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267 Cards in this Set
- Front
- Back
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Basic hospital expense
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firs dollar coverage with no deductible that pays for hostpial room and board only; pays policy limit or the amount of the claim
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Basic medical surgical expense
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covers surgical services performed in the hospital by a physician
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Basic physcians fees for non surgical hospital confienment
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covers doctors visits even tho no surgery
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Blue cross/ Blue Shield
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service organization known as producer cooperatives. Blue shield physicians and Blue cross hospitals join together as producer of medical providers.
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How do Blue Cross and Blue shield set up the payment schedule?
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Community based usual, customary and reasonable
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Major medical expense policies
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covers sickness or injury in and out of hospital
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stop loss provision
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in the 80/20 rule they have a limit on what the highest amount charged can be
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supplementary major medical plan
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adds extra insurance to what ever is not covered by regular medical insurance and applies the deductable rule where you pay corridor deductable and then pay 80/20
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Maternity?
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state laws require that newborn babies with contiengent birth defects be covered but maternity coverage is optional
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impairment riders
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speicifc exclusions for particular health conditions or dangerous hobbies
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Managed Indemnity Plans
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traditional medical insurance where provider reimbursment is fee for service basis and insured person is responsible for deductibles and coinsurance. unlimited choice of doctors
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PPO
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made up of hospitals and private physicians in a given area who agree to provide services to the insurers clients at a predetermined price. 100% minus copayment unless outside org than 80% minus co
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Third Party Administrators (TPA)
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firm that provides administrative services for employers and other associantions having group insurance policies
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Self Funded Health PLan
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claim costs are predictable and employer provides the funds to make claim payments for company employees and their dependents
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Administrative Services Only Contract
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the insurers provides claim forms, administers claims, and makes payment to health care providers
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Health Insuring Companies(HIC)
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reduce medical expense by stressing preventive medicine through physical exams and diagnostic testing procedures and by providing prepaid doctors and hospital care
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Group Practice Model
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an HIC that enters into a contract with an independent group of physicians
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Capitation fee
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a fixed monthly fee derived by multiplying the number of subscribers in the HIC by the per member fee negotiated with the medical group
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Staff Model
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HIC owns physcians hospital and medical personnel
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Independent Practice Association Model (ISPA)
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network of individually practicing physicians who contract with the HIC to provide health care services to its members
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Gatekeeper system
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where the member selects a PCP who provides or authorizes all care
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Point of Services (POS)
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HICS that provide coverage for out of network services
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primary focus of HIC
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preventive care
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utilization management
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insured obtain second medical opinion on elective surgery
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Managed Care
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was designed to manage the fees charged by providers as well as the appropriateness of the treatment
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prospective review
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sets the requirments that a doctor verify in advnace that hospitlitization is necessary, recommend outpatient treatments or determine that no treatment is necessary
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concurrent review
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review requires a medical monitor to consilt with the doctor in an effort to manage costs during treatment
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retrospective review
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requires medical monitor to review treatment previously provided to determine if it was approrpaite under the circumstances
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Maanged Care Uniform License Act
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-change HMO to HIC
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prepaid basis
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rate of premium established by the HIC to be paid by or on behalf of the subcriber at specific intervals monthyl or quarterly in return for basic and supplemental health care services
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HIC preexisting conditions
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are covered unlike traditional insurance companies and cannot be denied coverage
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How many days for application process for HIC?
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within 60 days
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HIC must submit annual report when?
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March 1st of every year
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Every HIC must be examined how often?
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once every three years no more than five years
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How long does the HIC enrollee have to cancel?
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72 hours from enrollment
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open enrollment period
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the HIC must accept all applicaions in this period and they cannot get denied due to pre existing conditons
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evidence of coverage
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explain co payments, benefits limit, and exclusions
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Specialty Health Insuring Copororations (SHIC)
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provide insurance for anything that isnt covered in HIC like dental rx vision and can only offer two of the list
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Flexible Spending Account
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employer issued for tax preffered growth used to cover anything that is not provided in the group insurance policy
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Health Reimbursement Account
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employer pays co pays co insurance such things
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Health Savings Account
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-high deductable health plan must be in progress to qualify
- must pay 20% penalty for taking money out before age 65 |
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Medical savings account
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same as health savings account except the ineligble distribution penalty is 15% and offered to groups of 50 or smaller
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High Deductible Health Plan
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1200 for single D
2400 for family D 6050 for single Out of Pocket 12100 for family out of pocket |
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embedded deductibles
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each person must pay the deductible
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unembedded deductible
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entire family has to pay deductible before anyone receives care
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coordination of benefits provision
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if the insured is covererd by more than one policy one policy is considered the primary and must be exahusted before the excess policy is used
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State Childrens Health Insurance Program (SCHIP)
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health insurance is provided to uninsured individuals under 19 years of age with a family income of 150-200% of the federal poverty level
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alcoholism treatment
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ohio requires every group policy must cover at least 550 for treatment
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Child dependent to age 28
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states that dependent children must be claimed until age 28 unless mentally disables
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what does health insurance not cover?
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sickness that is for life insurance
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what parties may a blanket disability policy may be written to?
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passengers on a common carrier, an employee group, a student group. a debtor or a sports team. they do not require individual applications and are not issued a certificate of insurance
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what is covered and not covered on the AD&D policy?
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loss of eyesight is covered but loss of hearing nor loss of limb is covered
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Accidental Means Clause
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restricts coverage if you intended to do whatever caused the injury
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in an AD&D policy what is the principal sum and what is the capital sum
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principal sum pays for death and severe dismemberment
capital sum pays for the loss of a limb |
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Short Term or Mini Meds?
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health insurance for a person in between jobs or waiting for a gorup coverage to start
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Critical Illness is sold as what?
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a ride on life insurance policies
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principle of indemnity
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states that you cannot recover more than you lost
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Legal Action Provision
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states if a claim is not paid within 60 days of loss then you can file law suit for up to three years
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what can the insurance company not do on non cancealble policy
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change the coverage or the rates
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What can you change on a guranteed renewable policy?
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cannot change coverage but can change the rates by class
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pro rated refund
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when the company cancels the policy
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short rate refund
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when the client cancels the policy
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a guranteed renewable policy is renewable...
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at the option of the insured by paying the premium up to a certain specified age
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Other Insurance Clause
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protects the insurer from those who attempt to over insure
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How long till notice of claim?
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20 days
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how long till claim forms?
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15 days
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how long till proof of loss?
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90 days
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how long till wait and see?
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60 days
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consideration clause defines?
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the amount and frequency of the premiums to be paid
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the face page of the health insurance policy describes?
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D(escribed)
I(nsuring) C(onsideration) E(xecution) |
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subrogation
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allows the company to act on behalf of the policy owner and purpose is to prevent an owner from profiting from a claim
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recurrent disability
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an old injury or illness that comes back again
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residual disability
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one that never goes away
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occupational coverage
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covers on and off the job
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non occupational coverage
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covers off the job only
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Future Increase Option
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allows the insured to purchase additional coverage at certain intervals without a physical exam
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own-occ
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one cannot do the duties of their own jo at the time of the disability
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any-occ
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means you are incapable of doing any job for which you are reasonably sutied by education training or experieces
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Presumptive Disability
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is presumed with the loss of sight, hearing, speech, or the loss of any two limbs
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Cost of Living Adjustment (COLA)
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will automatically increase the benefit during the period the insured is receiving monthly payments based on CPI
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Rehabilitation Benefit Rider
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pays a lump sum for necessary vocational training to help prepare for a new career
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Basic Hospital Expense
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only covers in hospital room and board and miscellaneous expenses up to a certain limit
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Major Medical Expense
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provide for catastophic injury or sickness in and out hospital covered. have deductible and co insurance higher the deductible the lower the premium
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outpatient services are called?
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ambulatory services
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credentialiing
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an HIC is screened before the HIC signs a contract with that provider
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mammograms and cytological screening how often for women?
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35-40 one screen
40-50 one every two years unless doctor shows high risk of cancer then one every year 50-60 one every year |
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Well Baby Care
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provides from birth to age 9 insurance for children
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What does HIPAA state?
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that a person previoously on a group insurance plan must be offered an individual health plan policy without any pre existing conditions
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What does COBRA state
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(applies to group medical expenses) allows an employee to continue group coverage for 18 months after termination of employment
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Credit Disability Insurance
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will make car payments if you are unable to due to diability
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Credit Life
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will pay off your loan in case of disability but payments go straight to creditor
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what does fee for service mean?
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that the hospital submits the bill directly to the insurer
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Reimbursment or Indeminty Plan
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states that insured pays the bills and submits them to the company for reimbursment and they can go to any doctor or hospital
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True Group Life Insurance
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must have atleast ten employees covered under the plan
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Multiple Employer Trusts
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provide insurance to small business owners and their employees and other small employers join the trust causing lower rates
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Who regulates MEWA?
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ERISA
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Conditons for Association Groups
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needs 100 minimum employees
have consitution and meets regularly |
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Credit Life and Health
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the creditor is the policy owner and the beneficiary andthe debtor pays the premium as part of the loan payment each month
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OASDHI stands for what and is what?
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Old Age Survivors Disability and Health insurance
is Social Security |
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Medicare is for?
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people age 65 and older anyone who has renal failure regardless of age
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How is Medicare A paid for?
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by payroll deductions and matching amounts from the employer
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What does Medicare Part B do?
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pays for medically necessary physicians charges and outpatient hospital care
paid for by deductions in Social Security monthly checks has co insurance and annual deductible |
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What is Medicare Part C?
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medicare advantage plan
get all your medicare covered health care throughout the plan must be enrolled in A and B and no co insurance or deductible |
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Medicare Part D?
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basically for prescription drugs and offers 250 deductible then 75% discount then donut hole then 95% discount
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Medi Gap and Medi Supp?
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refer to medicare supplement policy that covers the many gaps in medicare
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Medicaid?
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for low income families basically medical welfare
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What are the six Activities of Daily Living (ADL)
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dressing oneself
eating bathing oneself incontinence toileting transferring from one place to another |
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Qualified Long Term Care Policy allows what?
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the owner to tax deduct premiums and benefits are not taxed
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Non Qualified Long Term Care Policy allows what?
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all premiums minus claims to be refundede
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Long Term Care Policies are written how and why kind of reneawability?
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written individually and guranteed renewable
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Medi-Gap Plan A?
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covers 365 additional days of hospital care not covered in Medicare A
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What is the highest age LTC goes to and what is needed after that age
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goes to 80 and then requires Assessment of Functional Capacity
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what is the preexisting clause for LTC
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look back six months and exclude coverage for anything that happens in those six months
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How many standardized medigap policies are there?
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10 policies and A must be offered first and then you can choose from the rest
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who is medicare adminsited by?
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Center for Medicaid and Medicare services (CMS)
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what are the two non forfeiture options in LTC?
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amount of premiums paid
30x the daily nursing benefit |
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Premiums for Individual Disability Income and AD&D are what for taxes?
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non deductible but income tax free for benefits
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Business Overhead Expense is what in taxes?
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deductible thus benefits are taxable
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what does the conditions clause state?
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the insured duties in the event of a claim
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who is surplus lines coverage sold by?
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unauthorized companies
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who is a reciprocal insurance company managed by?
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attorney in fact
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Doctrine of Adhesion
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states that if the policy is vague and something happens the policy will go in favor to the insured because the company prepares the contract
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moral risk?
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dishonest client
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who used salaried agents instead of commision?
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direct writing insurance companies
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surcharge?
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counteroffer
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treaty reinsurance?
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when a company has a prenegotiated agreement with a reinsurance company
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faculative reinsurance
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depends on a case by case basis
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what are the three main financial rating service companies?
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AM best
Standard and Poor Moodys |
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what are the three types of agents authorities?
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express
implied apparent |
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implied authority
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things not expressed in contract but are things that you must have to do your job
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apparent authority
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what the policy owner thinks you have
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who does a solicitor represent?
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the agent
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how much CE training must be done?
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24 hours per two years
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when does the agent need to renew his license and how much is it?
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every two years with completeion of CE credits and a 25 dollar fee
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in what time frame should a change of address be reported about an agent to the DOI?
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30 days
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controlled business?
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51% or more of the business comes from one agent and its sources
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maximum amount the Ohio Guarantee Association will allow?
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300,000
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the aviation exclusion?
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applies to military and private pilots
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types of surcharges applied?
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higher age
flat fee percentage adujstment |
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What type of table must Whole Life policies contain
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a guaranteed cash value each year for 20 years
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how do you calculate gross premiums?
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motality + expenses - interest
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what are the personal uses for Life Insurance?
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survivor protection
estate creations cash accumulation liquidity estate conservation |
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What does the needs approach not consider?
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future earnings
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when do you use the interest adjusted net cost method index?
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when cash value is important
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when do you use comparative interest rate method?
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when the costs of death benefits are main concern
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viatical settlment
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when a policy owner sells a policy to an investor for a set price. the investor claims new beneficiary and ownership of policy and inherits money when upon death of previoulsy insured
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in a viatical settlement who is the owner of the policy?
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the viator
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what defines terminally ill?
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life expectancy of 24 months or less
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what types of policies allow you to skip reduce or increase premiums?
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Variable Universal and Traditional Universal Life
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How does renewable term insurance work?
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renewable without a physical examination up to a certain age
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Level Premium Term?
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has the same premium for the stated period then premium will go up and face amount never changes
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Continuous Premium (Straight Life)
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level premium and death benefit and the policy creates cash value equal to face amount at age 100, 120
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What two options does Universal Life have?
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option A- cash value plus new amount risk
option B- increasing death benefit that pays face amount plus cash value |
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Joint Life?
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first to die and buy/sell agreements
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Joint Life and Survivorship
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second to die and covers estate taxes
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Credit Life is backed by what?
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the policy itself and cannot be more than the amount of the loan
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When does Limited Pay Whole Life policies mature?
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paid up earlier but do not mature till 100,120
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On a 20-pay life when will the cash value equal the face amount?
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at maturity 100
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When do whole life and limited pay life reach maturity?
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at the same time 100,120
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step rate policy?
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increase premiums each year for a state period of time and then they become level for the remaining policy
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Common Disaster Clause
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when they can determine who died first
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Uniform Simultaneous Death Clause
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when it is unknown who dies first
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what is GIR
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you can purcahse additional amounts of insurance without physical examination at a certain date
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beneficiary designations
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individuals
classes estates minors trusts |
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per capita
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all equal beneficiaries share equally
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per stirpes
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means down the bloodline
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three non forefiture options in Life Insurance
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cash, extended term, reduced paid up
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Accidental Death Benefit
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states that the death must occur within 90 days of the accident
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six dividend options
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CRAPPO
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waiver of premium
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takes effect after six months of total disability
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Waiver of the Cost of Insurance
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rider used for Universal and Variable Universal Life and waives just the montly costs of the term insurance
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Payor Benefit Rider
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cover the parent of the child who has his own policy and if the parent becomes disable the premiums are waived till the child turns 18
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Accelerated Death Benefit
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pays portion of death benefit earlier if life expectancy is under 24 months
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What starts over in reinstatement?
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incontestability clause and suicide clause
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What is required in Life policies at reinstatement?
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proof of insurability
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Family Policy
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a combination policy that automatically covers dependents and new born children after 15 days of enrollment
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Ownership Clause
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states in a Life Policy who can change the beneficary, who can take a loan, who can take cash surrender and who can assign in the policy
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divorce conditions?
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after divorce a statement stating the continuation of the same beneficiary must be made or changed
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how are withdrawls taken from annuties?
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LIFO
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SPIA?
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paid with one premium and begans in 30 days
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FPDA?
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is purchased with periodic payments and pay out is deferred till a later date
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how long does joint annuity pay till?
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till the first dies
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how long does the joint and survivor ship life annuity pay till?
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till the second dies
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equity indexed annuities are linked to what?
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S&P 500 index with a minimum gurantee of principal and a modest minimum interest rate
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what annuity has no beneficiary
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life income annuity
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how often should an annuity or life insurance policy determine the cash value and death benefit?
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cash value monthly and death benefit annualy
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who enforces securities regulations for its members?
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NASD
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How long is the Variable Life and Variable Universal Life policy free look?
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45 days from application or 10 days from delivery
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Variable life agents do not have to be certified by who and have to be why who?
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dont have to be ny NYSE
have to be by FINRA and have 6 and 7 |
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The Securities Act of 1933?
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products and prospectus
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The Securities Act of 1934?
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regulates the actions of sales reps
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The Investment Company Act of 1940?
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regulates companies who invest money for clients and controls sales charge
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Variable Life and Variable Universal Life differences in premium?
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VLI has level premium
VUL has flexible premium |
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front load variable?
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sales charge at beginning
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back end loan
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sales charge at end
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MEC?
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occurs when the values in the policy accumulate faster than a seven pay life policy
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scheduled plan lists?
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basic dental procedures and states an upper dollar limit of the reimbursement for each procedure
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long term care is offered to?
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people who would buy their own policies
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disability police is designed to replace?
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net earned income
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small group coverage?
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two or more employees to be covered under a group medical insurance plan
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group insurance may be written without what?
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medical examinations
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forms of HIC?
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group model
independent practice model network model staff model |
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accident and health policies with quarterly semi annual or annual premium modes have how much grace period?
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31 days
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non occupational coverage?
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covers off the job disabilities
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law of large numbers?
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the larger the number of exposures to a given event the more closely the actual results will equal the predicted results
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key employee disability income policys are what in tax?
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premiums are non deductible and beneifts are income tax free
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non occupation group disability?
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offered for off the job accidents
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how many employees required to comply with COBRA?
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20 or more full/ part time employees
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how long till providing proof of loss?
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within 90 days of the claim
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pre paid dental plans should keep all files on complaint for how many years?
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three years
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Guranty Association provides how much coverage for health insurance?
|
100,000
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individual impairment rider?
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excludes one high risk situation that otherwise might cause the company to decline the applicant entirely or to charge high rates
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Endotonics?
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takes place at the base of the root end of the tooth
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how is medicare B paid for?
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75% from federal and 25% from social security checks
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non cancelable policy means?
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that the rates and right to coverage are guaranteed until certain age
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HIC and medical insurers are required to provide coverage for a child till what age?
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19
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What is The Commissioners STandard Mortality table used for?
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calculating premiums
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when must the FCRA Fair credit reporting act be given?
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when they begin the application process
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in a whole life policy what is guranteed?
|
the cash value is guranteed and cannot increase or decrease from the guranteed amount
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Section 403 plan is offered to?
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non profit schools hospitals and charities
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variable policy loan rates are based off of?
|
Moodys monthly corporate index
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Investment Company Act of 1940?
|
requires a company selling variable products to maintain a seperate account and sets the maximum sale charge the comapny may apply to variable products
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companys obligation if someone commits suicide within first two years?
|
return all premiums paid
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twisting?
|
an agent who misrepresents the provisons of any policy in order to get the prospect to amend lapse foreit change or surrender an existing policy in order to buy a new policy
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how long does information remain on credit reports?
|
7 years
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insurable interest can be proven by which two doctrines?
|
doctrine of love and affection
doctrine of economic interest |
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what is the primary reason endowments were purchased?
|
retirment income
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in small group plans an employee is eligible to enroll how soon?
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after the 90th day
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variable policy owners should get a full report how often?
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annually
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the viator can cancel the policy within how many days?
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15 days
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what is a qualified retirement plan?
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401 K
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telemarketing inc should check there list with do not call list how frequently?
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every 90 days
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policy owner controls?
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everything about the policy including cash value
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Superintendent can revoke license due to?
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felony not misdemeanor
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social security benefits are reffered to as?
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PIA primmary insurance amount
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when does an insurer deduct the cost of insruance from the policys cash value?
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monthly
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who can partcipate in section 457 plans?
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state and local government employees
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variable annuity creates what?
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annuity units
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PIA social security benefits are determined how?
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AIME average indexed monthly earnings
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dental plans do not require?
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anyone to convert to an indiviudla plan from a group plan
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in major medical policies what are the rules for who the client can see?
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can see any doctor or PPO
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absolute assignment?
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the assignment by the policy owner of all control and rights to a third party
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Accumulation at Interest Option?
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a dividend option under which the policy owner allows dividends to accumulate at interest with the company
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adverse selection?
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selection against the insurance company. poorer risks want insurance more often than standard risks
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aleatory?
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something that depends upon chance or is random
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aleatory contract?
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a contract in which both parties know that one or the other may receive more than paid in
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chartered life underwriters do not need to obtain what?
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they dont need to get pre licensing requirments because they get there degree from the American College
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pretexting?
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you have to state the purpose of the interview and accurately receal your identity
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how long does the temporary license for insurance last that is obtained by the spouse of the seller?
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180 days
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how many soliciters are agents allowed to have?
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1
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earliest age someone can retire while receiving benefits?
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62
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debit life insurance?
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sold in amounts of 500-5000 and these policies are now collected by home service agents
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prospectus?
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associated and given with any variable product you may be allowed to sell
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403 plan?
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for non profits, churches, and school teachers
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457 plan?
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public employees, state workers, police and firefighters
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401 plan
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defined contribution plan by employer
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408 plan?
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SEP
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what are the two allowed methods of vesting?
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graded and cliff
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small employer group consists of?
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2-50 employees
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eligiblity for small employee group insurance?
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25 hrs per week and 90 days worked
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insured must provide notice of claim within?
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20 days
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how long is the probationary period for reinstatement on a health policy?
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10 days
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prospective consultation?
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set to determine the most cost effective manner in which the needed care can be done
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concurrent consultation?
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occurs during the hospital stay
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what provision allows the company to change the policy provisions without the owners consent?
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optionally renewable
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open enrollment for HIC is offered after how many years?
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2 years
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how many members in union to qualify for group insurance?
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25
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