69O-156.106. Certification Form Required  


Effective on Sunday, July 1, 1979
  • 1It shall be the responsibility of each agent directly soliciting a policy of Medicare supplemental insurance to complete a form as indicated by Exhibit “A” herein. Substantially equivalent forms may be adopted with the prior approval of the Director. The original copy of such form shall be furnished to the applicant upon the taking of the application and a copy shall be maintained in the files of the company for a period of three years.

    76“EXHIBIT A”

    78CERTIFICATION

    79I, the undersigned insurance agent certify:

    85THAT, I have taken an application for Policy Form No. ________ offered by the ________ (Name of Insurance Company) to ________ (Applicant).

    107THAT, I have explained the provisions of the policy being applied for, including specifically, all the different benefits, exceptions and limitations of the plan.

    131THAT, I am a licensed agent of this insurance company and have given a company receipt for an initial premium in the amount of $________ (Insert zero if no premium received) which has been paid to me by () Check () Cash () Money Order (Check appropriate method of payment).

    181THAT, 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 Government.

    213THAT, I have not made any representation to the applicant that there is any endorsement whatsoever by the Social Security Administration or the Health Care Financing Administration of the Federal Government in connection with this insurance policy being applied for.

    253________

    254____________________________

    255Date

    256Signature of Agent

    259________________________________

    260____________________________

    261I, the undersigned

    264Name of Agency

    267applicant, have

     

    269received a copy of

     

    273this form

     

     

    275____________________________

     

    276Address of Agent or

     

    280Agency

    281________________________________

    282________

    283Applicant’s

    284Phone No.

    286signature

     

     

    287Specific Authority 289624.308(1), 290626.9611, 291626.9641 FS. 293Law Implemented 295624.307(1), 296626.830, 297626.9541(1), 298(2), (3), (5), (11), (12), 303626.9641(1)(a), 304(c), (e), (h) FS. History–New 7-1-79, Formerly 4-46.04, 4-46.004, 4-156.106.