5006 AssetGuard Materials

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v2.0 Materials AssetGuard Materials
AssetGuard
Table of Contents AssetGuard Product Summary ...................................................................................... 1 Asset Transfer Using the NGL Estate Planning Trust 2 Asset Protection Using the NGL Funeral Expense Trust ................................................ 3 The Process of NGL’s Irrevocable Trusts ....................................................................... 4 Advantages of Using Life Insurance in Combination with a NGL Trust .......................... 5 End of Life Expenses ..................................................................................................... 6 The Secrets to Selling AssetGuard 7 AssetGuard Standard Application................................................................................... 9 Irrevocable Assignment of Ownership to NGL Estate Planning Trust (form) 10 Irrevocable Assignment of Ownership to NGL Funeral Expense Trust (form) ................ 11 NGL Trust Claim Form .................................................................................................... 12

NGL AssetGuard

NGL’s Single Pay whole life product, when combined with our trust options, offers an increasing death benefit and provides a secure financial protection option for final expense and estate planning.

NGL Funeral Expense Trust

NGL Estate Planning Trust or Beneficiary Business

Payment plan:

Minimum face amount:

Maximum face amount:

Growth rate:

Issue age:

Health questions:

for Single Pay plans

Calculation of premium: Premium is the face amount multiplied by the appropriate premium rate.

For Agent Use Only.

NGL AssetGuard earns daily simple growth. See Trust Options summary for important and complete trust features. See www.mynglic.com for state-specific availability as well as product and Medicaid limits.

Products underwritten by National Guardian Life Insurance Company, Madison, Wis. National Guardian Life Insurance Company is not affiliated with The Guardian Life Insurance Company of America a.k.a. The Guardian or Guardian Life.

Death benefit: NEED HELP? CALL 800.762.9883

1
rates
Issue ages Premium rates
Premium
4880 04/23 Single Pay $2,500 $2,500 $15,000 $100,000 0.50% 0-99
Guaranteed
full death benefit 0-50 0.95000 51-55 0.97000 56-60 0.98000 61-65 0.99000 66-99 1.00000
None –
Issue Immediate

Asset Transfer Using the NGL Estate Planning Trust

The NGL Estate Planning Trust is designed to be used for asset transfer to help your clients easily transfer wealth to their heirs and favorite charities. This trust is offered at no cost to your clients, with no trust fees, and can be used in addition to any other trust they may already have.

NGL Estate Planning Trust ($2,500 - $100,000)*

• Set aside up to $100,000 to transfer assets and also cover final expenses

• Ideal for leaving a financial legacy to loved ones and charities

• Not designed for Medicaid planning, but may be exempt asset under Medicaid guidelines after 60-month lookback

• Funeral costs paid first with excess funds directed to named beneficiaries (as many as desired) or the estate of the insured

• Trust is policy owner and beneficiary

Benefits

• Trust proceeds are income tax free

• Exempt from probate – funds available immediately!

• Keeps assets safe from creditors

• Trust is totally free – no fees

• Funds are totally portable – can be used with any funeral home provider

• Anyone can qualify

• Simple to use – just add a trust assignment form to insurance application

• Funds paid within 48 hours**

• Trust provides peace of mind for your clients – priceless

As with any trust or irrevocable assignment, educate your client on irrevocable assignment and the resulting permanent transfer or ownership of policy rights: not able to surrender, loan or receive a premium refund after free look, not able to change ownership or beneficiary, not able to change policy face amount or plan.

For Agent Use Only. *Individual state regulations including product availability, allowed maximum or minimum may vary by state. We recommend your client contact a legal advisor for complete details on irrevocable assignments, Medicaid eligibility and using a trust to protect their assets, including a life insurance policy.

**In most cases.

Montana maximum for NGL Estate Planning trust is $15,000.

NEED HELP? Call 800.762.9883 or visit www.mynglic.com.

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2750-EPT 10/20

Asset Protection Using the NGL Funeral Expense Trust

The NGL Funeral Expense Trust* is designed to be used for asset protection and possibly to help your clients qualify for Medicaid. This trust is offered at no cost to your clients, with no trust fees, and can be used in addition to any other trust they may already have.

NGL Funeral Expense Trust ($2,500 - $15,000)**

• Set aside up to $15,000 to cover funeral and other final expenses (or state limit)

• May be exempt asset under Medicaid guidelines***

• Can help qualify for Medicaid now

• Funeral costs paid first with any excess funds going to the estate of the insured

• Trust is policy owner and beneficiary

Benefits

• Trust proceeds are income tax free

• Exempt from probate – funds available immediately!

• Keeps assets safe from creditors

• Trust is totally free – no fees

• Funds are totally portable – can be used with any funeral home provider

• Anyone can qualify

• Simple to use – just add a trust assignment form to insurance application

• Funeral provider paid within 48 hours****

• Trust provides peace of mind for your clients – priceless

As with any trust or irrevocable assignment, educate your client on irrevocable assignment and the resulting permanent transfer or ownership of policy rights: not able to surrender, loan or receive a premium refund after free look, not able to change ownership or beneficiary, not able to change policy face amount or plan.

For Agent Use Only. *Not available in Indiana. Indiana residents may use the NGL Final Expense Trust, which offers similar benefits using an Indiana-based trust.

**Individual state regulations including product availability, allowed maximum or minimum may vary by state. We recommend your client contact a legal advisor for complete details on irrevocable assignments, Medicaid eligibility and using a trust to protect their assets, including a life insurance policy.

***Medicaid limits the face amount of policies assigned to the NGL Funeral Expense Trust which they will consider excluded assets in the following states. Limits as of 01/01/2023: AZ - $9,000; CT - $10,000; DE - $15,000; GA - $10,000; IA - $13,125; IL - $6,562 (non-guaranteed or guaranteed services only. Prefunded Funeral Agreement/Statement of Goods & Services used at time of Medicaid qualification, otherwise no limit); IN - $10,000; KS - $10;820 LA - $10,000; MO - $9,999; NE - $5,372; PA - $15,000 (premium); SD$10,000; TN - $6,000; UT - $7,000; VT - $10,000 ****In most cases.

NGL Funeral Expense Trust not available in FL, MA, MI, NV, ND or TX.

NEED HELP? Call 800.762.9883 or visit www.mynglic.com.

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2750-FET 03/23

The Process of NGL’s Irrevocable Trusts

If your client is interested in easily transferring wealth as well as funding their final expenses, please see information available on the NGL Estate Planning Trust.

If your client is interested in protecting assets for Medicaid qualification and funding their funeral, please see information available on the NGL Funeral Expense Trust.

4 Life Insurance Policy NGL Irrevocable Trust Funeral provider paid within two business days Remaining monies paid to named beneficiary(ies) of trust
avoid probate costs and delays; expenses covered immediately
funds earn interest (income tax-free) until time of need Use money from savings, 1035 Exchanges, etc. Existing funds Policy assigned to Claim paid Death benefit GROWS!
Funds
Protected

Advantages of using life insurance in combination with a NGL Trust

Why use insurance?

NGL’s insurance product offers funding for your funeral, other final expenses, and allows for easy transfer of a portion of your assets while avoiding some of the common disadvantages of other funding options.

Are your funds protected?

Transferring ownership of your NGL policy into one of the NGL trusts is another step that may help protect your assets and easily transfer wealth. Plus, the trusts ensure that your funeral expenses are paid first and are protected from any creditors.

May be excluded asset in order to qualify for Medicaid and SSI?

Yes, but subject to state lookback period**

As indicated above, the policy may be considered an excluded asset in order to qualify for Medicaid and Supplemental Security Income (SSI).****

*Not available in Indiana. Indiana residents may use the NGL Final Expense Trust, which offers similar benefits using an Indiana-based trust.

**Some states may vary on Medicaid Rules and eligibility is not guaranteed; please consult an Elder Law Attorney in your state for assistance.

***Unless put into trust for funeral expenses.

****If you are assigning ownership to the NGL trust and apply for public assistance, you may be required to provide a list of services and merchandise you have selected from the funeral home of your choice.

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NGL AssetGuard Annuity Savings Account Certificate of Deposit Money Market Mutual Funds Proceeds avoid probate costs Yes Yes Depends Depends Depends Depends Federal income tax free death benefits Yes No No No No No Free of market risk Yes Depends Yes Yes No No Principal guaranteed Yes Yes Yes Yes No No Defined growth rate Yes Depends No Yes No No
NGL Funeral Expense Trust* NGL Estate Planning Trust Annuity Savings Account Certificate of Deposit Money Market Mutual Funds Benefit
directly to the funeral home
Yes Yes No No No*** No No Funds protected from creditors? Yes Yes No No No*** No No
Yes**
No No No*** No No
paid
first?

End of Life Expenses

Average Funeral Costs:

This list represents the most commonly selected services and merchandise according to the 2021 National Funeral Directors Association General Price List Survey.

**Funeral (based on optional costs such as flowers, obituary notice, grave opening and closing, burial plot, etc.) Optional costs could go as high as $10,000 depending on what is purchased

*Cremation: (cremation casket, rental casket, alternative cremation container, cremation jewelry, urn)

This is an advertisement for life insurance from National Guardian Life Insurance Company. This is not a contract for funeral services. This is only a listing of average prices related to final expenses. This life insurance does not specifically cover funeral goods or services, and may not cover the entire cost of your funeral at the time of your death. The beneficiary of this life insurance may use the proceeds for any purpose, unless otherwise directed. Insurance provided by National Guardian Life Insurance Company or its subsidiaries. *2021 National Funeral Directors Association General Price List Report. **2020 https:// www.fool.com/the-ascent/research/average-cost-funeral.

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Burial Cremation Item Price* Price* Non-declinable basic services fee $2,300 $2,300 Removal/transfer of remains to funeral home $350 $350 Embalming $775 $775 Other preparation of the body $275 $275 Use of facilities/staff for viewing $450 $450 Use of facilities/staff for funeral ceremony $515 $515 Use of a hearse $350 Use of a service car/van $150 $150 Basic memorial printed package $183 $183 Vault $1,572 ------Metal Casket $2,500 Cremation Fee $368 Total Cost of a Funeral $9,420 $5,365 Additional Costs $6,385** $1,905*
Total Cost of Typical Burial and Funeral Services $15,805+ $7,270+
Funeral Expenses Family Expenses (Typically 3 months) Total Expenses + =

The Secrets to Selling AssetGuard:

Identifying the right client at the right time

NGL’s AssetGuard, when combined with the right trust, enables your client to transfer up to $100,000 of their assets to a beneficiary while also setting aside money for their end-of-life expenses. The process is quick, easy and may offer asset protection for those needing to apply for Medicaid. Here are some helpful tips and strategies for selling the product.

What is the target age for AssetGuard?

The target age typically includes individuals in their mid-to-upper 60s to low-to-mid 70s. The average AssetGuard policyholder purchase age is 70 years old. Once a prospect begins to approach 70, life events start to bring mortality into focus so they begin to think about end-of-life expenses. By this time, these clients also have learned how to live in retirement and have figured out how much money they need to meet their monthly or annual expenses. They begin to think instead about how much money they can afford to pass on to their loved ones.

Attempting to sell the product to clients much younger than mid-to-upper 60s typically doesn’t translate well. Remember that people under that age may still be trying to build assets, not protect or transfer them. And they certainly are not thinking about funeral expenses or passing on their wealth as they may still be adjusting to retirement.

Who is the target market for AssetGuard?

There are primarily two distinct markets for AssetGuard.

Client A: This client has limited assets and is facing the need to qualify for Medicaid either immediately or in the foreseeable future (within 5 years). The goal with this client is to set aside and protect enough funds to pay for their end-of-life expenses, when needed. An AssetGuard policy assigned to NGL’s Funeral Expense Trust will ensure the funds for funeral expenses are secure and may be considered an exempt asset by Medicaid in most states.

Client B: This client has a sufficient amount of assets and is not likely to need to qualify for Medicaid (at least not within 5 years). The goal for this client is not only to set aside and protect funds for their end-of-life expenses but also to pass on a limited amount of their accumulated wealth to their children, grandchildren or even a favorite charity. The average purchase age of an AssetGuard policy assigned to NGL’s Estate Planning Trust tends to be slightly older as clients need to age to a certain point before they are ready to permanently transfer a larger amount of funds.

A couple of common objections:

Why not advise clients to go to the funeral home to preplan?

Advising a client to visit the local funeral home to preplan their funeral has been the standard advice given by many attorneys and financial planners over the years. However, the reality is that their clients rarely follow through. Furthermore, many people do not want to visit a funeral home to preplan.

The end result is nothing gets done. When the time comes, not only are there no plans in place, neither are there any funds readily available to pay for the funeral services. And with funeral homes typically requiring payment prior to providing any services, this can lead to some rather awkward family situations as to how the funeral bill will be paid and sometimes can even delay the actual funeral.

For your clients who purchase an AssetGuard policy and irrevocably assign it to one of NGL’s trusts, some of these problematic issues can be avoided.

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The Secrets to Selling AssetGuard:

Identifying the right client at the right time

What is the leverage value of AssetGuard?

The goal of the AssetGuard product is not to leverage or increase an asset; rather it is to protect it! AssetGuard is a guaranteed issue whole life insurance product, typically sold to older adults (ages 66-99) through a simplified underwriting process. Clients this age likely would not qualify for other types of underwritten insurance.

The real value of the AssetGuard product is in the free trust that helps protect the policy funds from Medicaid and other creditors. Establishing a trust of this type could cost a consumer anywhere from $1,500-$3,000 if done with an attorney or financial planner however, there is no cost for the trust when combined with NGL’s AssetGuard policy.

Funeral costs are paid out first, typically within two business days, and without a death certificate (in most states where not required).* Any remaining funds are paid out at the same time to the beneficiary(ies). This all happens outside of probate and significantly reduces the financial hardship, discomfort and inconvenience felt by survivors. Not only does traditional insurance require a death certificate, it often takes a minimum of 30 days to receive payment but the funeral home has to be paid prior to distribution of these funds.

The end result of using AssetGuard is that with only two pieces of paper, you ensure the funeral bill is paid and the designated beneficiary(ies) receive their proceeds within two business days, often times before the insured’s funeral has even taken place.* The family is saved from having to have that difficult conversation about who’s going to pay for the funeral. What’s the leverage value of all that?

Why do clients who have plenty of money need this product?

While a client may have more than ample resources, following a person’s death, those resources may not be readily available to pay end-of-life expenses. This can pose a problem since most funeral homes require immediate payment prior to providing any services. The AssetGuard product, combined with the NGL Estate Planning Trust, ensures the funds are there when they are needed. Difficult family conversations over how to pay for the funeral are avoided since the funeral home is paid within two business days.* If the NGL Estate Planning Trust is used, the policy proceeds may even be large enough to assist the family in covering other expenses (e.g. costs incurred by relatives traveling for the funeral, hotel costs, other immediate bills, etc.) The family can instead focus on the grieving process, starting with the funeral celebration.

The NGL team designed its AssetGuard whole life insurance product in conjunction with its unique NGL Trusts to specifically focus on estate planning and asset protection needs. For more information regarding ways that NGL can help you and your clients address their estate issues and protect assets, visit www.nglic.com

Products and trust limits may vary by state. Some states may vary on Medicaid rules and eligibility is not guaranteed; it is recommended to consult an Elder Law Attorney in your state for assistance.

*Claims are processed within two business days or less, in most cases. In most cases, payments are made the next business day, following receipt of completed claim. For agent use only. Not intended for consumer distribution. National Guardian Life Insurance Company is not affiliated with The Guardian Life Insurance Company of America, a/k/a The Guardian or Guardian Life.

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ILAOP 03/21

Premium $ ______________

Face Amount $ ______________ (If other than premium amount)

BANK ACCOUNT INFORMATION FOR EFT PAYMENT

Financial Institution (Bank Name) ___________________________________________________________________________

 Checking

 Savings

PREMIUM PAYMENT DISCLOSURE: When I provide my account information above, I authorize National Guardian Life Insurance Company (NGL) to make a one-time withdrawal from my bank account for the amount provided on this form to pay the policy premium. I authorize the financial institution to process the withdrawal as if I had signed it. If I provide a check as payment, I authorize NGL to use information from my check to make a one-time electronic fund transfer from my account. When information from my check is used to make an electronic fund transfer, funds may be withdrawn from my account as soon as the same day I make my payment, and I understand I will not receive my check back from my financial institution. In the event that my payment is not honored, NGL has the right to re-present the transaction.

AGENT’S STATEMENT I certify that any information recorded by me on this form is true and accurate to the best of my knowledge.

AGENT SPLIT DESIGNATION: Please list any agents not included in the AGENT’S

section. Agent listed in AGENT’S STATEMENT %

FRAUD WARNING STATEMENTS

For Residents of DE, ID, IL, IN, ND, NV and WY: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud.

For Residents of California: For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. For Residents of District of Columbia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. For Residents of GA and KS: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information may be guilty of insurance fraud.

For Residents of Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

To the best of my knowledge and belief, the above information is true and complete and I agree to all authorizations and disclosures included. I understand that no insurance will be effective until this form is approved and the Policy is issued while the Insured is living. I acknowledge that the Policy applied for provides funds at the time of death which may be used for the purchase of funeral services and merchandise, but does not provide specific funeral services and merchandise. It is not an agreement with a funeral establishment. I understand that any information provided regarding the cost of funeral services was provided as general consumer information only. No representations were made that specific merchandise and/or service have been purchased or will be provided at the time of death. If I am the Owner for insurance on the life of the Proposed Insured, I certify that I have an insurable interest in his or her life. I acknowledge that I have read the fraud warning statement on this form. 4840FE

9 ENROLLMENT FORM FOR GROUP SINGLE PREMIUM WHOLE LIFE INSURANCE National Guardian Life Insurance Company (NGL) - Phone 800.762.9883 Mailing Address: 123 Town Square Place • PMB 749 • Jersey City, NJ 07310 Mail Policy To:  Agent  Owner (Default) 4840FE 09/20 NGL AssetGuard PROPOSED INSURED  MALE  FEMALE ____________________________________ ______ _________________________________ ________________________ _________________ _____ First Name MI Last Name Social Security Number Date of Birth Age OWNER - Complete only if other than Insured ____________________________________ ______ _________________________________ ________________________ _______________________ First Name MI Last Name Social Security Number Relationship to Insured OWNER MAILING ADDRESS ________________________________________________________ _____________________________________ _____________ __________________ Street Address City State Zip __________________________________________________________________________________ _____________________________________________ Email Address Phone Number
INFORMATION
and Relationship of Primary Beneficiary, Estate of Insured, or NGL Trust
BENEFICIARY
Name
APPLICANT SIGNATURES
09/20
___ ___ ___ Account Number
_________________________________________ ____________________________
Routing Number ___ ___ ___ ___ ___ ___
________________________________________________________
Date
Signature of Owner City & State
________________________________________ _______________________ Agent Signature Agent Name Printed NGL Agent #
________________________________________ ______________________ _____ Additional Agent Signature Additional Agent Name Printed Additional NGL Agent # %  Check here for Agent Split.
STATEMENT
_______
EXAMPLE

Irrevocable Assignment of Ownership to NGL Estate Planning Trust

(herein called “Trust”)

National Guardian Life Insurance Company (NGL) Phone 800.762.9883 • Fax 866.228.9927 • www.nglic.com

Mailing Address:123 Town Square Place • PMB 749 • Jersey City, NJ 07310

Effective 45 days from the date NGL receives this form, I hereby assign ownership of this policy to the Trust. I understand that by transferring ownership of this policy to the Trust, as of the effective date:

1. This policy is accepted by the Trust subject to all the terms of the Trust which, if the Trust is the primary beneficiary on the policy, includes payment of the policy proceeds for the funeral, burial and cremation expenses for the Insured, as listed below;

2. The change of ownership is permanent and, except as stated herein, I renounce my power to control ownership of the policy;

3. I give up any remaining right to cancel the policy and receive a return of premium under the Right to Cancel provision;

4. I waive all rights under the policy to surrender it for cash, or to obtain a loan against the policy;

5. I give up the right to change the beneficiary on this policy or riders, if any;

6. I give up the right to change the Trust Beneficiary (except you may change the Trust Beneficiary if the Trust Beneficiary pre-deceases the insured. Please note: changing the Trust Beneficiary may affect the lookback period for public assistance);

7. Any proceeds received by the Trust in excess of the amount required to cover the cost of the approved goods and services for the Insured’s funeral, burial or cremation will be paid to the Trust Beneficiary named at the time of this assignment if any, otherwise, to the estate of the Insured;

8. It is my personal obligation to pay all premiums due on this policy (if any) and, if my failure to pay premiums results in the lapse of the policy, the Trust will have no obligation to pay my funeral or burial expenses; and

9. My ability to qualify for state and federal public assistance is not guaranteed.

I may obtain a full copy of the Trust, at any time, upon written request to:

National Guardian Life Insurance Company (NGL)

Mailing Address: 123 Town Square Place • PMB 749 Jersey City, NJ 07310 _______________________________________________________________

Signature of Owner

Date

The Trust accepts this assignment and agrees to use the proceeds of the Policy for the payment of funeral expenses.

Date

Authorized Expense Directive

Insured hereby expressly authorizes and directs Trustee to expend Trust assets to service or product providers in payment of expenses related to the provision of the following services and/or products.

List of possible goods and services qualifying for reimbursement

Basic Services of Funeral Director &

Staff

Other Professional Funeral Services

Embalming

Other Care of Deceased

Dressing/Cosmetology/Casketing

Funeral Home Facilities and/or Staff

Services

Viewing/Visitation

Funeral Service

Memorial Service/Celebration of Life

Graveside Service

Other

Cremation

Other Funeral Merchandise

Clergy Honorarium

Death Certificates

Musicians

Temporary Marker

Stationery Package

Obituary Notices

Flowers Clothing

Open/Close

Casket

Alternative Container

Outer Burial Container

Other Services

Transportation Equipment & Driver

Transfer of Deceased

Funeral Vehicle/Hearse

Car/Limousine

Utility/Service Vehicle

Other Cemetery Charges

10 For Home Office Use Only Insured: _________________________________________ Policy Number ________________________ Owner (If other than Insured) __________________________________________________________________ Trust Beneficiary for excess proceeds _____________________________________________________________
______________________
______________________
By: ____________________________________________________________
2591-EPT ILA 01/23
EXAMPLE

Irrevocable Assignment of Ownership to NGL Funeral Expense Trust (herein called “Trust”)

Owner (If other than Insured)

Effective 45 days from the date NGL receives this form, I hereby assign ownership and change the beneficiary of this policy to the Trust. This transfer, once effective, is made to comply with the requirements of any applicable state public assistance and federal public assistance programs.

I understand that if I am assigning ownership to the NGL Funeral Expense Trust, when applying for public assistance I may be required to provide a list of services and merchandise I have selected from the funeral home of my choice.

I understand that by transferring ownership of this policy to the Trust, as of the effective date:

1. This policy is accepted by the Trust subject to all the terms of the Trust which includes payment of the policy proceeds for the funeral expenses, burial and cremation for the Insured, as on the back of this form. My Funeral Home of choice is _____________________________________________________or any other Funeral Home as their interest may appear;

2. The change of ownership is permanent and, except as stated herein, I renounce my power to control ownership of the policy;

3. I give up any remaining right to cancel the policy and receive a return of premium under the Right to Cancel provision;

4. I waive all rights under the policy to surrender it for cash, or to obtain a loan against the policy;

5. I give up the right to change the beneficiary on this policy or riders, if any;

6. Policy proceeds that exceed the cost of the approved goods and services for the Insured’s funeral, burial or cremation shall be paid to the Guardianship/Conservatorship account of the insured, if applicable, otherwise to the State, if required by the applicable State’s Medicaid recovery program. If payment to the State is not required, or if excess proceeds exist after payment to the State, all such excess proceeds shall be paid to the Estate of the Insured. This supersedes any Beneficiary named on my policy application; and

7. It is my personal obligation to pay all premiums due on this policy (if any) and, if my failure to pay premiums results in the lapse of the policy, the Trust will have no obligation to pay my funeral expenses.

I may obtain a full copy of the Trust, at any time, upon written request to: National Guardian Life Insurance Company (NGL)

Mailing Address: 123 Town Square Place PMB 749 Jersey City, NJ 07310 ___________________________________________________________ _____________________

Signature of Owner Date

The Trust accepts this assignment and agrees to use the proceeds of the Policy for the payment of funeral expenses.

To be used for purposes of Immediate Medicaid Eligibility ONLY

For Applicant: I hereby elect to make this irrevocable assignment effective immediately. I understand that by making this election I give up all rights to cancel the Policy and receive a return of premium under the Right to Cancel provision of the policy. I understand that I may need to provide a list of services and merchandise I have selected from the funeral home of my choice, as noted above, if I wish to qualify for public assistance. To make an immediate transfer election please sign here

For Agent: I _____________________________certify that on ______________ I have explained to this insured that by signing the above line, he/she is forfeiting their right to cancel the policy and assert that he/ she is aware of the consequences of immediate transfer. I understand that this option should only be used if there is an immediate need to reduce assets in order to qualify for Medicaid.

Agent Signature: ___________________________________________

11 For Home Office Use Only Insured Policy Number ______________________
__________________________________________________________
(Insert funeral home name or leave blank if none chosen at this time)
_______________________ Administrator or Trustee Date
Date __________________
National Guardian Life Insurance Company (NGL) • Phone 800.762.9883 • Fax 866.228.9927 • www.nglic.com Mailing Address: 123 Town Square Place • PMB 749 • Jersey City NJ 07310 2591-FET-XCSGDN ILA 01/23 EXAMPLE

NGL Trust Claim Form

If the deceased received Medicaid benefits, excess proceeds from this policy may be subject to estate recovery. Contact your State Medicaid Office or an elder law attorney for details.

FUNERAL DIRECTOR AUTHORIZATION (applicable only if a portion of proceeds are payable to funeral home)

AUTHORIZATION

OF PAYMENT FOR FUNERAL GOODS AND SERVICES

As the person legally responsible for the funeral arrangements of the deceased Insured, I certify that the Funeral Provider provided the requested funeral goods and services on behalf of the insured, and authorize payment of the above amount to the Funeral Provider for the funeral goods and services furnished. I understand that the Company reserves the right to request a certified copy of the death certificate before benefits are paid. Thus, I understand it is important to retain original versions of these forms. I acknowledge that I have read the fraud warning statement on the last page of this form.

Signature of Person Legally Responsible for Making the Funeral Arrangement (Not the Funeral Director) Date Complete ONLY if benefits to be paid to BENEFICIARY (not applicable for policies assigned to the NGL Funeral Expense Trust)

EXAMPLE

Name of Trust Beneficiary(ies) for Excess Proceeds Relationship to Insured

Street/Mailing Address City State Zip __________________________________________

Signature of Trust Beneficiary(ies) Date

Claim Requirements:

1. Copy of Death Certificate listing cause and manner of death if:

• Claim form is signed in IN, KY, LA or MA

• OH & WI (must be submitted to NGL within 60 days)

• If cause of death is not natural (accidental, suicide or homicide)

2. Copy of the Funeral Bill (if paid in full, copy of proof of payment)

3. This completed form

FET-EPT 10/22

• In TN (if claim is over $15,000)

• All contestable claims

• Whenever a beneficiary is filing direct independent of the funeral home.

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National Guardian Life Insurance Company (NGL) • Phone 800.988.0826 • Fax 866.228.9450 • www.nglic.com Mailing Address: 123 Town Square Place • PMB 749 • Jersey City, NJ 07310 Policy Number(s) ________________________________ Name of Insured ____________________________________ Insured SSN _______________________ Insured Date of Birth _____________ Date of Death ______________ Immediate Cause of Death:  Natural  Accidental  Homicide  Suicide Cost of Funeral Provided $ __________________________________________ Name of Person Legally Responsible for Making the Funeral Arrangements Name of Funeral Provider __________________________________________ Street/Mailing Address Street/Mailing Address __________________________________________ City State Zip City State Zip __________________________________________ Relationship to the Insured Phone Number Send payment to funeral home via: Check Electronic Funds Transfer*
*If requesting payment via Electronic Funds Transfer, you must have completed “Request and Authorization to Pay Claims Via Electronic Funds Transfer” (Form #2636).
__________________________________ Signature of Funeral Director Date
___________________________
5006 03/23 Need help? Call 800.762.9883 or visit MyNGLIC.com. For agent use only. Product underwritten by National Guardian Life Insurance Company (NGL), Madison, Wis. National Guardian Life Insurance Company is not affiliated with The Guardian Life Insurance Company of America a.k.a The Guardian or Guardian Life.

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