Compliance Sheet for the State of  ARIZONA
This page was last updated on 02/17/2020
FOUNDATION SIGNATURE SERIES

Product Name / Policy Form

Application

Brochure

Outline of Coverage for all Applicants

**MedSupp Notice for Applicants on Medicare

Replacement Form

Instructions (See bottom of page)

Rates

FOUNDATION (MMGAP(02))

(R-MMGAP-HO)

MGAPB(02) /
MGAPB-ODF
F6388 DS-MMGAP MSNOT06-5 Not Required B, C, G, P Current
CANCER/CRITICAL ILLNESS

Product Name / Policy Form

Application

Brochure

Outline of Coverage for all Applicants

**MedSupp Notice for Applicants on Medicare

Replacement Form

Instructions (See bottom of page)

Rates

Cash Benefit (CANLS-2)

CANLS-AP(02)

FC901(02)

DS-CANLS-2(02)

MSNOT06-1

Not Required

C, G, N

Current

Health Guard (CILS)

CILS CILS-APR(02)

DS-CILS(02)

MSNOT06-1

Not Required

C, G

Current
ACCIDENT

Product Name / Policy Form

Application

Brochure

Outline of Coverage for all Applicants

**MedSupp Notice for Applicants on Medicare

Replacement Form

Instructions (See bottom of page)

Rates

UA-250

UA-250 U5201 R94

DS-UA-250

MSNOT06-8

Not Required

C, G

See Brochure

UAINADP

UAIN-TAP

F9238 Not Required

MSNOT06-8

Replacements Not Allowed

 

See Brochure
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

Instructions (See bottom of page)

Rates

A (MSA10)
B (MSB10)
C (MSC10)*
D (MSD10)
F (MSF10)*
HDF (MSHDF10)*
G (MSG10)
HDG (MSHDG)
K (MSK06)
L (MSL06)
N (MSN10)

MA15(02)

F4931(02) R20

DS-MS2020(02)

Not Required

REPMSM

C, G, H

Current

New

RESERVE FUND ANNUITY
The optional Reserve Fund Annuity below is available with Medicare supplement ProCare Plans A, B, D, HDF, G, HDG, K & L only. It should not be used to replace any existing life or annuity coverage.

Product Name / Policy Form

Application

Brochure

Outline of Coverage for all Applicants

**MedSupp Notice for Applicants on Medicare

Replacement Form

Instructions (See bottom of page)

Rates

Reserve Fund (USFMS)

USFMS-APR

F4546R16

Not Required Not Required Replacements Not Allowed

Not Required

None Applicable
WHOLE LIFE

Product Name / Policy Form

Application

Brochure

Outline of Coverage for all Applicants

**MedSupp Notice for Applicants on Medicare

Replacement Form

Instructions (See bottom of page)

Rates

Final Expense Whole Life UL14 (Located in the Life App-pack. See instruction T below.)

FD786R English

FD786-S-R Spanish

Not Required Not Required REPNOT/00 C, J, T

Rate Cards

Rate Calculators

Whole Life (SWL)
Terminal Illness
Accelerated Benefit Rider
(ABR1)

Whole Life Graded (SWLGD)

Juvenile Whole Life JUV14R (Located in the Life App-pack. See instruction T below.) UAI3962 Not Required Not Required REPNOT/00 C, J, T

Rate Cards

Rate Calculators

Whole Life (SWL)
Terminal Illness
Accelerated Benefit Rider
(ABR1)

INSTRUCTIONS

B

Applicant must complete and sign Consumer Form 3728. Original must be sent in with application and give a copy to Applicant.

C

HIPAA Authorization form F3978 must be signed by each Applicant (of legal capacity).
Original must be sent in with application and give copy to Applicant.

G

Separate Outline of Coverage (DS form) must be left with applicant.

H

If replacing a Medicare Supplement policy, give form REPMSM to applicant and send signed copy of form with application.

J

If applicant has existing life insurance coverage or annuity contract(s), have applicant complete and sign Replacement Form and return Home Office Copy with application.

N

Conditional receipt form F3520 must be completed and provided to the applicant.

P

A completed MMGAP Policy Suitability Review Form F6897 is required with all applications. The MMGAP maximum benefit amount must be the amount nearest, but which does not exceed, the estimated total out-of-pocket expenses indicated on #3 of Form F6897.

T

Carefully review and complete Life App-pack UAI3176 with the Applicant. For Juvenile Whole Life, use Life App-pack UAI3178. (2) Have Applicant complete and sign the Applicant Acknowledgement page of packet. (3) Attach signed Applicant Acknowledgement page with application. (4) Leave remainder of packet with Applicant.

*

Medicare Supplement Plan C, F and HDF will ONLY be available to those turning 65 prior to January 1, 2020, or first eligible for Medicare Part A due to age or disability prior to January 1, 2020.

**

If applicant is on Medicare (regardless of age), applicant must be given the appropriate Notice Form at time of application.