DEPARTMENT OF LABOR AND REGULATION

DIVISION OF INSURANCE

PARTNERSHIP CERTIFICATION FORM

Chapter 20:06:21

APPENDIX L

SEE: § 20:06:21:78

‎LONG-TERM CARE 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 policy or certificate form may not be issued in South Dakota as a partnership policy or certificate unless and until this form has been submitted to and approved by the Division of Insurance.

Under section 1917(b)(5)(B)(iii) of the Social Security Act (42 U.S.C. 1396p(b)(5)(iii)) and in accordance with applicable South Dakota requirements, the insurer hereby submits information relating to policy or certificate form _____________ (formnumber) to substantiate that the form includes all required consumer protection requirements set forth in section 1917(b)(5)(A) of the Social Security Act (42 U.S.C. 1396p(b)(5)(A)) and that it includes 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 (adoptedasofOctober2000) (referred to herein as the "2000 Model Regulation" and "2000 Model Act," respectively).

Part I:

Name of Insurer ___________________________________________

Company NAIC # ___________________________________________

Address ___________________________________________

___________________________________________

___________________________________________

Telephone ___________________________________________

Company Contact

Name ___________________________________________

Title ___________________________________________

Telephone ___________________________________________

E-Mail ___________________________________________

Part II:

2000 NAIC MODEL REGULATION AND 2000 NAIC MODEL ACT

Note to Insurer: Identify the page and/or provision within the policy or certificate form that addresses each requirement, or, if inapplicable, use the space identified to explain.

Policy/Certificate form ________________ meets the following requirements of the 2000 NAIC Model Long-Term Care Regulation and/or 2000 NAIC Model Long-Term Care Act, as indicated below:

NAIC Model Regulation Requirement

Identify Policy Page # and Provision OR use this space to explain if requirement is inapplicable

Section 6A (relatingtoguaranteedrenewalornoncancellability), other than paragraph (5) thereof, and the requirements of section 6B of the 2000 Model Act relating to such section 6A.

Section 6B (relatingtoprohibitionsonlimitationsandexclusions) other than paragraph (7) thereof.

Section 6C (relatingtoextensionofbenefits).

Section 6D (relatingtocontinuationorconversionofcoverage).

Section 6E (relatingtodiscontinuanceandreplacementofpolicies).

Section 7 (relatingtounintentionallapse).

Section 8 (relatingtodisclosure), other than sections 8F, 8G, 8H, and 8I thereof.

Section 9 (relatingtorequireddisclosureofratingpracticestoconsumer).

Section 11 (relating to prohibitions against post-claims underwriting).

Section 12 (relatingtominimumstandards).

Section 14 (relatingtoapplicationformsandreplacementcoverage).

Section 15 (relatingtoreportingrequirements).

Section 22 (relatingtofilingrequirementsformarketing).

Section 23 (relating to standards for marketing, including inaccurate completion of medical histories, other than paragraphs (1), (6), and (9) of section 23C).

Section 24 (relatingtosuitability).

Section 25 (relatingtoprohibitionagainstpreexistingconditionsandprobationaryperiodsinreplacementpoliciesorcertificates).

Section 26 (relating to contingent nonforfeiture benefits, if the policyholder declines the offer of a nonforfeiture provision described in section 7702B(g)(4) of the Internal Revenue Code of 1986 (26 U.S.C. 7702B(g)(4)).

Section 29 (relatingtostandardformatoutlineofcoverage).

Section 30 (relating to requirement to deliver shopper's guide).

NAIC Model Act Requirement

Identify Policy Page # and Provision OR use this space to explain if requirement is inapplicable

Section 6C (relatingtopreexistingconditions).

Section 6D (relatingtopriorhospitalization).

Section 8 (relatingtocontingentnonforfeiturebenefits).

Section 6F (relatingtorighttoreturn).

Section 6G (relatingtooutlineofcoverage).

Section 6H (relatingtorequirementsforcertificatesundergroupplans).

Section 6J (relatingtopolicysummary).

Section 6K (relatingtomonthlyreportsonaccelerateddeathbenefits).

Section 7 (relatingtoincontestabilityperiod).

Part III. INFLATION PROTECTON

Identify the policy provision or provide form number of endorsement or amendment form (anddateofapproval) for inflation protection coverage in compliance with ARSD 20:06:21:76:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

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 South Dakota.

________________________ _____________________________________

Date Name and title of officer of the Insurer

________________________ _____________________________________

Date Signature of officer of the Insurer

‎

Source: 33 SDR 230, effective July 2, 2007.