Section 2012.EXHIBIT M   Long-Term Care Insurance Partnership Certification Form

Long-Term Care Insurance Partnership Certification Form

NOTE:  This Form must be completed and submitted with each long-term care policy or certificate form for which the insurer is seeking Partnership qualification.  A separate form must be completed for each policy form and a specimen copy of the form, including all riders and endorsements, must be attached.  A long-term care insurance policy or certificate form may not be issued in Illinois as a partnership policy or certificate unless and until this form has been submitted to and approved by the Illinois Department of Insurance.

Under section 1917(b)(5)(B)(iii) of the Social Security Act (42 USC 1396p(b)(5)(B)(iii)), the state insurance commissioner of a state implementing a qualified state long-term care insurance partnership ("Qualified Partnership") may certify that long-term care insurance policies (including certificates issued under a group insurance contract) covered under the Qualified Partnership meet certain consumer protection requirements, and policies so certified are deemed to satisfy those requirements.  These consumer protection requirements are set forth in section 1917(b)(5)(A) of the Social Security Act (42 USC 1396p(b)(5)(A)) and principally include certain specified provisions of the Long-Term Care Insurance Model Regulation and Long-Term Care Insurance Model Act promulgated by the National Association of Insurance Commissioners (as adopted as of October 2000) (referred to herein as the "2000 Model Regulation" and "2000 Model Act", respectively).

I.          GENERAL INFORMATION

A.        Name, address and telephone number of issuer:

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B.        Name, address, telephone number, and email address (if available) of an employee of issuer who will be the contact person for information relating to this form:

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C.        Policy form numbers (or other identifying information, such as certificate series) for policies covered by this Issuer Certification Form:

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Specimen copies of each of the above policy forms, including any riders and endorsements, shall be provided upon request.

II.        QUESTIONS REGARDING APPLICABLE PROVISIONS

Please answer each of the questions below with respect to the policy forms identified in section I.C above.  For purposes of answering the questions below, any provision of the 2000 Model Regulation or 2000 Model Act listed below shall be treated as including any other provision of the 2000 Model Regulation or 2000 Model Act necessary to implement the provision. 

Part III.  INFLATION PROTECTION

Identify the policy provision or provide form number of endorsement or amendment form (and date of approval) for inflation protection coverage in compliance with 50 Ill. Adm. Code 2012.145(b)(1) through (b)(3).

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Part IV.  Certification

I hereby certify that the answers, accompanying documents, and other information set forth herein are, to the best of my knowledge and belief, true, correct and complete and the policy [certificate] satisfies the requirements necessary for a qualified State long-term care insurance partnership policy in the State of Illinois.

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Date                                              Name and Title of Officer of the Insurer

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Signature of Officer of the Insurer

(Source:  Added at 38 Ill. Reg. 2186, effective January 2, 2014)