application packet for signaturecare insurance 500 … · attach cover letter ... state law...

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© 2007 Massachusetts Mutual Life Insurance Company, Springfield, MA. All rights reserved. www.massmutual.comMassMutual Financial Group is a marketing name for Massachusetts Mutual Life Insurance Company (MassMutual) and its affiliated companies and sales representatives.

LTC500xx 1107

Rhode IslandApplication Packet for SignatureCare® Insurance 500 Policy Series

LTCNB-RI 0318

MM500Ref-SA-AI-2-RI Page 1 00

Long-Term Care Insurance Application Forms for Signature Care® 500 (Simplified Application)

RHODE ISLAND November 08, 2013

This replaces Application Instructions MM500Ref-AI-1-RI, and has been revised to reflect an updated HIPAA Privacy Notice (LTC2039 0913). IMPORTANT REMINDERS BEFORE YOU TAKE AN APPLICATION

• State regulations require agents to meet licensure and applicable presale training requirements (where

required) otherwise agents must not attempt to solicit, negotiate or sell long term care insurance. Requirements vary by state.

• Initially Quote Select Preferred rate class. NOTE: Final rate class will be based on the results of underwriting. • Provide “The Long Term Care Underwriting Process” (LTC4511) to your clients to prepare them for the

underwriting process. • Review Suitability Standards and Rate Stabilization with the applicant(s). • Prior to completing application, leave the “Shopper’s Guide to Long Term Care Insurance” (LTC2100) with the

applicant(s). • Outline of Coverage must be left with applicant(s). • The application and all required forms must be complete and submitted to the LTC Administrative Office within

30 days of the application signed date. • The application and all required forms MUST BE signed and dated where required and in all appropriate parts.

Incomplete applications result in processing delays. • Current date the application. The Policy Effective Date is the Underwriting Approval Date unless the

application indicates to save age. To save age (we will backdate up to 60 days), request this in the Special Request section under Section 3 of the application.

• Do NOT submit initial premium with the application.

STATE VARIATIONS • Partnership policies are available, if a Partnership Policy is selected, leave the “Partnership Program Notice”

(MMN-PRT-RI) with the applicant(s). • Suitability Standards and Rate Stabilization apply. Complete the LTC Insurance Personal Worksheet. See

Guidelines Regarding Suitability Standards for LTC Insurance located on page 3. • Facility Services Only Insurance Policy is not available. APPLICATION and OTHER REQUIRED FORMS & DISCLOSURES Copy to Each Applicant

Copy to LTC Admin Office

No Yes New Business Transmittal (MM-0109-4)

No Yes Long Term Care Insurance Application (MM500-SAP-1-1-RI 0612)

Yes Yes Long Term Care Insurance Personal Worksheet (MM500-WRK)

Yes Yes HIPAA Authorization/Personal Health-Related Information (F8186 0210)


Yes No Complete the Outline of Coverage (MM500-OOC-1-RI 0612) NOTE: the completed Outline of Coverage will print along with the illustration.

Yes No Important Notice to Persons on Medicare (MM-0166) Yes No Notice of HIPAA Privacy Practices (LTC2039 0913)

Yes No Disclosure Statement About Our Policy’s Premium Payment Options (COR4565a 1004)

Yes No Things You Should Know Before You Buy Long-Term Care Insurance (MM-N-LTC)

Yes No Long Term Care Insurance Potential Rate Increase Disclosure (MM-N-PRI-LP)

Yes No Partnership Program Notice (MMN-PRT-RI) (if Partnership is selected)

Yes No Important Privacy and Consumer Information (N2000)

OPTIONAL FORMS & DISCLOSURES YOU MAY NEED FOR SPECIAL SITUATIONS

Copy to Each Applicant

Copy to LTC Admin Office

Yes Yes Supplemental Application for Policy Ownership (MM500-AO-RI)

Yes Yes Notice to Applicant Regarding Replacement (MM-0116-B-2 0907)

Yes Yes Automatic Payment Authorization (F6445). Submit first copy with voided check.

Yes Yes Loyal Customer Discount Disclosure (MMD-LCD)

Yes Yes Adverse Underwriting Decision Release (MM500AUD)

OTHER IMPORTANT REMINDERS CHECKLIST

❏ Attach applicable Illustration to the application. ❏ Confirm applicant signed in their resident state, if partnership. ❏ Confirm the applicant(s) answered “NO” to all questions in the Insurability Information (Section 2). If any question is answered “YES” it is suggested that you do not submit the application. ❏ Consult Field Underwriting Guide (LTC 50900S) or Producer Reference Manual (LTC50900 1011) to confirm eligibility. ❏ Provide the applicant(s) with all required forms and notices as noted above. ❏ Attach Cover Letter (OPTIONAL) to explain any additional information that you may have regarding the applications to the underwriter. ❏ Please note the following: Applicants applying as Covered Partners have the option of selecting one or more of the Covered Partner Riders, as long as both select the same rider(s). The discounts are not cumulative, they are applied sequentially. Therefore in the event that more than one discount applies, the total discount percentage will be less than the sum of the applicable discount percentages.


GUIDELINES REGARDING SUITABILITY STANDARDS FOR LTC INSURANCE

State law requires both the agent and the Company to assist the applicant in determining the suitability of a potential purchase of long-term care insurance. It is therefore very important that you read, understand, and implement the procedures outlined in this instruction. It will allow you to determine that your sale will meet the required suitability standards.

There are two additional forms that are required for each sale: 1. The first form is MM-N-LTC and is titled "Things You Should Know Before You Buy Long-Term Care Insurance." You must review

this form with each applicant and it should help you finalize the sale.

2. The second form is MM500-WRK, "Long-Term Care Insurance Personal Worksheet." This worksheet must be filled out by the applicant with your assistance.

The first section - Premium Information, requires you to complete the policy form number and fill in the anticipated premium. Point out the policy's renewability provision to the applicant and the possibility of a future rate increase.

The second section - Questions Related To Your Income, requires you to check a box in each of two lines. In the first line of this section, the source of premium payments needs to be indicated. In the second line of this section, affordability of the policy needs to be indicated.

The third section - What Is Your Annual Income? Requires you to check a box in each of two lines. In the first line of this section, the annual income of the applicant needs to be indicated. In the second line of this section, the expectation for change in income needs to be indicated.

This section also requires you to analyze the applicant's ability to afford the premiums based on income. To do this, you must multiply the applicant's income by 7% (0.07). If this amount is less than the annual premium, then either family members must be paying the premium or savings must be the premium source with assets from the next section in the "Over $50,000" bracket. Otherwise, the proposed sale does not meet the suitability standards.

The fourth section - Will You Buy Inflation Protection? Requires you to answer "Yes" or "No" and explain the difference between future costs and the daily benefit selected.

The fifth section - What Elimination Period Are You Considering? Requires you to indicate the number of days, approximate cost for that period of care and discuss how the applicant plans to pay for this care.

The sixth section - Questions Related To Your Savings and Investments. The first line of this section requires you to check a box indicating the value of the applicant's assets (excluding the applicant's home) and the next line requires the applicant to indicate the expected change in these assets. If the assets are less than $30,000, the sale does not meet suitability standards.

The seventh section - Comparison to Current Coverage. If the insured has current coverage you are replacing, you must analyze the insured's current coverage and indicate (by checking the appropriate box) why the replacement is suitable. In addition, the premium for the applicant's existing coverage must be entered on the line provided.

The eighth section - Disclosure Statement, requires the applicant to certify that the answers in the worksheet are accurate, or that the applicant declines to provide the financial information. It also requires the applicant to acknowledge that you have reviewed the form with them and that the applicant understands that premium rates may be increased in the future. Authorization to Process Application, must be signed if the applicant declines to provide the financial information.

We will send a letter if we determine that the proposed purchase may not be suitable for the applicant. If a letter is sent, the applicant must respond again within 60 days, or we will not underwrite the coverage and the file will be closed. The next part of this section requires the agent to certify that the importance of this form has been properly explained to the applicant.

The last part of this section must be completed if the applicant's proposed purchase does not meet suitability standards. The applicant will have to provide a compelling reason for the company to consider the risk if the applicant does not meet the required suitability standards.

SUMMARY - In general, the purchase of a long-term care policy will not be considered suitable if: • Premiums for the proposed policy are more than 7% of applicant's income, unless the applicant's assets are greater than $50,000

or another premium source (such as family members) is indicated; or • Applicant's assets (savings and investments) are under $30,000.

MM-0109-4 01 *MM-0109-4*

*NBTRANS*

New Business Transmittal

❍ CAS ❍ Broker ❍ National Account

Applicant Information (Please list applicants alphabetically by last name) Submitted PremiumFirst Name, Initial, Last Name Age HOME OFFICE USE ONLY Mode Collected

Agent/Broker and Agency Information Note: All splits must be whole numbers Writing Agent/Broker Name: Agent/Broker Number: % FYC Split

% Renewal

Date:

Phone Number: E-mail Address: Agency:

Second Agent/Broker Name: Agent/Broker Number: % FYC Split

% Renewal

Date:


Third Agent/Broker Name: Agent/Broker Number: % FYC Split

% Renewal

Date:


Note: Policy splits are limited to three Agents. Direct any communication regarding this case to: Submitting Agency Name: Date:

Agency Affiliation: ❍ NB Coordinators ❍ LTCi Specialist ❍ Brokerage Director ❍ Agency Rep ❍ Other

How would you prefer to be contacted? ❍ E-mail ❍ Telephone

Contact's Phone Number: Contact's E-mail Address: Agency Number:

If the sale of this policy will be credited to more than one agency, specify below: (Note: This is limited to two Agencies)

Agency Name: Agency Number: % Split:

If a Career Corporation, please list Sub-Agent splits below: (Note: Splits must equal 100%)

Agency Name: Agency Number: % Split:

ATTACH PREMIUM CHECK HERE Note: We do not accept Agent/Agency checks or COD business

THANK YOU FOR YOUR BUSINESS

MM500-AP-1-RI 0612 - 1 - 00

*MM500-AP-1-RI 0612*

*APPFORM*

*MM500-AP-1-RI 0612*

*APPFORM*

Massachusetts Mutual Life Insurance Company Home Office: Springfield, MA 01111-0001 Long Term Care Administrative Office P.O. Box 4243 Woodland Hills, CA 91365-4243 888.505.8952

LONG TERM CARE INSURANCE APPLICATION MM500-AP-1-RI 0612 (PLEASE PRINT)

Coverage Type h Individual h (1 Partner Applying) h (Both Partners Applying) PART 1: PROPOSED APPLICANT PERSONAL INFORMATION Proposed Applicant 1 Proposed Applicant 2 Name (First) (MI) (Last)

Gender h Male h Female

Name (First) (MI) (Last)

Gender h Male h Female

Home Address (Street)(City) (State)(ZIP)

Home Address (Street)(City) (State)(ZIP)

Billing Address (if different)

Billing Address (if different)

Phone Home ( ) Work ( ) Best time to call? am or pm / home or work

Phone Home ( ) Work ( ) Best time to call? am or pm / home or work

SS No.

Birth Date

SS No.

Birth Date

State of Birth

Height & Weight

State of Birth

Height & Weight

Driver's License No.

License State

Driver's License No.

License State

Email (OPTIONAL)

Email (OPTIONAL)

Occupation (or if retired, date of retirement)

Smoker (current or within past 12 months) h Yes h No

Occupation (or if retired, date of retirement)

Smoker (current or within past 12 months) h Yes h No

PART 2: INSURABILITY INFORMATION Proposed Applicant 1 Proposed Applicant 2 1. Do you currently need assistance with bathing, dressing,

eating, taking medication, transferring from bed to chair or toileting? ..................................................... h Yes h No

1. Do you currently need assistance with bathing, dressing, eating, taking medication, transferring from bed to chair or toileting? ......................................................h Yes h No

2. During the past 10 years, have you been medically diagnosed or treated for any of the following:

AIDS or positive HIV status....................................h Yes h No

2. During the past 10 years, have you been medically diagnosed or treated for any of the following:

AIDS or positive HIV status ................................... h Yes h NoAlzheimer's Disease, Dementia......................... h Yes h No Alzheimer's Disease, Dementia .........................h Yes h NoAmyotrophic Lateral Sclerosis/Lou

Gehrig's Disease......................................... h Yes h NoCerebral Palsy ................................................... h Yes h NoCystic Fibrosis ................................................... h Yes h NoHepatitis-Chronic ............................................... h Yes h No

Amyotrophic Lateral Sclerosis/Lou Gehrig's Disease..........................................h Yes h No

Cerebral Palsy....................................................h Yes h NoCystic Fibrosis....................................................h Yes h NoHepatitis-Chronic................................................h Yes h No

Huntington's Chorea.......................................... h Yes h NoInsulin Dependent Diabetes .............................. h Yes h No

Huntington's Chorea ..........................................h Yes h NoInsulin Dependent Diabetes...............................h Yes h No

Kidney Disease requiring dialysis...................... h Yes h NoLiver Cirrhosis.................................................... h Yes h NoMultiple Sclerosis............................................... h Yes h No

Kidney Disease requiring dialysis ......................h Yes h NoLiver Cirrhosis ....................................................h Yes h NoMultiple Sclerosis ...............................................h Yes h No

Myasthenia Gravis............................................. h Yes h No Myasthenia Gravis .............................................h Yes h NoOrganic Brain Syndrome ................................... h Yes h No Organic Brain Syndrome....................................h Yes h NoParalysis ............................................................ h Yes h No Paralysis.............................................................h Yes h NoParkinson's /Parkinsonism ................................ h Yes h NoSchizophrenia.................................................... h Yes h NoStroke, TIA......................................................... h Yes h NoSystemic Lupus ................................................. h Yes h No

Parkinson's /Parkinsonism .................................h Yes h NoSchizophrenia ....................................................h Yes h NoStroke, TIA .........................................................h Yes h NoSystemic Lupus..................................................h Yes h No

PLEASE NOTE: Before you continue with this application: If you answered YES to any of the questions in Part 2, we suggest you do not submit the application. If you answered NO to every question, please continue.

MM500-AP-1-RI 0612 - 2 - 00

PART 3: MEDICAL INFORMATION If you answer "Yes" to any question in Part 3, please provide full details below. Proposed Applicant 1 Proposed Applicant 2 1. Are you currently receiving Social Security Disability or

Medicaid (not Medicare)? ........................................ h Yes h No1. Are you currently receiving Social Security Disability or

Medicaid (not Medicare)?.........................................h Yes h No2. Do you currently use or have you used in the past 12

months a walker, crutches, braces, wheelchair, motorized cart, hospital bed, oxygen, or cane?................................ h Yes h No

2. Do you currently use or have you used in the past 12 months a walker, crutches, braces, wheelchair, motorized cart, hospital bed, oxygen, or cane? ................................h Yes h No

3. Within the past 12 months have you been advised to have any special testing or surgery that has not yet been performed or are you aware of any symptoms or complaints for which you plan to seek medical advice or treatment? ......................... h Yes h No

3. Within the past 12 months have you been advised to have any special testing or surgery that has not yet been performed or are you aware of any symptoms or complaints for which you plan to seek medical advice or treatment?..........................h Yes h No

4. Within the past 12 months have you been hospitalized, received rehabilitative services including physical therapy, occupational therapy, home care or been confined to a nursing home or assisted living facility? ............................................. h Yes h No

4. Within the past 12 months have you been hospitalized, received rehabilitative services including physical therapy, occupational therapy, home care or been confined to a nursing home or assisted living facility? ..............................................h Yes h No

5. Within the past 12 months have you received disability income or workers' compensation or any other state disability? ................................................................. h Yes h No

5. Within the past 12 months have you received disability income or workers' compensation or any other state disability?..................................................................h Yes h No

6. Within the past 5 years, have you had or been issued a handicap tag? .......................................................... h Yes h No

6. Within the past 5 years, have you had or been issued a handicap tag?...........................................................h Yes h No

7. Within the past 5 years, have you been declined for long term care insurance? ............................................... h Yes h No

7. Within the past 5 years, have you been declined for long term care insurance?................................................h Yes h No

8. Within the past 10 years, have you received medical advice, consultation, or treatment for the following diseases, disorders or conditions?

Alcoholism, Drug Dependency .......................... h Yes h No Blood or Endocrine (Glandular) Disorder .......... h Yes h No High Blood Pressure.......................................... h Yes h No Diabetes ............................................................ h Yes h No Brain, Spinal Cord, or Neurological Disease ..... h Yes h No Cancer (Internal)................................................ h Yes h No Heart, Circulatory, Vascular Disorder ................ h Yes h No Kidney, Bladder, or Prostate Condition ............. h Yes h No Musculoskeletal (bone or joint) or Skin Disorderh Yes h No Progressive Eye Disease .................................. h Yes h No Psychiatric, Mental Disorder, or Depression ..... h Yes h No Respiratory or Lung Disorder ............................ h Yes h No Stomach, Esophagus, Intestine, Liver

or Pancreas Condition.................................... h Yes h No

8. Within the past 10 years, have you received medical advice, consultation, or treatment for the following diseases, disorders or conditions?

Alcoholism, Drug Dependency...........................h Yes h No Blood or Endocrine (Glandular) Disorder ...........h Yes h No High Blood Pressure ..........................................h Yes h No Diabetes.............................................................h Yes h No Brain, Spinal Cord, or Neurological Disease......h Yes h No Cancer (Internal) ................................................h Yes h No Heart, Circulatory, Vascular Disorder.................h Yes h No Kidney, Bladder, or Prostate Condition ..............h Yes h No Musculoskeletal (bone or joint) or Skin Disorderh Yes h No Progressive Eye Disease...................................h Yes h No Psychiatric, Mental Disorder, or Depression ......h Yes h No Respiratory or Lung Disorder .............................h Yes h No Stomach, Esophagus, Intestine, Liver

or Pancreas Condition ....................................h Yes h No9. Does/Did any family members (mother, father, siblings) have any

of the following: Alzheimer's disease ........ h ALS (Lou Gehrig's Disease)..... h Dementia ........................ h Heart Disease........................... h Parkinson's disease ........ h Polycystic Kidney Disease ....... h Huntington's disease....... h Stroke....................................... h

9. Does/Did any family members (mother, father, siblings) have any of the following:

Alzheimer's disease.........h ALS (Lou Gehrig's Disease) .....h Dementia .........................h Heart Disease ...........................h Parkinson's disease.........h Polycystic Kidney Disease........h Huntington's disease .......h Stroke .......................................h

MM500-AP-1-RI 0612 - 3 - 00

PART 3: MEDICAL INFORMATION (continued) Proposed Applicant 1 Proposed Applicant 2 10. Have you consulted a Health Care Professional in the past 5 years?

................................................................................. h Yes h No If "Yes", provide the Health Care Professional information. If "No", provide your current primary care physician or MD or other

Health Care Professional who has the most complete records of your medical history. If you changed doctors in the past 12 months, please provide the previous doctor's information also (medical records may be ordered.)

Name: Address: City, State ZIP: Phone: ( ) Date/reason for last visit:

10. Have you consulted a Health Care Professional in the past 5 years?.................................................................................h Yes h No

If "Yes", provide the Health Care Professional information. If "No", provide your current primary care physician or MD or other

Health Care Professional who has the most complete records of your medical history. If you changed doctors in the past 12 months, please provide the previous doctor's information also (medical records may be ordered.)

Name: Address: City, State ZIP: Phone: ( ) Date/reason for last visit:

LIST ALL MEDICATION(S) (attach additional sheet if needed) 11. List all medications taken or that have been prescribed to you at any

time during the past 2 years and include dosage/frequency/ reason/prescribing Health Care Professional.

11. List all medications taken or that have been prescribed to you at any time during the past 2 years and include dosage/frequency/ reason/prescribing Health Care Professional.

DETAILS: Indicate question number, include diagnosis or disorder, dates, names and addresses of all Health Care Professionals and medical facilities.

MM500-AP-1-RI 0612 - 4 - 00

PART 4: COVERAGE AND PREMIUM INFORMATION * If a PARTNERSHIP POLICY is selected below and You are age 75 or younger, 5% Compound Inflation Protection or 3% Compound Inflation

Protection must be selected and will be issued with Your Policy. Proposed Applicant 1 Proposed Applicant 2 1. Basic Plan Selection 1. Basic Plan Selection h Partnership Policy h Non-Partnership Policy h Partnership Policy h Non-Partnership Policy h Comprehensive (Facility Services and Home & Community

Based Services (HCBS)) h Comprehensive (Facility Services and Home & Community

Based Services (HCBS)) h Comprehensive with HCBS Monthly Benefit Rider h Comprehensive with HCBS Monthly Benefit Rider 2. Daily Benefit Amount (DBA) $ 2. Daily Benefit Amount (DBA) $ 3. Benefit Period h 6 Years h 5 Years h 4 Years h 3 Years h 2 Years

3. Benefit Period h 6 Years h 5 Years h 4 Years h 3 Years h 2 Years

4. Elimination Period 4. Elimination Period h 30 Days h 60 Days h 90 Days h 180 Days h 30 Days h 60 Days h 90 Days h 180 Days * Please refer to Partnership Program requirements above. * Please refer to Partnership Program requirements above. 5. Inflation Protection Rider (may select only one) h 5% Compound Inflation Protection h 3% Compound Inflation Protection

5. Inflation Protection Rider (may select only one) h 5% Compound Inflation Protection h 3% Compound Inflation Protection

6. Elimination Period Riders (may select only one) 6. Elimination Period Riders (may select only one) h HCBS Waiver of Elimination Period h Enhanced Elimination Period

h HCBS Waiver of Elimination Period h Enhanced Elimination Period

7. Other Riders h Shortened Benefit Period Nonforfeiture h Restoration of Benefits

7. Other Riders h Shortened Benefit Period Nonforfeiture h Restoration of Benefits

8. Covered Partner Riders (if applying as Covered Partners both must select any of the following riders)

8. Covered Partner Riders (if applying as Covered Partners both must select any of the following riders)

h Waiver of Premium for Covered Partner h Waiver of Premium for Covered Partner h Paid-Up Survivor h Shared Care (Covered Partner coverage must be identical)

(available with 2 Year or 3 Year Benefit Period only)

h Paid-Up Survivor h Shared Care (Covered Partner coverage must be identical)

(available with 2 Year or 3 Year Benefit Period only) * Please refer to Partnership Program requirements above. * Please refer to Partnership Program requirements above. REJECTION OF INFLATION PROTECTION RIDER

I have reviewed the Outline of Coverage and the graph that compares the benefits and premiums of this policy with and without the Inflation Protection Rider and I have chosen to reject the rider. Check Here h

REJECTION OF NONFORFEITURE RIDER I have reviewed the Outline of Coverage that describes

the Shortened Benefit Period Nonforfeiture Rider and I have chosen to reject the rider. Check Here h

REJECTION OF INFLATION PROTECTION RIDER I have reviewed the Outline of Coverage and the graph that compares the benefits and premiums of this policy with and without the Inflation Protection Rider and I have chosen to reject the rider. Check Here h

REJECTION OF NONFORFEITURE RIDER I have reviewed the Outline of Coverage that describes

the Shortened Benefit Period Nonforfeiture Rider and I have chosen to reject the rider. Check Here h

MM500-AP-1-RI 0612 - 5 - 00

PART 4: COVERAGE AND PREMIUM INFORMATION (continued) Proposed Applicant 1 Proposed Applicant 2 9. Discounts (see Application Instructions) h Covered Partner Discount (2 Proposed Applicants)

9. Discounts (see Application Instructions) h Covered Partner Discount (2 Proposed Applicants)

h Partner Discount (1 Proposed Applicant) h Partner Discount (1 Proposed Applicant) h Loyal Customer Discount Policy No. h Loyal Customer Discount Policy No. h Employer/Association Group Discount Group Name and Number

h Employer/Association Group Discount Group Name and Number

10. Premium Billing (may select only one) 10. Premium Billing (may select only one) h Direct Bill h Annually h Semi-Annually h Quarterly h PAC

h Direct Bill h Annually h Semi-Annually h Quarterly h PAC

h List Bill h Annually h Semi-Annually h Quarterly h PAC

h List Bill h Annually h Semi-Annually h Quarterly h PAC

11. Beneficiary Information (You may change the beneficiary at any time by notifying us in writing)

Name: _____________________________________________

Relationship: _______________________________________

Address: ___________________________________________

___________________________________________

11. Beneficiary Information (You may change the beneficiary at any time by notifying us in writing)

Name: _____________________________________________

Relationship: _______________________________________

Address: ___________________________________________

___________________________________________ Special Request:

Special Request:

PART 5: OTHER COVERAGE/REPLACEMENT INFORMATION Proposed Applicant 1 Proposed Applicant 2 1. Do you have a policy, certificate or application with this or any other

company providing long term care insurance (including health care service contract or health maintenance organization contract)? ................................................................................. h Yes h No

1. Do you have a policy, certificate or application with this or any other company providing long term care insurance (including health care service contract or health maintenance organization contract)? .................................................................................h Yes h No

2. Did you have another long term care insurance policy or certificate in force during the past 12 months? ........................ h Yes h No

If that policy lapsed, provide date of lapse ___________________

2. Did you have another long term care insurance policy or certificate in force during the past 12 months? .........................h Yes h No

If that policy lapsed, provide date of lapse ___________________ 3. Do you intend to replace any of your long term care, medical or

health insurance coverage with this policy? ............ h Yes h No

If you answered YES to any of the questions 1-3 above, provide full details below and complete the required replacement form(s):

3. Do you intend to replace any of your long term care, medical or health insurance coverage with this policy? .............h Yes h No

If you answered YES to any of the questions 1-3 above, provide full details below and complete the required replacement form(s):

Question No.

Company/Carrier:

Type of Policy: Issue Date:

Daily Benefit Amount: $ Paid to Date:

Question No.

Company/Carrier:



Question No.

Company/Carrier:



Question No.

Company/Carrier:



MM500-AP-1-RI 0612 - 6 - 00

PART 6: PROTECTION AGAINST UNINTENTIONAL LAPSE I understand that I have the right to designate at least one person other than myself to receive notice of lapse or termination of this long term care insurance policy for non-payment of premium. I understand that notice will not be given until thirty (30) days after a premium is due and unpaid. Proposed Applicant 1 (choose one): Proposed Applicant 2 (choose one): h I elect not to designate any person to receive such notice h I designate the following person to receive notice prior to

cancellation of my policy for non-payment of premium:

Name:

Address:

Phone: ( )

Relationship:

h I elect not to designate any person to receive such notice h I designate the following person to receive notice prior to

cancellation of my policy for non-payment of premium:

Name:

Address:

Phone: ( )

Relationship:

PART 7: COVERED PARTNER OR PARTNER DISCOUNT ELIGIBILITY To be eligible for the Partner Discount you must be: ● married; or ● named in a valid certificate or license of civil union recognized by the state in which the Policy is issued; or ● living with someone for the past three consecutive years in a committed relationship as partners or as family members and sharing basic living

expenses; and - are not married to each other or anyone else; and - not named in a certificate or license of civil union with each other or anyone else; and - if related, belong to the same family generation (e.g. siblings, cousins).

To be eligible for the Covered Partner Discount both applicants must meet the above criteria together. I meet the criteria listed above. h Yes h No I meet the criteria listed above. h Yes h No

PART 8: PROPOSED APPLICANT STATEMENT

NOTICE OF INSURANCE INFORMATION PRACTICES — To evaluate your application, we will need some personal information about you. It may be necessary to obtain some of that information from sources other than yourself. For your protection, you have a qualified right to learn what information we obtain about you. You also have the right to request correction of any erroneous information. The information we obtain about you will be used by Massachusetts Mutual Life Insurance Company to determine eligibility for insurance and/or benefits under an existing policy and for other business purposes in connection with the insurance relationship. The information obtained may not be released to any person or organization except to reinsuring companies, any third party administrators designated by Massachusetts Mutual Life Insurance Company or other persons or organizations performing services in connection with your application, claim or as may be otherwise lawfully required or as you may further authorize. We will furnish a more detailed summary of our information practices upon request. AGREEMENT — The answers given are complete and true to the best of my knowledge and belief. I understand that the Company will rely on my written answers to the questions in this application and that if my answers are not complete and true, my policy may not be valid. I also understand that the agent cannot determine eligibility for or alter the terms of the proposed policy. If a premium is paid to the agent in exchange for a Conditional Receipt, the Company is liable only as stated in that Receipt. If premium is not paid with this application, I understand that the policy will become effective and in force on the Policy Effective Date only if the following occur: (1) the application is approved by the Company; (2) a policy is issued during the lifetime of the Proposed Applicant; (3) the first premium is paid in full; and (4) there has been no change in the insurability of the Proposed Applicant since the date of completion of the application and the date the policy is delivered. ACKNOWLEDGMENT — I acknowledge receipt of an Outline of Coverage, NAIC Shopper's Guide, Potential Rate Increase Disclosure Form, Conditional Premium Receipt Information, and the Company's notices about the Medical Information Bureau, Inc. (MIB), the Fair Credit Reporting Act, the Company's privacy practices, and the HIPAA Notice of Privacy Practices. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime an may be subject to fines and confinement in prison.

This application in totality will be part of the insurance policy for which I am applying. Further, if this application has been completed by two Proposed Applicants I understand that a copy of this application will be included in my Covered Partner's policy. "I", "you", and "your" mean the Proposed Applicant 1 and if applicable, Proposed Applicant 2 applying for coverage under this application. CAUTION: If your answers on this application are incorrect or untrue, Massachusetts Mutual Life Insurance Company may have the right to deny benefits or rescind your policy. Signed at On (City) (State) (Date)

Signature of Proposed Applicant 1:

Signature of Proposed Applicant 2:

MM500-AP-1-RI 0612 - 7 - 00

PART 9: AGENT'S STATEMENT 9A: Rate Information What Rate Class was proposed? Proposed Applicant 1:h Ultra Preferred h Select Preferred h Preferred

Proposed Applicant 2:h Ultra Preferred h Select Preferred h Preferred

Did you consult the Field Underwriting Guide to determine rate class? h Yes h No

Did the proposed applicant(s) answer YES to any condition in Part 3 of the application? h Yes h No

If "Yes", is the condition(s) eligible for the rate class selected? (if "No", please explain) Proposed Applicant 1: h Yes h No Proposed Applicant 2: h Yes h No

9B: Other Coverage and Replacement Information Is this part of a multi-Life case (i.e. family members, business partners, etc.)?

Proposed Applicant 1: h Yes h No


Is there a Disability or Life Application being submitted concurrently with this Application?



Proposed Applicant 1 Proposed Applicant 2 To the best of your knowledge, is the insurance applied for intended to replace any long term care, medical or health insurance in force with this or any company? h Yes h No

List any other health insurance policies that you have sold to the Proposed Applicant(s):

Which of the policies listed above are still in force, if any?

To the best of your knowledge, is the insurance applied for intended to replace any long term care, medical or health insurance in force with this or any company? h Yes h No

List any other health insurance policies that you have sold to the Proposed Applicant(s):

Which of the policies listed above are still in force, if any?

Which of the policies listed above sold in the past 5 years are no longer in force, if any?

Which of the policies listed above sold in the past 5 years are no longer in force, if any?

9C: Forms Delivery and Signatures Did you provide Proposed Applicant(s) with all required notices? h Yes h No

(if "No", provide details)

Did you ask the Proposed Applicant(s) all the questions face to face and witness their signature(s)? h Yes h No

(if "No", provide details)

9D: Miscellaneous Information What is the amount of the Conditional Receipt Premium check? $

I certify that the answers to the questions provided by the Proposed Applicant(s) were fully and accurately recorded in the application, and that the questions in the Agent's Statement have been answered accurately. I have reviewed the current health insurance coverage of the Proposed Applicant(s) and find that the coverage of the type and amount applied for is appropriate for the needs of the Proposed Applicant(s). Further, if this is a replacement, I have reviewed the current health insurance coverage of the Proposed Applicant(s) and find that this replacement is appropriate for the needs of the Proposed Applicant(s).

Licensed Agent's Name (please print) Ident. Code

Licensed Agent's Signature Date

Agent's Phone

Agent's Fax Agency Number

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY CONDITIONAL PREMIUM RECEIPT INFORMATION CONDITIONAL PREMIUM RECEIPT INFORMATION

MM500-CNRT RETURN THIS COPY TO HOME OFFICE 01

*MM500-CNRT*

*CRTPREMINFO*

Proposed Applicant Name (Print) IMPORTANT NOTICE: There is no coverage in effect under this conditional premium receipt until Massachusetts Mutual Life Insurance Company approves the application. In this Conditional Premium Receipt "We", "Us", "Our" refer to Massachusetts Mutual Life Insurance Company. It is understood and agreed that payment made and accepted under this Conditional Premium Receipt is based on the Initial Premium amount set forth below in accordance with the rate class selected on the Application. The check for the Initial Premium amount must be honored on its first presentation for payment in order for this Conditional Premium Receipt to be valid. The Initial Premium may differ from the first premium due at delivery if coverage is issued other than as applied for or an anticipated discount does not apply. If We determine that the Proposed Applicant is insurable based on Our underwriting criteria and standards, then We will issue a Policy to be effective on the date that all the Initial Application Requirements have been completed to Our satisfaction. However, if a future effective date is requested, then We will issue the Policy to be effective on the requested effective date, if later. In either event, any change in the health status after the date that all of the Initial Application Requirements have been completed to Our satisfaction will not affect Our underwriting decision. For purposes of this Conditional Premium Receipt, the Initial Application Requirements are: 1. Proper completion of the required Application and the answer to each

question in Part 2 (Insurability Information) of the submitted Application is "No"; and

2. Completion of an initial health examination consisting of either a telephone health interview, an in-person health interview, or a paramedical examination as required by Us in accordance with Our underwriting rules.

The Initial Premium will be returned and this Conditional Premium Receipt will be null and void under any of the following circumstances: 1. Coverage is declined. 2. We are unable to obtain the Initial Application Requirements and

any other required underwriting documentation We deem necessary to determine insurability within 120 days from the date of the Application.

3. Any unpaid balance of the first premium due at delivery, in accordance with the premium mode you have selected, is not paid upon delivery of the Policy.







AUTHORITY OF THE AGENT: No agent, producer or representative has any power or authority to alter or waive any of the provisions of this agreement. All premium checks must be payable to Massachusetts Mutual Life Insurance Company. Do not make check payable to the agent, agency or leave payee blank.


I have received and read (or had read to me) and understand the Conditional Premium Receipt. I understand that if a future effective date is requested, certain rights and guarantees under the Conditional Premium Receipt may be waived. I agree to its terms and conditions.


Total Amount Received Initial Premium (minimum of two (2) months premium) $

Amount for This Applicant $



Proposed Applicant Signature

Date


Date

Signed at (City, State)


Signature of Proposed Policy Owner, if different than the Proposed Applicant


Agent Name (Print)

Agent Name (Print)

Agent Phone

Date Agent Phone

Date

Agent Signature

Agent Signature

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY CONDITIONAL PREMIUM RECEIPT INFORMATION CONDITIONAL PREMIUM RECEIPT INFORMATION

MM500-CNRT LEAVE THIS COPY WITH APPLICANT(S) 01






















Date


Date





Agent Name (Print)

Agent Name (Print)

Agent Phone

Date Agent Phone

Date

Agent Signature

Agent Signature

Turn the Page MM500-WRK RETURN TO HOME OFFICE 02 Page 1

*MM500-WRK*

*PERSWRKSHT*

Massachusetts Mutual Life Insurance Company Home Office: Springfield, MA 01111-0001

Long Term Care Administrative Office P.O. Box 4243

Woodland Hills, CA 91365-4243 888.505.8952

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, the insurance company must fill out part of the information on this worksheet and ask you to fill out the rest to help you and the company decide if you should buy this policy.

Premium Information

Policy Form Number:

The premium for the coverage you are considering will be $ per .

Type of Policy: 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 2000 and has sold this policy since 2008. The company has never raised its rates for any long term care policy it has sold in this state or any other state.

Questions Related To Your Income How will you pay each year's premium?

❍ From my income ❍ From my Savings/Investments ❍ My family will pay

❍ Have you considered whether you could afford to keep this policy if the premiums went up, for example, by 20%?

What Is Your Annual Income? (check one)

❍ Under $10,000 ❍ $10-20,000 ❍ $20-30,000 ❍ $30-50,000 ❍ Over $50,000

How do you expect your income to change over the next 10 years? (check one)

❍ No change ❍ Increase ❍ Decrease

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.

Continued on Next Page

MM500-WRK 02 Page 2

Will You Buy Inflation Protection? (check one) ❍ Yes ❍ No

If not, have you considered how you will pay for the difference between future costs and your daily benefit amount?


The national average annual cost of care in 20091 was: $72,000 in a nursing home; $38,000 in an assisted living facility and $20,000 for home health care, but these figures vary across the country. In ten years the national average annual cost would be about $117,360 in a nursing home; $61,940 in an assisted living facility and $32,600 for home health care, 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)


Questions Related To Your Savings and Investments Not counting your home, about how much are all of your assets (savings and investments) worth? (check one)

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

How do you expect your assets to change over the next ten years? (check one)

❍ Stay about the same ❍ Increase ❍ Decrease

If you are buying this policy 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.

Comparison To Current Coverage If you have existing long term care coverage and you intend to add to or replace your current coverage, please indicate your reason for doing so (check one):

❍ Additional or different benefits (please specify):

❍ No change in benefits, but lower premiums

❍ Fewer benefits and lower premiums

❍ Other (please specify):

Premium for your current long term care coverage: $ per .

1 2009 U.S. Department of Health and Human Services (www.longtermcare.gov/LTC/Main_Site/index.aspx)

MM500-WRK RETURN TO HOME OFFICE 02 Page 3

Disclosure Statement

(Check One) ❍ The answers to the questions above describe my financial situation.

Or

❍ I choose not to complete this information. However, I still want the Company to consider my application.

Authorization to Process Application My agent has explained to me that my personal financial circumstances are an important consideration in determining whether or not long term care insurance is an appropriate purchase for me. My agent has also given me a copy of "Things You Should Know Before You Buy Long Term Care Insurance" and has explained the importance of completing the Long Term Care Insurance Personal Worksheet. I hereby confirm that I have chosen not to complete the Long Term Care Insurance Personal Worksheet. Nevertheless, I request that you continue to process my application for long term care insurance.

❍ I acknowledge that the insurer and/or its agent (below) has reviewed this form with me 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 policy may increase in the future. (This box must be checked in order to consider your application for Long Term Care.)

Signed: (Proposed Applicant 1) (Date)

(Proposed Applicant 2) (Date)

❍ I explained to the proposed applicant(s) the importance of completing this information.

Signed: (Agent) (Date)

(Agent's Printed Name)

IN ORDER FOR US TO PROCESS YOUR APPLICATION, PLEASE RETURN THIS SIGNED STATEMENT TO MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY, ALONG WITH YOUR APPLICATION.

My agent has advised me that this policy does not appear to be suitable for me. However, I still want the Company to consider my application.

Signed: (Proposed Applicant 1) (Date)

(Proposed Applicant 2) (Date)

The Company may contact you to verify your answers. This confidential information will be used only to determine your suitability for long term care insurance and may not be used for any other purpose or disseminated outside of the Company or agency.

F8186 0210 This copy to Home Office with application 01

*F8186-0210*

*HIPAA*

Massachusetts Mutual Life Insurance Company and affiliates, Springfield, MA 01111-0001

Authorization for Release of Personal Health-RelatedInformation

This authorization complies with the HIPAA Privacy Rule

_____________________________________________ ____/____/____ Name of proposed insured/patient (please print) Date of birth

I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, or other health care provider that has provided payment, treatment or services to me or on my behalf within the past 10 years (“My Providers”) to disclose my entire medical record and any other personal health information concerning me. I further authorize any insurance company, my insurance agent, the MIB, Inc., pharmacy benefit manager, consumer reporting agencies, the Department of Motor Vehicles or other state or federal government agency (“Other Persons”) that has any record or knowledge of me or my health to give the Companies all such information.

This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases unless otherwise restricted under state law. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco, but excludes psychotherapy notes. Psychotherapy notes means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. Psychotherapy notes excludes (meaning the following information is included in this authorization) medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

By my signature below, I acknowledge that any agreements I have made to restrict my personal health information do not apply to this authorization and I instruct My Providers and Other Persons to release and disclose my entire medical record without restriction.

This information may be disclosed to the Massachusetts Mutual Life Insurance Company and its affiliated insurance companies, its agents, employees, and representatives (collectively referred to as “The Companies”) and its reinsurers.

The Companies and its reinsurers may disclose information obtained by this authorization to the MIB, Inc., reinsurers my insurance agent, and other persons and entities performing business or legal services in connection with my application.

I understand that a copy of my application will be attached to my policy at time of delivery and further may also be attached to any policy of a co-applicant who is issued coverage as a result of the same application.

This personal health information is to be disclosed under this Authorization so that The Companies may: 1) underwrite my application for coverage, make eligibility, risk rating, policy issuance, enrollment and premium determinations; 2) obtain reinsurance; and 3) conduct other legally permissible activities that relate to any coverage I have applied for with The Companies.

This authorization shall remain in force for 24 months following the date of my signature below, and a photocopy or facsimile of this authorization is as valid as the original.

I understand that I have the right to revoke this authorization in writing, at any time, by sending a written request for revocation to Massachusetts Mutual Life Insurance Company and its affiliated insurance companies at 1295 State Street, Springfield, MA 01111-0001 Attention: Authorization Administrator. I understand that a revocation is not effective to the extent that any of My Providers or Other Persons have relied on this Authorization or to the extent that The Companies have a legal right to contest a claim under an insurance policy or to contest the policy itself.

I understand that some information obtained pursuant to this authorization may be disclosed to persons or organizations that are not subject to the federal health information privacy laws and no longer protected under such laws. I further understand that such information may be re-disclosed only in accordance with applicable laws or regulations.

I understand that My Providers may not refuse to provide treatment or payment for health care services if I refuse to sign this authorization. I further understand that if I refuse to sign this authorization to release my complete medical record, The Companies may not be able to process my application. I acknowledge that I have received a copy of this authorization.

Signature of Proposed Insured/Patient or Personal Representative Date

Print name of signature above

Description of Personal Representative's Authority or Relationship to Patient

F8186 0210 This copy to Client 01



This authorization complies with the HIPAA Privacy Rule _____________________________________________ ____/____/____ Name of proposed insured/patient (please print) Date of birth















F8186 0210 This copy to Home Office with application 01

*F8186-0210*

*HIPAA*



This authorization complies with the HIPAA Privacy Rule

_____________________________________________ ____/____/____ Name of proposed insured/patient (please print) Date of birth















F8186 0210 This copy to Client 01



This authorization complies with the HIPAA Privacy Rule _____________________________________________ ____/____/____ Name of proposed insured/patient (please print) Date of birth















MM-0166 LEAVE WITH APPLICANT 00


IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

This is not Medicare Supplement Insurance

Federal law requires us to inform you that this insurance duplicates Medicare benefits in some situations.

• This is long term care insurance that provides benefits for covered nursing home and home care services.

• In some situations Medicare pays for short periods of skilled nursing home care, limited home health services and hospice care.

• This insurance does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

Neither Medicare nor Medicare Supplement insurance provides benefits for most long term care expenses.

Before You Buy This Insurance

✓ Check the coverage in all health insurance policies you already have.

✓ For more information about long term care insurance, review the Shopper’s Guide to Long Term Care Insurance, available from the insurance company.

✓ For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

✓ For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

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MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY

NOTICE OF HIPAA PRIVACY PRACTICES

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.

This Notice has been revised and is effective as of September 23, 2013.

You have received this Notice because you have applied for or have long term care insurance coverage ("LTC Coverage") with Massachusetts Mutual Life Insurance Company ("MassMutual ").

We collect, use and disclose information about you to evaluate and process any requests for coverage and claims for benefits you may make regarding your LTC Coverage. This Notice describes how we safeguard the protected health information we have about you which relates to your LTC Coverage ("Protected Health Information"), and how we may use and disclose this information. Protected Health Information includes individually identifiable information which relates to your past, present or future health, treatment or payment for health care services. This Notice also describes your rights with respect to the Protected Health Information and how you can exercise those rights.

We are required by law to maintain the privacy of your Protected Health Information; to provide you this Notice of our legal duties and privacy practices with respect to your Protected Health Information; and to follow the terms of this Notice.

We reserve the right to change the terms of this Notice. Any such changes will apply to all Protected Health Information that we already have about you as well as any Protected Health Information that we may receive in the future. If we make a material change to the terms of the Notice, we will promptly send the revised Notice to you should you still maintain coverage with us when the revised Notice becomes effective.

USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION

The following describes when we may use and disclose your Protected Health Information. Any uses or disclosures of your Protected Health Information other than for the purposes described in this Notice will be made only with your written authorization.

Uses and Disclosures with Your Authorization: Except as described below, we will not use or disclose your Protected Health Information for any reason unless we have a signed authorization from you or your legal representative. Please contact our HIPAA Privacy Administration office at the address below to obtain a form. You or your legal representative have the right to revoke an authorization in writing, except to the extent that we have taken action relying on the authorization, or if the authorization was obtained as a condition of obtaining your LTC coverage, or to the extent that we have a legal right to contest a claim under the policy or to contest the policy itself. In the event that we have psychotherapy notice related to you, such information will only be disclosed with your written authorization.

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Uses and Disclosures for Treatment. We may use and disclose your Protected Health Information as necessary for your treatment. For example, we may disclose at claim time your current health status to licensed health care practitioners to allow them to manage, coordinate and administer your treatment.

Uses and Disclosures for Payment: We may use and disclose your Protected Health Information as necessary for payment purposes. For example, when you present a claim for LTC benefits, we may obtain medical records from the doctor or health facility involved in your care to determine if you are eligible for benefits under the insurance policy and to pay benefits under your policy.

Uses and Disclosures for Health Care Operations: We may use and disclose your Protected Health Information as necessary for our health care operations which may include underwriting, premium rating, and other activities related to the issuance, renewal or replacement of LTC Coverage, or for reinsurance purposes. For example, when you apply for insurance we may collect medical information from your doctor (health care provider) or a medical facility that provided you health care services to determine if you qualify for insurance. We may also use and disclose Protected Health Information to conduct or arrange for medical review, legal services, business planning and development regarding the management and operation of our LTC Coverage processes, or auditing, including fraud and abuse detection and compliance programs. Protected Health Information may also be disclosed for customer service, servicing our current and future customer relationship as permitted by law, resolution of internal grievances and as part of a potential sale, transfer, merger, or consolidation in order to make an informed business decision regarding any such prospective transaction.

Uses and Disclosures to Family, Friends or Others Involved in Your Care: Unless you object, we may disclose your Protected Health Information to designated family, friends, personal representatives, or other individuals that you may identify as involved in your care or involved in the payment for your care. Should you become incapacitated or be faced with an emergency medical situation and not able to provide us with your written approval, we may disclose Protected Health Information about you that is directly relevant to such person's involvement in your care or payment for such care.

Uses and Disclosures with Business Associates: We may also disclose Protected Health Information to business associates (entities that perform functions or activities on our behalf, or provide services to us that involve the use and disclosure of Protected Health Information), but only if: the receipt of Protected Health Information is necessary for the business associate to provide a service to us, and the business associate contractually agrees to protect the Protected Health Information according to HIPAA rules. Other Uses and Disclosures: We are permitted or required by law to make the following uses or disclosures of your Protected Health Information without your authorization:

• Releasing Protected Health Information to state or local health authorities, as required by law, about particular communicable diseases, injury, birth, death, and for other required public health investigations;

• Releasing Protected Health Information to a governmental agency or regulator with health care oversight responsibilities;

• Releasing Protected Health Information to a coroner, medical examiner or funeral director to assist in identifying a deceased individual or to determine the cause of death;

• Releasing Protected Health Information to public health or other appropriate authorities, as required by law, when there is reason to suspect abuse, neglect, or domestic violence;

• Releasing Protected Health Information to the Food and Drug Administration (FDA) for purposes related to quality, safety or effectiveness of FDA-regulated products or activities;

• Releasing Protected Health Information if required by law to do so by a court or administrative ordered subpoena or discovery request, or for law enforcement purposes as permitted by law once

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we have met all administrative requirements of the HIPAA Privacy Rule. We may disclose Protected Health Information to any governmental agency or regulator with whom you have filed a complaint or as part of a regulatory agency examination;

• Releasing Protected Health Information for certain research purposes when such research is approved by an institutional review board with established rules to ensure privacy;

• Releasing Protected Health Information if you are a member of the military as required by armed forces services;

• Releasing Protected Health Information to federal officials for intelligence, counterintelligence, and other national security activities authorized by law;

• Releasing Protected Health Information to worker's compensation agencies if necessary for your worker's compensation benefit determination;

• Releasing Protected Health Information to avert a serious threat to someone's health or safety, including the disclosure of Protected Health Information to government or disaster relief or assistance agencies to allow such entities to carry out their responsibilities to specific disaster situations.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

Right to Request Restrictions: You have the right to request restrictions on certain of our uses or disclosures of your Protected Health Information for treatment, payment or health care operations, or that we disclose to someone who may be involved in your care or payment for your care, like a family member, friend or personal representative. You should submit your submission request in writing to our HIPAA Privacy Administration office at the address below. While we will consider your request, we are not required to agree to your restriction. If we do agree to the restriction, we will not use or disclose your Protected Health Information as requested, but reserve the right to terminate the agreed to restriction if such termination is deemed appropriate. In your request to restrict use and disclosure, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse or parent). We will not agree to restrictions on Protected Health Information uses or disclosures that are legally required, or which are necessary to administer our business.

Right to Request Confidential Communications: You have the right to request that we communicate with you about Protected Health Information in a certain way or at a certain location if you inform us that disclosure of such information will otherwise endanger you. Such a request must be in writing and sent to our HIPAA Privacy Administration office at the address below. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests.

Right to Inspect and Copy Your Protected Health Information: In most instances, you have the right to inspect and obtain a copy of the Protected Health Information that we maintain about you. Your request must be in writing and sent to our HIPAA Privacy Administration office at the address below. Your request should indicate what format you want the records (paper or electronic format) and we will provide you with the information in that format, if it is readily producible in such format. You may also request that we transmit your Protected Health Information to another person, and we will do so, provided your signed, written request clearly designates the recipient and the recipient's contact information.

We will deny inspection and copying of certain Protected Health Information, for example psychotherapy notes and Protected Health Information collected by us in connection with, or in reasonable anticipation of any administrative claim or legal proceeding. We must inform you in writing of such a denial. If you are denied access to your Protected Health Information, you may request that the denial be reviewed by submitting a written request to our HIPAA Privacy Administration office at the address below. We reserve the right to charge a fee for the costs of copying, mailing or other supplies associated with your request. We will notify you of the cost involved and you may choose to

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withdraw or modify your request at that time before any costs are incurred. In those circumstances that we may deny your request to inspect and obtain a copy of your Protected Health Information, you have the right to request a review of our denial.

Right to Amend Your Protected Health Information: You have the right to request that we amend your Protected Health Information in our records if you believe that it is inaccurate or incomplete. Your request must be in writing and sent to our HIPAA Privacy Administration office at the address below. If an amendment or correction request is accepted, we will amend or correct all appropriate records as well as notify others to whom we have disclosed the erroneous Protected Health Information. We may deny your request if you ask us to amend Protected Health Information that is accurate and complete; was not created by us, unless the creator of Protected Health Information is no longer available to make the amendment; is not part of the Protected Health Information kept by or for us; or is not part of the Protected Health Information which you would be permitted to inspect and copy. If we deny your request, we will provide you with an explanation for our denial and any further rights you may have regarding your request to amend.

Right to Receive an Accounting of Disclosures of Your Protected Health Information: You have the right to request an accounting or list of disclosures we have made of your Protected Health Information. This list will not include disclosures made for payment or health care operations, made for purposes of national security, made to law enforcement or to corrections personnel or made pursuant to your authorization or made directly to you. To request this list, you must submit your request in writing to our HIPAA Privacy Administration office at the address below. Your request must state the time period from which you want to receive a list of disclosures. The time period may not be longer than six years prior to the date of your request. The first list you request within a 12-month period will be free. We reserve the right to charge you for responding to any additional requests within the same 12 month period. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Receive Notice of a Breach of Unsecured Protected Health Information: As required by law, MassMutual will notify you within 60 days following a breach of your unsecured Protected Health Information.

Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, you must submit a written complaint to our HIPAA Privacy Administration office at the address below. You can be assured that you will not be retaliated against by MassMutual for filing a complaint.

For Further Information and Written Requests: For further information regarding this Notice or MassMutual's privacy practices, please contact Massachusetts Mutual Life Insurance Company, Long Term Care Administrative Office, ATTN: HIPAA PRIVACY ADMINISTRATION, P.O. Box 4243, Woodland Hills, CA 91365-4243. 888-505-8952.

Massachusetts Mutual Life Insurance Company and affiliates • Springfield, MA 01111-0001 COR4565a 1004

Disclosure Statement About Our Policy’s Premium Payment Options

Please Read This Information Carefully As a policyholder of MassMutual, you have the right to choose among four payment plan options for paying your annual premium. Each payment option, other than annual, costs more money. Among our policyholders, the additional cost varies depending upon the type of policy and its original issue date. A generic description of the payment options and range of costs, expressed as dollars and as annual percentage rates, are described below.

Premium Payment Options You may pay premiums once a year (annually), twice a year (semi-annually), or four times a year (quarterly) or twelve times a year (monthly).

If you pay your annual premium by installments, there will be an additional charge.

a. If you pay semi-annually, the additional charge equals an annual percentage rate (APR) in the range of 8.2% to 18%. This would amount to an additional annual charge in the range of $20 to $43 on an annual premium of $1,000.

b. If you pay quarterly, the additional charge equals an annual percentage rate (APR) in the range of 2.4% to 23.7%. This would amount to an additional annual charge in the range of $9 to $88 on an annual premium of $1,000.

c. If you pay monthly, the additional charge equals an annual percentage rate (APR) in the range of 4.3% to 22.1%. This would amount to an additional annual charge in the range of $20 to $103 on an annual premium of $1,000.

There may be other premium payment options available on certain products. Please contact MassMutual at 1-800-272-2216 for more information.

If you would like to know the exact dollar amount of the additional charge or the Annual Percentage Rate that you are paying because you pay your annual premium in installments, you may access our “Modal Charge Disclosure and Annual Percentage Calculator” link at www.massmutual.com/calculators and follow the simple instructions. Alternatively, you may call this toll free number 1-800-272-2216 and we will provide you with the information.

How To Change Your Premium Payment Option* You also have the right to change this option during the lifetime of your policy. In order to make a change, you must either:

• Inform your MassMutual agent that you wish to change the premium payment frequency for your policy; or

• Notify MassMutual in writing via regular mail (MassMutual Financial Group Customer Service Hub at 1295 State Street, Springfield, MA 01111-0001) or contact us at www.massmutual.com that you wish to change the premium payment frequency for your policy’s premium. To request a change in your policy’s premium payment frequency, be sure to include the policy number in your correspondence; or

• Contact a MassMutual Customer Service Representative at 1-800-272-2216 and inform the representative that you wish to change the premium payment frequency for your policy.

* If your premium is paid through a payroll deduction, there may be limitations on your ability to change the payment option. Contact your MassMutual agent to determine if your premium payment option can be changed.

This notice does not change any of the terms of your MassMutual policy.

MM-N-LTC LEAVE WITH APPLICANT 00


Things You Should Know Before You Buy Long-Term Care Insurance Long-Term Care Insurance

x 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.

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

x The personal worksheet includes questions designed to help you and the company determine whether this policy is suitable for your needs.

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

Medicaid x 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.

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

x 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.

x 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 x Make sure the insurance company or agent gives you a copy of a book called the National Association of Insurance Commissioners' "Shopper's Guide to Long-Term Care Insurance." 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 x 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.

Facilities x Some long-term care insurance contracts provide for benefit payments in certain facilities only if they are licensed or certified, such as in assisted living centers. However, not all states regulate these facilities in the same way. Also, many people move to a different state from where they purchased their long-term care insurance policy. Read the policy carefully to determine what types of facilities qualify for benefit payments, and to determine that payment for a covered service will be made if you move to a state that has a different licensing scheme for facilities than the one in which you purchased the policy.

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Long Term Care Insurance Potential Rate Increase Disclosure Form

1. Premium Rate: The premium rate that is applicable to you and the coverage you have applied for is shown on the application.

2. The premium for the Policy and any riders that are issued to you will be shown on the Benefit Schedule of your Policy. This rate will be in effect unless and until the Company requests a premium rate increase and it is approved by the state in which your Policy was issued.

3. Rate Schedule Adjustments:

Premium rate or rate schedule adjustments will be effective on the next Policy Anniversary Date following the date the state approves a rate increase.

4. Potential Rate Revisions:

This Policy is Guaranteed Renewable. This means that the rates for this product 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 policyholders with a Policy 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 Policy in force as is.

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

• Exercise your nonforfeiture option if purchased. (This option is available for purchase for an additional premium.)

• Exercise your contingent nonforfeiture option.* (This option may be available to you if you do not purchase a separate nonforfeiture option.)

*Contingent Nonforfeiture If the premium rate for your Policy goes up in the future and you didn't buy a nonforfeiture option you may be eligible for contingent nonforfeiture. Here's how to tell if you are eligible:

You will keep some long term care coverage, if:

• 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 Policy was first issued. If you have already received benefits under the Policy, 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 Policy benefits will remain at the levels attained at the time of the lapse and will not increase thereafter.

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

MM-N-PRI-LP 00 Page 2

Example:

• You bought the Policy 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 Policy (not pay any more premiums).

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

Contingent Nonforfeiture Cumulative Premium Increase Over Initial Premium That Qualifies for Contingent Nonforfeiture (Percentage Increase is cumulative from the date of original issue. It does NOT represent a one-time increase)

Issue Age Percent Increase Over

Initial Premium Issue Age Percent Increase Over

Initial Premium 40-44 150% 71 38% 45-49 130% 72 36% 50-54 110% 73 34% 55-59 90% 74 32%

60 70% 75 30% 61 66% 76 28% 62 62% 77 26% 63 58% 78 24% 64 54% 79 22% 65 50% 80 20% 66 48% 81 19% 67 46% 82 18% 68 44% 83 17% 69 42% 84 16% 70 40% 85 15%

In addition to the contingent nonforfeiture benefits described above, the following reduced "paid-up" contingent nonforfeiture benefit is an option in all policies that have a fixed or limited premium payment period, even if you selected a nonforfeiture benefit when you bought your Policy. If both the reduced "paid-up" benefit AND the contingent benefit described above are triggered by the same rate increase, you can choose either of the two benefits.

You are eligible for the reduced "paid-up" contingent nonforfeiture benefit when all three conditions shown below are met:

1. The premium you are required to pay after the increase exceeds your original premium by the same percentage or more shown in the chart below;

Triggers for a Substantial Premium Increase

Issue Age Percent Increase Over

Initial Premium

Under 65 50%

65-80 30%

Over 80 10%

MM-N-PRI-LP 00 Page 3

2. You stop paying your premiums within 120 days of when the premium increase took effect; AND

3. The ratio of the number of months you already paid premiums is 40% or more than the number of months you originally agreed to pay.

If you exercise this option your coverage will be converted to reduced "paid-up" status. That means there will be no additional premiums required. Your benefits will change in the following ways:

a. The total lifetime amount of benefits your reduced "paid-up" Policy will provide can be determined by multiplying 90% of the lifetime benefit amount at the time the Policy becomes "paid-up" by the ratio of the number of months you already paid premiums to the number of months you agreed to pay them.

b. The daily benefit amounts you purchased will also be adjusted by the same ratio.

If you purchased lifetime benefits, only the daily benefit amounts you purchased will be adjusted by the applicable ratio.

Example:

• You bought the Policy at age 65 with an annual premium payable for 10 years.

• In the sixth year, you receive a rate increase of 35% and you decide to stop paying premiums.

• Because you have already paid 50% of your total premium payments and that is more than the 40% ratio, your "paid-up" Policy benefits are .45 (.90 times .50) times the total benefit amount that was in effect when you stopped paying your premiums. If you purchased inflation protection, it will not continue to apply to the benefits in the reduced "paid-up" Policy.

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Massachusetts Mutual Life Insurance Company Home Office: Springfield, MA 01111-0001

Long Term Care Administrative Office P.O. Box 4243

Woodland Hills, CA 91365-4243 888.505.8952

Partnership Program Notice Important Consumer Information Regarding the Rhode Island Long-Term Care Insurance Partnership Program

Some long-term care insurance policies sold in Rhode Island may qualify for the Rhode Island Long-Term Care Insurance Partnership Program (the Partnership Program). The Partnership Program is a partnership between state government and private insurance companies to assist individuals in planning their long-term care needs. Insurance companies voluntarily agree to participate in the Partnership Program by offering long-term care insurance coverage that meets certain State and Federal requirements. Long-term care insurance policies that qualify as Partnership Policies may protect the Insured's assets through a feature known as "Asset Disregard" under Rhode Island's Medicaid program.

Asset Disregard means that an amount of the Insured's assets equal to the amount of long-term care insurance benefits received under a qualified Partnership Policy will be disregarded for the purpose of determining the insured's eligibility for Medicaid. This generally allows a person to keep assets equal to the insurance benefits received under a qualified Partnership Policy without affecting the person's eligibility for Medicaid. All other Medicaid eligibility criteria will apply and special rules may apply to persons whose home equity exceeds $500,000. Asset Disregard is not available under a long-term care insurance policy that is not a Partnership Policy. Therefore, You should consider if Asset Disregard is important to You, and whether a Partnership Policy meets Your needs. The purchase of a Partnership Policy does not automatically qualify You for Medicaid.

What are the Requirements for a Partnership Policy? In order for a policy to qualify as a Partnership Policy, it must, among other requirements:

• be issued to an individual after July 1, 2008;

• cover an individual who was an Rhode Island resident when coverage first becomes effective under the policy;

• be a tax-qualified policy under Section 7702(B)(b) of the Internal Revenue Code of 1986;

• meet stringent consumer protection standards and

• meet the following inflation requirements:

7 For ages 60 or younger - provides compound annual inflation protection

7 For ages 61 to 75 -provides some level of inflation protection

7 For ages 76 and older - no purchase of inflation protection is required

If You apply and are approved for long-term care insurance coverage, Massachusetts Mutual Life Insurance Company will provide You with written documentation as to whether or not Your Policy qualifies as a Partnership Policy.

What Could Disqualify a Policy as a Partnership Policy? Certain types of changes to a Partnership Policy could affect whether or not such policy continues to be a Partnership Policy. If You purchase a Partnership Policy and later decide to make any changes, You should first consult with Massachusetts Mutual Life Insurance Company to determine the effect of a proposed change. In addition, if You move to a state that does not maintain a Partnership Program or does not recognize Your Policy as a Partnership Policy, You would not receive beneficial treatment of Your Policy under the Medicaid program of that state. The information contained in this disclosure is based on current Rhode Island and Federal laws. These laws may be subject to change. Any change in law could reduce or eliminate the beneficial treatment of Your Policy under Rhode Island's Medicaid program.

Additional Information. If You have questions regarding long-term care insurance policies please contact Massachusetts Mutual Life Insurance Company. If You have questions regarding current laws governing Medicaid eligibility, You should contact the Rhode Island Department of Human Services.

of 2 Important Privacy & Consumer Information – 0515 N2000-US

Massachusetts Mutual Life Insurance Company1295 State Street, Springfield, MA 01111-0001

Important Privacy & Consumer Information

At Massachusetts Mutual Life Insurance Company (“MassMutual”), we recognize that our relationships with you are based on integrity and trust. As part of that trust relationship, we want you to understand that in order to provide our products and services to you, we must collect, use and share personal information about you. This Privacy Notice describes policies and practices about how we protect, collect and share personal information related to the products and services you receive from us, including life insurance, disability income insurance, long-term care insurance, and individual annuities. It also describes how you can limit some of that sharing.

Disclosures � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Privacy NoticeWe protect your personal information by:• Using security measures that include physical, electronic and

procedural safeguards to protect your personal information from unauthorized access or use in accordance with state and federal requirements.

• Training employees to safeguard personal information and restrict-ing access to personal information to those employees who need it to perform their job functions.

• Contractually requiring business partners with whom we share your personal information to safeguard it and use it exclusively for the purpose for which it was shared.

Personal information we may collect. The types of personal infor-mation we may collect depend on the type of product or service you have with us and may include:• Information that you provide to us on applications or forms, during

conversations with us or our representatives, or when you visit our website (for example, your name, address, Social Security num-ber,dateofbirth,income,andassets,beneficiaries,andmedicalorhealth information).

• Informationabout your transactionswithusandouraffiliates, in-cluding your policy coverages, premiums, and payment history.

• Information from third parties such as consumer or other reporting agencies and medical or health care providers.

We may share all of the personal information we collect, as de-scribed above, with:• Agents, brokers and others who provide our products and services

to you;• Ouraffiliatedcompanies,suchasinsuranceorinvestmentcompa-

nies, insurance agencies or broker-dealers that market our products and services to you;

• Companies that perform marketing or administrative services for us;• Nonaffiliatedcompaniesinordertoperformstandardbusinessfunc-

tions on our behalf including those related to processing transac-tions you request or authorize, or maintaining your policy or contract;

• Courts and government agencies in response to court orders or legal investigations;

• Credit bureaus; and• Otherfinancialinstitutionswithwhomwemayjointlymarketprod-

ucts, if permitted in your state.In addition, we may share certain of your personal information with yourMassMutualfinancialprofessional,ifheorsheisacareeragentof ours who terminates their relationship with us to join another fi-nancial institution (whomwe call a “departingMassMutual financialprofessional”) so that he or she can continue to work with you at his or her new company.Please note that any personal information consisting of medical or health information is only shared with third parties to perform busi-ness, professional or insurance functions on our behalf or as autho-rized by you.Important privacy choices. MassMutual respects your privacy choices. Ifyouhavea relationshipwithadepartingMassMutualfi-nancial professional, as described above, and you prefer that we do not share your personal information, such as information about your insurance policies or contracts held with us, with him or her under these circumstances, you can opt out of this sharing by directing us not to do so. If you wish to opt out of the sharing of your personal information with your departingMassMutual financial professional,you may:• Call us at (800) 272-2216.You may make this privacy choice and contact us at any time, how-ever, if we do not hear from you we may share your information with yourdepartingMassMutualfinancialprofessionalasdescribedabove.If this is a joint account, if one joint owner tells us not to share infor-mation that choice will apply to the other owner or owners. If you have already told us your choice, there is no need to do so again.If you have not purchased a product or service through a MassMutual financialprofessionaloryoudonothavearelationshipwithaMass-Mutualfinancialprofessional,asdescribedabove,youdonotneedtocontact us as we will not share your personal information other than as described in this notice.Other than as described above, we will only share your personal in-formation as permitted by law and, if the law requires us to obtain your consent or give you the opportunity to opt out of some types of sharing, we will do so before sharing the information.

of 2 Important Privacy & Consumer Information – 0515 N2000-US

Disclosures continued • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •Certain state laws may provide residents with additional protections for personal information. If you are a resident of one of the following states, we will not share your personal information with your depart-ing MassMutual financial professional unless we receive your ex-press consent:

Arizona Massachusetts North Carolina

California Minnesota North Dakota

Connecticut Montana Ohio

Georgia Nevada Oregon

Illinois New Jersey Vermont

Maine New Mexico Virginia

If you are no longer our customer, we may continue to share your per-sonal information as described in this Privacy Notice.If you have any questions or concerns about this Privacy Notice, please contact us at (800) 272-2216.MassMutual Financial Group is a marketing name for Massachusetts Mutual •Life •Insurance •Company •(MassMutual) •and •its •affiliated •com-panies and sales representatives. This Privacy Notice is being provid-ed on behalf of the following insurance companies in the MassMutu-al Financial Group with regard to their individual insurance business: Massachusetts Mutual Life Insurance Company, C.M. Life Insurance Company, and MML Bay State Life Insurance Company.Consumer NotificationThis notice is to inform you that a consumer report or an investigative consumer report may be obtained from a consumer reporting agen-cy for the purpose of evaluating your insurance application. The re-port may contain information bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal char-acteristics or mode of living, which has been obtained from public re-cord sources or through interviews with you, your family, neighbors, friends or associates. You have a right to receive a copy of the in-vestigative consumer report from the consumer reporting agency that conducts the investigation.

Medical Information Bureau NoticeInformationregardingyourinsurabilitywillbetreatedasconfidential.We or our reinsurers may, however, make a brief report thereon to the MIB Inc., formerly known as Medical Information Bureau, a not-for-profitmembershiporganizationofinsurancecompanies,whichoper-ates an information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage, oraclaimforbenefitsissubmittedtosuchacompany,MIB,uponre-quest,willsupplysuchcompanywiththeinformationinitsfile.Upon receipt of a request from you, MIB will arrange disclosure of any informationitmayhaveinyourfile.PleasecontactMIBat866-692-6901(TTY866-346-3642)ifyouquestiontheaccuracyofinformationinMIB’sfile.YoumaycontactMIBandseekacorrectioninaccordancewith the procedures set forth in the Fair Credit Reporting Act. The ad-dressofMIB’sinformationofficeis50BraintreeHillPark,Suite400,Braintree,Massachusetts02184-8734.We,orourreinsurers,mayalsoreleaseinformationinourfiletootherinsurance companies to whom you may apply for life or health insur-ance,ortowhomaclaimforbenefitsmaybesubmitted.Informationforconsumers about MIB may be obtained on its website at www.mib.com.The purpose of the bureau is to protect its member companies and their policyholders from the costs created by people who try to hide facts about their insurability. Information furnished by the bureau can-notbeusedasabasisforevaluatingrisks.However,itmaybeusedto alert us to the possible need for further investigation. THE BU-REAUDOESNOTHAVEMEDICALREPORTSFROMHOSPITALSAND DOCTORS. THE INFORMATION IN ITS FILES DOES NOTSHOWWHETHERAN INSURANCEAPPLICATIONWASACCEPT-ED,PLACEDINANINCREASEDPREMIUMCLASSORDECLINED.(This notice is only valid where permitted by law.)Our PurposePart of our basic Company purpose is to provide in surance at the lowest possible cost. The underwriting process is nec essary both to assure this low cost and to make sure that each poli cyholder contrib-utes his or her fair share of the cost. The procedures described above benefityouasapolicyholder,becausetheyassistusinprovidingyourinsurance at the lowest possible cost.

of 1 Voluntary Authorization to Disclose Health-Related Information (Home Office Copy) FR2200-US 1216


Voluntary Authorization to Disclose Health-Related Information

For use with Life, Disability Income (DI) & Long Term Care (LTC)

Use this form to authorize Massachusetts Mutual Life Insurance Company, MML Bay State Life Insurance Com-pany and/or C.M. Life Insurance Company (collectively the “Company”) to disclose information about the Pro-posed Insured, including health-related information, to the Producer and other third party designated below for the purpose of providing the Proposed Insured with additional information regarding the underwriting decisions made in connection with the application for insurance being submitted to the Company. Complete all questions for the Proposed Insured unless otherwise noted.

A Personal Information � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �1. Full legal name (First, MI, Last, Suffix): 2. Date of birth (mm/dd/yyyy): 3. Release information to (Select all that apply):

Producer’s full legal name (First, MI, Last, Suffix): Phone number: ( ) - Extension: Home Work Mobile

Other agency staff’s full legal name: Phone number: ( ) - Extension: Home Work MobileRelationship to Producer (e.g. New Business Coordinator):

B Disclosures � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �The types of information that may be disclosed by the Company pur-suant to this authorization include information contained in medical records such as test results and data on my medical care, treatment or surgery and prescription medicines. The following information will not be disclosed under the terms of this authorization: genetic information, including genetic test results; HIV test results, AIDS, and HIV related conditions; treatment for sexually transmitted diseases; mental illness; psychotherapy notes; psychiatric or psychological disorders; alcohol or drug abuse, including any data protected by Federal Regulations 42 CFR Part 2. In no event will information regarding your health history be disclosed if prohibited by law.I understand that:• I am not required to sign this authorization as a condition of

my application for insurance from the Company.• Signing, not signing or revoking this authorization will not af-

fect my treatment or my payment, enrollment or eligibility for insurance.

• My health information may be re-disclosed and no longer protected by the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA), if the person receiving this information is not

required to comply with HIPAA. HIPAA only regulates certain types of entities, such as insurers providing long-term care insurance and health care providers. However, the Company requires its employ-ees, agents, representatives, insurance producers and service pro-viders to protect the confidentiality of health information regardless of whether the employee, agent, representative, insurance produc-er or service provider is engaged in an insurance business subject to HIPAA. Information may only be re-disclosed in accordance with applicable laws or regulations.

• This authorization will be valid for 6 months after the date it is signed below unless revoked by me prior to that time.

• I have a right to revoke this authorization at any time and may do so by writing to: MassMutual, Attn: Authorization Administrator – Underwriting Department, 1295 State Street, Springfield, MA 01111-0001. I further understand, however, that any action taken by the Company in reliance on this authorization prior to receipt of my revocation by the Company will remain valid.

• I have received a copy of this authorization.• A copy or facsimile of this authorization is as valid as the original.

C Agreements & Signatures � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �I, the undersigned, authorize the Company to disclose information about me, including health-related information, to the individual(s) designated on this form for the purpose of providing me with additional information regarding the underwriting decisions made in connection with the applications I submit to the Company.

Signature of Proposed Insured or Personal Representative: Printed name: Date: Relationship to Proposed Insured (If Personal Representative):

MassMutual Financial Group is a marketing name for Massachusetts Mutual Life Insurance Company (MassMutual) and its affiliated companies and sales representatives.

of 1 Voluntary Authorization to Disclose Health-Related Information (Client Copy) FR2200-US 1216


Voluntary Authorization to Disclose Health-Related Information

For use with Life, Disability Income (DI) & Long Term Care (LTC)

Use this form to authorize Massachusetts Mutual Life Insurance Company, MML Bay State Life Insurance Com-pany and/or C.M. Life Insurance Company (collectively the “Company”) to disclose information about the Pro-posed Insured, including health-related information, to the Producer and other third party designated below for the purpose of providing the Proposed Insured with additional information regarding the underwriting decisions made in connection with the application for insurance being submitted to the Company. Complete all questions for the Proposed Insured unless otherwise noted.

A Personal Information � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �1. Full legal name (First, MI, Last, Suffix): 2. Date of birth (mm/dd/yyyy): 3. Release information to (Select all that apply):

Producer’s full legal name (First, MI, Last, Suffix): Phone number: ( ) - Extension: Home Work Mobile

Other agency staff’s full legal name: Phone number: ( ) - Extension: Home Work MobileRelationship to Producer (e.g. New Business Coordinator):

B Disclosures � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �The types of information that may be disclosed by the Company pur-suant to this authorization include information contained in medical records such as test results and data on my medical care, treatment or surgery and prescription medicines. The following information will not be disclosed under the terms of this authorization: genetic information, including genetic test results; HIV test results, AIDS, and HIV related conditions; treatment for sexually transmitted diseases; mental illness; psychotherapy notes; psychiatric or psychological disorders; alcohol or drug abuse, including any data protected by Federal Regulations 42 CFR Part 2. In no event will information regarding your health history be disclosed if prohibited by law.I understand that:• I am not required to sign this authorization as a condition of

my application for insurance from the Company.• Signing, not signing or revoking this authorization will not af-

fect my treatment or my payment, enrollment or eligibility for insurance.

• My health information may be re-disclosed and no longer protected by the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA), if the person receiving this information is not

required to comply with HIPAA. HIPAA only regulates certain types of entities, such as insurers providing long-term care insurance and health care providers. However, the Company requires its employ-ees, agents, representatives, insurance producers and service pro-viders to protect the confidentiality of health information regardless of whether the employee, agent, representative, insurance produc-er or service provider is engaged in an insurance business subject to HIPAA. Information may only be re-disclosed in accordance with applicable laws or regulations.

• This authorization will be valid for 6 months after the date it is signed below unless revoked by me prior to that time.

• I have a right to revoke this authorization at any time and may do so by writing to: MassMutual, Attn: Authorization Administrator – Underwriting Department, 1295 State Street, Springfield, MA 01111-0001. I further understand, however, that any action taken by the Company in reliance on this authorization prior to receipt of my revocation by the Company will remain valid.

• I have received a copy of this authorization.• A copy or facsimile of this authorization is as valid as the original.

C Agreements & Signatures � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �I, the undersigned, authorize the Company to disclose information about me, including health-related information, to the individual(s) designated on this form for the purpose of providing me with additional information regarding the underwriting decisions made in connection with the applications I submit to the Company.

Signature of Proposed Insured or Personal Representative: Printed name: Date: Relationship to Proposed Insured (If Personal Representative):

MassMutual Financial Group is a marketing name for Massachusetts Mutual Life Insurance Company (MassMutual) and its affiliated companies and sales representatives.

of 2 Client retains this page F6445-US 0617

Pre-Authorized Check (PAC)Premium Payment Service

Electronic Funds Transfer (EFT) from a checking or savings account

A Disclosures

General InformationRetain a copy of this document. “I”, “you” and “your” refer to theauthorized Bank Account Holder.By submitting your request, you authorize Massachusetts Mutual LifeInsurance Company (the “Company”) to debit the bank accountprovided to pay premiums on the Policy(ies) identified, subject to theterms and conditions listed here.Whenever possible, premium refunds will be returned via EFT directdeposit to the bank account provided.If a debit block has been placed on the bank account, contact CustomerService at 1-800-272-2216 for the necessary information to provide thebank in order to establish the Pre-Authorized Check (PAC) PremiumPayment Service.Paying the annual premium in installments may result in additionalexpenses. To obtain the total dollar amount and Annual PercentageRate of the additional expense, go to www.massmutual.com/calculators and access the “Modal Charge Disclosure and AnnualPercentage Rate (APR) Calculator”, or call the Company.The Company has the right to refuse a request to establish a PACAccount on a policy in its grace or lapse pending period until theCompany has received sufficient premium to bring the policy out ofgrace.Draft Day Availability. The draft day is the day the Company willwithdraw money from your bank account. Whenever possible, theCompany will draft on the day elected for the premium that is due.Unless otherwise noted below, the Bank Account Holder may elect tohave recurring premiums drafted any date between the 1st and the 28th

of the month. If no draft day is chosen, the Company will choose a datefor you. If the draft date falls on a weekend or holiday, the draft willoccur on the following business day.

Product Draft Day Options

Life, Long Term Care (LTC),Strategic Group Universal Life products*Strategic Group Variable Life products*Disability Income (DI)**

1st – 28th

Universal Life I*** 1st or 15th

Variable Life Select & Variable Life I*** 5th or 20th

*For Strategic Group Universal Life (SGUL) products and Strategic GroupVariable Life (SGVUL) products, you can elect monthly or quarterlybilling.

**For inforce DI policies beginning with an “8” and DI policies appliedfor but not yet issued (other than “over age 65 policies” applied for butnot yet issued in FL, MN, NJ or NY), you can elect any date between the1st and the 28th and either a monthly or quarterly draft frequency. Thedefault draft date is the Policy’s anniversary date. For all other DIpolicies (including “over age 65 policies” applied for but not yet issuedin FL, MN, NJ or NY), if you do not specify a date, we will select one.

***If no selection is made, the draft date will be the 15th for UniversalLife I, and the 20th for Variable Life Select & Variable Life I.

Establishing a New PAC AccountFor the initial premium:• An email address is required for the one-time EFT for initial

premium (cannot pay initial premium by PAC for SGUL or SGVULproducts). The email address is required because the Company willsend notice of the EFT to the email address provided. Bankinformation will not be provided in the email.

• With a Temporary Insurance Receipt/Agreement or ConditionalReceipt (“TIR”), the one-time EFT for the initial premium will occurimmediately when the Company receives this request in goodorder and the applicable terms and conditions of the TIR have beenmet. Otherwise, the one-time EFT will occur when the Companyreceives all required paperwork in good order. Signing andsubmitting the Pre-Authorized Check (PAC) Premium PaymentService Form (F6445) to draft the initial premium does not meanthat insurance coverage is effective. Coverage is effective only asstated in the application or TIR and the applicable terms andconditions therein have been met.

For recurring premiums:• If the Company is unable to draft on the scheduled draft day be-

cause of the required processing time to set up a PAC Account, theCompany will draft more than one month’s/quarter’s premium(including past premiums) on the next scheduled draft day to bringthe Policy to a current due date.

• The Company will draft premium payments monthly or quarterly(depending upon the policy type and frequency selected) and willnot be required to send monthly/quarterly bills.

• The option for choosing a draft amount for recurring premiumsapplies only to Strategic Group Universal Life, Strategic GroupVariable Life, Variable Life and Universal Life policies. Refer to thePolicy or contact your financial services representative for moreinformation about choosing draft amounts.

• If the Automatic Premium Loan (APL) plan, which is available onlyunder certain policies, has been elected, the APL plan will be inac-tive while premiums are payable under the PAC service.

Changing an Existing PAC AccountNotification of changes to an existing PAC Account must be received atleast 7 business days prior to the next draft date to be in effect as ofthat draft date.If the recurring draft amount changes as the result of a policy conver-sion, a rider, automatic renewal, cost of living adjustment, or otherpolicy change, the Company will notify you of the new draft amountprior to the next draft for which the change will take effect. TheCompany will be authorized to draft the new amount.

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A Disclosures (continued)

Returns/Insufficient FundsThe Company will consider the premium paid only if the EFT is hon- oredby your bank, and we receive the funds. If sufficient funds are notavailable on your scheduled draft date, the Company will automaticallyattempt to draft again one to five days later.

If sufficient funds are still not available:

• For the initial premium, (cannot pay initial premium by PAC forSGUL or SGVUL products) the Company will notify you via the emailaddress provided, and the Policy will remain inactive until thepremium has been successfully received by the Company. If the EFTdraft amount for the initial premium under this authorization is notenough to pay the full initial premium due, the Company willcontact you to obtain authorization to draft the additional requiredpremium.

For recurring premiums, For recurring premiums, the Company willattempt to draft both the missed premium and the next monthlypremium either 10 business days after the bank notifies theCompany of the return or on the next scheduled draft datedepending on policy type. For products on quarterly draft, theCompany will draft the missed quarterly premium either the nextmonth on the selected draft day or on the draft day of the nextquarter, depending upon policy type. The Company will notify youof the new amount prior to the draft.

The Company will not incur any liability as a result of your banknot honoring an EFT. If an EFT is not honored, your payment(s)into the Policy(ies) may not be made or may be made late. Eithersituation could result in a policy losing certain guarantees orcoverage lapsing in accordance with the terms of the Policy.

Terminating a PAC AccountThis authorization will remain in effect until the Company receivesnotification of its termination from the Bank Account Holder, ornotifies the Bank Account Holder of the termination of the PACservice.

By the Bank Account Holder: The Bank Account Holder may terminatethis authorization by calling or writing to the Company. Refer to theContact Information section below for applicable phone numbers andaddresses.

• A request to terminate this authorization for the one-time EFTfor the initial premium must be submitted immediately. It ispossible that the Company may not be able to honor such atermination request if the one-time EFT has already beenprocessed.

• Requests for termination must be received 7 business days priorto the next draft to be in effect as of the draft date.

By the Company: The Company reserves the right to terminate a PACAccount at any time for reasons including, but not limited to, twoconsecutive returns or three returns within one year.

B Contact Information

For more information or general questions, use the resources below or for additional information regarding the Policy, visit www.massmutual.com.

Life & Disability Income

Phone:1-800-272-2216Monday through Friday, 8 a.m. – 8 p.m.Eastern Time

Mail:MassMutualAttention: Life Hub 1295 State StreetSpringfield, MA 01111-0001

Fax:Attention: Life Hub 1-866-329-4527Retain this original and the fax machineconfirmation statement for your files.

Email:[email protected]

Strategic Group Universal Life & Strategic Group Variable Life

Phone:1-800-548-0073Monday through Friday, 8 a.m. – 5 p.m.Eastern Time

Mail:MassMutualPO Box 2488Springfield, MA 01101-2488

Fax:1-860-562-6154Retain this original and the fax machineconfirmation statement for your files.


LifeCarePhone:1-800-505-8942Monday through Friday, 8 a.m. – 5 p.m.Pacific Time

Mail:MassMutualLong Term Care Administrative Co.21600 Oxnard Street, Suite 1500PO Box 4243Woodland Hills, CA 91367

Fax:Attention: Long Term Care Administrative Co.1-818-887-4595Retain this original and the fax machineconfirmation statement for your files.


Massachusetts Mutual Life Insurance Company (MassMutual), 1295 State Street, Springfield, MA 01111-0001 and its subsidiaries: C.M. LifeInsurance Company and MML Bay State Life Insurance Company, 100 Bright Meadow Boulevard, Enfield, Connecticut 06082-1981

of 1 Return this page to Massmutual F6445-US 0617

Pre-Authorized Check (PAC)Premium Payment Service

For Internal Use OnlyAgent’s Name _____________________________

Agent’s Number _____________________________Agent’s Phone Number_____________________________

⃝ Initiate a one-time EFT transaction for the intialpremium (For Life and DI products only). Mustinclude e-mail address below in Section 4.

⃝ Establish a PAC Account for recurring

1For an existing PAC account:⃝ Change Bank/Financial Institution

⃝ Change draft date and/or draft amount

⃝ Add policies (list one policy from existing account):

Authorization to: (check all that apply)

2 Policy Information – For the one-time EFT for initial premium, include the name of the insured and draft amount. For recurring premiums, include the policynumber, name of the insured, draft date, draft amount (VL and UL policies only) and effective date to begin drafting for each policy. Please refer to theDisclosures in this form for information and restrictions regarding draft dates.

Policy Number Name of Insured Draft Date Draft Amount Effective Date(refer to Section C) (if applicable) (mm/yyyy)

$$$$$$$

3 Draft Frequency - This selection applies only to the SGUL, SGVUL & DI policies beginning with an 8. ⃝ Monthly ⃝ Quarterly

4 Bank Account Information or Copy of Voided Check – Please securely attach a voided check or completethe information below

Account Type – check only one option in each group below:

⃝ Individual ⃝Joint ⃝ Other (Corp., Trust, etc.): ⃝ Savings ⃝ Checking

Print Name of Finnancial Insitution City, State, Zip of Finnancial Institution

⃝ Check here to have the address of the Authorized Bank Account Holderchanged to the address listed below.

Bank Routing/Transit Number (always 9 digits) Bank Account Number

Authorized Account Holder Information

Print Name of Authorized Bank Account Holder Print Name of Additional Authorized Bank Account Holder

Sreet Address of Authorized Bank Holder City, State, Zip of Additional Authorized Bank Account Holder

E-mail Address of Authorized Bank Account Holder* Phone Number of Authorized Bank Account Holder

*E-mail address is required for the one-time EFT for the intial premium.

5 Signature Section – By signing below, the account holder(s) acknowledge(s) that they received, read and agree to the Disclosures on pages 1and 2 of this form and confirm(s) the accuracy of the information provided on this form.

X XSignature of Account Holder (& title when applicable) Date Signature of Additional Account Holder (& title when applicable) Date

Massachusetts Mutual Life Insurance Company (MassMutual), 1295 State Street, Springfield, MA 01111-0001 and its subsidiaries: C.M. LifeInsurance Company and MML Bay State Life Insurance Company, 100 Bright Meadow Boulevard, Enfield, Connecticut 06082-19

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