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Use this page to provide information about an insurance policy. You might choose to fill in fields below replace everything below with the text of the policy or simply provide link to the policy document online. Insurance Company Name Policy Owner. Insert policy owner name here. Insured. Insert names and ages of insured here. Group. Insert the name or number of group this policy is associated with. Policy Number. Insert the policy number here. Original Policy Effective Date. Insert the first date effective here.
Schedule Effective Date. Insert an effective date for this policy version here. Rate Classification. Insert any discount or other classifying information. Basic Policy Premium. Insert premium amount here and state period monthly quarterly yearly etc. Payment Options. If payments can be made in various ways state those methods and associated costs here. POLICY DETAILS Elimination Period. Insert number of days of covered service. Maximum Lifetime Benefit. Insert amount or calculation used to derive this benefit. Benefits Provided by Your Policy. List other benefits provided such as nursing home benefits ambulance services assisted living benefits injury or disability benefits home health care services care giving assistance hospice services medical appliances international travel coverage and so forth. Include dollar amounts or limitations on benefits.
If this is description of life insurance policy include information about beneficiaries how amounts would be calculated when and how payments would be made and so forth. SEE THE POLICY FOR FURTHER DETAILS.