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PHYSICIANS MUTUAL INSURANCE COMPANY PHYSICIANS LIFE INSURANCE COMPANY LONG-TERM CARE POLICY APPLICATION 2600 Dodge Street Omaha, Nebraska 68131 (Home Office Use Only) APPLICANT INFORMATION PLEASE

In this instance, an applicant shall not be eligible for the above insurance policy benefits (without an exception, see Section 9.). 1. To determine which policies are appropriate for use by any member of the Family or their respective dependents under the above guidelines. 2. The following: “Long Term Care” refers to “Indemnity,” “Life Insurance,” “Permanent Medical Disability,” “Dependent Living” coverage, “Indemnity,” “Health” coverages, “Group Term Life Insurance” (not applicable to certain Long Term Care policies) and “Non-Indemnity Insurance.” 3. Policies or provisions specifically excepted, excluded or limited from being eligible for the above benefit categories (listed in Item 3 of the above criteria). 4. The total premium amount on the applicable insurance policy or coverage on which the applicant is applying in any one year. 5. Proof of current and valid insurance coverage, i.e. driver's license, Social Security Card, etc. Note Applicants may be required to purchase or obtain their own Health Care Insurance policy from any commercial or labor organization before a Policy can be issued. 6. Any other requirements required by the Company or by the applicable insurance carrier. Note All policies or provisions not specifically excepted, excluded or limited from being eligible for the above benefit category listed in Item 3 of the above criteria shall be excluded from being eligible for the above benefit categories of this policy.

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What is ipipeline packaged forms?

Ipipeline packaged forms are a set of pre-configured forms and templates that are used in the insurance industry to facilitate the creation and submission of insurance applications. These forms are typically packaged in a digital format to streamline the application process.

Who is required to file ipipeline packaged forms?

Insurance agents, brokers, and other professionals involved in the insurance application process are typically required to file ipipeline packaged forms. This includes individuals and companies that are involved in selling and underwriting insurance policies.

How to fill out ipipeline packaged forms?

To fill out ipipeline packaged forms, users can typically input the required information directly into the digital forms using a computer or mobile device. The forms may include fields for personal and policyholder information, coverage details, and any additional information necessary for the insurance application.

What is the purpose of ipipeline packaged forms?

The purpose of ipipeline packaged forms is to standardize and streamline the insurance application process. By using pre-configured forms, insurance professionals can save time and ensure that the necessary information is accurately and consistently collected from applicants.

What information must be reported on ipipeline packaged forms?

The specific information that must be reported on ipipeline packaged forms may vary depending on the insurance product and application requirements. Typically, these forms require information such as personal details of the applicant, policy details, and any additional information relevant to determining coverage and pricing.

When is the deadline to file ipipeline packaged forms in 2023?

The deadline to file ipipeline packaged forms in 2023 may vary depending on the specific regulations and requirements of the insurance industry and jurisdiction. It is important to consult with the relevant authorities or institutions to determine the exact deadline for filing.

What is the penalty for the late filing of ipipeline packaged forms?

The penalty for the late filing of ipipeline packaged forms can vary depending on the insurance regulations and jurisdiction. Typically, late filing may result in fines or other disciplinary actions imposed by the governing authorities. It is advisable to consult the applicable regulations or seek guidance from the relevant insurance authorities to understand the specific penalties for late filing.

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