2011 STANDARD Medicare Supplement/ Life Insurance Plans - HealthPlanOne

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2011 STANDARD Medicare Supplement/Life Insurance PlansIssued by Forethought Life Insurance CompanyINDIANAMS3000-01-IN

2011 Forethought Standard Medicare SupplementInsurance PlansYou can rely on Forethought Standard Medicare Supplement Plans to help pay yourMedicare Part A and Medicare Part B charges that Medicare doesn’t cover.What’s more, you have: Five plans from which to select the coverage that best meets your needs. 30 days to review your Policy; if you’re not happy with it, we’ll refund your premium. Virtually no claims paperwork to file.The Forethought Standard Medicare Supplementinsurance is underwritten by:Forethought Life Insurance CompanyAdministrative officePO Box 14659Clearwater, FL 33766-4659Choose the Forethought Standard MedicareSupplement Plan that’s right for you.1

Choose the Forethought plan that best fits your needs!MEDICARE PAYSPLAN A PAYSPLAN C PAYSPLAN F PAYS PLAN G PAYSPLAN N PAYSMedicare Part Ahospital coverageDeductible 1,132 1,132 1,132 1,132First 60 days100%Coinsurance61–90 daysAll but 283a day 283a day 283a day 283a day 283a day 283a dayCoinsurance91–150 days(Lifetime Reserve)All but 566a day 566a day 566a day 566a day 566a day 566a sEligibleexpensesEligibleexpenses3 pints3 pints3 pints3 pints3 Up to 141.50a dayUp to 141.50a dayUp to 141.50a dayUp to 141.50a day 162 162Generally 20%Generally 20%Generally 20%Generally 20%†Extended hospitalcoverage (up toan additional365 daysin your lifetime)Benefit for bloodAll but 3 pintsHospice careAll but limitedcoinsurance foroutpatient drugsand inpatientrespite careSkilled nursingfacility careFirst 20 days100%Coinsurance21–100 daysAll but 141.50a dayMedicare Part Bphysician’s servicesand suppliesDeductibleCoinsuranceGenerally 80%Generally 20%Excess benefitsBenefit for blood100% up to100% up toMedicare’s limit Medicare’s limitAll but 3 pints3 pints3 pints3 pints3 pints3 pints80% tolifetime maxof 50,00080% tolifetime maxof 50,00080% tolifetime maxof 50,00080% tolifetime maxof 50,000Other benefits*Emergency carereceived outsidethe USA*Refer to the next page and your Outline of Coverage for more information.†Subject to copayment for office and emergency room visits.2

Your care benefitsMedicare Part A hospital coverageMedicare Part B physicianservices and suppliesThe Forethought Standard Medicare SupplementPlan pays the 1,132 Part A (inpatient) deductible forPlans C, F, G and N for each benefit period.Deductible – Plans C and F pay the 162 calendaryear deductible.First 60 days – After the Part A deductible, Medicarepays all eligible expenses for services from your firstthrough 60th day of hospital confinement. Servicesinclude semi-private room and board, general nursingand miscellaneous hospital services and supplies.Coinsurance – After the Part B deductible, Plans A, C,F and G generally pay 20% of eligible expenses forphysician’s services, supplies, physical and speechtherapy, and ambulance service.Coinsurance – Plans A, C, F, G and N pay 283 aday when you are hospitalized from the 61st daythrough the 90th day. When you are hospitalized fromthe 91st day through the 150th day, the Plans pay 566 a day for each Lifetime Reserve day used.After the Part B deductible, Plan N generally pays 20%of the eligible expenses for physician’s services, supplies,physical and speech therapy, and ambulance servicesexcept up to a 20 copayment for office visits and upto a 50 copayment for emergency room visits.For hospital outpatient services, the copaymentamount will be paid under a prospective paymentsystem. If this system is not used, then generally20% of eligible expenses will be paid.Extended hospital coverage – If you are in thehospital longer than 150 days during a benefit periodand you have exhausted your 60 days of Medicarelifetime reserve, Plans A, C, F, G and N pay the Part AMedicare eligible expenses for hospitalization, paid atthe Diagnostic Related Group (DRG) day outlier perdiem or other appropriate standard of payment,subject to a lifetime maximum benefit of an additional365 days.Excess benefits – Your bill for Part B services andsupplies may exceed the Medicare eligible expense.When that occurs, Plan F and G will pay 100% up tothe charge limitation established by Medicare.Benefit for blood – Medicare has one calendar yeardeductible for blood that is the cost of the first threepints. Plans A, C, F, G and N pay the deductible.Benefit for blood – Medicare has one calendar yeardeductible for blood that is the cost of the first threepints. Plans A, C, F, G and N pay the deductible.Other benefits*Skilled nursing facility care – Medicare pays alleligible expenses for the first 20 days.Emergency care received outside the U.S. – Afteryou pay a calendar-year deductible, Plans C, F, G andN pay you 80% of eligible expenses incurred duringthe first 60 days of a trip up to a lifetime maximum of 50,000. Benefits are payable for medically necessaryemergency care.Coinsurance – Plans C, F, G and N pay up to 141.50from the 21st through the 100th day during which youreceive skilled nursing care. You must enter a Medicarecertified skilled nursing facility within30 days of being hospitalized for at least three days.Hospice care benefit – Plans A, C, F, G and N paythe copayment/coinsurance amount for all Part AMedicare eligible hospice care and respite care expenses.*Refer to the next page and your Outline of Coverage for more information.3

Forethought Medicare Supplement PlansA Forethought Standard Medicare Supplementinsurance policy helps pay eligible expenses notpaid for by Medicare Part A and Medicare Part B.There may be charges that exceed what Medicareand your Standard Medicare Supplement insurancepolicy will pay.Coinsurance is the portion of the eligible expensenot paid by Medicare and paid by Standard MedicareSupplement Plans.Benefits are paid to you, your hospital or doctor.You have 31 days from your renewal date to payyour premium. Your policy will stay inforce duringthis 31-day grace period.“Medicare Eligible Expenses” means expensescovered by Medicare to the extent recognized asreasonable and medically necessary by Medicare.Your Policy is guaranteed renewable. Your policycannot be canceled. It will be renewed as long as thepremiums are paid on time and the information onyour application is correct.Forethought Standard Medicare SupplementPlans will not pay for: Any expense incurred before your Policy Date Services for which no charge is made Expenses paid by Medicare Hospital or skilled nursing facility confinementcharges incurred prior to the effective date ofcoverage of the policy Loss or expense that is payable under anyother Medicare Supplement insurance policyor certificateYou cannot be singled out for a rate increase nomatter how many times you receive benefits. Yourpremium changes only (a) each year on the renewaldate coinciding with or following the anniversary ofyour Policy Date until you reach age 99; and (b)when the same premium change is made on allinforce Forethought Standard Medicare Supplementpolicies of the same form issued to persons of yourclassification in the same geographic area ofyour state.Medicare Part A Eligible Expenses forhospital/skilled nursing facility care includeexpenses for semi-private room and board, generalnursing and miscellaneous services and supplies.This is a brief description of your coverage. Thisbrochure must be accompanied by the Outline ofCoverage. For a complete description of benefits,exceptions and limitations, please read your Outlineof Coverage and your Policy.A Benefit Period begins the first full day you arehospitalized and ends when you have not beenin a hospital or skilled nursing facility for 60consecutive days.Not connected with or endorsed by the UnitedStates government or the federal Medicareprogram.Medicare Part B Eligible Expenses for medicalservices include expenses for physician’s services,hospital outpatient services and supplies, physicaland speech therapy, and ambulance service.This is a solicitation of insurance and an agent willcontact you by telephone.*Refer to the next page and your Outline of Coverage for more information.4

Agent checklist for completing theMedicare Supplement / Life Insurance ApplicationThis packet contains the following forms needed to complete an Application For Medicare Supplement Insurance and LifeInsurance. Please tear out the application and all pages marked “RETURN TO COMPANY” and leave the remaining pageswith the applicant(s). Please review the following information carefully and complete all needed forms: Application For Medicare Supplement Insurance and Life Insurance (Form MSAP1000-01 or MSAPC1000-01) Medicare Supplement – If the applicant(s) is applying during Open Enrollment or a Guaranteed Issue period, Section 4is not required to be completed Life Insurance – Sections 4 and 5 are required when the applicant(s) is applying for life insurance Section 7 should be completed only if the applicant(s) would like his/her payments to be deducted automatically fromhis/her checking/savings account. This option applies only if premiums are paid monthly Agent Certification (Form AGTCRT10-01) – This form must be signed by the agent and by the applicant(s). Calculate your premium – This form is used to calculate the correct life insurance premium and, in coordination with theOutline of Coverage, to calculate the correct Medicare Supplement premium. This form must be returned with the application. Fax Transmittal – Follow the instructions on this form only if the applicant(s) elects to pay premiums using ACH and you aresubmitting the underwriting documents via fax instead of regular mail. Authorization to Release Confidential Medical Information (Form MS-HIPAA10-01) – Must be completed only if applyingoutside Open Enrollment or a Guaranteed Issue period for Medicare Supplement or if applying for life insurance. If bothspouses are applying for coverage on the same application, then both must sign the form. Notice to Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage (Form MS-RN10-01) –This form must be completed if replacement of an existing Medicare Supplement policy is involved. One signed copymust be returned to the Administrative Office and the other signed copy must be left with the applicant(s). Notice for Replacement of Life Insurance or Annuities (A7012-02) – This form must be completed if replacement ofexisting life insurance is involved. One signed copy must be returned to the Administrative Office and the other signedcopy must be left with the applicant(s). Investigative Consumer Report Notice to Applicant, Medical Information Bureau Disclosure Notice, Medicare Supplement/Select Initial Premium Receipt, and Life Insurance Conditional Coverage receipt (MSREC-01) – The Initial/ConditionalPremium Receipts must be left with the applicant(s) and the full modal premium is required with all applications.Please note, you are also required to provide the applicant(s) with the following items: Guide to Health Insurance for People with Medicare Outline of Coverage (Form MSOC10-01)Premiums and policy feeUtilize the Forethought ForeLife final expense premium chart to determine the correct monthly life insurance premium.Utilize the Outline of Coverage to determine Medicare Supplement premiums. Determine ZIP code where the client resides and find the correct rate page for that ZIP code Determine Plan Determine if tobacco or non-tobacco use Find age/gender – Verify that the age and date of birth are the exact age as of the application date, this will be yourbase monthly premium Use the Calculate your premium form to adjust the monthly premium for different modes and to add the policy feeSMThere will be a one-time Medicare Supplement application fee of 25.00 that must be collected with each applicant’s initialpayment. If both spouses are written on the same application, 50.00 in fees must be collected. This will not affect the renewalpremiums.Mailing AddressForethought Life Insurance CompanyAdministrative officeP.O. Box 14659Clearwater, FL 33766-4659Overnight/Express AddressForethought Life Insurance CompanyAdministrative office2536 Countryside Boulevard, Suite 501Clearwater, FL 33763FAX Number for New Business - EFT Applications 1-800-497-6115MSC4000-01-IN 2010 Forethought0810

NOT AVAILABLE

Agent CertificationFORETHOUGHT LIFE INSURANCE COMPANYAdministrative Office P.O. Box 14659, Clearwater, FL 33766-4659 1-877-492-5870I the undersigned insurance agent certify;THAT, I have taken an application for:Primary insured:Medicare SupplementStandardT Plan AT Plan CT Plan FT Plan GT Plan NMedicare SupplementSelectT Plan CT Plan FT Plan GT Plan NApplicant B:Medicare SupplementStandardT Plan AT Plan CT Plan FT Plan GT Plan NMedicare SupplementSelectT Plan CT Plan FT Plan GT Plan NOffered by FORETHOUGHT LIFE INSURANCE COMPANY,to(Applicant(s)),THAT, I have explained the provisions of the policy being applied for, including specifically, all thedifferent benefits, exceptions and limitations of the plan.THAT, I am a licensed agent of this insurance company and have given a company receipt for an initialpremium in the amount of which has been paid to me byT CheckT Money orderT ACH (Check appropriate method of payment)THAT, I have clearly explained any benefits of this plan are a supplement to any benefits that theapplicant may be entitled to receive from the Medicare Program of the Federal Government.THAT, I have not made any representation to the applicant that there is any endorsement whatsoeverby the Social Security Administration or the Centers for Medicare and Medicaid Services in connectionwith this insurance policy being applied for.DateSignature of agentI, the undersigned applicant, understand that I willreceive a copy of this form when my policy is issuedand delivered to me.Name of agencySignature of applicantAddress of agent / AgencySignature of spouse, if applyingAGTCRT10-01Phone numberRETURN TO COMPANY 2010 Forethought0810

Forethought ForeLifeFinal Expense Life InsuranceSMForethought ForeLifeSM is a whole life insurance product designed to help cover final expenses suchas the costs associated with funeral and burial expenses. The ForeLife product provides guaranteed,level premiums and uses the same simplified application as the Forethought Medicare SupplementStandard and Select Plans. Minimum face amount – 5,000 Maximum face amount – 30,000 full death benefit 20,000 graded death benefit Policy is rated on age at last birthday – may backdate 6 months to save age. Please refer to the ForeLife Height and Weight chart for eligibility. Monthly bank draft premiums are displayed on the rate chart.- Other modal premiums available are quarterly, semi-annual and annual.See rate chart for modal factors. Underwriting Classes are Smoker and Non-Smoker.- A smoker is considered anyone who has smoked cigarettes in the past 12 months. One check for both a Medicare Supplement policy and a ForeLife policy is acceptable. The Calculate your premium form must be completed and submitted with application.Death benefitFull benefitGraded benefit*Months 1-12Months 13-24Months 25-36Months 37 100% of face100% of face100% of face100% of face25% of face50% of face75% of face(NH, NJ – 100% offace)100% of face(Accidental Death - 100% of face)* Not available in all states.Please advise your client that a phone interview will be conducted within the next fewdays so they will be prepared to receive the call.This is only a brief description of the policy guidelines. Please refer additional questions to your licensedinsurance agent.MSC3001-011 2010 Forethought0910

5.54 5.80 6.06 6.31 6.57 6.92 7.44 7.96 8.48 9.00 9.52 10.21 10.99 11.76 12.63 13.49 3.98 4.15 4.41 4.67 4.93 5.19 5.45 5.80 6.14 6.49 6.92 7.44 8.04 8.65 9.43 10.29 23.27 24.13 25.43 26.73 28.03 29.32 30.62 32.35 34.08 35.81 37.97 40.57 43.60 46.62 50.52 54.84NSS 7,500SNSS 58.73 61.33 63.92 66.52 69.11 72.57 77.76 82.95 88.14 93.33 98.52 105.44 113.23 121.01 129.66 138.31 10,000 33.22 44.89 43.16 34.51 46.84 44.89 36.46 48.79 47.49 38.41 50.73 50.08 40.35 52.68 52.68 42.30 55.27 55.27 44.24 59.17 57.87 46.84 63.06 61.33 49.43 66.95 64.79 52.03 70.84 68.25 55.27 74.74 72.57 59.17 79.93 77.76 63.71 85.76 83.82 68.25 91.60 89.87 74.09 98.09 97.66 80.57 104.58 106.31NSFemale 31.05 32.35 33.65 34.95 36.24 37.97 40.57 43.16 45.76 48.35 50.95 54.41 58.30 62.19 66.52 70.84 5,00065666768697071727374757677787980Ages 5.10 5.36 5.71 6.06 6.40 6.83 7.35 7.87 8.39 8.91 9.43 10.03 10.73 11.50 12.46 13.41NS 7.61 8.13 8.65 9.17 9.69 10.21 10.81 11.50 12.20 12.98 13.84 14.71 15.66 16.69 17.82 19.03SPer 1,000 28.89 30.19 31.92 33.65 35.38 37.54 40.14 42.73 45.33 47.92 50.52 53.54 57.00 60.90 65.65 70.41NSSS 60.46 64.36 68.25 72.14 76.03 79.93 84.47 89.66 94.85 100.69 107.17 113.66 120.80 128.58 137.02 146.10 7,500NSMale 41.43 41.65 44.03 43.60 46.62 46.19 49.22 48.79 51.81 51.38 54.41 54.62 57.44 58.52 60.90 62.41 64.36 66.30 68.25 70.19 72.57 74.09 76.90 78.63 81.66 83.82 86.85 89.66 92.47 96.79 98.52 103.93 5,000 54.41 57.00 60.46 63.92 67.38 71.71 76.90 82.09 87.28 92.47 97.66 103.71 110.63 118.42 127.93 137.45NSS 79.49 84.68 89.87 95.06 100.25 105.44 111.50 118.42 125.34 133.12 141.77 150.42 159.94 170.32 181.56 193.67 10,000Monthly rates2For quarterly premium mode, multiply the monthly premium by 3.01For semi-annual premium mode, multiply the monthly premium by 5.95For annual premium mode, multiply the monthly premium by 11.56To estimate the monthly premium for face amounts other than 5,000, 7,500, or 10,000, multiply the “Per 1,000” factor by thedesired face amount, divide by 1,000 and add a 3.37 monthly policy fee.SNSPer 1,000Monthly EFT premium rates – full death benefit coverage onlySMFORETHOUGHT FORELIFE LIFE INSURANCE

Calculate your premiumForethought Medicare SupplementMedicare Supplement PlanBefore you begin: If you’re not in your open enrollment or guarantee issue period, please go to page 2 todetermine your eligibility for coverage.StepsExampleRate displayed is used forcalculation purposes only.PremiumWrite in your Medicare Supplement Plan’spremium from the Outline of Coverage table.Payment OptionsTo determine other payment schedules,multiply your monthly premium by:3 to pay four times a year (quarterly)6 to pay twice a year (semi-annually)12 to pay once a year (annually)Applicant’spremiumApplicant B’spremium 128.52 128.52 Monthly payment 385.56 Quarterly payment 771.12 Semi-annual payment 1,542.24 Annual paymentEnrollment/Policy feeThere is a one-time application fee of 25.00This will be collected with your initial payment and will NOT affect your renewalpremium. 128.52 25.00 153.52Example shows initial payment(monthly schedule).Calculate your premiumForethought Life InsuranceTO ADD FORETHOUGHT FORELIFESMFor total face amounts other than 5,000, 7,500, or 10,000, multiply the “Per 1,000” column bythe number of units applied for and add the 3.37 monthly policy fee to your calculation.Choose the base face amount oflife insurance coverage you wantto purchase ( 5,000, 7,500 or 10,000)Base face amount 5,000(Example based on Male age 75non-smoker)Premium amount 50.52Add any additional 1,000 FaceAmount increments1 Additional 1,000 incrementx 9.43 per 1,000Total additionalincrement premium 9.43Payment OptionsMultiply monthly premium by:3.01 for a quarterly premium5.95 for a semi-annual premium11.56 for an annual premiumBILLING MODE MUST BE THESAME AS THE MEDICARESUPPLEMENT BILLING MODE 50.52 base premium 9.43 additional increment 59.95 total monthly premiumfor life insuranceTotal life premiumAdd the Medicare Supplement(from top section) and LifeInsurance premiums (this section)together MSC4001-01Applicant’spremiumcalculationApplicant B’spremiumcalculation 50.52 9.43 59.95x3.01 (Quarterly) 180.45x5.95 (Semi-annual) 356.70x11.56 (Annual) 693.02One check payableto Forethought LifeInsurance Companyfor 213.47 153.52 (Med Supp) 59.95 (Life Ins) 213.47COMPLETE AND RETURN WITH APPLICATION1 2010 Forethought0810

Height and weight chartsTo determine whether you may purchase coverage, locate your height, then weight in the chartsbelow. If your weight is not in the Standard column for either product, we’re sorry, you’re not eligiblefor coverage at this time. If your weight is located in the Standard column for one or both products,you may proceed in completing the application.FORETHOUGHT FORELIFESMLIFE INSURANCEFORETHOUGHT MEDICARE SUPPLEMENTHeight4’ 2’’4’ 3’’4’ 4’’4’ 5’’4’ 6’’4’ 7’’4’ 8’’4’ 9’’4’ 10’’4’ 11’’5’ 0’’5’ 1’’5’ 2’’5’ 3’’5’ 4’’5’ 5’’5’ 6’’5’ 7”5’ 8’’5’ 9’’5’ 10’’5’ 11’’6’ 0’’6’ 1’’6’ 2’’6’ 3’’6’ 4’’6’ 5’’6’ 6’’6’ 7’’6’ 8’’6’ 9’’6’ 10’’6’ 11’’7’ 0’’7’ 1’’7’ 2’’7’ 3’’7’ 4’’MSC4001-01DeclineWeight 54 56 58 60 63 65 67 70 72 75 77 80 83 85 88 91 93 96 99 102 105 108 111 114 117 121 124 127 130 134 137 140 144 147 151 155 158 162 166StandardWeight54 – 14556 – 15158 – 15760 – 16363 – 17065 – 17667 – 18270 – 18972 – 19675 – 20277 – 20980 – 21683 – 22485 – 23188 – 23891 – 24693 – 25496 – 26199 – 269102 – 277105 – 285108 – 293111 – 302114 – 310117 – 319121 – 328124 – 336127 – 345130 – 354134 – 363137 – 373140 – 382144 – 392147 – 401151 – 411155 – 421158 – 431162 – 441166 – 451DeclineWeight146 152 158 164 171 177 183 190 197 203 210 217 225 232 239 247 255 262 270 278 286 294 303 311 320 329 337 346 355 364 374 383 393 402 412 422 432 442 452 Height4’ 7’’4’ 8’’4’ 9’’4’ 10’’4’ 11’’5’ 0’’5’ 1’’5’ 2’’5’ 3’’5’ 4’’5’ 5’’5’ 6’’5’ 7’’5’ 8’’5’ 9’’5’ 10’’5’ 11’’6’ 0”6’ 1’’6’ 2’’6’ 3’’6’ 4’’6’ 5’’6’ 6’’6’ 7’’6’ 8’’6’ 9’’6’10”6’11”2DeclineWeight 80 84 87 90 93 96 99 103 106 109 112 116 119 123 126 129 133 137 140 144 148 152 155 160 164 168 171 175 180StandardWeight80 – 17284 – 17987 – 18690 – 19393 – 19996 – 20699 – 213103 – 220106 – 227109 – 234112 – 241116 – 248119 – 255123 – 263126 – 270129 – 277133 – 285137 – 293140 – 301144 – 309148 – 318152 – 326155 – 333160 – 342164 – 351168 – 359171 – 367175 – 376180 – 385DeclineWeight173 180 187 194 200 207 214 221 228 235 242 249 256 264 271 278 286 294 302 310 319 327 334 343 352 360 368 377 386 2010 Forethought0810

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Forethought Life Insurance Company (“Forethought”), provides innovative insurance and financial solutionsfor families managing retirement and end-of-life needs. Headquartered in Indianapolis, Indiana, Forethoughtprovides life insurance and annuities.Forethought has been consistently recognized by A.M. Best for financial strength.As of June 30, 2010, Forethought has assets owned and under management in excess of 4.7 billion,approximately 1.1 billion in annual revenue, more than 4.9 billion of life insurance and annuity businessin force, and has served more than 2 million policyholders since 1985.Forethought Life Insurance CompanyAdministrative officePO Box 14659Clearwater, FL 33766-4659Phone: 1-877-492-5870www.forethought.comMS3000-01-IN 2011 Forethought0111

Issued by Forethought Life Insurance Company 2011 STANDARD Medicare Supplement/ Life Insurance Plans MS3000-01-IN. You can rely on Forethought Standard Medicare Supplement Plans to help pay your Medicare Part A and Medicare Part B charges that Medicare doesn't cover. What's more, you have:

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Research shows adventure tourism to be a part icularly resilient niche, and when destinations proactively invest in their adventure markets, arrivals increase. For instance, at the AdventureNEXT trade event in May 2018, Jordan’s Tourism minister Lina Annab revealed that subsequent to a focused approach toward adventure tourism development, which included several collaborations with ATTA and .