Florida Administrative Code (Last Updated: October 28, 2024) |
69. Department of Financial Services |
69O. OIR – Insurance Regulation |
69O-156. Medicare Supplement Insurance |
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.