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MONTGOMERY COUNTY AGENCIES - Rockville_ Maryland

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This booklet is intended to be a summary of Long Term Care (LTC) insurance benefits from
The Prudential Insurance Company of America and does not include all plan provisions,
exclusions and limitations. Details of your LTC coverage can be found in your certificate. If
there are any discrepancies between this booklet and the certificate, the certificate governs.
This coverage may not be available in all states.

The long term care insurance described in this booklet is intended to be federally tax
qualified long term care insurance as defined by the Internal Revenue Code Section
7702B(b). As such, the benefits you may receive under this plan may not be considered
taxable income. In addition, some or all of the premiums you pay toward this coverage may
be tax deductible as a medical expense subject to certain limitations. Consult a tax advisor
for more information concerning this deduction.

30-Day Free Look: If you are enrolled, you will have 30 days to review your insurance
certificate without obligation. If you receive your certificate and are not completely satisfied
with your coverage, simply return the insurance certificate to us within this time. Any
premiums you may have paid will be fully refunded.




It’s   time...
          help   protect your assets, your choices and your family.
Plan Today…
  Live on Your Terms Tomorrow
      When you picture your future, you may imagine yourself healthy, active,
      independent…enjoying a lifestyle you have worked hard to create, protected by
      good financial planning: pensions, savings, investments, health, life, and property
      insurance. As you work towards saving and investing for retirement, you may want
      to consider protecting your assets against the real possibility of needing long term
      care and preserving the choice and dignity you deserve when such care is needed.

      Long term care insurance is a logical step in a comprehensive blueprint to sound
      financial planning. Just as you would not wait to have an automobile accident before
      applying for car insurance, or wait until your house is on fire before getting a good
      homeowner’s policy, it makes sense not to put off planning for something as
      probable as needing long term care.

      We are all part of a population living far longer than previous generations. We are
      facing challenges our parents never had to face. Current research into the possible
      effects of our unprecedented longevity tells us that one out of every two Americans
      may someday need some form of assistance with normal everyday activities1 such as
      getting in and out of bed, eating, and getting dressed.

      Find that hard to believe? We suspect many people do. But it is a possibility we may
      all have to face. Part of facing that possibility is realizing the cost of such care.
      Nursing home care averages roughly $50,000 2 a year nationally, and over $105,000 3
      in some areas. And these numbers only speak to the situation today. The effects of
      inflation are likely to triple these figures by the time some of us may need care.

      What’s more, you may even find yourself in a situation where you will be glad to
      have long term care insurance sooner than you might think. Over 40% of all
      Americans receiving long term care services are part of the working-age
      population…people under the age of 65.4




      1
          “Who Buys Long Term Care Insurance? 1994-95 Profiles and Innovations in a Dynamic Market,”
          “Health Insurance Association of America/LifePlans, Inc. p.2.
      2
          “Health Care Financing Administration, 1997 Statistics
      3
          “Estimated 1998 Daily Average NYS Nursing Home Rates by Region,”
          “N Y State Partnership for Long-Term Care and State of CT Department of Social Services, 2/98.
      4
          “Long-Term Care: Diverse, Growing Population Includes Millions of Americans of All Ages,”
          “General Accounting Office, November 1994, GAO-HEHS-95-26, p.3.
    Important Points To Consider About
      Long Term Care Insurance
                  Long term care insurance is designed to help protect your assets,
                  your independence and your options in the future. If and when you need
                  care, you will want independence—choice, dignity, flexibility—and the way
                  to preserve your options is with a sound long term care insurance plan.

                  No other kind of insurance is designed to cover what long term care
                  insurance covers—not medical insurance, not disability insurance.
                  Long term care insurance is not the same as disability insurance.
                  You may have disability insurance to help replace lost wages during your
                  working years—wages which are needed to pay your everyday bills and
                  expenses—but long term care insurance helps protect your assets both
                  during and after your working years by paying for the added cost of care
                  you may need.

                  This long term care insurance plan, underwritten by The Prudential
                  Insurance Company of America, is fully portable. This means your
                  coverage stays with you regardless of your employment situation.

                  If you should ever need long term care services, it may be very hard
                  to fund the care on your own. Many people believe they can pay for this
                  kind of care out of their own savings. But add the average annual cost for
                  care to the costs needed to sustain the lifestyles of a healthy spouse and
                  children and you can see why many families, even those who have planned
                  well financially, may not have the resources to fund these kinds of expenses
                  on their own.

                  Long term care insurance is not as expensive as you may think.
                  Before you make a judgment on the cost or value of long term care
                  insurance, we encourage you to refer to the enclosed rate sheet to
                  determine just how affordable this coverage may be for you.

         This brochure provides a general description of your Group Long Term Care
         Insurance plan. The materials located in this packet provide details on your specific
         coverage options and rates. Please carefully review all of the information, so you can
         make an informed decision about participating in this plan.




3
What Is Long Term Care Insurance?
      Before you can understand what long term care insurance covers, you need to
      understand what long term care is.

      Long term care is the care you may need to go about everyday activities such as
      bathing, eating, and getting dressed. It is not acute medical care. Most long term
      care services do not require doctors and nurses. It is care you may need as a result
      of an accident, debilitating disease, or ailment due to common aging.

      Long term care may be provided in your home by a home health care agency. It is
      care that may be provided in the community in perhaps an adult day care facility.
      Or, as most people often envision, it is care that may be provided in a nursing home
      or in an assisted living facility.

      With Prudential’s Long Term Care Insurance plan, you select the amounts you
      would like to be reimbursed for daily nursing home and home & community based
      care. Once you qualify for benefits and satisfy the benefit waiting/elimination period
      (if applicable), benefits will be paid for eligible expenses up to the applicable
      Lifetime Maximum depending on the Daily Maximum option you select. Please
      review the Plan Details for specifics on your plan.




How Do I Enroll?
      To enroll, simply complete the appropriate enrollment form included in the forms
      section of this kit. Return the completed enrollment form to Prudential using the
      envelope provided. A separate form must be submitted for each family member who
      applies for coverage.

      Our customer service representatives are here to help if you have any questions or
      need additional enrollment kits. You may call our toll-free number: 1-800-732-0416.




                                                                                             4
    Important Plan Features
          Coverage Amounts
          This plan has been created especially for your employer or association with choices
          which will enable you to customize the plan to fit your individual needs. This plan
          is designed to reimburse you for covered long term care expenses up to the Daily
          Maximum you select for nursing home and home & community based care. Any
          benefits you receive will then be deducted from your Lifetime Maximum which
          corresponds to the Daily Maximum option you select.


          Level Premiums
          You may be asking yourself, “Why do I need to worry about long term care
          insurance right now? Can’t this wait until I am older?” Your premium is based
          on your age when you enroll. Enrolling now at your current age allows for a lower
          premium rate than if you wait to enroll when you are older.


          Portability
          You may keep this coverage even if you decide to change jobs. Your coverage will
          remain in effect as long as you continue to pay your premiums on a timely basis
          and do not exhaust your benefits.




5
Inflation Protection
It is very likely that you may not need to make use of your long term care insurance
coverage for 10, 20, maybe even 30 years. For this reason, we offer you the choice of
inflation protection. The additional cost for this feature will help protect your benefits
against the effects of inflation regardless of changes in your future health status.

At least every three years, you will be given the opportunity to purchase additional
coverage. There will be no medical evidence required as long as you have not
declined the previous two consecutive offers to purchase inflation coverage. The
additional premium for the new layer of coverage will be based on your age at the
time the increase goes into effect. NOTE: These inflation protection options will
only be made to participants who do not elect the Automatic Inflation Option
where available. See Plan Details for specifics on your plan.


Non-Forfeiture Option - Shortened Benefit Period Option
Some people feel more comfortable knowing they may get something out of their
insurance plan even if they decide to stop paying premiums at some point in the
future. If you are one of these people, you may wish to consider purchasing this
option. Please refer to the Plan Details for availability of this feature under your plan.


Lifestyle Changes Benefit
Very often, a few modifications to the home can mean the difference between going
to a nursing home or remaining at home—the place many people would prefer to
receive care if given the choice. This benefit allows you to be reimbursed for
expenses such as home modifications and medical alert systems.




                                                                                         6
    Respite Care
    Most people would rather be taken care of by someone they know. This benefit
    provides some relief to the friend or family member who may be caring for you.


    Bed Reservation Benefit
    Families may spend a great deal of time and effort locating a suitable nursing
    home only to lose the bed because of a short absence due to a hospital stay.
    This benefit will help prevent this from happening to you and your loved ones
    by reserving your bed should you ever need to be hospitalized.


    Care Counseling Services
    Prudential is dedicated to providing you with as much freedom as possible when
    it comes to making your long term care decisions. Information/referral services,
    advice, and care counseling are provided by Prudential Care Counselors who are
    available to you at any time, even if you are not receiving benefits.


    Alternate Plan of Care Feature
    There are situations in which the services included in this insurance plan may
    not be available in your part of the country. There may also be situations in which
    new or different modes of care may become available over time. This feature
    enables covered services to grow and change as new technologies and trends
    become available. Prudential intends to be flexible in allowing coverage for
    emerging trends.


    Death Benefit
    If you should die prematurely, a portion of your premiums may be refunded to your
    spouse (if applicable, otherwise to your estate). The percentage of premiums to
    be refunded is based on your age at death and is reduced by any benefits paid.
    NOTE: This feature is not meant to take the place of life insurance. For more
    details, please refer to the Plan Details.




7
Qualifying for Benefits
      In order to qualify for benefits, you must be confirmed as having a Chronic Illness
      or Disability. A Chronic Illness or Disability is defined as a:

             Loss of ability to perform, without Substantial Assistance, for at least
             90 days, two or more of the following Activities of Daily Living: Bathing,
             Continence, Dressing, Eating, Toileting, or Transferring:

             Similar disability as described above, or

             Severe Cognitive Impairment which requires Substantial Supervision
             to protect you from threats to health and safety.

      Once you are determined to be eligible for benefits and have satisfied the benefit
      waiting/elimination period, benefits will be payable according to the Plan of Care
      developed for you by the Licensed Health Care Practitioner responsible for your care.




Accessing Benefits
      Prudential wants to make using your benefits as easy as possible. To begin the
      benefits process, call our Long Term Care Customer Service Center toll free at
      1-800-732-0416 before you incur charges for long term care services.




About Prudential
      Prudential has been a trusted and reliable source of insurance and employee
      benefits products for much of this century. As a provider of group life insurance
      coverage since 1916 and a provider of group long term care insurance since 1986,
      Prudential is one of the most powerful brands in the insurance and financial
      services industry. As we move into the new millennium, we continue to be
      recognized for services and product features that meet diverse employee needs.




                                                                                          8
    Definitions
          The following are general definitions related to this Long Term Care Insurance
          plan. Some state variations may apply. Since benefits may vary by state, please
          carefully review the outline of coverage and your insurance certificate for
          possible state variations.


          Activities of Daily Living
               Bathing—Washing oneself by sponge bath; or in either a tub or shower,
               including the task of getting into or out of the tub or shower.

               Continence—The ability to maintain control of bowel and bladder function,
               or, when unable to maintain control of bowel or bladder function, the ability
               to perform associated personal hygiene (including caring for catheter or
               colostomy bag).

               Dressing—Putting on and taking off all items of clothing and any necessary
               braces, fasteners or artificial limbs.

               Eating—Feeding oneself by getting food into the body from a receptacle
               (such as a plate, cup or table) or by feeding tube or intravenously.

               Toileting—Getting to and from the toilet, getting on and off the toilet,
               and performing associated personal hygiene.

               Transferring—Sufficient mobility to move into or out of a bed, chair or
               wheelchair, or to move from place to place, either by walking, using a
               wheelchair or by other means.




9
Adult Day Care Facility
A facility licensed, certified or otherwise qualified as an Adult Day Care Facility by
the state in which the services are rendered.


Assessor
A Licensed Health Care Practitioner, acceptable to Prudential, who is qualified to
evaluate conditions relevant to your ability. Qualifications are based on training and
experience, and may include health care industry, state or national standards.


Care Counselor
A Licensed Health Care Practitioner, designated by Prudential, who is qualified to
evaluate assessments and the appropriateness of your Plan of Care. Qualifications
are based on training and experience, and may include health care industry, state,
or national standards.


Chronic Illness or Disability
An illness or disability in which there is a:

        Loss of the ability to perform, without Substantial Assistance, at least two
        Activities of Daily Living for a period of at least 90 consecutive days;

        Similar level of disability as that described above; or

        Severe Cognitive Impairment which requires Substantial Supervision to
        protect you from threats to health or safety.




                                                                                       10
     Cognitive Impairment
     A loss or deterioration in intellectual capacity that is (a) comparable to and
     includes Alzheimer’s Disease and similar forms of irreversible dementia; and
     (b) measured by clinical evidence and standardized tests that reliably measure
     impairment in the individual’s (i) short-term or long-term memory, (ii) orientation
     as to people, places, or time, and (iii) deductive or abstract reasoning.


     Daily Maximum
     The maximum amount payable for one day’s worth of covered long term care
     services. This amount varies based on the services provided.


     Home & Community Based Care
     Services received through any facility or agency that is state licensed or certified
     to provide personal assistance in a supervised setting such as a state licensed or
     certified Home Health Care Agency, Adult Day Care Facility, Assisted Living
     Facility, Hospice Center, etc.


     Licensed Health Care Practitioner
     A physician, a Registered Nurse, a licensed social worker, or another professional
     individual who meets the requirements prescribed by the United States Secretary
     of The Treasury.


     Long Term Care
     Medical, social and personal care services, such as Nursing Home Care, Home &
     Community Based Care, Hospice Care or Respite Care required over a long period
     of time by a person with a Chronic Illness or Disability.




11
Nursing Home
A facility or institution which is licensed, certified, or otherwise qualified as such
by the state in which services are rendered.


Plan of Care
A written plan that:

       has been developed for you;

       describes the type, the frequency, and the duration
       of Long Term Care that you need;

       describes the types of providers that are needed; and

       is signed by the Licensed Health Care Practitioner responsible
       for your care.


Substantial Assistance
The physical assistance of another person without which you would not be able
to perform an Activity of Daily Living or the constant presence of another person
within arm’s reach which is necessary to prevent, by physical intervention, injury
to you while you are performing an Activity of Daily Living.


Substantial Supervision
Continual oversight that may include cueing by verbal prompting, gestures or other
demonstrations by another person and which is necessary to protect you from
threats to your health or safety.




                                                                                       12
     Exclusions
           This is a general list of exclusions. However, state variations may apply. Please see
           the Outline of Coverage in this kit for a complete listing of exclusions in your state.
           This plan is designed to provide coverage to pay for the long term care you need when
           you need it. However, there are some special circumstances that limit or exclude the
           availability of benefits under this plan. No benefits will be payable if any of the following
           situations apply:

           Work-connected Conditions Charge: A charge covered by a worker’s compensation
           law, occupational disease law or similar law.

           Government Plan Charge: A charge for a service or supply:

             a) furnished by or for the United States government or any other government,
                unless payment of the charge is required by law; or

             b) to the extent that the service or supply, or any benefit for the charge, is
                provided by any law or governmental plan under which the patient is or could
                be covered. This (b) does not apply to a state plan under Medicaid or to any
                law or plan when, by law, its benefits are excess to those of any private
                insurance program or other non-governmental program. When this (b) applies
                to Medicare, the benefits provided by Medicare will be deemed to include any
                amount that would have been payable by Medicare in the absence of a
                deductible or coinsurance requirement under that program.

           War: Charges for a condition due to war or any act of war while insured. “War”
           means declared or undeclared war and includes resistance to armed aggression.

           Self-inflicted Injury or Suicide: Charges arising from intentionally self-inflicted
           injury or attempted suicide, while sane or suffering from inorganic based insanity.

           Services and Supplies Outside the United States: Charges for services or supplies
           outside of the United States and its possessions.

           Mental or Nervous Illnesses: Charges for services or supplies connected with
           mental, psychoneurotic and personality disorders of an inorganic nature. Conditions
           such as Schizophrenia, Manic Depression, Depression, Neuroses and Psychoses are
           considered to be inorganic. Conditions such as Alzheimer’s disease, Chronic Brain
           Syndrome, Senile Dementia and Pre-senile Dementia are considered to be organic.




13
Close Relative: Charges for services and supplies furnished and charged for by
a close relative other than a licensed professional who provides covered services
within the terms of his or her licensure. Close relatives include the insured, the
insured’s spouse, or a child, grandchild, brother, sister, or parent of the insured
or the insured’s spouse.

Services or Supplies Normally Furnished Without Charge: Services or supplies
for which no charge would be made in the absence of coverage.

Chronic Alcoholism or Chemical Dependency: Charges in connection with chronic
alcoholism or chemical dependency.

Employer’s Other Programs: Charges to the extent they would be covered under
any other program paid for in full or in part, directly or indirectly, by the employer.
This includes insured and uninsured programs. If a program provides benefits in the
form of services, the cash value of each service rendered is considered the benefit
provided for that service.

Charge Not Reasonably Necessary: A charge for a service not reasonably
necessary, or not customarily performed, for the long term care of the person.
To be considered “reasonably necessary,” a service must meet all of these tests:

       It is commonly and customarily recognized as appropriate for the
       insured’s condition.

       It is neither educational nor experimental in nature.

       It is not furnished mainly for the purpose of medical or other research.

Felony, Riot or Insurrection: Charges for a condition due to the insured’s
participation in an act of felony, riot or insurrection.

Non-Covered Services: Charges for services and supplies which are not listed as
a covered service in the coverage.
   Standard Provisions and Plan Features                                   For Montgomery County Agencies
Eligibility to Participate                              Montgomery County Public Schools (MCPS):
                             To participate you must be a full-time* (working at least 40 hours per week) or part-time employee,
                             spouse, qualified domestic partner, parent, parent in-law, grandparent, grandparent in-law of an
                             eligible employee, a retiree or retiree’s spouse or the parent or parent-in-law of a retiree.

                                                          Montgomery County Government (MCG):
                             To participate you must be a full-time* (working at least 40 hours per week) or part-time (working
                             at least 16 hours per week) employee or a crossing guard actively at work, the spouse, qualified
                             domestic partner, parent, parent in-law, grandparent, grandparent in-law of an eligible employee, or
                             a retiree or retiree’s spouse or the parent or parent-in-law of a retiree.

                                                                   Montgomery College (MC):
                             To participate you must be a full-time* (working at least 40 hours per week) or part-time (working
                             at least 20 hours per week) employee actively at work, the spouse, parent, parent in-law,
                             grandparent, grandparent in-law of an eligible employee, or a retiree or retiree’s spouse or the
                             parent or parent-in-law of a retiree.

                                          Maryland National Capital Park & Planning Commission (MNCPPC):
                             To participate you must be a full-time* (working at least 40 hours per week) or part-time (working
                             at least 20 hours per week) employee actively at work, the spouse, parent, parent in-law,
                             grandparent, grandparent in-law of an eligible employee, or a retiree or retiree’s spouse or the
                             parent or parent-in-law of a retiree.

                                                   Washington Suburban Sanitary Commission (WSSC):
                             To participate you must be a full-time* (working at least 40 hours per week) or part-time (working
                             at least 16 hours per week) employee actively at work, the spouse, parent, parent in-law,
                             grandparent, grandparent in-law of an eligible employee, or a retiree or retiree’s spouse or the
                             parent or parent-in-law of a retiree.
                             *Due to state laws, full-time status is not required for residents of Vermont.

                                                                 The City of Rockville (COR):
                             To participate you must be a full-time* (working at least 37.5 hours per week) or part-time
                             (working at least 20 hours per week) employee actively at work, the spouse, same-sex domestic
                             partner, parent, parent in-law, grandparent, grandparent in-law of an eligible employee, or a retiree
                             or retiree’s spouse, same-sex domestic partner or the parent or parent-in-law of a retiree.
Coverage Amounts
                                                       Nursing Home Care           Home & Community           Lifetime
                                                        Daily Maximum                   Based Care           Maximum
                                                                                     Daily Maximum               **
                                  Option $100                    $100                      $50                $182,500
                                  Option $150                    $150                      $75                $273,750
                                  Option $200                    $200                      $100               $365,000
                             **All benefits paid will be deducted from the Lifetime Maximum.
Guaranteed Coverage                                      Montgomery County Public Schools (MCPS)
                             If you are a full-time* or part-time (working at least 20 hours) employee, actively at work, and
                             enroll within the end of the first full month following your date of hire.
                                                          Montgomery County Government (MCG)
                             If you are a full-time* or part-time (working at least 20 hours) employee or a crossing guard,
                             actively at work, and enroll within 60 days of date of hire.
                                                                   Montgomery College (MC)
                             If you are a full-time* or part-time (working at least 20 hours) employee, actively at work, and
                             enroll within 60 days of date of hire.
                                           Maryland National Capital Park & Planning Commission (MNCPPC)
                             If you are a full-time* or part-time (working at least 20 hours) employee, actively at work, and
                             enroll within 30 days of date of hire.
                                                 Washington Suburban Sanitary Commission (WSSC)
                          If you are a full-time* or part-time (working at least 16 hours) employee, actively at work, and
                          enroll within 30 days of date of hire.

                                                              The City of Rockville (COR):
                          If you are a full-time* or part-time (working at least 20 hours) employee, actively at work, and
                          enroll during the open enrollment period 05/12/08 – 05/23/08 or within 30 days of date of hire.
Medical                   All applicants other than those described under Guaranteed Coverage above must be medically
Evidence Requirements     underwritten. Note: Applicants age 72 and older will receive an in-person assessment to
                          supplement the information provided on the enrollment form.
Information/Referral      Prudential is dedicated to providing you with as much freedom as possible when it comes to making
Services                  your long term care decisions. Information/referral services, and advice and care counseling are
                          provided by Prudential Care Counselors who are available to you at any time, even if you are not
                          receiving benefits. Prudential Care Counselors may be reached toll free at 1-800-732-0416
                          Monday through Friday, 8am to 8pm EST.
                          In the event you decide you would rather use care management services other than Prudential Care
                          Counselors, Prudential will reimburse you for up to six private care management consultations per
                          calendar year up to the elected Daily Maximum per consultation.
Benefit                   Before benefits are payable, you must satisfy the 90 day Benefit Waiting/Elimination Period. This
Waiting/Elimination       period is counted in calendar days and begins on the date you contact Prudential to arrange for an
Period                    assessment (assuming you are determined to be eligible for benefits). You do NOT need to receive
                          formal long term care services to satisfy the waiting period. This waiting period needs to be
                          satisfied only once during your lifetime. Note: There is no waiting period for Respite Care or
                          Lifestyle Changes Benefits. However, Prudential must be notified at least 7 days prior to using
                          services or incurring expenses for these benefits.
Waiver of Premium         Once you satisfy the Benefit Waiting/Elimination Period and begin receiving benefits, Prudential
                          will waive your premium payments. This waiver applies to all benefits with the exception of
                          Respite Care, Lifestyle Changes Benefit, and Information/ Referral Services.
Lifestyle Changes         This benefit will reimburse you up to 5 times your Nursing Home Daily Maximum for costs
Benefit                   incurred for such things as home modifications and medical alert systems. There is no Benefit
                          Waiting/Elimination Period for this benefit.
Bed Reservation Benefit   This benefit reserves your nursing home bed for up to 20 days should you ever require a hospital
                          stay.
Death Benefit             If you should die before the age of 74, a portion of your premiums may be refunded to your spouse
                          (if applicable, otherwise to your estate). The percentage of premiums to be refunded is based on
                          your age at death. The refund will be reduced by any benefits paid.
                                                          Percent of Premium Refunded
                                  Age                             (less benefits paid)
                              64 & Under                                 100%
                              65                                          90%
                              66                                          80%
                              67                                          70%
                              68                                          60%
                              69                                          50%
                              70                                          40%
                              71                                          30%
                              72                                          20%
                              73                                          10%
                              74 & Over                                    0%
Respite Care              This benefit provides relief for a family member who normally provides unpaid care to you. The
                          benefit pays up to 20 days of Respite Care per calendar year, 100 days per lifetime. Care received
                          in a nursing home, your home, or in the community will be paid up to the applicable Daily
                          Maximum for these services. There is no Benefit Waiting/Elimination Period for this benefit.
     Optional Plan Features
  Automatic Inflation           If you elect this option, your benefits will automatically increase by 5% compounded annually
  Option                        while your premiums remain level based on your original issue age. If you do not elect this option,
                                Prudential will offer you opportunities to increase your coverage over time, but the rates for the
                                increase will be based on your attained age.
  Non-Forfeiture Benefit -      This option will allow you to retain access to a portion of your insurance benefits in the event you
  “Shortened Benefit            cease making premium payments. This rider will pay benefits according to the conditions in effect
  Period Option”                at the time insurance ended, up to the Daily Maximums you have chosen but with a reduced Lifetime
                                Maximum. This means you will have the full daily benefits available, but for a shorter period of
                                time.
                                This benefit can be used at any time during your lifetime until the reduced Lifetime Maximum is
                                exhausted. If your insurance ended due to non-payment of premium on or after the fifth
                                anniversary of your effective date, you may be entitled to receive benefits under this provision.
                                However, you must request benefits and Prudential must determine your eligibility. Your benefits
                                will be based on the Daily Maximums in effect at the time your insurance ended.
                                Should you elect this optional Rider, a table of shortened benefit periods for your coverage will be
                                provided when you receive your Certificate of insurance.
  Cash Benefit Option           Many people prefer the flexibility of cash benefit payments as opposed to a benefit that reimburses
                                for bills already paid. If you elect this option, you will receive benefit cash payments equal to the
                                Home & Community Based Care Daily Maximum you elect without having to incur formal
                                expenses. The cash benefits you receive can be used at your own discretion. Since benefits paid
                                under this optional rider are made without regard to costs incurred by you, part of the benefits could
                                be considered taxable income. You should consult a tax advisor for more information concerning
                                any possible tax implications.

Delay of Effective Date - The effective date of your insurance will be delayed if on the date your insurance would otherwise take
effect: (a) you are an Employee and you are not actively at work for the Group Contract Holder; or (b) you are eligible other than
as an Employee and you are confined in a health care institution or you are receiving home and community-based care or non-
institutional hospice care. The effective date will be delayed until the first day of the month following the date you, as an
Employee, return to work for the Group Contract Holder; or you are discharged from confinement and are not receiving care.

Coordination of Benefits -The benefits of this plan may be coordinated with certain other coverages that provide benefits for the
same services covered by this insurance. Consult your insurance certificate for more details.




This brochure has been designed to provide you with a brief summary of the important provisions of the Prudential Long Term
CareSM Insurance plan. This is not an insurance policy or contract. Issuance of coverage may be subject to Prudential’s
underwriting requirements. The insurance certificate you will receive if you are approved for coverage describes in detail the
benefit, limitations, and exclusions of this coverage. Since benefits vary by state, please carefully review your insurance
certificate for possible state variations. The Prudential Insurance Company of America is licensed in all states. All plans and
options may not be available in your state. Coverage is issued under Prudential Long Term CareSM Insurance 83500 contract
series. If there are any discrepancies between this brochure and the certificate, the certificate governs. Please be sure to review
the Outline of Coverage for definitions of important terms and more details of Prudential Long Term CareSM Insurance and its
features.

Prudential Long Term CareSM Insurance is underwritten by The Prudential Insurance Company of America; principal offices at
751 Broad Street, Newark, NJ 07102-3777. (800) 732-0416.

  INST-A000142
    How To Determine Your Rate
x   Select the plan below that best meets your needs (see Plan Details for
    a description of Optional Plan Features).

                   Basic Plan
                   Basic Plan plus Cash Benefit Option
                   Basic Plan plus Automatic Inflation
                   Basic Plan plus Automatic Inflation & Cash Benefit

    Shortened Benefit Period Option can be added to any of the above
    plans [see Step {].

y   Select the Daily Maximum Option that best meets your needs.

                        Nursing          Home &
                       Home Care       Community-
                         Daily         Based Care          Lifetime
                       Maximum        Daily Maximum        Maximum
      Option             $100               $50            $182,500
      $100
      Option               $150              $75            $273,750
      $150
      Option               $200              $100           $365,000
      $200


z   Locate your age on the rate sheet and read across to your selected
    plan [from Step x]. Then locate your selected Daily Maximum
    Option within that plan [from Step y].

{   If you elect the Shortened Benefit Period Option, your rate [from Step
    z] will be adjusted +23%.

    EXAMPLE
    If you select the Basic Plan, Option $100, and if you are 30 years old,
    your monthly premium rate will be $6.01.

    If you elect to add the Shortened Benefit Period Option to this plan,
    your premium rate will be $6.01 x 1.23 = $7.39.
Monthly Long Term Care Insurance Premium Rates
For Montgomery County Agencies

                                    Basic Plan                 Basic Plan                 Basic Plan
              Basic                    Plus                      Plus                 Plus Auto Inflation
              Plan              Cash Benefit Option        Automatic Inflation         & Cash Benefit
      Option Option   Option   Option Option    Option   Option   Option   Option   Option   Option   Option
Age   $100    $150    $200     $100    $150     $200     $100     $150     $200     $100     $150     $200
<25   $4.03   $6.05   $8.06    $6.86   $10.29   $13.72   $22.64   $33.96   $45.28   $32.81   $49.22   $65.62
 25    4.31    6.47    8.62     7.28    10.92    14.56    23.65    35.48    47.30    34.21    51.32    68.42
 26    4.61    6.92    9.22     7.73    11.60    15.46    24.71    37.07    49.42    35.67    53.51    71.34
 27    4.93    7.40    9.86     8.21    12.32    16.42    25.82    38.73    51.64    37.19    55.79    74.38
 28    5.27    7.91   10.54     8.72    13.08    17.44    26.98    40.47    53.96    38.77    58.16    77.54
 29    5.63    8.45   11.26     9.26    13.89    18.52    28.19    42.29    56.38    40.42    60.63    80.84
 30    6.01    9.02   12.02     9.83    14.75    19.66    29.45    44.18    58.90    42.14    63.21    84.28
 31    6.42    9.63   12.84    10.44    15.66    20.88    30.77    46.16    61.54    43.93    65.90    87.86
 32    6.87   10.31   13.74    11.09    16.64    22.18    32.15    48.23    64.30    45.79    68.69    91.58
 33    7.34   11.01   14.68    11.79    17.69    23.58    33.59    50.39    67.18    47.73    71.60    95.46
 34    7.84   11.76   15.68    12.53    18.80    25.06    35.10    52.65    70.20    49.76    74.64    99.52
 35    8.38   12.57   16.76    13.32    19.98    26.64    36.68    55.02    73.36    51.87    77.81   103.74
 36    8.95   13.43   17.90    14.15    21.23    28.30    38.32    57.48    76.64    54.07    81.11   108.14
 37    9.57   14.36   19.14    15.04    22.56    30.08    40.04    60.06    80.08    56.35    84.53   112.70
 38   10.23   15.35   20.46    15.98    23.97    31.96    41.84    62.76    83.68    58.75    88.13   117.50
 39   10.93   16.40   21.86    16.98    25.47    33.96    43.72    65.58    87.44    61.24    91.86   122.48
 40   11.68   17.52   23.36    18.05    27.08    36.10    45.69    68.54    91.38    63.84    95.76   127.68
 41   12.53   18.80   25.06    19.29    28.94    38.58    47.85    71.78    95.70    66.71   100.07   133.42
 42   13.46   20.19   26.92    20.62    30.93    41.24    50.12    75.18   100.24    69.72   104.58   139.44
 43   14.44   21.66   28.88    22.04    33.06    44.08    52.49    78.74   104.98    72.87   109.31   145.74
 44   15.50   23.25   31.00    23.56    35.34    47.12    54.97    82.46   109.94    76.15   114.23   152.30
 45   16.64   24.96   33.28    25.17    37.76    50.34    57.57    86.36   115.14    79.58   119.37   159.16
 46   17.87   26.81   35.74    26.91    40.37    53.82    60.29    90.44   120.58    83.17   124.76   166.34
 47   19.17   28.76   38.34    28.77    43.16    57.54    63.16    94.74   126.32    86.93   130.40   173.86
 48   20.58   30.87   41.16    30.74    46.11    61.48    66.14    99.21   132.28    90.84   136.26   181.68
 49   22.09   33.14   44.18    32.85    49.28    65.70    69.28   103.92   138.56    94.94   142.41   189.88
 50   23.72   35.58   47.44    35.12    52.68    70.24    72.55   108.83   145.10    99.22   148.83   198.44
 51   25.73   38.60   51.46    37.85    56.78    75.70    76.58   114.87   153.16   104.38   156.57   208.76
 52   27.92   41.88   55.84    40.80    61.20    81.60    80.82   121.23   161.64   109.79   164.69   219.58
 53   30.28   45.42   60.56    43.98    65.97    87.96    85.29   127.94   170.58   115.49   173.24   230.98
 54   32.86   49.29   65.72    47.40    71.10    94.80    90.02   135.03   180.04   121.49   182.24   242.98
 55   35.66   53.49   71.32    51.10    76.65   102.20    95.02   142.53   190.04   127.79   191.69   255.58
 56   38.68   58.02   77.36    55.07    82.61   110.14   100.28   150.42   200.56   134.42   201.63   268.84
 57   41.96   62.94   83.92    59.36    89.04   118.72   105.84   158.76   211.68   141.40   212.10   282.80
 58   45.53   68.30   91.06    63.98    95.97   127.96   111.71   167.57   223.42   148.74   223.11   297.48
 59   49.40   74.10   98.80    68.97   103.46   137.94   117.90   176.85   235.80   156.46   234.69   312.92
Monthly Long Term Care Insurance Premium Rates
For Montgomery County Agencies

                                           Basic Plan                    Basic Plan                      Basic Plan
                   Basic                      Plus                         Plus                      Plus Auto Inflation
                   Plan                Cash Benefit Option           Automatic Inflation              & Cash Benefit
         Option Option     Option    Option Option      Option     Option      Option   Option     Option   Option   Option
 Age     $100     $150    $200        $100     $150    $200        $100    $150          $200      $100    $150     $200
  60     53.59    80.39   107.18      74.34    111.51 148.68       124.43 186.65         248.86    164.58 246.87 329.16
  61     58.16    87.24   116.32      79.98    119.97 159.96       131.72 197.58         263.44    173.25 259.88 346.50
  62     63.12    94.68   126.24      86.04    129.06 172.08       139.43 209.15         278.86    182.37 273.56 364.74
  63     68.50    102.75 137.00        92.57   138.86 185.14       147.58 221.37         295.16    191.98 287.97 383.96
  64     74.34    111.51 148.68        99.60   149.40 199.20       156.22 234.33         312.44    202.08 303.12 404.16
  65     80.67    121.01 161.34       107.15   160.73 214.30       165.36 248.04         330.72    212.73 319.10 425.46
  66     87.55    131.33 175.10       115.29   172.94 230.58       175.04 262.56         350.08    223.93 335.90 447.86
  67     95.02    142.53 190.04       124.02   186.03 248.04       185.27 277.91         370.54    235.72 353.58 471.44
  68     103.11   154.67 206.22       133.44   200.16 266.88       196.11 294.17         392.22    248.14 372.21 496.28
  69     111.91   167.87 223.82       143.57   215.36 287.14       207.59 311.39         415.18    261.21 391.82 522.42
  70     121.45   182.18 242.90       154.45   231.68 308.90       219.73 329.60         439.46    274.97 412.46 549.94
  71     134.74   202.11 269.48       170.11   255.17 340.22       237.45 356.18         474.90    295.95 443.93 591.90
  72     149.48   224.22 298.96       187.36   281.04 374.72       256.60 384.90         513.20    318.54 477.81 637.08
  73     165.85   248.78 331.70       206.34   309.51 412.68       277.30 415.95         554.60    342.86 514.29 685.72
  74     184.01   276.02 368.02       227.25   340.88 454.50       299.66 449.49         599.32    369.03 553.55 738.06
  75     204.14   306.21 408.28       250.29   375.44 500.58       323.83 485.75         647.66    397.20 595.80 794.40
  76     226.91   340.37 453.82       276.60   414.90 553.20       352.33 528.50         704.66    430.30 645.45 860.60
  77     252.22   378.33 504.44       305.69   458.54 611.38       383.33 575.00         766.66    466.16 699.24 932.32
  78     280.36   420.54 560.72       337.84   506.76 675.68       417.07 625.61         834.14    505.00 757.50 1,010.00
  79     311.63   467.45 623.26       373.37   560.06 746.74       453.78 680.67         907.56    547.08 820.62 1,094.16
  80     346.39   519.59 692.78       412.62   618.93 825.24       493.72 740.58         987.44    592.67 889.01 1,185.34
  81     373.31   559.97 746.62       443.57   665.36 887.14       524.42 786.63        1,048.84   627.56 941.34 1,255.12
  82     402.31   603.47 804.62       476.84   715.26 953.68       557.04 835.56        1,114.08   664.51 996.77 1,329.02
  83     433.57   650.36 867.14       512.59   768.89 1,025.18     591.69 887.54        1,183.38   703.63 1,055.45 1,407.26
  84     467.25   700.88 934.50       551.04   826.56 1,102.08     628.48 942.72        1,256.96   745.05 1,117.58 1,490.10
  85     503.54   755.31 1,007.08     592.37   888.56 1,184.74     667.57 1,001.36      1,335.14   788.91 1,183.37 1,577.82




To add the Shortened Benefit Period Option to any plan, add 23% to the rate.
                               Instructions
If you are an active Full-Time or Part-Time Montgomery County Public Schools
employee working at least 20 hours* per week and enroll by the end of the first
month following your date of hire

                                       or
If you are an active Full-Time or Part-Time Montgomery College employee working
at least 20 hours* per week and enroll within 60 days of your date of hire

                                      or
If you are an active Full-Time or Part-Time Montgomery County Government
employee working at least 20 hours per week or a Crossing Guard working at least 16
hours per week and enroll within 60 days of your date of hire

                                         or
 If you are an active Full-Time or Part-Time Maryland National Capitol Parks &
  Planning Commission employee working at least 20 hours* per week and enroll
                         within 30 days of your date of hire

                                         or
If you are an active Full-Time or Part-Time Washington Suburban Sanitary
Commission employee working at least 16 hours per week and enroll within 30 days
of date of hire

                                           or
If you are an active Full-Time or Part-Time City of Rockville employee working at
least 37.5 hours per week full-time, or 20 hours per week part-time and enroll
between 5/12/08 and 5/23/08, or within 30 days of date of hire


                             USE THIS FORM
                                        Ö
i Return this enrollment form to Prudential using the enclosed Business Reply
  Envelope.

i For your convenience, you may elect monthly Electronic Funds Transfer (EFT) by
   completing the enclosed EFT Authorization Form.
The Prudential Insurance Company America
The Prudential Insurance Company of of America
Prudential Long Term Care Customer Service Center
Prudential Long Term Care Customer Service Center                         Prudential Long Term Care™ Insurance for
P.O. Box 8526, Philadelphia,    19101-8526 • 1-800-732-0416
P. O.Box 8526, Philadelphia, PA 19176 • 1-800-732-0416                                 Montgomery SM Insurance for
                                                                        Prudential Long Term CareCounty Agencies
                                                                                    Montgomery County Agencies



Eligibility
 WHO CAN ENROLL FOR THIS COVERAGE?

The following persons can enroll for the Prudential         You must be at least age 18 but less than age 85 when
Long Term CareSM Insurance Plan sponsored by                your Enrollment Form is completed.
Montgomery County Agencies:
                                                            Retired Employees, all Qualified Family Members, and
1) An Employee or Retiree of Montgomery County              Domestic Partners are required to provide evidence of
   Agencies; or                                             insurability as part of the enrollment process. All
2) Persons who are related to an Employee in one of         sections of the Enrollment Form must be completed.
   the following ways:
   a) The spouse or Domestic Partner of the Employee;
      or
   b) The parent or grandparent of the Employee or
      the Employee’s spouse; or
   c) The spouse of the parent or grandparent; or
   d) The adult child of an Employee or the adult
      child’s spouse; or
3) The spouse or Domestic Partner of a Retiree.

A Domestic Partner is a person of the same or
opposite sex of an Employee or Retiree, who:

1) is someone other than your spouse;
2) has lived with you for at least 6 months and intends
   to remain a member of your household for the
   period of Coverage;
3) has a serious and committed relationship with you;
4) is financially interdependent with you; and
5) is not related to you in a way that would prohibit
   legal marriage or legally married or a Domestic
   Partner to anyone else.




GRP 112971    MD     MCA 33208 10/01/2005         Page 1 of 6
    Prudential Insurance Company America
The Prudential Insurance Company ofof America
PrudentialLong Term Care Customer Service Center
Prudential Long Term Care Customer Service Center                            Prudential Long Term Care™ Insurance for
 .O. Box 8526, Philadelphia, PA 19101-8526 • 1-800-732-0416
P O.Box 8526, Philadelphia, PA 19176 • 1-800-732-0416
P.                                                                         Prudential Long Term CareSM Insurance for
                                                                                          Montgomery County Agencies
                                                                                       Montgomery County Agencies



Privacy Notice
 IMPORTANT NOTICE ABOUT PRUDENTIAL’S INFORMATION PRACTICES

Thank you for choosing The Prudential Insurance               Your Right to Information
Company of America (Prudential) for your insurance            If we do not issue the policy you requested, we will tell
needs. Before we can issue coverage we must review            you and explain the reasons for our decision. If you
your application/enrollment form. To do this, we need         write to us, we will describe the information we have
to collect and evaluate personal information about            relating to this insurance transaction, describe how
you. This notice tells you about Prudential’s                 you may access it, and tell you how you may request
information practices.                                        correction, amendment or deletion of information that
                                                              you dispute. Please note that requested information
Collecting Information for Underwriting                       from your medical records will only be released to a
Prudential will review information about you to decide        medical professional designated by you.
if you are eligible for coverage. In addition to your
application/enrollment form, Prudential may obtain            Upon receipt of a request from you, the MIB will
information about you from the following sources: a           arrange disclosure of any information it may have in
medical examination which we may ask you to take;             your file. If you question the accuracy of the
an in-person health interview; the Medical Information        information in the MIB’s file, you may contact the MIB
Bureau (MIB); and doctors, hospitals or health care           and seek a correction in accordance with the
providers who have information about you or your              procedures set forth in the federal Fair Credit Reporting
mental or physical health.                                    Act. The address of the MIB’s information office is Post
                                                              Office Box 105, Essex Station, Boston, Massachusetts
Disclosing Information                                        02112, telephone number (617) 426-3660.
We will treat any information we obtain or have
obtained about you as confidential. However, we may           *This sentence does not apply to residents of
disclose it to: your doctor, if we find a serious health      Minnesota.
problem you do not know about; the MIB; anyone
conducting mortality or morbidity studies; and
Company affiliates for insurance marketing,
underwriting, policyholder service or claims handling.
We may also disclose information to Company
affiliates for non-insurance marketing purposes unless
you write to us at our Long Term Care Customer
Service Center and direct us not to make such a
disclosure.* The Company or its reinsurers may make
a brief report to the MIB, a non-profit membership
organization of life insurance companies, which
operates an information exchange on behalf of its
members. If you apply to another MIB member
company for life or health insurance coverage, or a
claim for benefits is submitted to such a company, the
MIB, upon request, will supply such company with the
information in its file. Similarly, the Company or its
reinsurers may release information in its file to other
life insurance companies to which you may apply for
life or health insurance or to which a claim for benefits
may be submitted.




GRP 112971    MD      MCA 33208 10/01/2005          Page 2 of 6
The Prudential Insurance Company America
The Prudential Insurance Company of of America
Prudential Long Term Care Customer Service Center
Prudential Long Term Care Customer Service Center                       Prudential Long Term Care™ Insurance for
P.O. Box 8526, Philadelphia, PA 19101-8526 • 1-800-732-0416
P. O.Box 8526, Philadelphia, PA 19176 • 1-800-732-0416                               Montgomery SM Insurance for
                                                                       Prudential Long Term CareCounty Agencies
                                                                                  Montgomery County Agencies



State Notices
 IMPORTANT STATE NOTICES ABOUT PRUDENTIAL LONG TERM CARESM INSURANCE

Caution: Any person who, knowingly and with intent to defraud any insurance company or other person, files
an application for insurance or statement of claim containing any materially false information, or conceals, for
the purpose of misleading, information concerning any fact material thereto, may commit a fraudulent insurance
act, which is a crime that may subject such person to criminal and/or civil penalties.




GRP 112971    MD     MCA 33208 10/01/2005         Page 3 of 6
The Prudential Insurance Company America
The Prudential Insurance Company of of America
Prudential Long Term Care Customer Service Center
Prudential Long Term Care Customer Service Center                                Prudential Long Term Care™ Insurance for
P.O. Box 8526, Philadelphia,    19101-8526 • 1-800-732-0416
P. O.Box 8526, Philadelphia, PA 19176 • 1-800-732-0416                                        Montgomery SM Insurance for
                                                                               Prudential Long Term CareCounty Agencies
                                                                                           Montgomery County Agencies



Enrollment Form
                             complete all necessary parts this enrollment form. Please print using blue or
INSTRUCTIONS: Read and complete all necessary parts ofof this enrollment form. Please print using blue or
                   “X” to mark boxes where indicated. Provide your signature in areas required. Return com-
black ink. Use an “X”to mark boxes where indicated. Provide your signature in all all areas required. Return
completed forms to: Prudential Long Term Care Unit, P 8526, 8526, Philadelphia, PA you have questions, call
pleted forms to: Prudential Long Term Care Unit, P.O. Box.O. BoxPhiladelphia, PA 19176. If19101-8526. If you have
1-800-732-0416.
questions, call 1-800-732-0416.


 A     APPLICANT INFORMATION


 Eligibility Status              Mr.      Mrs.     Ms.      ____               Marital Status       Married          Unmarried
 (check one)
    Active Full-time
            Full-time         Full name
    Employee
    Employee
    Active Part-time
    Active Part-time          Address                                                                          Apt.
    Employee
    Employee                      .O.
                              No P Boxes please
    SubstituteTeacher
                Teacher
    (MCPSonly)
    (MCPS only)               City                                             State                           ZIP
    Retiree
    Retiree
    Spouse
    Spouse                    Daytime phone (        )              -          Evening phone (             )          -
    Domestic Partner
    Domestic Partner          Best time to call:   AM          PM
    (MCPS and MCG only)
    (MCPS, MCG, and
    Parent
    COR [same-sex] only)      Date                   Date                        Social Security
    Parent-in-law
    Parent                    of birth               of hire                     number
    Grandparent
    Parent-in-law
    Parent-in-Law
    Grandparent-in-law        If married, is your spouse applying for this insurance?                          Yes        No
    Grandparent
     Grandparent-in-law
     Grandparent-in-Law       If your spouse currently has Prudential Long Term Care       SM

                              Insurance, please provide policy/certificate number:

If this application is for someone other than an eligible employee (e.g., a spouse, family member, domestic partner
or other relation), please provide information about the eligible employee in this section.
Employee full name                                                                 Date of hire

Employee Social Security number

Daytime phone (           )          -                            Evening phone (               )      -

 B     BENEFIT OPTIONS SELECTION for Federally Tax Qualified Long Term Care Insurance contract
1. Coverage Amounts       Nursing Home Care Daily Maximum               Lifetime Maximum
     Plan 1               $100                                          $182,500
     Plan 2               $150                                          $273,750
     Plan 3               $200                                          $365,000
2. Home and Community-Based Care Daily Maximum
   is 50% of the Nursing Home Care Daily Maximum
3. Optional Automatic Inflation Increase Rider — I have reviewed the Outline of Coverage                       Yes        No
   and the graphs which compare the benefits and premiums of this Coverage with and without
   this Rider, and I want this Rider included in my Coverage.
    If you choose “NO” for the Automatic Inflation Increase Rider, please sign below.
    I reject inflation protection.

     X Applicant Signature                                                                                     Date



GRP 112971    MD      MCA 33208 10/01/2005          Page 4 of 6
4. Optional Non-Forfeiture Benefit Rider — I have reviewed the explanation of the optional        Yes            No
   Non-Forfeiture Benefit in the Outline of Coverage, and I want this Rider included in my Coverage.
5. Optional Cash Benefit Rider                                                                         Yes       No


 C     PAYMENT METHOD
Choose ONE of the following payment plans.
     Electronic Funds Transfer (EFT) — Monthly Payment If choosing this option, you must complete and return
     the enclosed EFT Authorization Form and a sample voided check.
   Direct Billing
   Bill to:               How often:           Billing address, if different from Section A:
      Applicant             Quarterly
       Employee, if other   Semi-Annually
       than applicant       Annually


 D     INSURANCE HISTORY

1. Are you covered by Medicaid or Medi-Cal (not Medicare)?                                               Yes     No
2. Do you have another long term care insurance policy or certificate in force (including
   health care service contract or health maintenance organization contract)?                            Yes     No
3. Did you have another long term care insurance policy or certificate in force during the
   last 12 months?                                                                                      Yes      No
4. Do you intend to replace any of your medical or health insurance coverage with this insurance? Yes            No
  If you answered “YES” to questions 3 or 4 of this section, please provide the following information.
  Name of company                                                 Name of company

  Address                                                         Address



  Policy number                                                   Policy number
  Check type:                Amount of                            Check type:              Amount of
    Group     Individual     Coverage: $                            Group     Individual   Coverage: $

      Check here if you        Check here if this                   Check here if you       Check here if this
      intend to replace        policy lapsed.                       intend to replace       policy lapsed.
      this policy.             Give date:                           this policy.            Give date:




GRP 112971     MD     MCA 33208 10/01/2005          Page 5 of 6
 E      NOTIFICATION OF UNINTENTIONAL LAPSE

You can provide Prudential with the name of a friend or relative to notify if your coverage is about to lapse
because the premium was not paid when due. This designation does not constitute an acceptance of liability by
the person named. Prudential will notify you each year of your right to designate or change the existing
designation for this purpose. Choose ONE of the following options:

     Name a Designee                                               Waive this Notice option

 First name                                 M.I.                 I understand that I have the right to name at least
                                                                 one person other than myself to receive notice of
 Last name                                                       lapse or termination of my long term care insurance
                                                                 coverage for non-payment of premium. I understand
 Address                                                         that notice will not be given until 30 days after the
                                                                 premium is due and not paid. By my signature, I elect
                                                                 NOT to name any person to receive such notice.

 City
                                                                 X Applicant’s signature
 State                             ZIP                              Date


 F      APPLICANT AGREEMENTS

Caution: If your answers on this Enrollment Form are misstated or untrue, Prudential may have the right to deny
benefits or rescind your coverage.

To the best of my knowledge and belief, the answers on this Enrollment Form are complete and true. I understand
and agree that:
 1. The Long Term Care Insurance coverage is underwritten by The Prudential Insurance Company of America
    (Prudential), whose corporate offices are located in Newark, New Jersey.
 2. This Enrollment Form will be the basis for the Long Term Care Insurance coverage for which I am applying to
    Prudential under a Group Contract.
 3. My coverage will NOT take effect unless Prudential has approved this Enrollment Form. If issued, my Long
    Term Care Insurance coverage will take effect on the Effective Date assigned by Prudential.
 4. Prudential has the right to change premium rates in the future but only on a class basis.
 5. I have received the Outline of Coverage and A Shopper’s Guide to Long Term Care Insurance.
 6. I have received the Privacy Notice concerning Prudential’s Information Practices.
 7. If I am eligible for Medicare, I have received the Guide to Health Insurance for People with Medicare.
 8. I have read, or had read to me, the completed Enrollment Form, and I understand that any false statement or
    misrepresentation in my Enrollment Form may result in loss of coverage under the Group Contract.
 9. Benefits and the costs of each of the options have been fully explained to me.

X Applicant’s signature                                                                         Date




GRP 112971    MD     MCA 33208 10/01/2005          Page 6 of 6
     Montgomery County Agencies
            Enrollment Instructions

                              If you are:


              An eligible FAMILY MEMBER,

                                   -or-

    an EMPLOYEE enrolling after the initial open
       enrollment or new hire eligibility period.

                PLEASE USE THIS FORM

                                Ö
Please be sure to complete all sections of the application form and
provide your signature where indicated and return all forms to Prudential
using the enclosed business reply envelope.
i   Application;
i   Medical History & Insurability form;
i   Authorization of the HIPAA Privacy Rule;
i   Long-Term Care Insurance Personal Worksheet;
i   EFT Authorization Form (if applicable)
The Prudential Insurance Company America
The Prudential Insurance Company of of America
Prudential Long Term Care Customer Service Center
Prudential Long Term Care Customer Service Center                         Prudential Long Term Care™ Insurance for
P.O. Box 8526, Philadelphia,    19101-8526 • 1-800-732-0416
P. O.Box 8526, Philadelphia, PA 19176 • 1-800-732-0416                                 Montgomery SM Insurance for
                                                                        Prudential Long Term CareCounty Agencies
                                                                                    Montgomery County Agencies



Eligibility
 WHO CAN ENROLL FOR THIS COVERAGE?

The following persons can enroll for the Prudential         You must be at least age 18 but less than age 85 when
Long Term CareSM Insurance Plan sponsored by                your Enrollment Form is completed.
Montgomery County Agencies:
                                                            Retired Employees, all Qualified Family Members, and
1) An Employee or Retiree of Montgomery County              Domestic Partners are required to provide evidence of
   Agencies; or                                             insurability as part of the enrollment process. All
2) Persons who are related to an Employee in one of         sections of the Enrollment Form must be completed.
   the following ways:
   a) The spouse or Domestic Partner of the Employee;
      or
   b) The parent or grandparent of the Employee or
      the Employee’s spouse; or
   c) The spouse of the parent or grandparent; or
   d) The adult child of an Employee or the adult
      child’s spouse; or
3) The spouse or Domestic Partner of a Retiree.

A Domestic Partner is a person of the same or
opposite sex of an Employee or Retiree, who:

1) is someone other than your spouse;
2) has lived with you for at least 6 months and intends
   to remain a member of your household for the
   period of Coverage;
3) has a serious and committed relationship with you;
4) is financially interdependent with you; and
5) is not related to you in a way that would prohibit
   legal marriage or legally married or a Domestic
   Partner to anyone else.




GRP 112971    MD     MCA 33208 10/01/2005         Page 1 of 6
    Prudential Insurance Company America
The Prudential Insurance Company ofof America
PrudentialLong Term Care Customer Service Center
Prudential Long Term Care Customer Service Center                            Prudential Long Term Care™ Insurance for
 .O. Box 8526, Philadelphia, PA 19101-8526 • 1-800-732-0416
P O.Box 8526, Philadelphia, PA 19176 • 1-800-732-0416
P.                                                                         Prudential Long Term CareSM Insurance for
                                                                                          Montgomery County Agencies
                                                                                       Montgomery County Agencies



Privacy Notice
 IMPORTANT NOTICE ABOUT PRUDENTIAL’S INFORMATION PRACTICES

Thank you for choosing The Prudential Insurance               Your Right to Information
Company of America (Prudential) for your insurance            If we do not issue the policy you requested, we will tell
needs. Before we can issue coverage we must review            you and explain the reasons for our decision. If you
your application/enrollment form. To do this, we need         write to us, we will describe the information we have
to collect and evaluate personal information about            relating to this insurance transaction, describe how
you. This notice tells you about Prudential’s                 you may access it, and tell you how you may request
information practices.                                        correction, amendment or deletion of information that
                                                              you dispute. Please note that requested information
Collecting Information for Underwriting                       from your medical records will only be released to a
Prudential will review information about you to decide        medical professional designated by you.
if you are eligible for coverage. In addition to your
application/enrollment form, Prudential may obtain            Upon receipt of a request from you, the MIB will
information about you from the following sources: a           arrange disclosure of any information it may have in
medical examination which we may ask you to take;             your file. If you question the accuracy of the
an in-person health interview; the Medical Information        information in the MIB’s file, you may contact the MIB
Bureau (MIB); and doctors, hospitals or health care           and seek a correction in accordance with the
providers who have information about you or your              procedures set forth in the federal Fair Credit Reporting
mental or physical health.                                    Act. The address of the MIB’s information office is Post
                                                              Office Box 105, Essex Station, Boston, Massachusetts
Disclosing Information                                        02112, telephone number (617) 426-3660.
We will treat any information we obtain or have
obtained about you as confidential. However, we may           *This sentence does not apply to residents of
disclose it to: your doctor, if we find a serious health      Minnesota.
problem you do not know about; the MIB; anyone
conducting mortality or morbidity studies; and
Company affiliates for insurance marketing,
underwriting, policyholder service or claims handling.
We may also disclose information to Company
affiliates for non-insurance marketing purposes unless
you write to us at our Long Term Care Customer
Service Center and direct us not to make such a
disclosure.* The Company or its reinsurers may make
a brief report to the MIB, a non-profit membership
organization of life insurance companies, which
operates an information exchange on behalf of its
members. If you apply to another MIB member
company for life or health insurance coverage, or a
claim for benefits is submitted to such a company, the
MIB, upon request, will supply such company with the
information in its file. Similarly, the Company or its
reinsurers may release information in its file to other
life insurance companies to which you may apply for
life or health insurance or to which a claim for benefits
may be submitted.




GRP 112971    MD      MCA 33208 10/01/2005          Page 2 of 6
The Prudential Insurance Company America
The Prudential Insurance Company of of America
Prudential Long Term Care Customer Service Center
Prudential Long Term Care Customer Service Center                       Prudential Long Term Care™ Insurance for
P.O. Box 8526, Philadelphia, PA 19101-8526 • 1-800-732-0416
P. O.Box 8526, Philadelphia, PA 19176 • 1-800-732-0416                               Montgomery SM Insurance for
                                                                       Prudential Long Term CareCounty Agencies
                                                                                  Montgomery County Agencies



State Notices
 IMPORTANT STATE NOTICES ABOUT PRUDENTIAL LONG TERM CARESM INSURANCE

Caution: Any person who, knowingly and with intent to defraud any insurance company or other person, files
an application for insurance or statement of claim containing any materially false information, or conceals, for
the purpose of misleading, information concerning any fact material thereto, may commit a fraudulent insurance
act, which is a crime that may subject such person to criminal and/or civil penalties.




GRP 112971    MD     MCA 33208 10/01/2005         Page 3 of 6
The Prudential Insurance Company America
The Prudential Insurance Company of of America
Prudential Long Term Care Customer Service Center
Prudential Long Term Care Customer Service Center                                Prudential Long Term Care™ Insurance for
P.O. Box 8526, Philadelphia,    19101-8526 • 1-800-732-0416
P. O.Box 8526, Philadelphia, PA 19176 • 1-800-732-0416                                        Montgomery SM Insurance for
                                                                               Prudential Long Term CareCounty Agencies
                                                                                           Montgomery County Agencies



Enrollment Form
                             complete all necessary parts this enrollment form. Please print using blue or
INSTRUCTIONS: Read and complete all necessary parts ofof this enrollment form. Please print using blue or
                   “X” to mark boxes where indicated. Provide your signature in areas required. Return com-
black ink. Use an “X”to mark boxes where indicated. Provide your signature in all all areas required. Return
completed forms to: Prudential Long Term Care Unit, P 8526, 8526, Philadelphia, PA you have questions, call
pleted forms to: Prudential Long Term Care Unit, P.O. Box.O. BoxPhiladelphia, PA 19176. If19101-8526. If you have
1-800-732-0416.
questions, call 1-800-732-0416.


 A     APPLICANT INFORMATION


 Eligibility Status              Mr.      Mrs.     Ms.      ____               Marital Status       Married          Unmarried
 (check one)
    Active Full-time
            Full-time         Full name
    Employee
    Employee
    Active Part-time
    Active Part-time          Address                                                                          Apt.
    Employee
    Employee                      .O.
                              No P Boxes please
    SubstituteTeacher
                Teacher
    (MCPSonly)
    (MCPS only)               City                                             State                           ZIP
    Retiree
    Retiree
    Spouse
    Spouse                    Daytime phone (        )              -          Evening phone (             )          -
    Domestic Partner
    Domestic Partner          Best time to call:   AM          PM
    (MCPS and MCG only)
    (MCPS, MCG, and
    Parent
    COR [same-sex] only)      Date                   Date                        Social Security
    Parent-in-law
    Parent                    of birth               of hire                     number
    Grandparent
    Parent-in-law
    Parent-in-Law
    Grandparent-in-law        If married, is your spouse applying for this insurance?                          Yes        No
    Grandparent
     Grandparent-in-law
     Grandparent-in-Law       If your spouse currently has Prudential Long Term Care       SM

                              Insurance, please provide policy/certificate number:

If this application is for someone other than an eligible employee (e.g., a spouse, family member, domestic partner
or other relation), please provide information about the eligible employee in this section.
Employee full name                                                                 Date of hire

Employee Social Security number

Daytime phone (           )          -                            Evening phone (               )      -

 B     BENEFIT OPTIONS SELECTION for Federally Tax Qualified Long Term Care Insurance contract
1. Coverage Amounts       Nursing Home Care Daily Maximum               Lifetime Maximum
     Plan 1               $100                                          $182,500
     Plan 2               $150                                          $273,750
     Plan 3               $200                                          $365,000
2. Home and Community-Based Care Daily Maximum
   is 50% of the Nursing Home Care Daily Maximum
3. Optional Automatic Inflation Increase Rider — I have reviewed the Outline of Coverage                       Yes        No
   and the graphs which compare the benefits and premiums of this Coverage with and without
   this Rider, and I want this Rider included in my Coverage.
    If you choose “NO” for the Automatic Inflation Increase Rider, please sign below.
    I reject inflation protection.

     X Applicant Signature                                                                                     Date



GRP 112971    MD      MCA 33208 10/01/2005          Page 4 of 6
4. Optional Non-Forfeiture Benefit Rider — I have reviewed the explanation of the optional        Yes            No
   Non-Forfeiture Benefit in the Outline of Coverage, and I want this Rider included in my Coverage.
5. Optional Cash Benefit Rider                                                                         Yes       No


 C     PAYMENT METHOD
Choose ONE of the following payment plans.
     Electronic Funds Transfer (EFT) — Monthly Payment If choosing this option, you must complete and return
     the enclosed EFT Authorization Form and a sample voided check.
   Direct Billing
   Bill to:               How often:           Billing address, if different from Section A:
      Applicant             Quarterly
       Employee, if other   Semi-Annually
       than applicant       Annually


 D     INSURANCE HISTORY

1. Are you covered by Medicaid or Medi-Cal (not Medicare)?                                               Yes     No
2. Do you have another long term care insurance policy or certificate in force (including
   health care service contract or health maintenance organization contract)?                            Yes     No
3. Did you have another long term care insurance policy or certificate in force during the
   last 12 months?                                                                                      Yes      No
4. Do you intend to replace any of your medical or health insurance coverage with this insurance? Yes            No
  If you answered “YES” to questions 3 or 4 of this section, please provide the following information.
  Name of company                                                 Name of company

  Address                                                         Address



  Policy number                                                   Policy number
  Check type:                Amount of                            Check type:              Amount of
    Group     Individual     Coverage: $                            Group     Individual   Coverage: $

      Check here if you        Check here if this                   Check here if you       Check here if this
      intend to replace        policy lapsed.                       intend to replace       policy lapsed.
      this policy.             Give date:                           this policy.            Give date:




GRP 112971     MD     MCA 33208 10/01/2005          Page 5 of 6
 E      NOTIFICATION OF UNINTENTIONAL LAPSE

You can provide Prudential with the name of a friend or relative to notify if your coverage is about to lapse
because the premium was not paid when due. This designation does not constitute an acceptance of liability by
the person named. Prudential will notify you each year of your right to designate or change the existing
designation for this purpose. Choose ONE of the following options:

     Name a Designee                                               Waive this Notice option

 First name                                 M.I.                 I understand that I have the right to name at least
                                                                 one person other than myself to receive notice of
 Last name                                                       lapse or termination of my long term care insurance
                                                                 coverage for non-payment of premium. I understand
 Address                                                         that notice will not be given until 30 days after the
                                                                 premium is due and not paid. By my signature, I elect
                                                                 NOT to name any person to receive such notice.

 City
                                                                 X Applicant’s signature
 State                             ZIP                              Date


 F      APPLICANT AGREEMENTS

Caution: If your answers on this Enrollment Form are misstated or untrue, Prudential may have the right to deny
benefits or rescind your coverage.

To the best of my knowledge and belief, the answers on this Enrollment Form are complete and true. I understand
and agree that:
 1. The Long Term Care Insurance coverage is underwritten by The Prudential Insurance Company of America
    (Prudential), whose corporate offices are located in Newark, New Jersey.
 2. This Enrollment Form will be the basis for the Long Term Care Insurance coverage for which I am applying to
    Prudential under a Group Contract.
 3. My coverage will NOT take effect unless Prudential has approved this Enrollment Form. If issued, my Long
    Term Care Insurance coverage will take effect on the Effective Date assigned by Prudential.
 4. Prudential has the right to change premium rates in the future but only on a class basis.
 5. I have received the Outline of Coverage and A Shopper’s Guide to Long Term Care Insurance.
 6. I have received the Privacy Notice concerning Prudential’s Information Practices.
 7. If I am eligible for Medicare, I have received the Guide to Health Insurance for People with Medicare.
 8. I have read, or had read to me, the completed Enrollment Form, and I understand that any false statement or
    misrepresentation in my Enrollment Form may result in loss of coverage under the Group Contract.
 9. Benefits and the costs of each of the options have been fully explained to me.

X Applicant’s signature                                                                         Date




GRP 112971    MD     MCA 33208 10/01/2005          Page 6 of 6
The Prudential Insurance Company America
The Prudential Insurance Company ofof America
Prudential Long Term Care Customer Service Center
Prudential Long Term Care Customer Service Center                           Prudential Long Term Care™ Insurance for
P. Box 8526, Philadelphia, PA 19176 • 1-800-732-0416
 .O.
P O. Box8526, Philadelphia, PA 19101-8526 • 1-800-732-0416                Prudential Long Term CareSM Insurance for
                                                                                         Montgomery County Agencies
                                                                                      Montgomery County Agencies



Medical History & Insurability Form
for Long Term Care Insurance
INSTRUCTIONS: Read and complete all necessary parts of this Medical History & Insurability           Please print
INSTRUCTIONS: Read and complete all necessary parts of this Medical History & Insurability Form. Please print
using blue or black ink. Use an “X” mark boxes where indicated. Provide your signature in               required.
using blue or black ink. Use an “X” to mark boxes where indicated. Provide your signature in all areas required.
                “NO” to each question, attach the completed Insurability Profile Form your Enrollment Form
If you answer “NO” to each question, attach the completed Insurability Profile Form toto your Enrollment Form
          it in the enclosed, postage-paid envelope Prudential Long Term Care Unit, P.O. Box 8526,
and mail it in the enclosed potage-paid envelope to:to: Prudential Long Term Care Unit, P Box 8526,
                                                                                         .O.
                   19176. If you you questions, call call 1-800-732-0416.
Philadelphia, PA 19101-8526. If havehave questions,1-800-732-0416.
Caution: Any person who, knowingly and with intent to defraud any insurance company or other person, files an
application for insurance or statement of claim containing any materially false information, or conceals, for the
purpose of misleading, information concerning any fact material thereto, may commit a fraudulent insurance act,
which is a crime that may result in criminal and/or civil penalties.


 A    APPLICANT INFORMATION

Full name

Daytime phone (        )      -           Evening phone (          )     -            Best time to call:   AM    PM

Date on accompanying enrollment form                      Group Contract Holder Montgomery County Agencies


 B    TELL US ABOUT YOUR INSURABILITY

1. Within the past 7 years, have you had, do you currently have, or have you been diagnosed or treated
   by a Licensed Health Care Practitioner as having any of the following medical conditions:
   Amyotrophic lateral sclerosis, multiple sclerosis, muscular dystrophy, or Parkinson’s disease?       Yes     No
   Alzheimer’s disease, chronic memory loss, frequent or persistent forgetfulness, senility,
   dementia or organic brain syndrome?                                                                  Yes     No
   Congestive heart failure, diagnosed or symptomatic, within the past 12 months?                       Yes     No
   Diabetes treated with insulin or liver cirrhosis?                                                    Yes     No
   Metastatic cancer (cancer that has spread from the original site or location)?                       Yes     No
   Stroke or cerebrovascular accident?                                                                  Yes     No
   Transient Ischemic Attack (TIA) within the past 5 years, multiple TIAs, or TIA in combination
   with diabetes or any heart surgery?                                                                  Yes     No
2. Within the past 48 months, have you been diagnosed or treated for cancer of a major body organ? Yes          No
3. Do you use any of the following: walker or quad-cane, wheelchair or motorized cart, oxygen,
   respirator, or kidney dialysis?                                                                      Yes     No
4. Within the past 12 months, have you needed home health care/home care, used adult day
   care, or received care in a nursing home, assisted living/residential care facility or other long
   term care facility?                                                                                  Yes     No
5. Within the past 12 months, have you been medically advised to enter a nursing home,
   assisted living/residential care facility, or other long term care facility?                         Yes     No
6. Do you currently need assistance or supervision by another person for taking your medication Yes             No
   or in performing any of the following Activities of Daily Living (ADLs): bathing, eating, toileting,
   bowel or bladder control (continence), dressing, or moving in and out of bed or chair?




GRP 113207   MD     MCA 33208 10/01/05               Page 1 of 4
7. This section pertains to Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) and, if
   permitted, HIV-related (Human Immunodeficiency Virus) diagnosis and treatment.
  Within the past 7 years, have you had, do you currently have, or have you been diagnosed or treated by a
  Licensed Health Care Practitioner, as having any of the following medical conditions:
  Acquired Immune Deficiency Syndrome (AIDS)?                                                     Yes     No
  AIDS Related Complex (ARC)?                                                                     Yes     No
  Any HIV infection (Human Immunodeficiency Virus)?                                               Yes     No
NOTE: If you answered “YES” to any question in Part B, do not complete the remainder of this form. We regret
that we will be unable to offer you long term care coverage because you do not meet our minimum acceptance
criteria. If you answered “NO” to all questions in Part B, please continue.

 C    TELL US ABOUT YOUR MEDICAL HISTORY

1. Height:     ft    in   Weight:           lbs   Gender:      Male    Female
2. List any activities in which you regularly participate
   outside your home (e.g., walking or gardening):
3. Have 2 or more years passed since you received ANY medical examination or treatment
   by a healthcare professional?                                                                     Yes   No
4. Who is your Primary Care Physician with most of your medical records? (Please print neatly)

  Name                                                                        Phone

  Address

  City                                                                        State                Zip

  Reason for last visit                                                       Date of last visit


5. Within the past 3 years, have you been advised by a Licensed Health Care Practitioner to have
   surgery that has not been performed?                                                              Yes   No
  Condition                                                                   Date last treated
6. Check the appropriate boxes for any care received within the past 3 years:
  Home health care                                                                                   Yes   No
  Adult day care                                                                                     Yes   No
  Nursing home, assisted living/residential care facility or other long term care facility           Yes   No




GRP 113207    MD     MCA 33208 10/01/05               Page 2 of 4
7. Within the past 5 years (7 years for cancer), have you received any advice or treatment from
   a Licensed Health Care Practitioner, taken any medications for, or been medically diagnosed for:
  Any heart or circulatory conditions (angina, congestive heart failure, heart attack, heart surgery,
  irregular heart beat, numbness or peripheral vascular disease)?                                       Yes     No
  Cancer of any kind, Hodgkin’s disease, leukemia, or lymphoma?                                         Yes     No
  Tumors (non-cancerous) or skin ulcers, amputation or paralysis?                                       Yes     No
  Any breathing conditions, such as asthma, chronic bronchitis, chronic obstructive pulmonary
  disease, emphysema, shortness of breath or tuberculosis?                                              Yes     No
  Cirrhosis, non-insulin dependent diabetes or hepatitis?                                               Yes     No
  Brain disorder, black-outs, convulsions, epilepsy or seizures?                                        Yes     No
  Anxiety, depression or other mental, emotional or nervous disorder?                                   Yes     No
  Alcoholism or chemical dependency?                                                                    Yes     No
  Bone or spinal disorders such as osteoarthritis or rheumatoid arthritis, osteoporosis or
  joint replacement?                                                                                    Yes     No
  High blood pressure, dizziness, or balance problems?                                                  Yes     No
  In the space below, provide details for any “YES” answers. If additional space is required, attach the details on a
  separate piece of paper, including your name and Social Security number. You must also sign and date that page.

  Condition                                                    Condition

  Date last treated                                            Date last treated

  Name, address and phone of the Licensed Health Care          Name, address and phone of the Licensed Health Care
  Practitioner who treated your condition:                     Practitioner who treated your condition:




8. Within the past 5 years, have you received any advice or treatment from a Licensed Health Care
   Practitioner other than your Primary Care Physician for any reason not stated?                 Yes           No
   (For residents of California, Connecticut, Florida, Maine, New Jersey, New York, North Dakota,
   Vermont, and Wisconsin, this does not include HIV testing (Human Immunodeficiency Virus).)
                      ,
  If you answered “YES” please provide details below.
  Condition                                                    Condition
  Date last                   Check here if treated by your    Date last                  Check here if treated by your
  treated                     Primary Care Physician only.     treated                    Primary Care Physician only.
  Name, address and phone of any other Licensed                Name, address and phone of any other Licensed
  Health Care Practitioner who treated your condition:         Health Care Practitioner who treated your condition:




GRP 113207    MD      MCA 33208 10/01/05              Page 3 of 4
9. Are you currently taking any drug or medication?                                                       Yes      No

                      ,
  If you answered “YES” please provide details below.
  Drug or medication                                           Drug or medication

  Dosage                                                       Dosage

  How long have you been taking this medication?               How long have you been taking this medication?


     Check here if treated by Primary Care Physician only.          Check here if treated by Primary Care Physician only.
  If prescribed by another Licensed Health Care                If prescribed by another Licensed Health Care
  Practitioner, give name, address and phone number,           Practitioner, give name, address and phone number,
  and the condition:                                           and the condition:




  Drug or medication                                           Drug or medication

  Dosage                                                       Dosage

  How long have you been taking this medication?               How long have you been taking this medication?


     Check here if treated by Primary Care Physician only.          Check here if treated by Primary Care Physician only.
  If prescribed by another Licensed Health Care                If prescribed by another Licensed Health Care
  Practitioner, give name, address and phone number,           Practitioner, give name, address and phone number,
  and the condition:                                           and the condition:




 D    READ AND SIGN APPLICANT AGREEMENTS

Caution: If your answers on this form are incorrect or untrue, or fail to include all material medical information
requested, Prudential may have the right to deny benefits or rescind your insurance coverage.
To the best of my knowledge and belief, the answers on this form are complete and true. I understand and agree:
• The information on this form is the basis for the coverage for which I am applying to The Prudential Insurance
  Company of America (Prudential).
• My coverage will NOT take effect unless: Prudential has approved this form and statements and answers given
  in applying for this coverage do not change materially until the date this form is approved.
• I have read this form or had this form read to me, and I understand that any false statement or
  misrepresentation in this form may result in loss of coverage under the Group Contract.


X Applicant signature                                                                          Date




GRP 113207    MD     MCA 33208 10/01/05               Page 4 of 4
The Prudential Insurance Company of America
Prudential Long Term Care Customer Service Center
 .O.
P Box 8526, Philadelphia, PA 19176-8526 • 1-800-732-0416




Health Insurance Portability
and Accountability Act (HIPAA) Form
 AUTHORIZATION FOR RELEASE OF HEALTH-RELATED INFORMATION
 This authorization is intended to comply with the HIPAA Privacy Rule.
Please print.

Name of applicant

Date of birth                                   Social Security number


I authorize any health plan, doctor, health care professional, hospital, clinic, laboratory, pharmacy, medical facility,
or other health care provider that has provided treatment or services to me or on my behalf (“My Providers”), and
any other medical or insurance organization, institution or professional, to disclose my entire medical record and
any other health information concerning me, without restriction, to The Prudential Insurance Company of America
and its agents, employees and representatives (“Prudential”). This includes medical records and information on
diagnoses and/or treatment relating to Human Immunodeficiency Virus (HIV) infection or Acquired Immunodeficiency
Syndrome (AIDS), sexually transmitted disease, mental illness, and the use of alcohol, drugs, and tobacco, but
excludes psychotherapy notes.

By my signature below, I terminate any agreements I have made with My Providers to restrict my protected health
information and, for purposes of this authorization, I instruct My Providers to release and disclose my entire medical
record without restriction to Prudential.

This information is to be disclosed under this authorization so that Prudential may do the following, with respect
to long term care insurance I am applying for: underwrite or make rating determinations, evaluate and determine
my eligibility for long term care insurance, or conduct other legally permissible activities related to my application.

This authorization shall remain in force for 24 months following the date of my signature below, unless state law
imposes a shorter duration. A copy of this authorization is as valid as the original. I understand that I have the right
to withdraw this authorization in writing, at any time, by sending a written request to: The Prudential Insurance
Company of America, Long Term Care Customer Service Center, P            .O. Box 8519, Philadelphia, PA 19176, ATTN:
Privacy Contact. I understand that a withdrawal is not effective if any of My Providers has relied on this authorization
or to the extent that Prudential has a legal right to contest a claim under an insurance policy or to contest the policy
itself. I understand that any information disclosed pursuant to this authorization may be re-disclosed, to the extent
allowable under federal law and no longer covered by certain federal rules governing privacy and confidentiality
of health information.

I understand that if I refuse to sign this authorization, Prudential may not be able to process my application or, if
coverage has been issued, may not be able to make any benefit payments. I understand that Prudential will provide
me with a copy of this authorization.


X   Signature of applicant
    or personal representative                                                                 Date

    Description of personal representative’s authority or relationship to applicant




GRP 113392                  Detach and mail with your enrollment form.
The Prudential Insurance Company of America
Prudential Long Term Care Customer Service Center
 .O.
P Box 8526, Philadelphia, PA 19176-8526 • 1-800-732-0416




Health Insurance Portability
and Accountability Act (HIPAA) Form
 AUTHORIZATION FOR RELEASE OF HEALTH-RELATED INFORMATION
 This authorization is intended to comply with the HIPAA Privacy Rule.
Please print.

Name of applicant

Date of birth                                  Social Security number


I authorize any health plan, doctor, health care professional, hospital, clinic, laboratory, pharmacy, medical facility,
or other health care provider that has provided treatment or services to me or on my behalf (“My Providers”), and
any other medical or insurance organization, institution or professional, to disclose my entire medical record and
any other health information concerning me, without restriction, to The Prudential Insurance Company of America
and its agents, employees and representatives (“Prudential”). This includes medical records and information on
diagnoses and/or treatment relating to Human Immunodeficiency Virus (HIV) infection or Acquired Immunodeficiency
Syndrome (AIDS), sexually transmitted disease, mental illness, and the use of alcohol, drugs, and tobacco, but
excludes psychotherapy notes.

By my signature below, I terminate any agreements I have made with My Providers to restrict my protected health
information and, for purposes of this authorization, I instruct My Providers to release and disclose my entire medical
record without restriction to Prudential.

This information is to be disclosed under this authorization so that Prudential may do the following, with respect
to long term care insurance I am applying for: underwrite or make rating determinations, evaluate and determine
my eligibility for long term care insurance, or conduct other legally permissible activities related to my application.

This authorization shall remain in force for 24 months following the date of my signature below, unless state law
imposes a shorter duration. A copy of this authorization is as valid as the original. I understand that I have the right
to withdraw this authorization in writing, at any time, by sending a written request to: The Prudential Insurance
Company of America, Long Term Care Customer Service Center, P            .O. Box 8519, Philadelphia, PA 19176, ATTN:
Privacy Contact. I understand that a withdrawal is not effective if any of My Providers has relied on this authorization
or to the extent that Prudential has a legal right to contest a claim under an insurance policy or to contest the policy
itself. I understand that any information disclosed pursuant to this authorization may be re-disclosed, to the extent
allowable under federal law and no longer covered by certain federal rules governing privacy and confidentiality
of health information.

I understand that if I refuse to sign this authorization, Prudential may not be able to process my application or, if
coverage has been issued, may not be able to make any benefit payments. I understand that Prudential will provide
me with a copy of this authorization.


X   Signature of applicant
    or personal representative                                                                 Date

    Description of personal representative’s authority or relationship to applicant




GRP 113392                           Keep for your records.
The Prudential Insurance Company of America
Prudential Long Term Care Customer Service Center
 .O.
P Box 8526, Philadelphia, PA 19176-8526 • 1-800-732-0416



Federal HIPAA Notice of Privacy Practices
for Protected Health Information
 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
 HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

“We” refers to The Prudential Insurance Company of          There are also times when federal law permits or
America in its capacity as a provider of Group and          requires us to use or disclose your information without
Individual Long Term Care insurance. “You” or “yours”       your written permission.
refers to any individual covered by a Long Term Care
insurance policy issued by The Prudential Insurance         Additionally, where appropriate, we may disclose
Company of America.                                         protected health information to a group health plan or
                                                            plan sponsor in accordance with federal law.
Federal law—meaning the Health Insurance Portability
and Accountability Act and related privacy rules—           Permitted Disclosures
requires The Prudential Insurance Company of America        We may not make all of the uses and disclosures listed
to keep your health information private. We are not         here, but federal law permits use or disclosure of your
allowed to use or disclose it unless we receive your        information without your permission:
permission or unless permitted by law. Federal law          • When we disclose your information to you.
requires us to give you this Notice of our legal duties
and privacy practices. This Notice is to inform you of      • To third party non-Prudential business associates that
uses and disclosures of your health information that          perform services for us or on our behalf, such as
we may make. It also informs you of your rights and           vendors.
our duties with regard to this health information.          • Where disclosure is required by law.
                                                            • To a public health authority authorized by law to
We must follow the terms of this Notice. We do reserve        collect or receive your information to prevent or
the right to change the terms of this Notice and make         control disease, injury or disability or when reviewing
the new Notice provisions apply to all the health             reports of child abuse or for the conduct of other
information we keep. This includes health information         authorized public health activities and
we had prior to any change in this Notice. We must            responsibilities.
promptly change this Notice when there is a material        • To a governmental authority when we reasonably
change to our uses or disclosures, your rights, our           believe you may be a victim of abuse, neglect or
duties and other related circumstances. We will mail          domestic violence where the governmental authority
you any such revised Notice, unless you have agreed           is allowed by law to have such information.
to receive Notices electronically. To receive such
Notices by E-mail, you should tell the contact listed at    • To a health oversight agency for such activities.
the end of this Notice.                                     • For judicial and administrative proceedings.
                                                            • To a law enforcement official for a law enforcement
Use and Disclosure of Protected Health Information            purpose.
Federal law permits us to use and disclose protected        • To a medical examiner for the purpose of identifying
health information for purposes of treatment, payment         a deceased person, determining the cause of death,
and health care operations as those terms are defined         or other duties authorized by law.
under federal law. As an insurer, we do not provide
treatment, but we may use and disclose protected            • To organ donor organizations in order to aid in such
health information for payment purposes, such as in           donations.
connection with the payment of an insurance claim.          • For certain research purposes authorized by and
We may also use and disclose protected health                 subject to federal law.
information for our health care operations such as          • To avert a serious threat to health or safety.
when we decide to give you insurance or when we
                                                            • To government officials regarding military personnel
renew or replace your insurance. We will also comply
                                                              and certain domestic and foreign government officials
with any state or federal law that is more restrictive as
                                                              for certain functions authorized by federal law.
to our uses and disclosures of protected health
information.                                                • To comply with workers’ compensation and other
                                                              similar programs.
                                                            • To make certain marketing communications and for
                                                              certain fundraising purposes.



GRP 113394
Required Disclosures                                         FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO
We are required to disclose your information when            AMEND PROTECTED HEALTH INFORMATION: You have
required by the Secretary of the Department of Health        the right to request that we amend your information
and Human Services to make sure we comply with               kept in our records. We are allowed to deny your
federal law.                                                 request if we did not create the information in the
                                                             record. We will review your request and respond to you
We are also required, with certain exceptions, to            in writing. All requests should be in writing and sent to
provide you with access to inspect and obtain a copy         the contact listed at the end of this Notice. All requests
of your information that we keep. See “Your Right To         should provide needed details, including your name,
Inspect and Copy Protected Health Information” below.        address, insurance policy number, and the reason you
                                                             think your information needs to be changed. If you
Need for Authorization                                       wish additional information, you should write to the
We will not make any uses or disclosures other than          contact listed at the end of this Notice.
those mentioned above without your permission.
You may withdraw such permission in writing. Your            FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO
withdrawal will not be effective (1) if we took action       AN ACCOUNTING: You have the right to receive an
relying on your permission before it was withdrawn,          accounting from us of disclosures of your information
or (2) if we obtained your permission as a condition         made for up to the six (6) years prior to your request.
of issuing you insurance, and the law allows us to           This right does not apply to: disclosures made to carry
contest a claim under the policy or to contest the           out treatment, payment, or health care operations;
policy itself. To withdraw your authorization, please        disclosures made with your permission; disclosures
write the contact listed at the end of this Notice. If you   made for police purposes; disclosures allowed by law;
wish additional information, you should write to the         or disclosures made before April 14, 2003. Any request
contact listed at the end of this Notice.                    should be sent to the contact listed at the end of this
                                                             Notice. If you wish additional information, you should
Individual Rights with Respect to Your Protected             write to the contact listed at the end of this Notice.
Health Information
FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO                   FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO
REQUEST RESTRICTIONS: You have the right to                  A PAPER COPY OF THIS NOTICE: You have the right,
request that restrictions be placed on certain uses and      even if you have agreed to receive notice by E-mail, to
disclosures of your information. We are not required         get a paper copy of this Notice. All requests should be
to agree. If we do agree, we may not use or disclose         in writing and sent to the contact listed at the end of
any of your information except where you need                this Notice.
emergency treatment. We may end an agreement to
restrict as allowed by federal law. If you wish additional   FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO
information, you should write to the contact listed at       FILE A COMPLAINT. If you believe your privacy rights
the end of this Notice.                                      have been violated, you have the right to complain
                                                             to us by writing to the contact listed at the end of this
FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO                   Notice or to the Secretary of the U.S. Department of
ALTERNATIVE CONFIDENTIAL COMMUNICATION OF                    Health & Human Services, Hubert H. Humphrey Building,
PROTECTED HEALTH INFORMATION: If you choose to               200 Independence Avenue, Washington, DC 20201.
have your information sent to you by a means of your         Federal law prohibits retaliation against you for filing
choice or to an address of your choice, we will do so        such a complaint. The contact listed at the end of this
if the request is reasonable. You must clearly state that    Notice is also available to provide you information
disclosure of all or any part of your information could      regarding questions you have or other information
endanger you if not sent per your choice. Any such           concerning this Notice.
request should be sent in writing to the contact listed
at the end of this Notice. If you wish additional            When you contact us in writing, you should include
information, you should write to the contact listed at       your name, address, and policy number. The contact to
the end of this Notice.                                      whom you should address your complaint is:
FEDERAL LAW PROVIDES YOU WITH THE RIGHT                      The Prudential Insurance Company of America
TO INSPECT AND COPY PROTECTED HEALTH                         Privacy Contact
INFORMATION: You have the right to inspect and copy          Long Term Care Customer Service Center
your information, except for any psychotherapy notes,         .O.
                                                             P Box 8519
certain information relating to civil, criminal, or          Philadelphia, PA 19176
administrative proceedings, and certain information
prohibited by law from disclosure. We are allowed by         Telephone number: 1-800-732-0416
law to deny access in some cases, and subject to
certain procedures. Any request should be sent in            The effective date of this notice is March 1, 2005.
writing to the contact listed at the end of this Notice.
If you wish additional information, you should write
to the contact listed at the end of this Notice.




GRP 113394
The Prudential Insurance Company of America
Prudential Long Term Care Customer Service Center
 .O.
P Box 8526, Philadelphia, PA 19176 • 1-800-732-0416


Electronic Funds Transfer Authorization
 INSTRUCTIONS
To enroll in Prudential’s monthly electronic funds transfer (EFT) payment service, please provide us with the
following information. If you wish to use your checking account, enclose your blank, voided check for that
account. If you wish to use your savings account, you must confirm that your financial institution permits
electronic fund withdrawals from savings accounts, and obtain your financial institution’s transit routing
number. Please note that we cannot obtain acceptable banking information from deposit slips. If you have any
questions, please call our Long Term Care Customer Service Center, toll free, at 1-800-732-0416. Please print
except where signatures are required. Use blue or black ink.

 A      APPLICANT/INSURED INFORMATION

Complete information for each applicant for whom this EFT Authorization will be used.                Please indicate the
Full name                                                      Policy/Cert. No. (If known)           bill date you prefer:
                                                                                                         1st*    15th
Full name                                                      Policy/Cert. No. (If known)               8th     22nd

 B      BANKING INFORMATION

Name of financial institution
                                                               Financial institution
Type of account             Checking            Savings        9-digit transit routing number

Account number                                                 Local branch telephone number (       )         -
Full name of account owner
(If other than applicant/insured)                              Relationship to applicant/insured

 C      EFT PAYMENT SERVICE AUTHORIZATION

I hereby request and authorize The Prudential Insurance Company of America (Prudential) to make electronic fund
withdrawals or other forms of pre-authorized withdrawals from my account named above, for payment of the
premium due the policy(ies) or certificate(s) indicated above. My signature below is exactly as it appears in my
financial institution’s records for this account. I agree that withdrawals shall be made approximately 3 to 5 days after
the bill date indicated above. I understand that premium notices will not be mailed. I understand that if a withdrawal
request is not honored by my financial institution, Prudential shall consider that my premium has not been paid. Any
withdrawal returned due to insufficient funds may be re-deposited for collection by Prudential, at its sole discretion.
If this authorization pertains to insurance (or an increase in insurance) for which an application is pending, this
authorization shall take effect on the Effective Date of the insurance applied for. This authorization shall not be
construed as: (a) an approval by Prudential of that application; or (b) a modification of any provisions of any
existing coverage. Otherwise, this authorization shall take effect on the date signed.
Either I or Prudential may cancel this authorization at any time by giving 30 days written notice to the other party.
Any notice hereunder will not be deemed effective until Prudential has had a reasonable time to act. I agree that
Prudential shall not be liable for any loss, liability, cost or expense for acting on this Authorization.

Full name of account owner

             .O.
Address (No P Boxes please)                                                                        Apt.

City                                                                          State                ZIP

X Applicant’s signature that on file with the Financial Institution)
  (Must be the same as
                                                                                                   Date


*If no bill date is selected, the 1st will be the bill date.
GRP 112215 Detach and mail to insurer.
The Prudential Insurance Company of America
Prudential Long Term Care Customer Service Center
 .O.
P Box 8526, Philadelphia, PA 19176 • 1-800-732-0416


Electronic Funds Transfer Authorization
 INSTRUCTIONS
To enroll in Prudential’s monthly electronic funds transfer (EFT) payment service, please provide us with the
following information. If you wish to use your checking account, enclose your blank, voided check for that
account. If you wish to use your savings account, you must confirm that your financial institution permits
electronic fund withdrawals from savings accounts, and obtain your financial institution’s transit routing
number. Please note that we cannot obtain acceptable banking information from deposit slips. If you have any
questions, please call our Long Term Care Customer Service Center, toll free, at 1-800-732-0416. Please print
except where signatures are required. Use blue or black ink.

 A      APPLICANT/INSURED INFORMATION

Complete information for each applicant for whom this EFT Authorization will be used.                Please indicate the
Full name                                                      Policy/Cert. No. (If known)           bill date you prefer:
                                                                                                         1st*    15th
Full name                                                      Policy/Cert. No. (If known)               8th     22nd

 B      BANKING INFORMATION

Name of financial institution
                                                               Financial institution
Type of account             Checking            Savings        9-digit transit routing number

Account number                                                 Local branch telephone number (       )         -
Full name of account owner
(If other than applicant/insured)                              Relationship to applicant/insured

 C      EFT PAYMENT SERVICE AUTHORIZATION

I hereby request and authorize The Prudential Insurance Company of America (Prudential) to make electronic fund
withdrawals or other forms of pre-authorized withdrawals from my account named above, for payment of the
premium due the policy(ies) or certificate(s) indicated above. My signature below is exactly as it appears in my
financial institution’s records for this account. I agree that withdrawals shall be made approximately 3 to 5 days after
the bill date indicated above. I understand that premium notices will not be mailed. I understand that if a withdrawal
request is not honored by my financial institution, Prudential shall consider that my premium has not been paid. Any
withdrawal returned due to insufficient funds may be re-deposited for collection by Prudential, at its sole discretion.
If this authorization pertains to insurance (or an increase in insurance) for which an application is pending, this
authorization shall take effect on the Effective Date of the insurance applied for. This authorization shall not be
construed as: (a) an approval by Prudential of that application; or (b) a modification of any provisions of any
existing coverage. Otherwise, this authorization shall take effect on the date signed.
Either I or Prudential may cancel this authorization at any time by giving 30 days written notice to the other party.
Any notice hereunder will not be deemed effective until Prudential has had a reasonable time to act. I agree that
Prudential shall not be liable for any loss, liability, cost or expense for acting on this Authorization.

Full name of account owner

             .O.
Address (No P Boxes please)                                                                        Apt.

City                                                                          State                ZIP

X Applicant’s signature that on file with the Financial Institution)
  (Must be the same as
                                                                                                   Date


*If no bill date is selected, the 1st will be the bill date.
GRP 112215 Keep for your records.
                                                                The Prudential Insurance Company of America
                                                                Long Term Care Unit
                                                                P.O. Box 8526
                                                                Philadelphia, PA 19176
                                                                Tel 800 732-0416


                             Long-Term Care Insurance
                                Personal Worksheet
People buy long-term care insurance for many reasons. Some don’t want to use their
own assets to pay for long-term care. Some buy insurance to make sure they can choose
the type of care they get. Others don’t want their family to have to pay for care or don’t
want to go on Medicaid. But, long-term care insurance may be expensive and may not be
right for everyone.
By state law, Prudential must fill out part of the information on this worksheet and ask
you to fill out the rest to help you and Prudential decide if you should buy this policy.
Premium Information
Policy Form Number(s)         _____________________________
The premium for the coverage you are considering will be $________________ per year.
Type of Policy (noncancellable/guaranteed renewable): Guaranteed renewable
The Company’s Right to Increase Premiums: The company has a right to increase
premiums on this policy form in the future, provided it raises rates for all policies in the
same class in this state.
Rate Increase History
The company has sold long-term care insurance since 1986 and has sold this policy since
2002. The company has never raised its rates for any long-term care insurance policy it
has sold in this state or any other state.
Questions Related To Your Income
How will you pay each year’s premium? (check one)
F From my Income              F From my Savings/Investments           F My Family will Pay
Have you considered whether you could afford to keep this policy if the premiums were
raised, for example, by 20%?
What is your annual income? (check one)
F Under $10,000               F $10,000-20,000              F $20,000-30,000
F $30,000-50,000              F Over $50,000
How do you expect your income to change over the next 10 years? (check one)
F No change         F Increase          F Decrease




GRP 112406                              Over, please                                      1/2007
If you will be paying premiums with money received only from your own income, a rule
of thumb is that you may not be able to afford this policy if the premiums will be more
than 7% of your income.

Will you buy inflation protection? (check one) F Yes               F No
If not, have you considered how you will pay for the difference between future costs and
your daily benefit amount?

 F From my Income           F From my Savings/Investments          F My Family will Pay

The national average annual cost of care in 2006 was $74,000, but this figure varies
across the country. In ten years, the national average annual cost would be about
$120,500 if costs increase 5% annually.

What elimination period are you considering? Number of days _______
Approximate cost $_____________ for that period of care.

How are you planning to pay for your care during the elimination period? (check one)

F From my Income            F From my Savings/Investments          F My Family will Pay

Questions Related to Your Savings and Investments

Not counting your home, about how much are all of your assets (your savings and
investments) worth? (check one)

F Under $20,000         F $20,000-$30,000 F $30,000-$50,000 F Over $50,000

How do you expect your assets to change over the next ten years? (check one)
F Stay about the same     F Increase                    F Decrease

If you are buying this coverage to protect your assets and your assets are less than
$30,000, you may wish to consider other options for financing your long-term care.




GRP 112406                                  2                                      1/2007
                            DISCLOSURE STATEMENT

If you are an active employee or the spouse of an active employee, no further action
is required. If you are not an active employee or spouse, this must be completed and
signed and returned to Prudential in order for us to process your enrollment form.

Check one.

F The answers to the questions above describe my financial situation.
or
F I choose not to complete this information.

Please check the box.

F I acknowledge that I have reviewed this form including the premium, premium rate
increase history and potential for premium increases in the future. I understand the above
disclosures. I understand that the rates for this coverage may increase in the future.
(This box must be checked).


Signed: ________________________________________                  __________________

                   (Applicant)                                              (Date)

Note: In order for us to process your enrollment form, please return this
signed statement to Prudential along with your enrollment form.
However, if you are an active employee or the employee’s spouse, you do
not need to return this Personal Worksheet in order for Prudential to
process your enrollment form.
                   Prudential may contact you to verify your answers.




GRP 112406                                  3                                        1/2007
       THINGS YOU SHOULD KNOW BEFORE YOU BUY LONG-TERM CARE INSURANCE

Long-Term Care Insurance

   •   A long-term care insurance policy may pay most of the costs for your care in a nursing home. Many policies
       also pay for care at home or other community settings. Since policies can vary in coverage, you should read
       this policy and make sure you understand what it covers before you buy it.

   •   You should not buy this insurance policy unless you can afford to pay the premiums every year. Remember
       that Prudential can increase premiums in the future.

   •   The Personal Worksheet includes questions designed to help you and the company determine whether this
       policy is suitable for your needs.

Medicare

   •   Medicare does not pay for most long-term care.

Medicaid

   •   Medicaid will generally pay for long-term care if you have very little income and few assets. You probably
       should not buy this policy if you are now eligible for Medicaid.

   •   Many people become eligible for Medicaid after they have used up their own financial resources by paying
       for long-term care services.

   •   When Medicaid pays your spouse’s nursing home bills, you are allowed to keep your house and furniture, a
       living allowance and some of your joint assets.

   •   Your choice of long-term care services may be limited if you are receiving Medicaid. To learn more about
       Medicaid, contact your local or state Medicaid agency.

Shopper’s Guide

   •   Make sure the insurance company or agent gives you a copy of a book called A Shopper’s Guide to Long-
       Term Care Insurance published by the National Association of Insurance Commissioners. Read it
       carefully. If you have decided to apply for long-term care insurance, you have the right to return the policy
       within 30 days and get back any premium you have paid if you are dissatisfied for any reason or choose not
       to purchase the policy.

Counseling

   •   Free counseling and additional information about long-term care insurance are available through your state’s
       insurance counseling program. Contact your state insurance department or department on aging for more
       information about the senior health insurance counseling program in your state.


GRP 111412
                                                              The Prudential Insurance Company of
                                                              America
                                                              Long Term Care Unit
                                                              P.O. Box 8526
                                                              Philadelphia, PA 19176-8526
                                                              Tel 800 732-0416



                         Long Term Care Insurance
                   Potential Rate Increase Disclosure Form

1. Premium Rate: The premium rate that is applicable to you and that will be in effect
until a request is made and filed for an increase is $ ___________________________
(fill in amount from Rate Sheet based on plan design and options you choose).

2. The premium for this Certificate will be shown on the Confirmation Statement
you will receive together with your Certificate of Insurance.

3. Rate Schedule Adjustments: The company will provide a description of when
premium rate or rate schedule adjustments will be effective (e.g., next anniversary date,
next billing date, etc.) (fill in the blank): No premium rate or rate schedule adjustments
are scheduled for this coverage.

4. Potential Rate Revisions: This Certificate is Guaranteed Renewable. This means
that the rates for this coverage may be increased in the future. Your rates can NOT be
increased due to your increasing age or declining health, but your rates may go up based
on the experience of all insureds with coverage similar to yours.

If you receive a premium rate or premium rate schedule increase in the future, you
will be notified of the new premium amount and you will be able to exercise at least
one of the following options:

   •   Pay the increased premium and continue your coverage in force as is.

   •   Reduce your benefits to a level such that your premiums will not increase.
       (Subject to state law minimum standards.)

   •   Exercise your non- forfeiture option if purchased. (This option may be available
       for purchase for an additional premium.)

   •   Exercise your contingent non-forfeiture rights.* (This option may be available if
       you do not purchase a separate non- forfeiture option.)

*Contingent Non-forfeiture

If the premium rate for your coverage goes up in the future and you didn't buy a non-
forfeiture option, you may be eligible for contingent non forfeiture. Here's how to tell if
you are eligible:

You will keep some long term care insurance coverage, if:


GRP 112407                                  1                                       (1201)
   •   Your premium after the increase exceeds your original premium by the
       percentage shown (or more) in the following table and

   •   You lapse (not pay more premiums) within 120 days of the increase.

The amount of coverage (i.e., new lifetime maximum benefit amount) you will keep will
equal the total amount of premiums you've paid since your coverage was first issued. If
you have already received benefits, so that the remaining maximum benefit amount is
less than the total amount of premiums you've paid, the amount of coverage will be that
remaining amount.

Except for this reduced lifetime maximum benefit amount, all other benefits will remain
at the levels attained at the time of the lapse and will not increase thereafter.

Should you choose this Contingent Non- forfeiture option, your coverage with this
reduced maximum benefit amount will be considered paid up with no further premiums
due.

Example:

You bought the coverage at age 65 and paid the $1,000 annual premium for 10 years, so
you have paid a total of $10,000 in premium.

In the eleventh year, you receive a rate increase of 50%, or $500 for a new annual
premium of $1,500, and you decide to lapse the coverage (not pay any more premiums).

Your paid-up benefits are $10,000 (provided you have at least $10,000 of benefits
remaining.)




GRP 112407                                2                                     (1201)
                                  Contingent Non-forfeiture
                      Cumulative Premium Increase over Initial Premium
                        That qualifies for Contingent Non-forfeiture

(Percentage increase is cumulative from date of original issue. It does NOT represent a one-time increase.)

                     Issue Age                          Percent Increase Over Initial Premium
                    29 and under                                        200%
                       30 – 34                                          190%
                       35 – 39                                          170%
                       40 – 44                                          150%
                       45 – 49                                          130%
                       50 – 54                                          110%
                       55 – 59                                           90%
                         60                                              70%
                         61                                              66%
                         62                                              62%
                         63                                              58%
                         64                                              54%
                         65                                              50%
                         66                                              48%
                         67                                              46%
                         68                                              44%
                         69                                              42%
                         70                                              40%
                         71                                              38%
                         72                                              36%
                         73                                              34%
                         74                                              32%
                         75                                              30%
                         76                                              28%
                         77                                              26%
                         78                                              24%
                         79                                              22%
                         80                                              20%
                         81                                              19%
                         82                                              18%
                         83                                              17%
                         84                                              16%
                         85                                              15%
                         86                                              14%
                         87                                              13%
                         88                                              12%
                         89                                              11%
                     90 and over                                         10%



    GRP 112407                                      3                                          (1201)
                  THE PRUDENTIAL INSURANCE COMPANY OF AMERICA
                     751 Broad Street, Newark, New Jersey 07102-3777
                                       1-800-732-0416
                                LONG TERM CARE INSURANCE
                                   OUTLINE OF COVERAGE
                                Group Contract No. LT-33208-MD
The following applies to applicants who must answer medical questions in order to qualify for the
Long Term Care Insurance.
Caution: The issuance of the Long Term Care Coverage is based upon your responses to the
questions on your Enrollment Form. If you provide evidence of insurability, you should retain the
copy of your Enrollment Form to attach to your insurance Certificate if coverage is issued. If
your answers are incorrect or untrue, Prudential has the right to deny benefits or rescind your
Coverage. The best time to clear up any questions is now, before a claim arises! If, for any
reason, any of your answers are incorrect, contact Prudential at this address: The Prudential
Insurance Company of America, Long Term Care Customer Service Center, P. O. Box 8526,
Philadelphia PA 19176 or call 1-800-732-0416.

Notice to Buyer: This Plan may not cover all of the costs associated with Long Term Care
incurred by you during the period of Coverage. You are advised to review carefully all Coverage
limitations.
This Certificate has not been approved under the Maryland Partnership for Long Term
Care Program under Title 15, Subtitle 4 of the Health - General.
1. POLICY DESIGNATION. The policy is a group policy which was issued in the State of
Maryland.
2. PURPOSE OF OUTLINE OF COVERAGE. This outline of coverage provides a very brief
description of the important features of the Coverage. You should compare this outline of
coverage to outlines of coverage for other long term care coverage available to you. This is not
the insurance contract and only the actual group policy provisions will control the rights and
obligations of the parties to it. The group policy itself sets forth in detail those rights and
obligations applicable to both you and Prudential. It is very important, therefore, that YOU
READ YOUR CERTIFICATE CAREFULLY!
3. TAX STATUS -- QUALIFIED PLAN. The group Long Term Care Coverage described in
this Outline is intended to be Qualified Long Term Care Insurance as defined by the
Internal Revenue Code Section 7702B(b). To find out if you can deduct part or all of your
premiums or exclude benefits received for Long Term Care expenses, you should speak with
your personal tax advisor.
4. TERMS UNDER WHICH THE CERTIFICATE MAY BE CONTINUED IN FORCE OR
DISCONTINUED.
Renewability: The Long Term Care Coverage described in this Outline is guaranteed
renewable. This means you have the right to continue this Coverage as long as you pay your
premiums on time and have not exhausted your Lifetime Maximum. Prudential cannot change
the terms of your Coverage on its own, except for the following:
x It may increase the premiums you pay. Any change in premium rates will; apply on a class
   basis to all insureds; and
x It may automatically change the provisions of the Coverage to conform with Prudential’s
   interpretation of any state or federal law or regulation that applies to the Coverage, subject to
   the approval of the Maryland Insurance Administration.

GRP 110500                               1                                         (MCA-MD-06/2008)
Continuation of Coverage: This coverage may be continued if your coverage ends for any
reason other than nonpayment of premiums or exhaustion of the Lifetime Maximum. You may
elect to continue the coverage by paying the applicable premium for it. This continuation feature
is described in full detail in the Certificate.
Waiver of Premiums: After you complete the required benefit waiting period and begin to
receive benefits for Nursing Home Care, Home and Community-Based Care, Hospice Care, Bed
Reservation, or Alternate Plan of Care, the premiums for your Coverage will be waived.
Premiums will not be waived if the only Eligible Charges you are incurring are for Respite Care,
Information and Referral Service or Lifestyle Changes. Premiums will begin again as of the first
day of the month following the month in which you no longer incur Eligible Charges for the
services to which this waiver applies.
Premium Rate Changes: Prudential reserves the right to change premium rates. Any change
will apply on a class basis to all insureds.
5. TERMS UNDER WHICH THE CERTIFICATE MAY BE RETURNED AND PREMIUM
REFUNDED. You may surrender the Certificate of Long Term Care Coverage without obligation
or penalty within 30 days from the date of delivery of the Certificate. If you decide to surrender
the Certificate, you must provide notice of the surrender to Prudential at the following address:
The Prudential Insurance Company of America, Long Term Care Customer Service Center, P.
O. Box 8526, Philadelphia PA 19176. Any attempt to obtain a waiver of your right to surrender is
unlawful. Surrender entitles you to a refund of all moneys within 30 days after receipt of notice
of surrender. Also, in the event Coverage is denied, Prudential will refund any premiums paid
within 30 days after the date of denial of Coverage.
The Certificate does contain provisions which provide for a refund or partial refund upon the
death of the insured. Please refer to the section entitled “15. Additional Features” which
describes the Death Benefit.

6. THIS IS NOT MEDICARE SUPPLEMENT COVERAGE. If you are eligible for Medicare,
review the Guide to Health Insurance for People with Medicare available from Prudential by
calling the Long Term Care Customer Service Center at 1-800-732-0416. Prudential is not
representing Medicare, the federal government or any state government.
7. LONG-TERM CARE COVERAGE. Long Term Care insurance is designed to provide
coverage for necessary diagnostic, preventive, therapeutic, curing, treating, mitigating, and
rehabilitative services, and maintenance or personal care services, provided in a setting other
than an acute care unit at a hospital, such as in a Nursing Home, in the community or in the
home. The group policy provides coverage in the form of reimbursement benefits, according to
the option you choose, for covered Long Term Care expenses, subject to the Coverage waiting
period and daily, annual and Lifetime Maximums.
Certain terms used in this Outline of Coverage, indicated in italics, are defined in the Certificate.




GRP 110500                                2                                         (MCA-MD-06/2008)
8. BENEFITS PROVIDED BY THIS PLAN. The Plan pays benefits for Eligible Charges
incurred by you for Nursing Home Care, Home and Community-Based Care, Hospice Care, Bed
Reservation, Respite Care, Lifestyle Changes, Information and Referral Services, and Alternate
Plan of Care.
A 90 day benefit waiting period must be met once during your lifetime before benefits are
payable. This plan has only one combined benefit waiting period for Nursing Home Care, Home
and Community-Based Care, Bed Reservation and Alternate Plan of Care. This is a 90 day
period, counted in calendar days, which begins on the date you contact Prudential to arrange for
an assessment. If you were incurring Eligible Charges during the seven day period before that
date, the benefit waiting period will begin as of the first day you incurred Eligible Charges during
this seven day period. No benefits are payable during the benefit waiting period for charges for
which the benefit waiting period applies.
Nursing Home Care -- This plan provides Coverage for care provided in a Nursing Home or in
an Assisted Living Facility. 100% of the Eligible Charges will be paid up to the applicable Daily
Maximum for Nursing Home Care according to the option you choose.
Home and Community-Based Care -- This plan provides Coverage for each day you receive
Home Health Care from a Home Health Care Agency or receive Adult Day Care. 100% of the
Eligible Charges will be paid up to your Daily Maximum for all Home and Community-Based
Care. The Daily Maximum applies to all such care received on any day.
Hospice Care -- This plan provides Coverage for Hospice Care benefits if you are Terminally Ill
and includes: part-time nursing care by or supervised by a registered graduate nurse;
counseling, including dietary counseling, for you; Family Counseling for the immediate family or
Family Caregiver before your death; medical supplies, equipment, and medication required to
maintain your comfort and manage your pain. For Hospice Care received in a Nursing Home,
an Assisted Living Facility, or in an inpatient Hospice and for non-institutional Hospice Care,
100% of the Eligible Charges will be paid up to your Daily Maximum for Hospice Care. The
Benefit Waiting Period does not need to be satisfied.
Bed Reservation - When you are receiving care in a Nursing Home or Assisted Living Facility
you may have to spend some time in a hospital. This benefit pays for charges by the Nursing
Home or Assisted Living Facility to reserve your bed while you are in the hospital. This benefit is
payable if your Nursing Home or Assisted Living Facility stay is being covered under this plan.
The charge made for reserving the bed must be one that the Nursing Home or Assisted Living
Facility customarily makes to patients in like circumstances according to established policy. This
benefit will be paid at 100% of the Eligible Charges up to your Daily Maximum for Nursing Home
Care for up to the number of days per hospital stay shown in the Schedule of Benefits.
Respite Care - This plan provides Coverage for short-term care provided for limited periods of
time in a Nursing Home, an Assisted Living Facility, or a Hospice, or for all types of Home and
Community-Based Care provided in your home to relieve your Primary Informal Caregiver.
Eligible Charges will be paid for these services, up to the applicable Daily Maximum for Respite
Care depending upon where care is received. See the Schedule of Benefits for limits on the
Respite Care benefit. The Benefit Waiting Period does not need to be satisfied.




GRP 110500                               3                                         (MCA-MD-06/2008)
Lifestyle Changes - This plan provides a lifetime benefit of five times the Daily Maximum for
Nursing Home Care you have chosen to pay for a personal emergency response system or
home modifications aimed at allowing you to stay at Home. The Benefit Waiting Period does not
need to be satisfied.
Information and Referral Services - Prudential designated Care Counselors are available to
assist you and your family; they are available to provide you with information or refer you
(regardless of whether you are eligible for benefits) to specific community resources. Care
Counselors can be reached at 1-800-732-0416.
You may wish to select your own Private Care Manager to provide this information or to
coordinate your Long Term Care. If you meet the Benefit Eligibility Criteria, Coverage will be
provided up to the Private Care Management Consultations limit. Each consultation will be paid
up to your Daily Maximum for Nursing Home Care. The Benefit Waiting Period does not need to
be satisfied.
Alternate Plan of Care -- Prudential recognizes there are emerging trends in the delivery of
Long Term Care. We have attempted to describe the types of institutional an Home and
Community-Based Care settings that are covered under this plan. However, we will consider a
claim for benefits for care received in an alternate setting or for non-institutional services
designed to help eligible individuals remain independent in their Homes. Determination of your
eligibility for this benefit and the benefit amount will be made on an individual basis at the sole
discretion of Prudential. To qualify, such care shall be a qualified long term care service within
the meaning of Internal Revenue Code 7702B.




GRP 110500                               4                                         (MCA-MD-06/2008)
Benefit maximums apply according to the level of benefits option you have chosen. The
benefits are payable for Eligible Charges incurred for Long Term Care. You may choose one of
the following options:

                                                       Option 1       Option 2       Option 3
  NURSING HOME CARE
    Daily Maximum for Nursing Home care and               $      100      $    150    $      200
    Assisted Living Facility
  HOME AND COMMUNITY-BASED CARE
    Daily Maximum for Adult Day Care and Home
    Health Care, combined                                 $       50       $    75    $      100
  HOSPICE CARE
    Daily Maximum for inpatient and Non-                  $      100      $    150    $      200
    Institutional Hospice Care
  BED RESERVATION
    Up to the Daily Maximum for Nursing Home              $      100     $     150    $      200
    care
    20 Day Benefit Limit per Hospital Stay                $    2,000     $   3,000    $   4,000
  RESPITE CARE
    Daily Maximum for Respite Care
      For Nursing Home care, Assisted Living              $      100     $     150    $      200
      Facility or Hospice Care
      For Home and Community-Based Care                   $       50      $     75     $     100
    20 Day Calendar Year Benefit Limit
      For Nursing Home care, Assisted Living              $    2,000     $   3,000    $   4,000
      Facility or Hospice Care
      For Home and Community-Based Care                   $    1,000     $   1,500    $   2,000
    100 Day Lifetime Benefit Limit
      For Nursing Home care, Assisted Living              $ 10,000       $ 15,000     $ 20,000
      Facility or Hospice Care
      For Home and Community-Based Care                   $    5,000     $   7,500    $ 10,000
  LIFESTYLE CHANGES
    (Personal Emergency Response Systems,
     Home Modifications) Lifetime Benefit                 $      500     $     750    $   1,000
  INFORMATION AND REFERRAL SERVICES
    Prudential designated Care Counselors               No charge      No charge     No charge
    Private Care Manager
      Per Consultation visit                              $      100     $     150    $      200
        Calendar Year Benefit Limit                       $      600     $     900    $   1,200
  LIFETIME MAXIMUM**
    For all Long Term Care during Your Lifetime           $ 182,500      $ 273,750    $ 365,000
   * The Lifetime Maximum is equal to the Daily Maximum for Nursing Home care you choose,
       times 365 days, times 5 years. For example, electing the $100 Daily Maximum for Nursing
       Home care provides a Lifetime Maximum of $182,500 ($100 x 365 x 5).




GRP 110500                            5                                      (MCA-MD-06/2008)
Benefit Eligibility Criteria --
In order to receive benefits you must FIRST be assessed by an Assessor and confirmed as
having a Chronic Illness or Disability. A Chronic Illness or Disability is one in which there is:
1) A loss of the ability to perform, without Substantial Assistance, at least two Activities of Daily
   Living for a period of at least 90 consecutive days. Activities of Daily Living are: Bathing,
   Continence, Dressing, Eating, Toileting, and Transferring; or
2) A severe Cognitive Impairment which requires Substantial Supervision to protect you from
   threats to health and safety.
Unless within the preceding 12-month period a Licensed Health Care Practitioner certified that
you meet the requirements above, you will not be considered to have a Chronic Illness or
Disability if you otherwise meet these requirements.
Prudential will arrange for a trained Assessor to assess you. As part of the assessment
process, you and your caregiver may be interviewed. The interview may be either by telephone
or in-person. The assessment must be based on objective standards of measurement. Based
on the information obtained during the assessment, Prudential’s Care Counselor will determine if
you are eligible for benefits. If you are eligible, you will need a Plan of Care. Your Plan of Care
will be used to determine benefits based on the Benefit Option you choose.

9. LIMITATIONS AND EXCLUSIONS. Charges Not Covered:
1) Work-connected Conditions Charge: A charge covered by a workers’ compensation law,
occupational disease law or similar law.
2) Government Plan Charge: A charge for a service or supply:
   (a) furnished by or for the United States government or any other government, unless
   payment of the charge is required by law; or
   (b) to the extent that the service or supply, or any benefit for the charge, is provided by any
   law or governmental plan under which the patient is or could be covered. This (b) does not
   apply to a state plan under Medicaid or to any law or plan when, by law, its benefits are
   excess to those of any private insurance program or other non-governmental program.
   When this (b) applies to Medicare, the benefits provided by Medicare will be deemed to
   include any amount that would have been payable by Medicare in the absence of a
   deductible or coinsurance requirement under that program.
3) War: Charges for a condition due to war or any act of war while you are insured. "War"
means declared or undeclared war and includes resistance to armed aggression.
4) Self-inflicted Injury or Suicide: Charges arising from intentionally self-inflicted injury or
attempted suicide, while sane or suffering from inorganic based insanity.
5) Services and Supplies Outside the United States: Charges for services or supplies outside of
the United States and its possessions.
6) Close Relative: Charges for services and supplies furnished and charged for by a close
relative other than a licensed professional who provides covered services within the terms of his
or her licensure. Close relatives include you, your spouse, or a child, grandchild, brother, sister,
or parent of you or your spouse.
7) Services or Supplies Normally Furnished Without Charge: Services or supplies for which no
charge would be made in the absence of Coverage.
8) Chronic Alcoholism or Chemical Dependency: Charges in connection with chronic
alcoholism or chemical dependency.



GRP 110500                                 6                                          (MCA-MD-06/2008)
9) Other Programs: Charges to the extent they would be covered under any other program paid
for in full or in part, directly or indirectly, by the Montgomery County Agencies. This includes
insured and uninsured programs. If a program provides benefits in the form of services, the
cash value of each service rendered is considered the benefit provided for that service.
10) Charge Not Reasonably Necessary: A charge for a service not reasonably necessary, or
not customarily performed, for the Long Term Care of the person. To be considered "reasonably
necessary," a service must meet all of these tests:
a) It is commonly and customarily recognized as appropriate for your condition.
b) It is neither educational nor experimental in nature.
c) It is not furnished mainly for the purpose of medical or other research.
11) Felony, Riot or Insurrection: Charges for a condition due to your participation in an act of
   felony, riot or insurrection.
12) Non-Covered Services: Charges for services and supplies which are not listed as a
Covered Service in this Coverage.
13) Prohibited Practitioner Referral: Payment of any claim, bill, or other demand or request for
payment for health care services that the appropriate regulatory board determines were made
as a result of a prohibited referral.
                    THE GROUP POLICY MAY NOT COVER ALL
          THE EXPENSES ASSOCIATED WITH YOUR LONG-TERM CARE NEEDS.
10. RELATIONSHIP OF COST OF CARE AND BENEFITS. Because the costs of Long Term
Care services will likely increase over time, you should consider whether and how the benefits of
this Coverage may be adjusted. The benefit level will not increase over time unless you
purchase additional coverage.
Periodic Inflation Protection Offers - At least every three years, you will be offered the
opportunity to increase your benefits to keep up with inflation. Your Daily Maximum benefits
would increase by at least five percent, compounded annually. Your age on the effective date of
the increase will be used to determine the additional separate premium for the increased
Coverage. You do not have to provide evidence of insurability to take inflation increases.
However, it you decline two offerings in a row, and then want to increase Coverage, you will be
required to submit satisfactory evidence of insurability the next time you accept an offer. You
will be offered the increase in Coverage even if you are receiving benefits. However, the
increased Coverage will not take effect until you stop receiving benefits.
Automatic Inflation Increase Rider - You may select the Automatic Inflation Increase Rider
instead of the Period Inflation Protection Offer. Under this Rider, your benefits will automatically
increase on the anniversary of the effective date of your Coverage. These increases will occur
even if you are receiving benefits. Each increase will equal 5% of each Daily Maximum,
compounded annually. Your Lifetime Maximum will also increase accordingly. With this rider,
your premiums remain level, subject to Prudential’s right to change rates on a class basis. The
cost for the Automatic Inflation Increase Rider is included in the premium for the Options with
Automatic Inflation Increase Rider, shown in the Premium Tables with your enrollment material.




GRP 110500                               7                                         (MCA-MD-06/2008)
Please review the Comparison Charts of Inflation Protection Options on page 8A which compare
benefits and costs when inflation protection options are not included (Charts 1 and 1A), when
inflation protection is provided under the Periodic Inflation Protection Offers provision (Charts 2
and 2A), and when inflation protection is provided under the Automatic Inflation Increase Rider
(Charts 3 and 3A). The Benefit Comparison Charts demonstrate the benefits over time,
depicting a plan originally purchased with a Daily Maximum for Nursing Home Care of $150 per
day. The Cost Comparison Charts demonstrate the premiums over time, again depicting a plan
originally purchased with a Daily Maximum for Nursing Home Care of $150 per day. All
comparisons assume an entry age of 40.

The following examples are for illustrative purposes only. Examples assume an entry age
of 40 and an initial Daily Maximum Benefit of $100.

Chart 1: Comparison of Benefit Amounts                                      Chart 2: Comparison of Costs


 CHART 1A : Level Premium, Level Benefit                                 CHART 2A: Level Benefit, Level Premium
 NO INFLATION PROTECTION OPTIONS                                         NO INFLATION PROTECTION OPTIONS

                 100                                                                   12
                  80                                                                   10
          Daily                                                                         8
        Maximum 60                                                             Monthly
                                                                                        6
         Benefit  40                                                           Premium
                                                                                        4
                  20                                                                    2
                   0                                                                    0
                           40        49        58    67    76   85                          40        49     58     67      76    85
                                      Attained Age                                                          Attained Age




  CHART 1B: Increasing Benefit, Increasing Premium                       CHART 2B: Increasing Benefit, Increasing Premium
  PERIODIC INFLATION PROTECTION OFFERS                                   PERIODIC INFLATION PROTECTION OFFERS

                                                                                         2000
              1000
               800                                                                       1500
               600
                                                                                         1000
               400
               200                                                                        500
                  0
                                                                                             0
                      40        49        58        67    76    85
                                                                                                 40    49      58     67     76    85
                                      Attained Age
                                                                                                             Attained Age




  CHART 1C: Increasing Benefit, Level Premium                            CHART 2C: Increasing Benefit, Level Premium
  AUTOMATIC INFLATION INCREASE RIDER                                     AUTOMATIC INFLATION INCREASE RIDER


               1000                                                                        50

             800                                                                           40
      Daily
             600                                                                Monthly 30
    Maximum
                                                                                Premium 20
     Benefit 400
             200                                                                           10
                  0                                                                         0
                      40        49        58        67    76    85                              40    49      58     67     76    85
                                      Attained Age                                                           Attained Age




GRP 110500                                                           8                                                   (MCA-MD-06/2008)
11. ALZHEIMER’S DISEASE AND OTHER ORGANIC BRAIN DISORDERS. The plan
provides coverage for clinically diagnosed Alzheimer’s Disease or other organic brain disorders.
12. PREMIUM. You are responsible for the entire cost of this Coverage and your premium
payments. The initial premium for your Coverage will be determined from the premium rate
schedules contained in your enrollment material based on the option selected and your issue
age.
If you will be billed directly by Prudential, the due date will be indicated on your bill. If premium
is not received within 30 days of the due date, you and your designee (if applicable) will be
mailed a notice requesting payment within 30 days. The additional 30 days is your grace period.
The Certificate remains in force during the grace period. If Prudential does not receive payment
within this time, your Coverage will be terminated.
13. DISCLOSURE REGARDING FEDERAL TAX TREATMENT OF LONG TERM CARE
INSURANCE CERTIFICATE. The Long Term Care Coverage described in this Outline is
intended to be Qualified Long Term Care Insurance as defined by the Internal Revenue Code
Section 7702B(b). As such, the benefits you may receive under this Coverage should not be
considered taxable income. In addition, some or all of the premiums you pay towards this
Coverage may be tax deductible as a medical expense subject to certain limitations. Consult a
tax advisor for more information concerning this deduction.
Public guidance issued by the Internal Revenue Service or Treasury Department may provide
that a provision of this Coverage does not comply with the requirements of Code Section 7702B.
If the Contract Holder wishes the Long Term Care Coverage to maintain tax qualified status, a
change in the Group Contract will be made in an amendment to it that is signed by an officer of
Prudential and Montgomery County Agencies.
14. SENIOR COUNSELING PROGRAMS. Please refer to A Shopper’s Guide To Long Term
Care Insurance contained in your enrollment material for the telephone number of the Senior
Counseling Program in your state.
15. ADDITIONAL FEATURES.
Eligibility and Medical Underwriting: To enroll for Coverage under this Plan, eligible
persons must complete an Enrollment Form. Persons eligible to apply include employees,
retirees, and Qualified Family Members as follows:
Montgomery County Public Schools (MCPS):
You must be a full-time* (working at least 40 hours per week) or part-time (working on other
than a temporary basis) employee actively at work, or a retiree. Qualified Family Members are
the spouse, qualified domestic partner, parent, parent in-law, grandparent, or grandparent in-law
of an eligible employee or retiree.
Montgomery County Government (MCG):
You must be a full-time* employee (working at least 40 hours per week) or part-time employee
(working at least 20 hours per week, except crossing guards), or a crossing guard employee
actively at work, or a retiree. Qualified Family Members are the spouse, qualified domestic
partner, parent, parent in-law, grandparent, or grandparent in-law of an eligible employee or
retiree.




GRP 110500                                9                                         (MCA-MD-06/2008)
Montgomery College (MC):
You must be a full-time* (working at least 40 hours per week) or part-time (working at least 20
hours per week) employee actively at work, or a retiree. Qualified Family Members are the
spouse, parent, parent in-law, grandparent, or grandparent in-law of an eligible employee or
retiree.
Maryland National Capital Park & Planning Commission (MNCPPC):
You must be a full-time* (working at least 40 hours per week) or part-time (working at least 20
hours per week) employee actively at work, or a retiree. Qualified Family Members are the
spouse, parent, parent in-law, grandparent, or grandparent in-law of an eligible employee or a
retiree.
Washington Suburban Sanitary Commission (WSSC):
You must be a full-time* (working at least 40 hours per week) or part-time (working at least 16
hours per week) employee actively at work, or a retiree. Qualified Family Members are the
spouse, parent, parent in-law, grandparent, or grandparent in-law of an eligible employee or a
retiree.
The City of Rockville (COR):
You must be a full-time* (working at least 37.5 hours per week) or part-time (working at least 20
hours per week) employee actively at work, or a retiree. Qualified Family Members are the
spouse, qualified domestic partner, parent, parent in-law, grandparent, or grandparent in-law of
an eligible employee or retiree.
*Due to state law, full-time and part-time status is mandated at 17.5 hours per week for
residents of Vermont.
Only persons between the ages of 18 and 85 are eligible to enroll. "Actively at Work" means
performing the full-time duties of the employee's job at his or her usual place of employment or
other location where Montgomery County Agencies business requires the employee to travel,
without absence for reasons other than cold, influenza, or vacation, within the 30 days prior to
enrollment.
Medical underwriting is used. Satisfactory evidence of good health is required, except for
newly hired and newly eligible employees of Montgomery County Public Schools, Montgomery
County Government and Montgomery College who apply within 60 days of becoming eligible
and except for newly hired and newly eligible employees of Maryland National Capitol Park and
Planning Commission and Washington Suburban Sanitary Commission who apply within 30
days of becoming eligible. Newly hired and newly eligible employees who apply after their
initial period of eligibility must provide satisfactory evidence of good health.
THIRD PARTY LAPSE DESIGNEE: Unless you decline to do so in your Enrollment Form, you
have the right to name a third party as your authorized designee to be notified when the lapse of
your coverage is imminent. It is our responsibility to notify you and this designee prior to
canceling your Coverage due to lack of premium payment. This notification will be given by first
class United States mail, postage prepaid, and shall be deemed to have been given as of five
days after the date of mailing. Notice will not be given until 30 days after a premium is due and
unpaid. You may change your designee at any time by notifying Prudential in writing.




GRP 110500                              10                                       (MCA-MD-06/2008)
REINSTATING COVERAGE: If, due to your Chronic Illness or Disability, you fail to pay your
premium and your Coverage ends for this reason, you may be eligible to reinstate your
Coverage. You or your representative may request reinstatement if:
1) The request is made within five months of the date premiums were due; and
2) Your Chronic Illness or Disability is confirmed by Prudential. See the Benefit Eligibility
    Criteria for details.
If you are eligible for reinstatement, you must pay past due premiums to reinstate your
Coverage. Upon reinstatement, you will have the same level of Coverage you had before your
Coverage ended.
DEATH BENEFIT: If you die before age 74, Prudential will pay a death benefit. This benefit will
be based on a percentage of the premiums you have paid minus the benefits Prudential has
paid. This benefit will be paid even if, at the time of your death, you are receiving benefits and
premiums have been waived. Waived premiums are not considered paid premiums and will not
be returned as a death benefit. In the event of your death, Prudential will pay the death benefit
to your spouse, if living, otherwise to your estate. The Certificate provides further details on how
the death benefit amount will be determined.
16. OPTIONAL BENEFITS WHICH MAY BE AVAILABLE TO YOU. Under the Group
Contract, several options are available for your selection. The optional Automatic Inflation
Increase Rider is described in item 10, “Relationship of Cost of Care and Benefits.” Other
optional benefits are the Cash Benefit Rider and Non-Forfeiture Rider described below.
CASH BENEFIT RIDER: The Long Term Care Coverage requires you to submit a bill with a
claim form in order to receive benefits. For this Cash Benefit, you do not need to incur charges
and submit a bill to receive benefits for Home and Community-Based Care.
To use this benefit you must satisfy the following:
x You must apply for and be determined by Prudential to be eligible for benefits.
x You must submit a claim form monthly requesting the cash benefit payment.
x You must satisfy any applicable benefit waiting period under the Coverage before benefits
   are payable.
x You must continue to be eligible for benefits when Prudential conducts periodic
   reassessments.
At least each month, Prudential will pay you a benefit equal to the Daily Maximum benefit for
Home and Community-Based Care that would apply to you, multiplied by the number of days in
that month. If we determine you are eligible on a day other than the first day of the month, your
benefit will be pro-rated based on the number of days remaining in that month. You will continue
to receive a monthly payment as long as you meet the conditions for this benefit. These benefits
are subject to your Lifetime Maximum.
NOTICE: Since benefits paid under this Rider are made without regard to costs incurred by you,
part of the benefits could be considered taxable income. If the benefits paid under this Rider are
in excess of the per diem limit as prescribed by law, they could be considered taxable income.
This per diem limit is indexed for inflation. You should consult with a tax advisor for more
information concerning the tax implications.




GRP 110500                               11                                        (MCA-MD-06/2008)
NON-FORFEITURE BENEFIT RIDER: This rider provides a non-forfeiture benefit in the form of
a shortened benefit period. This rider will pay benefits according to the conditions in effect at the
time insurance ended, up to the Daily Maximums you have chosen but with a reduced Lifetime
Maximum. This means you will have the full daily benefits available, but for a shorter period of
time. This benefit can be used at any time during your lifetime until the reduced Lifetime
Maximum is exhausted. If your insurance ended due to non-payment of premium on or after the
fifth anniversary of your effective date, you may be entitled to receive benefits under this
provision. However, you must request benefits and Prudential must determine your eligibility.
Your benefits will be based on the Daily Maximums in effect at the time your insurance ended.
Should you elect this optional Rider, a table of shortened benefit periods for your Coverage will
be provided when you receive your Certificate of Insurance.




GRP 110500                               12                                        (MCA-MD-06/2008)

								
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