DEPARTMENT OF LABOR AND
REGULATION
DIVISION OF INSURANCE
PARTNERSHIP CERTIFICATION
FORM
Chapter 20:06:21
APPENDIX L
SEE: § 20:06:21:78
Source: 33 SDR 230, effective July 2, 2007.
LONG-TERM
CARE PARTNERSHIP
CERTIFICATION
FORM
Note: This Form must be
completed and submitted with each long-term care policy or certificate form for
which the insurer is seeking partnership qualification. A separate form must be
completed for each policy form and a specimen copy of the form, including all
riders and endorsements, must be attached. A long-term care policy or
certificate form may not be issued in South Dakota as a partnership policy or
certificate unless and until this form has been submitted to and approved by
the Division of Insurance.
Under section
1917(b)(5)(B)(iii) of the Social Security Act (42 U.S.C. 1396p(b)(5)(iii)) and
in accordance with applicable South Dakota requirements, the insurer hereby
submits information relating to policy or certificate form _____________ (form
number) to substantiate that the form includes all required consumer protection
requirements set forth in section 1917(b)(5)(A) of the Social Security Act (42
U.S.C. 1396p(b)(5)(A)) and that it includes certain specified provisions of the
Long-Term Care Insurance Model Regulation and Long-Term Care Insurance Model
Act promulgated by the National Association of Insurance Commissioners (adopted
as of October 2000) (referred to herein as the "2000 Model
Regulation" and "2000 Model Act," respectively).
Part I:
Name of Insurer ___________________________________________
Company NAIC # ___________________________________________
Address ___________________________________________
___________________________________________
___________________________________________
Telephone ___________________________________________
Company Contact
Name ___________________________________________
Title ___________________________________________
Telephone ___________________________________________
E-Mail ___________________________________________
Part II:
2000
NAIC MODEL REGULATION AND 2000 NAIC MODEL ACT
Note
to Insurer: Identify the page and/or provision within the policy or certificate
form that addresses each requirement, or, if inapplicable, use the space
identified to explain.
Policy/Certificate
form ________________ meets the following requirements of the 2000 NAIC Model
Long-Term Care Regulation and/or 2000 NAIC Model Long-Term Care Act, as
indicated below:
|
NAIC
Model Regulation Requirement
|
Identify
Policy Page # and Provision OR use this space to explain if requirement is
inapplicable
|
|
Section 6A
(relating to guaranteed renewal or noncancellability), other than paragraph
(5) thereof, and the requirements of section 6B of the 2000 Model Act
relating to such section 6A.
|
|
|
Section 6B
(relating to prohibitions on limitations and exclusions) other than paragraph
(7) thereof.
|
|
|
Section
6C (relating to extension of benefits).
|
|
|
Section
6D (relating to continuation or conversion of coverage).
|
|
|
Section
6E (relating to discontinuance and replacement of policies).
|
|
|
Section
7 (relating to unintentional lapse).
|
|
|
Section
8 (relating to disclosure), other than sections 8F, 8G, 8H, and 8I thereof.
|
|
|
Section
9 (relating to required disclosure of rating practices to consumer).
|
|
|
Section
11 (relating to prohibitions against post-claims underwriting).
|
|
|
Section
12 (relating to minimum standards).
|
|
|
Section
14 (relating to application forms and replacement coverage).
|
|
|
Section
15 (relating to reporting requirements).
|
|
|
Section
22 (relating to filing requirements for marketing).
|
|
|
Section
23 (relating to standards for marketing, including inaccurate completion of
medical histories, other than paragraphs (1), (6), and (9) of section 23C).
|
|
|
Section
24 (relating to suitability).
|
|
|
Section
25 (relating to prohibition against preexisting conditions and probationary
periods in replacement policies or certificates).
|
|
|
Section
26 (relating to contingent nonforfeiture benefits, if the policyholder
declines the offer of a nonforfeiture provision described in section
7702B(g)(4) of the Internal Revenue Code of 1986 (26 U.S.C. 7702B(g)(4)).
|
|
|
Section
29 (relating to standard format outline of coverage).
|
|
|
Section
30 (relating to requirement to deliver shopper's guide).
|
|
|
NAIC
Model Act Requirement
|
Identify
Policy Page # and Provision OR use this space to explain if requirement is
inapplicable
|
|
Section
6C (relating to preexisting conditions).
|
|
|
Section
6D (relating to prior hospitalization).
|
|
|
Section
8 (relating to contingent nonforfeiture benefits).
|
|
|
Section
6F (relating to right to return).
|
|
|
Section
6G (relating to outline of coverage).
|
|
|
Section
6H (relating to requirements for certificates under group plans).
|
|
|
Section
6J (relating to policy summary).
|
|
|
Section
6K (relating to monthly reports on accelerated death benefits).
|
|
|
Section
7 (relating to incontestability period).
|
|
Part III. INFLATION PROTECTON
Identify
the policy provision or provide form number of endorsement or amendment form
(and date of approval) for inflation protection coverage in compliance with
ARSD 20:06:21:76:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Part IV. CERTIFICATION
I
hereby certify that the answers, accompanying documents, and other information
set forth herein are, to the best of my knowledge and belief, true, correct,
and complete and the policy [certificate] satisfies the requirements necessary
for a qualified state long-term care insurance partnership policy in the State
of South Dakota.
________________________ _____________________________________
Date Name
and title of officer of the Insurer
________________________ _____________________________________
Date Signature
of officer of the Insurer