Compliance Sheet for the State of NEW YORK
This page was last updated on 6-01-2010

MEDICARE SUPPLEMENTS
 A Guide to Health Insurance for People with Medicare must be given to all applicants

Product Name / Policy Form

Application

Brochure

Outline of Coverage for all Applicants

**MedSupp Notice for Applicants on Medicare

Replacement Form (If a Replacement Occurs)

Instructions (See bottom of page)

ProCare Plans:

 

A (NYMSA10) 
B (NYMSB10)
C (NYMSC10)
D (NYMSD10)
F (NYMSF10)
HDF(NYMSHDF10)
G (NYMSG10)
K (NYMSK06R)
L (NYMSL06R)
N (NYMSN10)

NYMA14

F4931NY R10

DS-NYMS2010

 Not Required

NYREPMSM; NYU-1366 R10

I, 1
ANNUITIES
Annuity Buyer's Guide must be given to all applicants

Product Name / Policy Form

Application

Brochure

Outline of Coverage for all Applicants

**MedSupp Notice for Applicants on Medicare

Replacement Form (If a Replacement Occurs)

Instructions (See bottom of page)
Flexible Premium Annuity

(NYFPDA02)

 NYFPDA02 NYFPDA-APR   Not Required Not Required Not Allowed J, 2
INSTRUCTIONS
I If replacing existing coverage, give form NYREPMSM and NYU-1366 R10 to applicant and send signed copy of form with application.
J Definition of Replacement Form, NY-DEF must be completed and send signed copy of form with application.
1 Conditional Receipt Form NYMSCR10 must be completed and left with applicant.
2 Certificate of Receipt  NYFPDA02-CR must be completed and left with applicant and send signed copy of form with application.
** If applicant is on Medicare (regardless of age), applicant must be given the appropriate Notice Form at time of application.