Fla. Admin. Code R. 69O-156.106
It 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.
"EXHIBIT A"
CERTIFICATION
I, the undersigned insurance agent certify:
THAT, I have taken an application for Policy Form No. ________ offered by the ________ (Name of Insurance Company) to ________ (Applicant).
THAT, I have explained the provisions of the policy being applied for, including specifically, all the different benefits, exceptions and limitations of the plan.
THAT, 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).
THAT, 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.
THAT, 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.
________ | ____________________________ |
Date | Signature of Agent |
________________________________ | ____________________________ |
I, the undersigned | Name of Agency |
applicant, have | |
received a copy of | |
this form | |
____________________________ | |
Address of Agent or | |
Agency | |
________________________________ | ________ |
Applicant's | Phone No. |
signature |
Fla. Admin. Code Ann. R. 69O-156.106
Rulemaking Authority 624.308(1), 626.9611, 626.9641 FS. Law Implemented 624.307(1), 626.830, 626.9541(1), (2), (3), (5), (11), (12), 626.9641(1)(a), (c), (e), (h) FS.
New 7-1-79, Formerly 4-46.04, 4-46.004, 4-156.106.