to buy such a policy or certificate, you m

ay be guaranteed accepted in one or more of our M

edicare Supplement plans. Please

include a copy of the notice from your prior insurer w

ith your application. PLEASE A

NSW

ER ALL Q

UESTIO

NS. Please m

ark “YES” or “N

O” w

ith an “X” to the questions below.


ledge: A

PPLICAN

T

APPLICA

NT B

1.

Are you applying during a guaranteed issue period? (N

OTE: If the answ

er above is “YES,” please attach proof of eligibility.) 2.

Do you have another M

edicare Supplement Insurance policy or certificate in

force (Select or Standard)? (a) If “YES,” please com

plete the following:

Yes N

o

Yes N

o

Yes N

o

Yes N

o

APPLICA

NT

Nam

e of Com

pany Policy/C

ertificate Num

ber Plan

Issue Date

APPLICA

NT B

N

ame of C

ompany

Policy/Certificate N

umber

Plan Issue D

ate (b) If “YES,” do you intend to replace your current M

edicare supplement

policy/certificate with this policy?

(c) If “YES,” indicate termination date. _____________/______________

Applicant A

pplicant B (d) If “YES,” have you received a copy of the replacem

ent notice? If you have had any other M

edicare plan coverage as referenced below, not to

include Medicare supplem

ent, please complete questions (a-g) below

. If not, skip to question #4.

3. If you had coverage from

any Medicare plan other than original M

edicare within

the past 63 days (for example, a M

edicare Advantage plan, or a Medicare H

MO

or PPO

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

this plan, leave “END

” blank. START____________ EN

D __________ / START____________ EN

D __________

Applicant A

pplicant B (a)

If you are still covered under the Medicare plan, do you intend to replace

your current coverage with this new

Medicare supplem

ent policy?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

MS

AP

1000-01-WA

Page 3 of 7 0710

APPLICA

NT

Nam

e of Com

pany Kind of Policy/C

ertificate

APPLICA

NT B

Nam

e of Com

pany Kind of Policy/C

ertificate

(b) What are your dates of coverage under the other policy/certificate? If you are still covered under this plan,

leave “END

” blank. START____________ END

__________ / START____________ END

__________ A


(c) Reason for termination/disenrollm

ent? ________________________________________________/___________________________________________

Applicant A

pplicant B

(d) Planned date of termination/disenrollm

ent? ________________________________________________/___________________________________________

Applicant A

pplicant B

5.

Are you covered for medical assistance through the state M

edicaid program?

(NO

TE TO APPLIC

ANT: If you are participating in a “Spend-D

own Program

” and have not m

et your “Share of Cost,” please answ

er “NO

” to this question.) If “YES,” (a) W

ill Medicaid pay your prem

iums for this M

edicare supplement policy?

(b) Do you receive any benefits from

Medicaid O

THER TH

AN paym

ent toward

your Medicare Part B prem

ium?

6. Producers shall list any other health insurance policies/certificates they have sold to the applicant. (a) List policies/certificates sold w

hich are still in force.

Yes N

o

Yes N

o

Yes N

o

Yes N

o

Yes N

o

Yes N

o

APPLICA

NT (attach a separate sheet if needed)

Nam

e of Com

pany Policy/C

ertificate #

Description of Benefits

Effective Date of C

overage

List policies/certificates sold in the past five (5) years which are no longer in force:

Nam

e of Com

pany Policy/C

ertificate #


Effective Date of C

overage

APPLICA

NT B (attach a separate sheet if needed)

Nam

e of Com

pany Policy/C

ertificate #


Effective Date of C

overage

List policies/certificates sold in the past five (5) years which are no longer in force:

Nam

e of Com

pany Policy/C

ertificate #


Effective Date of C

overage

(b) If “YES,” have you received a copy of the replacement notice?

(c) Reason for termination/disenrollm

ent? _____________________________________/____________________________

Applicant A

pplicant B

(d) Planned date of termination/disenrollm

ent? _____________________________________/____________________________ A


(e) W

as this your first time in this type of M

edicare plan? (f)

Did you drop a M

edicare supplement or M

edicare Select policy/certificate to enroll in this M

edicare plan? 4.

Have you had coverage under any other health insurance w

ithin the past 63 days? (For exam

ple, an employer, union, or individual non-M

edicare supplement

plan.) (a) If “YES,” w

ith what com

pany and what kind of policy/certificate?(list below

)

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

MS

AP

1000-01-WA

Page 4 of 7 0710

If applying during Open Enrollm

ent or a Guaranteed Issue period, SK

IP SECTION

4 and GO

TO SECTIO

N 5.

SECTION

4 PLEASE AN

SWER ALL O

F THE FO

LLOW

ING

QU

ESTION

S. Make sure all questions are answ

ered by each applicant. If either you or Applicant B answ

er “YES” to any of the following questions 1-14, that person is not eligible for coverage.


ledge: A

PPLICAN

T

Yes N

o

Yes N

o

Yes N

o

Yes N

o

Yes N

o

Yes N

o

Yes N

o

Yes N

o

Yes N

o

Yes N

o

Yes N

o

Yes N

o

Yes N

o

Yes N

o

APPLICA

NT B

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

1. Are you currently hospitalized or confined to a nursing facility; or are you bedridden or confined to a w

heelchair? 2.

Have you been diagnosed w

ith emphysem

a, Chronic O

bstructive Pulm

onary Disease (C

OPD

) or other chronic pulmonary disorders?

3. H

ave you been diagnosed with Parkinson’s D

isease, Systemic Lupus,

Myasthenia G

ravis, Multiple or Lateral Sclerosis, O

steoporosis with

fractures, Cirrhosis or kidney disease requiring dialysis?

4. H

ave you been diagnosed with Alzheim

er’s Disease, Senile D

ementia, or

any other cognitive disorder? 5.

Have you been diagnosed w

ith or treated for Acquired Imm

une D

eficiency Syndrome (AID

S), AIDS Related C

omplex (ARC

), or Hum

an Im

munodeficiency V

irus (HIV

)? 6.

If you have diabetes, do you have any of the following conditions:

diabetic retinopathy, peripheral vascular disease, neuropathy, any heart condition (including high blood pressure) or kidney disease? If you do not have diabetes, this question should be answ

ered “NO

”. 7.

Do you have diabetes that has ever required m

ore than 50 units of insulin daily?

8. W

ithin the past two years have you been treated for or been advised by

a physician to have treatment for internal cancer, alcoholism

or drug abuse, m

ental or nervous disorder requiring psychiatric care or have you had any am

putation caused by disease? 9.

Within the past tw

o years have you been treated for or been advised by a physician to have treatm

ent for heart attack, heart, coronary or carotid artery disease (not including high blood pressure), peripheral vascular disease, congestive heart failure or enlarged heart, stroke, transient ischem

ic attacks (TIA) or heart rhythm disorders?

10. Within the past tw

o years have you been treated for degenerative bone disease, crippling/disabling or rheum

atoid arthritis or have you been advised to have a joint replacem

ent? 11. H

ave you been advised by a physician that surgery may be required

within the next 12 m

onths for cataracts? 12. H

ave you been advised by a physician to have surgery, medical tests,

treatment or therapy that has not been perform

ed? 13. H

ave you been hospital confined three or more tim

es in the last two

years? 14. H

ave you had an organ transplant or been advised by a physician to have an organ transplant?

15. Are you taking or have you taken any prescription or over-the-counter m

edications within the past 12 m

onths? If “YES,” please list the drug and the condition in the follow

ing table.

Yes

No

Yes

No

APPLICA

NT (attach a separate sheet if needed)

Medication N

ame (pharm

acy label)

Date O

riginally Prescribed

Frequency and Dosage

D

iagnosis/Condition

APPLICA

NT B (attach a separate sheet if needed)

Medication N

ame (pharm

acy label)

Date O

riginally Prescribed

Frequency and Dosage

D

iagnosis/Condition

MS

AP

1000-01-WA

Page 5 of 7 0710

SECTION

5 - BILLING

INFO

RMA

TION

A

. ELECTRO

NIC FU

ND

S TRAN

SFER (EFT)

Checking

Savings

Account # ABA Routing/Transit N

umber

Standard Date (approxim

ately 30 days from the issue date of coverage)

Custom

Date__________________ (Select 1-28)

When processing is not com

plete prior to the custom date selected, tw

o (2) premium

payments m

ay be withdraw

n the follow

ing month to keep your policy current. To prevent this from

happening, you may prefer to include an additional

premium

payment.

Nam

e and Telephone Num

ber of Financial Institution

Social Security Num

ber of Account Holder

B. IN

ITIAL CRED

IT CARD

PAYM

ENT – (Initial Prem

ium can be m

ade on credit card; this is not available for Renew

al Premium

s)

Account #___________________________________ Exp. Date________________

Please print clearly

Cardholder N

ame

C. A

UTO

MA

TIC PAYM

ENT A

UTH

ORIZA

TION

– (Must be com

pleted for EFT)

I authorize Forethought Life Insurance Com

pany (“Forethought”) to charge/deduct my insurance prem

ium from

my

account. This authorization is to remain in effect until I revoke m

y automatic m

onthly premium

payment by notifying

Forethought.

Payor’s Signature (As it appears on the bank account)

D

ate

N

OT AVA

ILABLE

MS

AP

1000-01-WA

Page 6 of 7 0710

SECTION

6 – SIGN

ATU

RES – PLEASE REA

D A

ND

SIGN

BELOW

IM

PORTA

NT STA

TEMEN

TS TO BE REA

D BY A

PPLICAN

T IF PU

RCHA

SING

MED

ICARE SU

PPLEMEN

T INSU

RAN

CE COV

ERAG

E • You do not need m

ore than one Medicare supplem

ent policy. • If you purchase this policy, you m

ay want to evaluate your existing health coverage and decide if you need m

ultiple coverage.

• You may be eligible for benefits under M

edicaid and may not need a M

edicare supplement policy.

• If, after purchasing the policy, you become eligible for M

edicaid, the benefits and premium

s under your Medicare

supplement policy can be suspended, if requested, during your entitlem

ent to benefits under Medicaid for 24 m

onths. You m

ust request this suspension within 90 days of becom

ing eligible for Medicaid. If you are no longer entitled to M

edicaid, your suspended M

edicare supplement policy (or, if that is no longer available, a substantially equivalent policy) w

ill be reinstituted if requested w

ithin 90 days of losing Medicaid eligibility. If the M

edicare supplement policy provided coverage

for outpatient prescription drugs and you enrolled in Medicare Part D

while your policy w

as suspended, the reinstituted policy w

ill not have outpatient prescription drug coverage, but will otherw

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

• If you are eligible for, and have enrolled in a Medicare supplem

ent policy by reason of disability and you later become

covered by an employer or union-based group health plan, the benefits and prem

iums under your M

edicare supplement

policy can be suspended, if requested, while you are covered under the em

ployer or union-based group health plan. If you suspend your M

edicare supplement policy under these circum

stances, and later lose your employer or union-based group

health plan, your suspended Medicare supplem

ent policy (or, if that is no longer available, a substantially equivalent policy) w

ill be reinstituted if requested within 90 days of losing your em

ployer or union-based group health plan. If the M

edicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in M

edicare Part D

while your policy w

as suspended, the reinstituted policy will not have outpatient prescription drug coverage, but w

ill otherw

ise be substantially equivalent to your coverage before the date of the suspension. • C

ounseling services may be available in your state to provide advice concerning your purchase of M

edicare supplement

insurance and concerning medical assistance through the state M

edicaid program, including benefits as a Q

ualified M

edicare Beneficiary (QM

B) and a Specified Low-Incom

e Medicare Beneficiary (SLM

B). I understand that Forethought m

ay obtain an investigative consumer report on m

e and a telephone interview m

ay be necessary to verify or supplem

ent information given on this application. I understand that it is m

y right to request to be interview

ed and that I may request a copy of the report if no personal interview

is conducted. A photocopy of this form

will be as valid as the original. This Authorization and Acknow

ledgment w

ill be valid for 24 months after it is signed. I

understand that no producer has the right to waive any of Forethought’s rights or requirem

ents, or to make or alter any

contract or policy. I agree that my statem

ents and answers to the questions in this application are com

plete and true to the best of m

y knowledge and belief and are the basis for issuing a policy.

By this application I am applying to Forethought for a M

edicare supplement insurance policy. I understand that, (a) upon

acceptance of the completed application, each applicant w

ill receive a separate policy; (b) my policy benefits can start no

earlier than my M

edicare effective date(s), my first m

onth’s premium

has been received and/or processed and my

application has been approved by Forethought.

It is a crime to know

ingly provide false, incomplete, or m

isleading information to an insurance com

pany for the purpose of defrauding the com

pany. Penalties include imprisonm

ent, fines, and denial of insurance benefits. Signed this _____ day of _______, _______ in _________________, _________. _____________________________________ D

ay Month Year City State A

PPLICAN

T SIGN

ATU

RE Signed this _____ day of _______, _______ in _________________, _________. _____________________________________ D

ay Month Year City State A

PPLICAN

T B SIGN

ATU

RE (if applicable)

PROD

UCER O

NLY SECTIO

N - PREM

IUM

MU

ST ACCO

MPA

NY A

PPLICATIO

N

I certify that during an interview w

ith the applicant(s) I have truly and accurately recorded in the application the inform

ation supplied by the applicant(s). __________________________________________________________________________________________________________ Producer’s N

ame (PRIN

T) Producer Num

ber Telephone Num

ber Producer’s Signature

MS

AP

1000-01-WA

Page 7 of 7 0710

SECTION

FOR A

DD

ITION

AL CO

MM

ENTS

APPLICANT B - (please attach a separate sheet if needed)

APPLICANT - (please attach a separate sheet if needed)

THIS PA

GE LEFT IN

TENTIO

NA

LLY BLAN

k

I the undersigned insurance agent certify;

thA

t, I have taken an application for:

Primary insured:

A

pplicant B: M

edicare Supplement

Medicare Supplem

ent M

edicare Supplement

Medicare Supplem

ent Standard

Select Standard

Select

❑ Plan A

❑

Plan C ❑

Plan A

❑ Plan C

❑ Plan C

❑ Plan F

❑ Plan C

❑ Plan F

❑ Plan F

❑ Plan G

❑

Plan F ❑

Plan G

❑ Plan G

❑

Plan N

❑ Plan G

❑

Plan N

❑

Plan N

❑

Plan N

Offered by Fo

rEtho

uG

ht LiFE iN

SurA

NCE Co

MPA

Ny,

to _______________________________________________________________________ (A

pplicant(s)),

thA

t, I have explained the provisions of the policy being applied for, including specifically, all the different benefits, exceptions and lim

itations of the plan.

thA

t, I am a licensed agent of this insurance com

pany and have given a company receipt for an initial

premium

in the amount of

$____________________ which has been paid to m

e by

❑ Check

❑ M

oney order ❑

ACH

(Check appropriate method of paym

ent)

thA

t, I have clearly explained any benefits of this plan are a supplement to any benefits that the

applicant may be entitled to receive from

the Medicare Program

of the Federal Governm

ent.

thA

t, I have not made any representation to the applicant that there is any endorsem

ent whatsoever

by the Social Security Adm

inistration or the Centers for Medicare and M

edicaid Services in connection w

ith this insurance policy being applied for.

I, the undersigned applicant, understand that I will

receive a copy of this form w

hen my policy is issued

and delivered to me.

Date

Signature of agent

Signature of applicant

Address of agent / A

gency

Signature of spouse, if applying

Phone number

Nam

e of agency

rEturN

to Co

MPA

Ny

Agent CertificationFO

RETHO

UG

HT LIFE IN

SURA

NCE CO

MPA

NY

Adm

inistrative Offi

ce P.O. Box 14659, Clearw

ater, FL 33766-4659 1-877-492-5870

AGTCRT10-01


NO

T AVAILA

BLE

THIS PA

GE LEFT IN

TENTIO

NA

LLY BLAN

k

THIS PA

GE LEFT IN

TENTIO

NA

LLY BLAN

k

Authorization to release Confidential M

edical information

records and information obtained w

ill be disclosed to Forethought Life insurance Company so

that it can: 1) evaluate my application for insurance; 2) obtain reinsurance; 3) determ

ine or fulfill responsibility for coverage and provision of benefits; 4) and adm

inister coverage.

I, the undersigned, hereby authorize any and all medical practitioners, physicians, pharm

acists, hospitals, clinics, nurses, records custodians, the M

IB, Inc., the Veterans Adm

inistration, or other insurance com

panies, who has know

ledge of my m

edical records and history to release any and all records and inform

ation to be exchanged between Forethought Life Insurance Com

pany and its agents, reinsurer(s), contractors, em

ployees, representatives, and affiliates, and it assigns as necessary to fulfill the purpose

of this disclosure.

I hereby authorize you to release any and all records and information w

ithin your possession, custody or control regarding m

e pursuant to this Authorization. Any and all records and inform

ation regarding diagnosis, testing, treatm

ent and prognosis of my physical or m

ental condition are to be released. Such records and inform

ation to be released may include, but not be lim

ited to, testing, treatment, or advice

for the following: alcohol abuse, drug abuse, psychiatric and psychological disorders, heart disease,

mental disease, pharm

acy prescriptions, HIV or A

IDS, sexually transm

itted diseases, hepatitis, and Sickle Cell A

nemia.

i understand that when inform

ation is used or disclosed pursuant to this authorization, it may be

subject to re-disclosure by the insurance company and m

ay no longer be protected by the same

rule that applied in the first instance. i understand Forethought Life insurance Company m

ay report inform

ation to MiB, inc. or to other insurance com

panies to which i have or m

ay apply. i understand this A

uthorization will rem

ain in effect a m

aximum

of two (2) years from

my date

of signature below. i understand i m

ay revoke this Authorization in w

riting, at any time, by

sending a written request for revocation to Forethought Life insurance Com

pany at the address listed above, unless action has already been taken in reliance upon it, or during a contestability period under applicable law

. i understand a photocopy of this Authorization w

ill be treated in the sam

e manner as the original.

I understand that if I refuse to sign this Authorization to release complete m

edical records, Forethought Life Insurance Com

pany may not be able to process m

y application. I understand that I or my authorized

representative may request a copy of this Authorization.

MS-H

IPAA10-01

rEturN

to Co

MPA

Ny

©

2010 Forethought

0610

Forethought Life insurance Company

Po Box 14659

Clearwater, FL 33766-4659

Nam

e of Proposed Insured (please print) N

ame of Proposed Insured B (please print)

Signature of Proposed Insured Signature of Proposed Insured B

Date

Date

THIS PA

GE LEFT IN

TENTIO

NA

LLY BLAN

k

THIS PA

GE LEFT IN

TENTIO

NA

LLY BLAN

k

Decline

StandardD

eclineH

eightW

eightW

eightW

eight5’ 9’’

< 102102 – 277

278 + 5’ 10’’

< 105105 – 285

286 + 5’ 11’’

< 108108 – 293

294 + 6’ 0’’

< 111111 – 302

303 + 6’ 1’’

< 114114 – 310

311 + 6’ 2’’

< 117117 – 319

320 + 6’ 3’’

< 121121 – 328

329 + 6’ 4’’

< 124124 – 336

337 + 6’ 5’’

< 127127 – 345

346 + 6’ 6’’

< 130130 – 354

355 + 6’ 7’’

< 134134 – 363

364 + 6’ 8’’

< 137137 – 373

374 + 6’ 9’’

< 140140 – 382

383 + 6’ 10’’

< 144144 – 392

393 + 6’ 11’’

< 147147 – 401

402 + 7’ 0’’

< 151151 – 411

412 + 7’ 1’’

< 155155 – 421

422 + 7’ 2’’

< 158158 – 431

432 + 7’ 3’’

< 162162 – 441

442 + 7’ 4’’

< 166166 – 451

452 +

Medicare Supplem

ent Plan _________Before you begin: If you’re not in your open enrollm

ent or guarantee issue period, please see chart below

to determine your eligibility for coverage.

StepsExam

pleRate displayed is used for calculation purposes only.

Applicant’s

premium

Applicant B’s

premium

Premium

Write in your M

edicare Supplement Plan’s

premium

from the O

utline of Coverage table.$128.52

Payment o

ptionsTo determ

ine other payment schedules,

multiply your m

onthly premium

by:3 to pay four tim

es a year (quarterly)6 to pay tw

ice a year (semi-annually)

12 to pay once a year (annually)

$128.52 Monthly paym

ent

$385.56 Quarterly paym

ent$771.12 Sem

i-annual payment

$1,542.24 Annual paym

ent

Enrollment/Policy fee

There is a one-time application fee of $25.00

this will be collected w

ith your initial pay-m

ent and will N

ot aff

ect your renewal

premium

.

$128.52 + $25.00 = $153.52

Example show

s initial payment

(monthly schedule).

CoM

PLEtE AN

D rEtu

rN w

ith A

PPLiCAtio

N

Calculate your premium

Forethought® M

edicare Supplement


MS4001-01

To determine w

hether you may purchase coverage, locate your height, then w

eight in the chart below

. If your weight is not in the Standard colum

n, we’re sorry, you’re not eligible for coverage

at this time. If your w

eight is located in the Standard column, you m

ay proceed in completing the

application.

Height and w

eight chart

Decline

StandardD

eclineH

eightW

eightW

eightW

eight4’ 2’’

< 5454 – 145

146 + 4’ 3’’

< 5656 – 151

152 + 4’ 4’’

< 5858 – 157

158 + 4’ 5’’

< 6060 – 163

164 + 4’ 6’’

< 6363 – 170

171 + 4’ 7’’

< 6565 – 176

177 + 4’ 8’’

< 6767 – 182

183 + 4’ 9’’

< 7070 – 189

190 + 4’ 10’’

< 7272 – 196

197 + 4’ 11’’

< 7575 – 202

203 + 5’ 0’’

< 7777 – 209

210 + 5’ 1’’

< 8080 – 216

217 + 5’ 2’’

< 8383 – 224

225 + 5’ 3’’

< 8585 – 231

232 + 5’ 4’’

< 8888 – 238

239 + 5’ 5’’

< 9191 – 246

247 + 5’ 6’’

< 9393 – 254

255 + 5’ 7”

< 9696 – 261

262 + 5’ 8’’

< 9999 – 269

270 +

FORETH

OU

GH

T® MED

ICA

RE SUPPLEM

ENT

THIS PA

GE LEFT IN

TENTIO

NA

LLY BLAN

k

THIS PA

GE LEFT IN

TENTIO

NA

LLY BLAN

k

THIS PA

GE LEFT IN

TENTIO

NA

LLY BLAN

kM

SRN10-01-W

A LEAV

E with

APPLiCA

Nt

©

2010 Forethought

0610

NO

TICE TO

APPLIC

AN

T REG

AR

DIN

G R

EPLAC

EMEN

T OF M

EDIC

AR

E SUPPLEM

ENT IN

SUR

AN

CE

OR

MED

ICA

RE A

DVA

NTA

GE

Forethought Life Insurance Com

panyA

dministrative O

ffice P.O

. Box 14659 · C


SAVE THIS N

OTIC

E! IT MAY B

E IMPO

RTA

NT TO

YOU

IN TH

E FUTU

RE

According to your application, you intend to term

inate existing Medicare S

upplement insurance or M

edicare Advantage

and replace it with a policy to be issued by Forethought Life Insurance C

ompany. Your new

policy will provide thirty

(30) days within w

hich you may decide w

ithout cost whether you desire to keep the policy. For your ow

n information

and protection, you should be aware of and seriously consider certain factors w

hich may affect the insurance available

to you under the new policy.

You should review this new

coverage carefully. Com

pare it with all accident and sickness coverage you now

have. If, after due consideration, you find that the purchase of this M

edicare Supplem

ent coverage is a wise decision, you

should terminate your present M

edicare Supplem

ent or Medicare A

dvantage coverage. You should evaluate the need for other accident and sickness coverage you have that m

ay duplicate this policy.

STATE

ME

NT TO

AP

PLIC

AN

T BY IS

SU

ER

, PR

OD

UC

ER

I HAV

E R

EV

IEW

ED

YO

UR

CU

RR

EN

T ME

DIC

AL O

R H

EA

LTH IN

SU

RA

NC

E C

OV

ER

AG

E. To the best of m

y know

ledge, this Medicare supplem

ent policy will not duplicate your existing M

edicare Supplem

ent or, if applicable M

edicare Advantage coverage because you intend to term

inate your existing Medicare S

upplement coverage or leave

your Medicare A

dvantage plan. The replacement policy is being purchased for the follow

ing reasons:

1. State law

s provide that your replacement policy or certificate m

ay not contain new pre-existing conditions, w

aiting periods, elim

ination periods or probationary periods. The insurer will w

aive any time periods applicable to pre-existing

conditions, waiting periods, elim

ination periods or probationary periods in the new policy (or coverage) for sim

ilar benefits to the extent such tim

e was spent (depleted) under the original policy.

2. If you still wish to term

inate your present policy and replace it with new

coverage, be certain to truthfully and com

pletely answer all questions on the application concerning your m

edical and health history. Failure to include all m

aterial medical inform

ation on an application may provide a basis for any com

pany to deny any future claims and to

refund your premium

as though your policy had never been in force. After the application has been com

pleted and before you sign it, review

it carefully to be certain that all information has been properly recorded.

❑ A

dditional benefits. ❑ M

y plan has outpatient drug coverage and I am

enrolling in P

art D.

❑ N

o change in benefits, but lower prem

iums. ❑

Disenrollm

ent from a M

edicare Advantage P

lan.

P

lease explain reason for disenrollment.

______________________________________❑

Fewer benefits and low

er premium

s. ❑

Other, (please specify) ____________________.

Do not cancel your present policy until you have received your new

policy and are sure that you w

ant to keep it.

______________________________________S

ignature of Producer, B

roker or other Representative

______________________________________P

RIN

TED

Nam

e and Address of Issuer, P

roducer, or Broker

______________________________________A

pplicant’s Signature

______________________________________S

ignature of Applicant B

, if applying

______________________________________D

ate

Forethought Life insurance Company

Po Box 14659

Clearwater, FL 33766-4659

iNV

EStiGAtiV

E CoN

SuM

Er rEPort N

otiCE to

APPLiCA

Nt

Federal law requires that notice of investigation be given to persons applying for insurance. In m

aking this application for insurance to Forethought Life Insurance Com

pany (the Company), it is understood

that an investigative consumer report m

ay be prepared whereby inform

ation is obtained through personal interview

s with your neighbors, friends, or others w

ith whom

you are acquainted. This inquiry includes inform

ation as to your character, general reputation, personal characteristics, and mode of

living (the term “m

ode of living” does not relate directly or indirectly to the sexual orientation of any proposed insured). You m

ay request to be interviewed for the consum

er report. You may, upon w

ritten request, be inform

ed whether or not the report w

as ordered, and if so, the name and address of the

consumer reporting agency w

hich made the report. U

pon proper identification, you have the right to inspect and/or receive a copy of the report from

the consumer reporting agency. You have the right to

make a w

ritten request to the Company w

ithin a reasonable period of time to receive additional detailed

information about the nature and scope of the investigation. W

rite to: Underw

riting Departm

ent, Forethought Life Insurance Com

pany, P.O. Box 14659, Clearw

ater, Florida, 33766-6960.

MiB, iN

C. DiSCLo

SurE N

otiCE

Information regarding your insurability w

ill be treated as confidential. Forethought Life Insurance Com

pany (the Company) or it’s reinsurer(s) m

ay, however, m

ake a brief report thereon to the MIB, Inc.,

formerly know

n as Medical Inform

ation Bureau, a not-for-profit mem

bership organization of insurance com

panies, which operates an inform

ation exchange on behalf of its mem

bers. If you apply to another M

IB, Inc. mem

ber company for life or health insurance coverage, or a claim

for benefits is submitted to

such a company, M

IB, Inc., upon request, will supply such com

pany with the inform

ation about you in its file. U

pon receipt of a request from you, M

IB, Inc. will arrange disclosure of any inform

ation in your file. Please contact M

IB, Inc. at 866-692-6901. If you question the accuracy of the information in M

IB, Inc.’s file, you m

ay contact MIB, Inc. and seek a correction in accordance w

ith the procedures set forth in the Federal Fair Credit Reporting A

ct. The address of MIB, Inc.’s inform

ation office is 50 Braintree

Hill Park, Suite 400, Braintree, M

assachusetts 02184-8734. The Company or its reinsurer(s) m

ay also release inform

ation from its file to other insurance com

panies to whom

you may apply for life or health

insurance, or to whom

a claim for benefits m

ay be submitted. Inform

ation for consumers about M

IB, Inc. m

ay be obtained on its website at w

ww

.mib.com

.

MED

iCArE Su

PPLEMEN

t / SELECt iNitiA

L PrEMiu

M rECEiPt

MA

kE CH

ECk PAYA

BLE TO: FO

RETHO

UG

HT LIFE IN

SURA

NC

E COM

PAN

Y

Received from ____________________________(Proposed Insured) an application for a

Medicare Supplem

ent / Medicare Select Policy w

ith Forethought Life Insurance Company (the

Company), and $ __________________ for the initial prem

ium. In the event the application is not

accepted by the Company, the above am

ount will be refunded. N

o obligation is incurred by the Com

pany unless said application is approved by the Company at its A

dministrative O

ffice and a

policy is issued.

Agent’s N

ame (please print)

Agent’s Signature

Date

MS-REC-02

LEAVE w

ith A

PPLiCAN

t

©2012 Forethought

0712

MSRN

10-01-WA

rEturN

to Co

MPA

Ny

©

2010 Forethought

0610

NO

TICE TO

APPLIC

AN

T REG

AR

DIN

G R

EPLAC

EMEN

T OF M

EDIC

AR

E SUPPLEM

ENT IN

SUR

AN

CE

OR

MED

ICA

RE A

DVA

NTA

GE

Forethought Life Insurance Com

panyA

dministrative O

fficeP.O

. Box 14659 · C


SAVE THIS N

OTIC

E! IT MAY B

E IMPO

RTA

NT TO

YOU

IN TH

E FUTU

RE

According to your application, you intend to term

inate existing Medicare S

upplement insurance or M

edicare Advantage

and replace it with a policy to be issued by Forethought Life Insurance C

ompany. Your new

policy will provide thirty

(30) days within w

hich you may decide w

ithout cost whether you desire to keep the policy. For your ow

n information

and protection, you should be aware of and seriously consider certain factors w

hich may affect the insurance available

to you under the new policy.

You should review this new

coverage carefully. Com

pare it with all accident and sickness coverage you now

have. If, after due consideration, you find that the purchase of this M

edicare Supplem

ent coverage is a wise decision, you

should terminate your present M

edicare Supplem

ent or Medicare A

dvantage coverage. You should evaluate the need for other accident and sickness coverage you have that m

ay duplicate this policy.

STATE

ME

NT TO

AP

PLIC

AN

T BY IS

SU

ER

, PR

OD

UC

ER

I HAV

E R

EV

IEW

ED

YO

UR

CU

RR

EN

T ME

DIC

AL O

R H

EA

LTH IN

SU

RA

NC

E C

OV

ER

AG

E. To the best of m

y know

ledge, this Medicare supplem

ent policy will not duplicate your existing M

edicare Supplem

ent or, if applicable M

edicare Advantage coverage because you intend to term

inate your existing Medicare S

upplement coverage or leave

your Medicare A

dvantage plan. The replacement policy is being purchased for the follow

ing reasons:

1. State law

s provide that your replacement policy or certificate m

ay not contain new pre-existing conditions, w

aiting periods, elim

ination periods or probationary periods. The insurer will w

aive any time periods applicable to pre-existing

conditions, waiting periods, elim

ination periods or probationary periods in the new policy (or coverage) for sim

ilar benefits to the extent such tim

e was spent (depleted) under the original policy.

2. If you still wish to term

inate your present policy and replace it with new

coverage, be certain to truthfully and com

pletely answer all questions on the application concerning your m

edical and health history. Failure to include all m

aterial medical inform

ation on an application may provide a basis for any com

pany to deny any future claims and to

refund your premium

as though your policy had never been in force. After the application has been com

pleted and before you sign it, review

it carefully to be certain that all information has been properly recorded.

❑ A

dditional benefits. ❑ M

y plan has outpatient drug coverage and I am

enrolling in P

art D.

❑ N

o change in benefits, but lower prem

iums. ❑

Disenrollm

ent from a M

edicare Advantage P

lan.

P

lease explain reason for disenrollment.

______________________________________❑

Fewer benefits and low

er premium

s. ❑

Other, (please specify) ____________________.

Do not cancel your present policy until you have received your new

policy and are sure that you w

ant to keep it.

______________________________________S

ignature of Producer, B

roker or other Representative

______________________________________P

RIN

TED

Nam

e and Address of Issuer, P

roducer, or Broker

______________________________________A

pplicant’s Signature

______________________________________S

ignature of Applicant B

, if applying

______________________________________D

ate

THIS PA

GE LEFT IN

TENTIO

NA

LLY BLAN

k

THIS PA

GE LEFT IN

TENTIO

NA

LLY BLAN

k

Consumers choosing to have initial prem

iums paid

through ACh

(Autom

ated Clearing house) for

Medicare Supplem

ent Applications m

ay have their initial premium

autom

atically deducted from their checking or savings account through

the Electronic Funds transfer (EFt) process. when they do,

you may fax the application and required form

s instead of mailing them

.

Follow these easy steps to subm

it Medicare Supplem

ent Apps using ACH

for the initial premium

:

StEP 1 – CoM

PLEtE thE A

uth

oriZAtio

N Fo

r ELECtroN

iC FuN

DS

trAN

SFEr SECtioN

oN

thE A

PPLiCAtioN

.

Applicants w

ishing to pay electronically will need to com

plete the appropriate M

edicare Supplement Authorization for Electronic Funds Transfer section on the Application

and include a voided check.

StEP 2 – FAX th

E FoLLo

wiN

G itEM

S to th

E DED

iCAtED LiN

E For

ACh

PAyMEN

tS At 1-855-808-0944

1) ACH fax transm

ittal cover sheet on the back of this form

2) Medicare Supplem

ent Application and other required forms

including authorization for EFT

3) Voided check for EFT

if you fax the application, do not mail it as processing errors occur and

additional charges could result in the duplication.

For producer use only. Not for use w

ith the general public.

Forethought Life Insurance Company


MSFA

X01-02

FAX trA

NSM

ittAL

For u

SE with

EFt Mo

Nth

Ly PrEMiu

M A

PPLiCAtioN

S oN

Ly

1-855-808-0944

Use this fax num

ber only for applications and new business docum

ents. Applications faxed to any

other number can cause delays in processing your business.

Please complete the follow

ing information:

Total number of pages being faxed including this cover sheet _____________

Producer Nam

e __________________________________________________________________

Producer Num

ber or SSN __________________________________________________________

Producer Phone Num

ber __________________________________________________________

Producer Fax Num

ber _____________________________________________________________

Comm

ents ______________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

This comm

unication and any attachments transm

itted with it are confidential and are solely for the use of the addressee.

It may contain m

aterial that is legally privileged, proprietary or subject to copyright belonging to Forethought Life Insurance Com

pany and its affiliates. It m

ay be subject to protection under federal or state law. If you are not the

intended recipient, you are notified that any use of this material is strictly prohibited. If you received this transm

ission in error, please contact the sender im

mediately by telephone, at 1-877-492-5870. W

e will arrange for you to return the

original material to us via the U

S Postal Service and if requested, we w

ill reimburse you for such expense.

Forethought Life Insurance Company


MSFA

X01-02

Documents

, FL 33766-4659 (877) 492-5870 age · 01-WA age 1 f 7 hought e 0710 ON) TE: n ed. 1 . T n C G e ) C G e il P o d r l $ l m $ de i-y y EFT T B an C G ip e P) C G e d r l $ l m $ de