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Exhibit 1.10(d)
FIRST PENN-PACIFIC [10 North Martingale Road
LIFE INSURANCE CO. Schaumburg, Illinois 60173-2268
A member of Lincoln Financial Group (847) 466-8000]
SUPPLEMENTAL APPLICATION FOR INSURANCE
Proposed Date of
Insured #1______________________ Birth _________________
Proposed Insured #2 Date of
(Second-to-Die only) __________________ Birth ________________
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Application Questions (provide details to yes answers below) Proposed Proposed
Insured #1 Insured #2
<S> Yes No Yes No
<C> <C>
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1. Does any Proposed Insured have any impairment, whether mental or physical,
for which any Proposed Insured needs or receives assistance or supervision in
performing every day living activities such as bathing, dressing, eating,
transferring or locomotion, toileting, or bowel and bladder control? ---- --- ---- ---
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2. Does any Proposed Insured use a wheelchair, walker or cane, oxygen, catheter,
dialysis machine, or other mechanical device? ---- --- ---- ---
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3. Has any Proposed Insured received a medical diagnosis within the past five
years under which any Proposed Insured was advised to have any surgical
operation which has not yet been performed? ---- --- ---- ---
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4. Within the past 5 years, has any Proposed Insured been confined to a nursing
home or recommended admission to same? ---- --- ---- ---
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5. Is any Proposed Insured currently confined to a hospital or nursing facility? ---- --- ---- ---
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6. In the past 5 years, has any Proposed Insured received home health care? ---- --- ---- ---
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7. Has any Proposed Insured ever been rejected or rated for nursing care or home
health care coverage? ---- --- ---- ---
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8. Is any Proposed Insured currently covered by Medicaid? ---- --- ---- ---
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Proposed Insured Question No. Date Details
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<S> <C> <C> <C>
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Existing Coverage (provide details to yes answers below) Proposed Proposed
Insured #1 Insured #2
Yes No Yes No
<S> <C> <C>
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1. Does any Proposed Insured currently have, or within the last 12 months has
any Proposed Insured had, any long-term care policies or riders (including
healthcare service or health maintenance organization contracts) in force or
pending? ---- --- ---- ---
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2. Do any of the long-term care policies or riders include Home Health Care
coverage? ---- --- ---- ---
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3. Does any Proposed Insured intend to replace any long-term care policies? ---- --- ---- ---
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Maximum Daily
Proposed Insured Question No. Existing Insurance Co. Benefit Details
________________ ____________ ______________ __________ ___________________
<S> <C> <C> <C> <C>
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I understand that any person who submits an application or files a claim with
intent to defraud or helps commit a fraud against an insurer, as determined by
a court of competent jurisdiction, is guilty of a crime.
Caution: If your answers on this Supplemental Application are incorrect or
untrue, the Company may have the right to deny benefits or rescind your policy.
I hereby declare that the statement and answers to the above questions are
complete and true to the best of my knowledge and belief. I agree that a copy of
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this Supplemental Application shall be attached to and form a part of any policy
issued.
Dated at: ___________________________________________
City State
On: _____________________________________
Month Day Year
_______________________________________________________________________________
Witness:
_______________________________________________________________________________
Signature of Proposed Insured #1
_______________________________________________________________________________
Witness:
_______________________________________________________________________________
Signature of Proposed Insured #2, if applicable
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