N.Y. Comp. Codes R. & Regs. tit. 11, § 58.5 – Required disclosure statement for policies and certificates meeting definition of sections 52.11 and 52.14 of this Title issued with an effective date for coverage on or after June 1, 2010.

(a) The disclosure statement required by an issuer of policies and certificates of Medicare supplement insurance meeting the standards of sections 52.11 and 52.14 of this Title and sections 58.1 and 58.4 of this Part shall consist of four parts: a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The disclosure statement shall be in the language and format prescribed below in no less than 12-point type. All benefit plans "A" through "D," "F," “F+," "G," “G+”, and "K" through "N" shall be shown on the cover page, and the plan(s) that are offered by the issuer shall be prominently identified. Premium information for plans that are offered shall be shown on the cover page or immediately following the cover page and shall be prominently displayed. The premium and mode shall be stated for all plans that are offered to the prospective applicant. All possible premiums for the prospective applicant shall be illustrated.
(b) No individual accident and health insurance policy shall be delivered or issued for delivery in this State, unless the appropriate disclosure form in this section is provided to the applicant at the time that the application is presented to the prospective applicant and, except for direct response insurance, written acknowledgment of receipt of the requisite disclosure statement shall be obtained from the applicant by the issuer.
(c) Every issuer of a certificate of Medicare supplement insurance delivered or issued for delivery in this State shall provide the applicant for the coverage with a disclosure statement in the form prescribed in this section except that all references to "policy" shall be replaced with "certificate," where appropriate. The disclosure statement must be provided at the time that the application is presented to the prospective applicant and, except in the case of direct response insurance, written acknowledgment of receipt of the requisite disclosure statement shall be obtained from the applicant by the insurer.
(d) If the Medicare supplement insurance policy or certificate is issued on a basis that would require revision of the disclosure statement, then a substitute disclosure statement properly describing the policy or certificate shall accompany such policy or certificate when it is delivered and contain the following statement, in not less than 12-point type, immediately above the company name:
"NOTICE: Read this disclosure statement (outline of coverage) carefully. It is not identical to the disclosure statement (outline of coverage) provided upon application and the coverage originally applied for has not been issued."
(e) Attached is an appendix (Appendix 12B, infra) containing the items that shall be included in the disclosure statement in the order prescribed therein.