long term care application - npfba ltc application.pdf · long term care plan ... $130/day nursing...

national peace officers andfire fighters benefit associationTM

NPFBATM TM

TM

A Jointly Sponsored Long Term Care Trust of The California Law Enforcement Association® and The California Association of Professional Firefighters®

Protecting Those Who Protect the Public

Long Term Care Application

2 | NPFBA Long Term Care Application

OFFICE USE ONLY

Field Service Manager: _____________________________________________________________________

InstructIons for completIng thIs ApplIcAtIon

This Application must be completed by the Applicant.

When the Applicant signs this application he/she is making a certification under penalty of perjury that all answers are true and correct to the best of his/her knowledge.

NOTE: Employee and Spouse must complete separate applications. All Incomplete Applications will be returned.

An application will be considered incomplete for any of the following reasons: • Thesignatureblocksarenotsigned. • Themedicalquestionsarenotthoroughlyexplained. • Anyquestionorfieldisleftblank.

Allapplicationswillbeindividuallyunderwritten.Ifnecessary,wewillobtainyourmedical recordsorrequestashortparamedicalexamtoassistusintheunderwritingprocess.

All spouses of active employees are required to complete a paramedical exam at the expense of NPFBA as part of the underwriting process.

Please mail your completed application in the postage-paid envelope provided.

If this envelope was not provided to you, please mail to:

NPFBA Long Term Care PlanPOBox31Martell,CA95654-0031

Onceyourapplicationisapprovedyoumayberequiredtosignthe“StatementofContinuingGoodHealth”beforecoveragewillbeissued.

If you have any questions about this Plan or if you need assistance in completing your application, please call toll free 877-582-0003, option #2. Our office hours are Monday through Friday 8:00 am to 5:00 pm.

NPFBA Long Term Care Application | 3

Employees and their eligible spouses may apply for coverage through this Association.

All Applicants must complete all questions and sign and date where indicated.

Applicant must be age 60 or less and must fall into one of the following categories:

1. Memberofpolicedepartmentorfiredepartmentofmunicipalorpublic corporation or district including volunteers or reserves. 2. Peaceorlawenforcementofficerwhoisaregularandsalariedofficeror employeeofthestateorofasinglecountyorotherpoliticalsubdivision or public or municipal corporation. 3. Personwhoisanemergencymedicalservicespersonnelandemployedbya firedepartmentofacity,countyordistrict. 4. Personwhoatthetimeofbecomingamemberofsuchassociationswasqualified pursuanttoparagraphs1,2,or3above. 5. Spouseofqualifiedemployeepursuanttoparagraphs1,2,or3above. 6. Retireesmaynotapplyunlesstheyareotherwisequalifiedinoneofthe above sections.

The above list of qualified applicants would generally include County DA Investigators, County Probation Officers with peace officer status, State of California Investigators with peace officer status, Correctional Officers with the Department of Corrections of the State of California, California Highway Patrol Officers, County Correctional Officers, Firefight-ers, and CalFire Firefighters. Others who believe they qualify and are not listed above must contact the Plan Administrator to determine eligibility.

IcertifyunderpenaltyofperjurythatIhavereadtheabovestatementandagreethatIqualifyundertherequirementsstatedabove.

_____________________________________________ _______________________Applicant Date


plAn optIons

Check Applicable Box

❑ Plan 130 / 70 / 50

$130/DayNursingHome

70%ResidentialCare

50%HomeHealthCare

5%InflationProtectionperyear

RespiteCare

❑ Plan 150 / 70 / 50

$150/DayNursingHome

70%ResidentialCare

50%HomeHealthCare

5%InflationProtectionperyear

RespiteCare

❑ Group Plan / Negotiated Benefits Plan / Modified Payment Plan, may be available.

Department/Plan: ___________________________________________________

pAyment term

Check Applicable Box

❑ 25 Years ❑ 30 Years ❑ 35 Years ❑ 40 Years ❑ 45 Years

The maximum payment term is based on your age at time of application. Please see the published cost (rate) schedule to determine the length of time that you are allowed to make payments.

ApplIcAnt InformAtIon

Please PrintI am applying as: (check the appropriate box below)

HaveyoumetordiscussedthiscoveragewitharepresentativeofNPFBA? ❑ Yes ❑ No

Ifno,howdidyouhearaboutNPFBALongTermCarePlan?

❑Referral ❑ Mailer ❑ Poster ❑ Website

Nameofrepresentative: _______________________________________________________

Employee

❑ ActiveFullTimeFirefighter

❑ ActiveFullTimeLawEnforcementOfficer

❑ Volunteer/PaidCallFirefighter

❑ VolunteerLawEnforcementMember

❑ ReserveLawEnforcementOfficer

❑ Non-SafetyFireDept.Employee

❑ Non-SafetyLawEnforcementDept.Employee

Spouse

❑ SpouseofActiveFullTimeFirefighter

❑ SpouseofActiveFullTimeLawEnforcementOfficer

❑ SpouseofaVolunteer/PaidCallFirefighter

❑ SpouseofaVolunteerLawEnforcementMember

❑ SpouseofaReserveLawEnforcementOfficer

❑ SpouseofaNon-SafetyFireDept.Employee

❑ SpouseofaNon-SafetyLawEnforcementDept.Employee


NameofAgencythatEmployeeisemployedwith: __________________________________________________________

JobTitleofEmployee: _______________________________________________________________________________

Employee Name: _________________________________________ Employee SS#: __________________________

Spouse’s Employer: __________________________________________________________________________________

Last Name

Height

Mailing Address

PhysicalAddress

HomePhoneNumber

AlternatePhoneNumber Best Time to Call Email

Best Time to Call Social Security # Marital Status

City

City

State

State

Zip

Zip

Weight Sex DateofBirth AgeLastBirthday

First Name M.I.

❑ Male

❑ Female

❑ Married❑Divorced

❑ Single❑ Widowed

BenefIcIAry

Full Name: _____________________________________

Relationship: ____________________________________

PhoneNumber: __________________________________

Address: ________________________________________

______________________________________________

Email: _________________________________________

Full Name: _____________________________________

Relationship: ____________________________________

PhoneNumber: __________________________________

Address: ________________________________________

______________________________________________

Email: _________________________________________

Please do not designate beneficiaries under the age of 18.

AlternAte (contIngent)prImAry


pAyment optIons

Note: EachApplicantwillbebilledonanindividualbasis(surchargesareperApplicant).Combinedbillingisnotavailable.

Please select one of the following methods of payment:

❑ Monthly Bank Draft ($1.00 surcharge per transaction)

Please deduct my monthly payment from (choose one):

❑ Checking ❑ Savings

__________________________________________ ____________________________________________ AccountNumber RoutingNumber

__________________________________________ ____________________________________________ FinancialInstitutionName Telephone

__________________________________________________________________________________________ FinancialInstitutionAddressincludingCity,State&Zip

Attach VOIDED check here. We are unable to process your application without this information.

I hereby authorize NPFBA or its designated agent and the financial institution named below to initiate monthly withdrawals from my checking/savings account. This authority will remain in effect until I provide written notification to cancel this Plan or my affiliation with NPFBA, its designated agent or my financial institution.

I understand that if the required funds are not on deposit in my account on the day designated to execute the automatic deduction, I will be subject to the payment collection provision shown in the Evidence of Coverage and that any charges for overdraft or insufficient funds may be charged to me along with any service charges applied by NPFBA.

____________________________________________________ _________________________________ Signature Date

❑ Credit Card❑ Annual ❑ Semi-Annual ($1.00 surcharge per transaction) ❑ Quarterly ($2.00 surcharge per transaction)

Type of Credit Card: ❑ Master Card ❑ Visa ❑ Discover

__________________________________________ ______________________ CardNumber ExpirationDate

____________________________________________________ Signature

❑ Group Plan / Negotiated Benefits Plan / Modified Payment Plan.


medIcAl InformAtIon & hIstory

Please answer all of the following questions. If answering “Yes” to any question, please provide details in the space provided on page 10.

1. Areyouemployedordoyouengageinhobbies,socialactivities,orvolunteerwork?

2. Haveyougainedorlostmorethan5poundsinthepasttwelve(12)months?

3. a.AreyoureceivinganytypeofDisabilityBenefits?

b.Areyounow,orhaveyoueverreceivedbenefitsfromMedi-Cal?

c.Duetoanypresentorpastmentalorphysicaldisability,isanypersonorinstitution currentlyauthorizedtoactonyourbehalf?

d.Areyoudependentontheuseofawalkerorwheelchair?

e.Areyouconfinedtoyourbed,home,hospital,ornursinghome?

f.Doyouuseanymedicalappliancesuchasacatheter,oxygenequipment,respirator, oradialysismachine?

4. Doyourequireassistance,supervisionorareyoulimitedinanywayinperforminganyof thefollowingdailyactivities:bathing,dressing,toileting,mealpreparation,eating, mobility,housekeepingormanagingmedications?

5. Haveyoueverbeendiagnosedortreatedbyahealthcareprofessionalforstroke(CVA), TransientIschemicAttack(TIA)orcerebralaneurysm?

6. Withinthepast5YEARS,haveyoubeenmedicallyadvisedthatyouwillneedsurgery, whichhasnotbeenperformed?

7. Whenyouwalk4blocksatanormalpaceorclimbaflightofstairs,doyouexperience anydifficultiessuchasshortnessofbreath,dizzinessorlegcramps?

8. Doyounow,orhaveyouduringthepast3YEARS,usedanytobaccoproductsincluding cigarettes,cigars,pipes,chewingtobacco,marijuana,etc?

9. Haveyoueverusedrestrictedorcontrolledsubstancesexceptasprescribedbyalicensedphysician?

10.Duringthepast5years,haveyoubeencounseled,treatedorhospitalizedfortheuse ofalcoholordrugs?

11.Doyou,anyhealthcareprovidersoranyoneelseyouknow,haveanyconcerns overyourpresenthealth?

12.Inthelast5years,hasahealthprofessionalrecommendedthatyoushouldhaveany surgeries,tests,orprocedures(includingdiagnostic&screeningprocedures)that havenotbeenperformed?

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No


❑ AcquiredImmuneDeficiencySyndrome(AIDS)/ AIDSRelatedComplex(ARC)/HIVPositive

❑ ADDorADHD

❑ AlcoholismorDrugAbuse

❑ ALS(LouGehrig’sDisease)

❑ Alzheimer’sDiseaseorDementia

❑ Amputation

❑ Aneurysm

❑ Angina

❑ Anxiety

❑ Arrhythmia

❑ Arthritis

❑ Atrial Fibrillation

❑ Asthma,COPD,Emphysema,or ChronicLungDisease

❑ Auto-ImmuneDisease

❑ BloodDisease:Anemia,SickleCell,or BleedingDisorder

❑ Bypass Surgery

❑ Cancer(External)AnyForm

❑ Cancer(Internal)AnyForm

❑ CarotidArteryDisease

❑ CerebralVascularDisease

❑ CirrhosisoftheLiver

❑ ClottingDisorder

❑ Colitis

❑ Congestive Heart Failure

❑ CPAPorBiPAPMachine

❑ Cystic Fibrosis

❑ Diabetes/DiabeteswithInsulin

❑ Dizziness

❑ EatingDisorders:Anorexia,Bulimia

❑ FibromyalgiaorChronicFatigue

❑ Fractures

❑ Glaucoma,MacularDegenerationorother EyeDisorder

❑ HeartAttackorAngioplasty

❑ Heart Valve Impairment

❑ Hemophilia

❑ Hepatitis

❑ HighBloodPressure

❑ Huntington'sChorea

❑ Incontinence/BladderorBowelControl

❑ JointDisorderorReplacement

❑ KidneyDiseaseorFailure

❑ LeukemiaorLymphoma

❑ Lupus

❑ Memory Loss

❑ Meniere'sDisease

❑ Mental/NervousDisorder

❑ Multiple Sclerosis

❑ MuscularDystrophy

❑ Obesity

❑ Organ Transplant

❑ Organic Brain Syndrome

❑ Osteopenia/Osteoporosis

❑ Paralysis

❑ Parkinson'sDisease

❑ VascularDisease

❑ PsychiatricDisorder (Depression,BipolarDisorder,etc.)

❑ Raynaud'sSyndrome

❑ RetinitisPigmentosa

❑ RheumatoidArthritis

❑ Schizophrenia

❑ Scleroderma

❑ SeizureDisorder

❑ Single/MultipleTransientIschemicAttack(TIA)

❑ SleepApneaorSleepDisorders

❑ SpineorBackDisordersincludingScoliosis

❑ Stroke

❑ Tremor

❑ WeightLossSurgery:GastricBypass,LapBandor othermethod

❑ Check this box if you have not been diagnosed or treated for any of the conditions listed above.

13.Haveyoubeendiagnosedortreatedbyamemberofthemedicalprofessionforanyofthefollowingconditions? (Please review the following list carefully. Place an X in the box next to those that apply. If you answered yes to any of the following, please provide details on Page 10)


14.Haveyoueverbeendiagnosed,advisedof,orreceivedmedicaltreatmentbyamemberof themedicalprofessionforanyconditionnotnamedabove(otherthanroutinephysical examswithnormalfindings)?

15.Duringthepast5YEARS,haveyou:(Place an X in the box next to those that apply)

a.Soughtmedicaladviceortreatmentforanyofthefollowingconditions?

b.Usedanyofthefollowing:

16.DoyouhaveapendingoractiveWorkers’CompensationClaim?

17.Haveyoueverhadgenetictesting?

Ifyes,whatfor:___________________________________________________________

18.Pleaseprovidefamilyhistory. Additional space provided on page 10.

19.Haveyoubeenhospitalized,beenadvisedtohave,orhadsurgery,medicalcare,EKG,x-ray, diagnostictestorconfinedtoanyfacilityinthelastfive(5)years? If yes, please provide details on page 10 including test(s) performed, date, reason, results, and name and contact information for medical advisor requesting test(s).

Haveanyofyournaturalparents,brothersorsisters,eitherlivingordead,eversuffered fromanyofthefollowingconditions:PolycysticKidneyDisease,CysticFibrosis, Hemophilia,MultipleSclerosis,Huntington’sChorea,MotorNeuronDisease, MuscularDystrophy,Alzheimer’s,Dementiaoranyotherformofinheriteddisease? If yes, please provide details. Please attach additional page if necessary.

20.Doyoulivealone?Ifno,wholiveswithyou? ____________________________________

21.Doyoudrive?Ifno,why? ___________________________________________________

22.Hasyourdriver’slicenseeverbeensuspended?

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

❑Confusion/Disorientation

❑DeteriorationofVision

❑ Fainting

❑ Falling

❑LossofAppetite

❑ Numbness

❑ Tremors

❑ Unstable Gait

❑ Braces

❑ Cane

❑ Scooter

❑Walker

❑Wheelchair

❑Other: ______________________________________

Family Member

Age at Onset

Age (if living)

Age at Death

Mother

Father

Sister(s)

Brother(s)

Condition Cause of Death


If you answered “Yes” or checked a box on any of the previous questions please explain below, giving full details including: Name, Phone Number and Address of Physician, Condition, Treatment Dates, and any resulting limitations.

Item # Description – Dates – Details – Narrative

❑ I do not take any medications or supplements.

medIcAtIons And supplements

Medication/Supplement Reason and Frequency Currently Use

❑

❑

❑

❑❑

❑

List ALL Medications and Supplements you use regularly OR have regularly used within the past 5 YEARS. Please include prescription medications, non-prescription medications (Over the Counter – OTC), and dietary supplements.

Please attach additional page if necessary.

Please attach additional page if necessary.


protectIon AgAInst unIntended lApse

IunderstandthatIhavetherighttodesignateatleastonepersonotherthanmyselftoreceivenoticeoflapseorterminationofthislong-termcarecoveragefornonpaymentofdues.Iunderstandthatnoticewillnotbegivenuntilthirty(30)daysafterduesisdueandunpaid.

❑ I designate the following person(s) to receive notice prior to cancellation of my coverage for nonpayment of dues:

Full Name: ________________________________________________________________________________

Address: ___________________________________________________________________________________

PhoneNumber: ____________________________ Email: __________________________________________

❑ I elect not to designate any person to receive such notice.

other long term cAre

1. Doyounowhaveinforce,orareyouapplyingfor,anyotherlongtermcare,nursing homeorhomehealthcarepolicy,riderorcertificate(includingahealthcareservice contractorahealthmaintenanceorganizationcontract)?

2. Otherthantheabove,didyouhavealongtermcarepolicy,riderorcertificatein forceduringthelast12months?

3. HaveyoueverhadanapplicationforLife,HealthorLongTermCareinsurance declined,postponed,modifiedorrated?

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

If yes, please explain: __________________________________________________________________

Please provide company names for the purpose of benefit coordination:

__________________________________________________________________________________

physIcIAn InformAtIon

Name: ____________________________________________________ PhoneNumber: _______________________

Address: ____________________________________ City: ____________________ State: ______ Zip: __________

Applicant’sKaiserorHMOI.D.Number: ___________________________

Haveyoubeenseenbyanyotherphysicianand/ormedicalfacilityinthepast2YEARS? ❑ Yes ❑ No

Pleaseprovidephysician’sname,address,phonenumberandreasonforvisit.Additional space on page 10.

1. ______________________________________________________________________________________________

2. ______________________________________________________________________________________________

Please provide information for primary physician and any additional treating physicians.


ApplIcAnt certIfIcAtIon

IcertifythatIhavereviewedalltheinformationandnoticescontainedinthisapplicationandthatallinfor-mationsuppliedonthisapplicationistruetothebestofmyknowledge.

IalsounderstandandagreethatthecoverageforwhichIamapplying,ifissued,shallbesubjecttothesestate-mentsandwilltakeeffectontheeffectivedatestatedonthescheduleofbenefits.Ifstatementsinthisapplica-tionarefraudulentormateriallyuntrue,sanctionsthatcouldincluderescissionofmycoverageorabenefitdenialmaybeapplied.IfIhavesubmittedintentionallyfraudulentstatements,Iunderstandthatmynamemaybesubmittedtotherelevantauthorityforcriminalprosecution.

IunderstandthatthePlanIamapplyingforhasbeenapprovedbytheTrusteesoftheNationalPeaceOfficerandFireFightersBenefitAssociation(NPFBA),butdoesnotqualifyforMedi-Calspend-downprotectionundertheCaliforniaPartnershipforLongTermCare.

Iunderstandthatbasedonthemedicalinformationprovided,Imayreceiveapreferred,standard,ormodifiedrating.Thestandardratingwillhaveaneliminationperiodof90days,whilethepreferredratingwillhaveaneliminationperiodof60days.AmodifiedratingwillbeaneliminationperiodagreeduponbytheapplicantandtheTrust.Modifiedratingsaresometimesofferedinlieuofadenialofcoverage.Certainotherridersandexclusionsmaybeaddedtothecertificatewithagreementofbothparties.Iwillhavetheopportunitytoacceptordenythecertificateifitisnotissuedonapreferredbasis.IfIdenythecertificateofcoverage,Iwillreceivemyfull-prepaidpaymentwithin30daysofmydecision.

Additionally,IunderstandthatifIuseorifIhaveusedanytobaccoproductswithinthelast36months,IwillbeissuedacertificateonastandardbasisandIwillautomaticallyhavea90-dayeliminationperiod.

Thiscoveragewillnotbeeffectiveuntilthe“StatementofContinuingGoodHealth”hasbeensignedandreturnedonaformprovidedbytheAdministrator.ThisStatementofGoodHealthconfirmsthatallinforma-tionontheinitialapplicationcontinuestobecorrectandthatnothinghaschangedsincetheoriginalapplica-tion was submitted.

No coverage will be provided for any job related injury or an injury caused by a third party where a cash settlement was provided in lieu of future medical coverage. Keep this in mind whenever you are offered cash in lieu of future medical coverage. This is particularly important in workers’ compensation claims.

I have read and understand the above statements concerning information that may be fraudu-lent, and the probable penalty of making such statements.

I agree that I shall abide by the related provisions as noted in the Plan Documents and Cor-porate Bylaws. Under the terms of the Plan, any dispute not resolved through the Plan’s claim procedure will be resolved by binding arbitration with the American Arbitration Association.

_____________________________________________________________________________________Signature of Applicant Date

This certification is made in connection with the application for Long Term Care (LTC) coverage with the National Peace Officers and Fire Fighters Benefit Association Trust.

_____________________________________________________________________________________Print Name as it appears in Applicant Information of Application

______________________________________ ______________________________________Social Security Number Date of Birth


AuthorIzAtIon for releAse of InformAtIon – hIpAA complIAnt – pArt 1

Records Subject:

Individual: ___________________________________________________________________

AKA: _______________________________________________________________________

Social Security Number: _____________________

DateofBirth: _____________________________

Service Provider:

RequestingRecordsfrom:

____________________________________________________________________________

Requested By:

LawFirm/InsuranceCompanyrequestingrecords:NationalPeaceOfficersandFirefightersBenefitAssociation(NPFBA)

TheServiceProviderisdirectedtomakeavailableforcopyingallrecordspertainingtotheIndi-vidual.Including,butnotlimitedto,anyandallfiles,photographs,videoand/oraudiotapesand/orrecordsforallinjuriesorconditionsintheServiceProvider’spossessionorundertheServicePro-vider’scontrolthatisheldforanypurpose.Nothingshallberemoved,deleted,alteredorwithheld.

If additional items are to be disclosed or NOT disclosed by Service Provider, you must check ALL appropriate boxes.

Release RecordsDo NOT

Release Records

Allmedicalrecordsduringthecareandtreatment,hospitalizations,evaluations,testing,examination,officevisits,emergencyroom,orlabtesting.Includ-ing,butnotlimitedto,nurse’snotes,operativeandpathologyreports,emergencyroomrecords,surgeryrecords,physicaltherapyrecords,in-patientandoutpatientcharts,MDprogressnotes,consults,MDorders,dischargesummary,MDorders,prescriptions,EKG,andEMG,EEG.

❑ ❑



AllOriginalX-rayfilms,MRIfilms,CTScans, andfilmreports.

Allpsychiatric,drugand/oralcoholtreatment,evaluation,treatment,abusetesting,counseling,rehabilitationrecords.

InItIAl here _______

Allmentalhealthinformationconsistingof,butnotlim-itedto,allnotes,recordsandreportsofpsychotherapydiagnosis,evaluationandtreatment.


Allemploymentrecords,including,butnotlimitedto,payrollrecords,absenteeismortimeoff,benefits,applica-tions,andclaimrecords,applicationsforemployment,workabsenteerecords,timecards,incidentreports, W-2s,1099s,pre-employmentexamrecordsand employee progress records.

Allinsurancerecords,includingcorrespondence,pay-ments,photographs,underwritingandclaimrecords.Including,butnotlimitedto,copiesofpoliciesinvolved,paymentsmadethereunder,medicalrecordssubmittedbythecompanyorotherphysicians.Anyandalldocuments,including,butnotlimitedto,DeclarationsofCoverage,whichevidencecompliancewithCaliforniaFinancial ResponsibilityLawsatthetimeoftheaccident.

AllHIVtestresultsoranyrelatedAIDSvirusinformation.


Release RecordsDo NOT

Release Records

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AttherequestoftheIndividualthisinformationwillbeusedforthepurposeofaidingtheIndividualandhisorherattorneyinestablishingtheliability,natureandextentofaclaimforinjuriesanddisabilitiesandtoestablishbenefits,expenses,compensationanddamages.TheinformationprovidedmaybedisclosedbyNPFBAtootherpartiesand/ortreating/evaluatingphysicians.ThisAuthorizationdoesnotpermittheServiceProvidertoallowthecopyingofrecordsbyanyothercopyserviceorbusinessassoci-ateasdefinedbytheHealthInsurancePortabilityandAccountabilityAct(HIPAA).ThisAuthorizationdoesnotpermitdisclosureofanyinformationtoanyperson,entity,providerorinsurancecompanyotherthanthecopyingofrecordsbyarepresentativeofNPFBA.AnyandallAuthorizationssignedbeforethisAuthorizationarerevoked.

IndividualdesignatesandauthorizesNPFBAashis/herrepresentativetopursueanyandalllegalremediesnecessarytocompeltheproductionofrecordsfromtheProvider.

AcopyofthisAuthorizationisasvalidastheoriginal;theoriginalisnotrequiredtobeshown.TheIndividualhastherighttorevokethisAuthorizationatanytimebygivingtheProviderwrittennoticeofrevocationofthisAuthorization.AcopyofthissignedAuthorizationwillbegiventotheIndividualafterithasbeensigned.The Individual has the right to refuse to sign this Authorization.

This authorization shall expire three years from the date of execution below unless a different date is specified here ______________.

___________________________________________ ____________________Individual’sSignatureorRepresentative Date

___________________________________________ ____________________IfsignedbyotherthanIndividualindicaterelationship Date (Parent,GuardianorConservator)

Thisauthorizationwascreatedin14-pointtypeinaccordancewithCaliforniaLegisla-tureAssemblyBill715.

Administrator:CaliforniaAdministrationInsuranceServices,Inc.CALic#0544968 Revised4-13

1-877-582-0003, Option #2 • Fax(209) 223-2966PO Box 31 • Martell, CA 95654-0031

national peace officers andfire fighters benefit associationTM

NPFBATM TM

TM

www.NPFBA.org