(GEORGIA APPLICATION & OC ATTACHED)
NATIONAL STATES INSURANCE COMPANY
1830 CRAIG PARK COURT, ST. LOUIS, MISSOURI 63146 (800) 868-6788
THE POLICY IS NOT A MEDICARE SUPPLEMENT POLICY. IF YOU ARE ELIGIBLE FOR
MEDICARE, REVIEW THE POLICY THE GUIDE TO HEALTH INSURANCE FOR PEOPLE WITH
MEDICARE AVAILABLE FROM THE COMPANY.
OUTLINE OF COVERAGE FOR POLICY FORM MAS-1(06)
LIMITED BENEFIT HEALTH COVERAGE
RETAIN THIS OUTLINE FOR YOUR RECORDS
Read Your Policy Carefully – This outline of coverage provides a very brief description of the important features of your policy. This is not the
insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your
insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!
LIMITED BENEFIT HEALTH COVERAGE – Policies of this category are designed to provide, to persons insured, limited or supplemental coverage.
SPECIFIC BENEFITS ARE:
DAILY HOSPITAL BENEFIT
If you are confined in a hospital as a resident inpatient, because of injury or sickness, the policy pays at the rate of $_________ per day for each day
you are confined up to a maximum of 10 days per Period of Care. ($100-$400)
The maximum time for which this Hospital Confinement Benefit shall be payable is 365 days for all Periods of Care combined.
The following benefits are only applicable if you choose to purchase them for an additional premium at the time you apply for the policy.
Dental, Vision and Hearing Care Expense Rider Form R-DVH-3(06) (Optional) – If this Rider is purchased, benefits will be paid as follows:
Covers services of all licensed dentists, including the cost of fillings, bridges, and dentures; visits to an Ophthalmologist or Optometrist for
refraction, including the cost of eyeglasses or contact lenses; and the cost of initial hearing aids and repairs to initial hearing aids. A $100
deductible is applied in each calendar year and 80% of expenses after the deductible are covered. A maximum of $1,000 is payable under the
Rider in each calendar year. Replacement or repair of existing dentures, bridges, eyeglasses, or contact lenses are not covered until this Rider
has been in effect for over 12 months. Replacement of, or repair to, existing hearing aids is not covered by this Rider.
EXCEPTIONS AND LIMITATIONS
This policy does not cover loss resulting from: treatment, injury or sickness resulting from war or any act of war, whether war is declared or not; mental
disease or disorder, intoxicants or drug abuse (unless the result of narcotics administered or prescribed by a doctor); dental treatment, except for injury;
cosmetic surgery, except when necessary to restore normal bodily function or for reconstructive purposes incidental to or following surgery resulting
from sickness or injury; any type of care or service for which you have no legal obligation to pay in the absence of insurance (except Medicaid); any
type of care or service covered under workers’ compensation or occupational disease law; care or service received outside the United States; illegal
Loss that is incurred within 6 months after the Policy Date and which results from a preexisting condition, is not covered. A preexisting condition is any
condition that was diagnosed or treated by a doctor within 6 months prior to the Policy Date, or any condition which produced symptoms within 6
months prior to the Policy Date that would have caused an ordinarily prudent person to seek medical diagnosis or treatment.
The policy is guaranteed renewable which means you have the right to continue the policy as long as you pay the premiums on time. The Company
may increase premiums on all policies of this type in your state. The Company cannot raise premiums just on your policy because of a change in your
health, or claims that you file.
Base Policy with Dental, Vision, Hearing Rider R-DVH-3(06) $__________ $__________ Annual
Policy Fee $__________ $__________ Semi-Annual
Total Initial Premium $__________ $__________ Quarterly
$__________ Monthly Bank Draft or List Bill
Date____________________ Agent’s Printed Name______________________________________________________________________
Agent’s Address & Phone Number________________________________________________________________________________________
Form OC-MAS-1(06) (GA)
MAS-1(06) Application to
National States Ins. Company
1830 Craig Park Court, St. Louis, Missouri 63146 Effective Date
Deferred Effective Date Requested:
1. Applicant's Name (Print) Date of Birth Social Security No.
Last First Initial Sex Mo. Day Year Age
Address City State Zip Telephone No.
Applicant's E-Mail Address Employer's Name or Group/Association Name (if applicable) Sect. Dept. # Occupation
HEALTH UNDERWRITING QUESTIONS
In the past 18 months have you been medically treated or medically diagnosed for:
cancer; heart attack; congestive heart failure; stroke; chronic kidney disease; chronic lung disease; chronic liver disease; any dis-
order requiring transplant; alcohol or drug abuse; any disease requiring amputation; any type of progressive terminal disease; or
within the past 18 months have you been confined to a hospital; nursing home; or other medical facility? Yes No
Have you ever been medically diagnosed or treated for AIDS or ARC (AIDS Related Complex); or have you ever been advised by
a medical professional that you have tested HIV positive? Yes No
Please explain any "Yes" answers __________________________________________________________________________
Does this Insurance replace any insurance you now have? Yes No
(If "Yes", give details to include name(s) of company(ies), policy nos., types of coverage.)
COVERAGE(S) APPLIED FOR PREMIUM MODE OF PAYMENT
Daily Hospital Benefits: $100* $200 $400 (10 days) $ Monthly List Bill (5 or more)
Dental, Vision, Hearing Rider R-DVH-3(06)............................................. $ Monthly Bank Draft
Total Premium.................................................................................... $ Quarterly
Policy Fee (one time)........................................................................... $ 20.00 Semi-Annual
Total Initial Premium..........................................................................$ Annual
*$100 Benefit not available under age 60
NOTICE: Any person who, with intent to defraud or knowing that he is facilitating a fraud against any insurer, submits an application
or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
I agree that all answers above are true and complete to the best of my knowledge, and I understand that my eligibility for coverage will
be determined based on my responses shown on this application. I understand the agent cannot waive any of the Company's rights
or make any changes in the policy.
I acknowledge receipt of:
[ ] an outline of coverage [ ] "Guide to Health Insurance for People with Medicare" and "Notice that this is not a Medicare
Supplement" (for applicants on Medicare).
I understand that this policy has a 6 month waiting period for preexisting conditions.
Caution: If your answers on this application are incorrect or untrue, National States Insurance Company has the right to deny benefits
or rescind your policy, subject to the policy's Time Limit on Certain Defenses provision.
Signed at _________________________ this ____ day of ______________ 20 ____. Amount paid $___________ for first_____months.
I certify that I have truly and accurately recorded herein the information given by the Applicant.
Agent's Signature Applicant's Signature
Agent's Printed Name Branch Office # Pers. Code # Mail Policy to APPLICANT AGENT
Form APP-MAS(GAC) (GA)
AUTHORIZATION TO HONOR CHECKS DRAWN BY NATIONAL STATES INSURANCE COMPANY
Name of Your Bank: __________________________________________________________________________________________________
Your Bank's Address: _________________________________________________________________________________________________
I hereby request the above named bank to honor checks drawn on me by the National States Insurance Company of St. Louis, Missouri, and to charge
such checks against my account until further notice. I agree that there shall be no liability whatsoever on the bank's part for any reason whatsoever for
payment of or failure to pay any such checks drawn on me. I understand that if for any reason these checks are not honored by my bank that the pre-
authorized check privilege will be automatically discontinued by National States and that it will be my responsibility to pay any premiums due directly to
National States. I further understand that it is my responsibility to review my bank statement to be sure that pre-authorized checks have been properly
submitted and honored. I would like my account drafted _________________________ and I have enclosed a copy of a check bearing the
account number to be drafted. (Annually, Semi-annually, Quarterly or Monthly)
(Customer's Signature EXACTLY as it appears on Bank Records) (Date)
IMPORTANT NOTICE TO AGENTS - Attach sample copy of Applicant's check.
TO: The Bank named on the reverse side
In order to induce you to comply with the request of your customer to provide the service authorized on the other side of this card, the National
States Insurance Company of St. Louis, Missouri, undertakes and agrees:
1. To indemnify you and hold you harmless from any loss you may suffer as a consequence of your actions resulting from or in connection with the execution
and issuance of any check, draft or order, whether or not genuine, purporting to be executed or issued by or on behalf of the undersigned company and
received by you in the regular course of business for purpose of payment, including any costs or expenses reasonably incurred in connection herewith.
2. In the event that any such check, draft or order shall be dishonored, whether with or without cause, and whether intentionally or inadvertently, to indemnify
you for any loss even though dishonor results in a forfeiture of the insurance.
3. To defend at our own cost and expense any action which might be brought by the depositor or any other person because of your actions taken pursuant to
the foregoing requests, or in any manner arising by reason of your participation in the foregoing plan of premium collection.
THE NATIONAL STATES INSURANCE COMPANY OF ST. LOUIS, MISSOURI
Authorized in a Resolution adopted by the Board of Directors of the National
States Insurance Company of St. Louis, Missouri, June 1, 1972
* MAKE CHECKS PAYABLE TO: National States Insurance Company
MAIL NEW BUSINESS TO: General Agent Center
15575 N 79th Pl - #100
Scottsdale, AZ 85260
* The check must accompany the application.
There are 3 payment options:
1) Monthly Bank Draft - 1st Month Payment by Check Required.
2) Direct Bill with payment by check accepted for: Quarterly Semi Annual or Annual only.
3) Monthly List Bill (5 Minimum) - Call your Agent or GAC for the forms.
National States Insurance Company
Daily Hospital Benefit with Dental-Vision-Hearing Rider
(NO Return of Premium Rider)
Bank Draft / List Bill Rates Quarterly Rates
Issue Age $100/Day $200/Day $400/Day $100/Day $200/Day $400/Day
18-29 N/A $27.55 List Bill Only $35.62 N/A $86.92 List Bill Only $112.36
30-34 N/A 28.56 List Bill Only 37.63 N/A 90.10 List Bill Only 118.72
35-39 N/A 29.90 List Bill Only 40.32 N/A 94.34 List Bill Only 127.20
40-44 N/A 32.26 List Bill Only 45.02 N/A 101.76 List Bill Only 142.04
45-49 N/A 36.29 53.09 N/A 114.48 167.48
50-54 N/A 39.65 59.81 N/A 125.08 188.68
55-59 N/A 45.36 71.23 N/A 143.10 224.72
60-64 $35.45 51.41 83.33 $111.83 162.18 262.88
65-69 38.14 56.78 N/A 120.31 179.14 N/A
70-74 41.66 63.84 N/A 131.44 201.40 N/A
75-79 44.69 69.89 N/A 140.98 220.48 N/A
80-84 47.21 74.93 N/A 148.93 236.38 N/A
85-99 51.74 84.00 N/A 163.24 265.00 N/A
Semi-Annual Rates Annual Rates
Issue Age $100/Day $200/Day $400/Day $100/Day $200/Day $400/Day
18-29 N/A $170.56 List Bill Only $220.48 N/A $328.00 List Bill Only $424.00
30-34 N/A 176.80 List Bill Only 232.96 N/A 340.00 List Bill Only 448.00
35-39 N/A 185.12 List Bill Only 249.60 N/A 356.00 List Bill Only 480.00
40-44 N/A 199.68 List Bill Only 278.72 N/A 384.00 List Bill Only 536.00
45-49 N/A 224.64 328.64 N/A 432.00 632.00
50-54 N/A 245.44 370.24 N/A 472.00 712.00
55-59 N/A 280.80 440.96 N/A 540.00 848.00
60-64 $219.44 318.24 515.84 $422.00 612.00 992.00
65-69 236.08 351.52 N/A 454.00 676.00 N/A
70-74 257.92 395.20 N/A 496.00 760.00 N/A
75-79 276.64 432.64 N/A 532.00 832.00 N/A
80-84 292.24 463.84 N/A 562.00 892.00 N/A
85-99 320.32 520.00 N/A 616.00 1,000.00 N/A
Policy Fee: $20 payable once at the time of application.
Not required in Kentucky & Michigan.
Return of Premium not available in: AR, GA, IN, IA, MI, NE, OR, PA, SD, TN, TX, VA, WA & WI
Form: MAS w/DVH