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State of Maryland Medical Assistance Manual Revised April 2014

SECTION III (To Be Completed By Insurance Company)

CID#_____________________

Name: ____________________ Please Complete Numbers 1-8

TO WHOM IT MAY CONCERN: Please provide the following information regarding life insurance policies owned by applicant/spouse. When completed and signed, please mail to office address listed on page 1 or fax to ________________.

APPLICANT (AP) SSN__________________ SPOUSE (SP) SSN______________________

1. Name of Insured AP Policy (1) ______________ Policy (2) _____________ Policy (3) __________________ SP Policy (1) ______________ Policy (2) _____________ Policy (3) __________________

2. Name of Policy AP Policy (1) ______________ Policy (2) ______________ Policy (3) __________________ SP Policy (1) ______________ Policy (2) ______________ Policy (3) __________________

3. Policy Number AP Policy (1) ______________ Policy (2) ______________ Policy (3) ___________________ SP Policy (1) ______________ Policy (2) ______________ Policy (3) ___________________

4. Original Face Value AP Policy (1) ______________ Policy (2) ______________ Policy (3) ____________________ SP Policy (1) ______________ Policy (2) ______________ Policy (3) ____________________

5. Accumulated Face Value AP Policy (1) ______________ Policy (2) ______________ Policy (3) ___________________ SP Policy (1) ______________ Policy (2) ______________ Policy (3) ___________________

6. Loan(s) Against AP Policy (1) ______________ Policy (2) _____________ Policy (3) ___________________ SP Policy (1) ______________ Policy (2) _____________ Policy (3) ___________________

7. Has additional insurance been purchased with dividends? AP Policy (1) ______________ Policy (2) ______________ Policy (3) ____________________ SP Policy (1) ______________ Policy (2) ______________ Policy (3) ____________________

8. Total Cash Value Does this amount include #5 above? Yes No AP Policy (1) ______________ Policy (2) ______________ Policy (3) ____________________ SP Policy (1) ______________ Policy (2) ______________ Policy (3) ____________________

Signature of Applicant/Recipient/Representative of Insurance Company

Date

_______________________________________

___________________________

Title

Telephone Number

DES 2001 (LTC) Revised 12/08 (2)