stonebridge medicare supplement insurance brochure
TRANSCRIPT
Medicare Supplement InsuranceStonebridge Life Insurance Company
Application for Oregon
You can rely on Stonebridge Life Insurance Company’s Medicare Supplement Plans to help pay your Medicare Parts A and B charges Medicare doesn’t cover.
What’s more, you have:
• Multipleplansfromwhichtoselectthecoveragethatbestmeetsyourneeds.
• Yourchoiceofphysiciansandspecialistsforyourpersonalizedcare.
• Theoptiontouseanyhospitalormedicalfacility.
• Virtuallynoclaimspaperworktofile.
Put a Stonebridge Life Insurance Company Medicare Supplement Plan on your team today.
Medicare Supplement insurance is underwritten by:
Stonebridge Life Insurance CompanyAdministrativeOffice:
4333EdgewoodRoadNE,CedarRapids,Iowa52499HomeOffice:Rutland,VT
Choose the MediCare suppleMent plan that’s right for You.
ThisprogramisnotconnectedwithorendorsedbytheU.S.GovernmentortheFederalMedicareProgram.
2014 MediCare suppleMent insuranCe plans
78965MS_OR 1113
MediCare part a hospital Coverage
The Stonebridge Standard Plan pays the $1,216Part A (inpatient) deductible for plans F, G &N for eachbenefitperiod.
First 60-days -AfterthePartADeductible,Medicarepaysalleligibleexpenses forservices fromyourfirst through60thdayofhospitalconfinement.Servicesincludesemi-privateroomandboard,generalnursingandmiscellaneoushospital services and supplies.
Co-insurance –StonebridgeStandardPlansA,F,G&Npay$304adaywhenyouarehospitalizedfromthe61stdaythroughthe90thday.Whenyouarehospitalizedfromthe91stdaythroughthe150thday,StonebridgeStandardPlanspay$608adayforeachLifetimeReserveday used.
Extended Hospital Coverage – If you are in the hospital longerthan150daysduringabenefitperiodandyouhaveexhaustedyour60daysofMedicareLifetimeReservetheStonebridgeStandardPlansA,F,G&NpaythePartAMedicareeligibleexpensesforhospitalization,paidatthesamerateMedicarewouldhavepaidhadMedicarePartAhospitaldaysnotbeenexhausted,subjecttoalifetimemaximumbenefitofanadditional365days.
Benefit for Blood – Medicare has one calendar year deductible for blood that is the cost of the first threepints.StonebridgeStandardPlansA,F,G&Npay the deductible.
Skilled Nursing Facility Care – Medicare pays all eligible expensesforthefirst20days.StonebridgeStandardPlansF,G&Npayupto$152fromthe21stthroughthe100thdayduringwhichyoureceiveskillednursingcare.YoumustenteraMedicarecertifiedskillednursingfacilitywithin30daysofbeinghospitalizedforatleastthreedays.
Hospice Care – Medicare pays all but a very limited Co-insurance/Co-payment for outpatient drugs and inpatient respitecare.StonebridgeStandardPlansA,F,G&Npaythe Co-insurance/Co-payment.
MSH1A,F,G,NOR(EXISTINGBUSINESS)MSH2A,F,G,NOR(NEWBUSINESS)
MediCare part B phYsiCianserviCes and supplies
Deductible -StonebridgeStandardPlanFpaysthe$147calendar-year deductible.
Co-insurance –AfterthePartBDeductible,StonebridgeStandardPlansA,F,G&Ngenerallypay20%ofeligibleexpenses for physician’s services, supplies, physicaland speech therapy and diagnostic tests and durable medical equipment.
AfterthePartBdeductible,PlanNpaysbalanceoftheeligibleexpensesforphysician’sservices,supplies,physicalandspeechtherapy,diagnostictestsanddurablemedicalequipmentexceptuptoa$20co-paymentforofficevisitsanduptoa$50co-paymentforemergencyroomvisits.
Forhospitaloutpatientservices,theco-paymentamountwillbepaidunderaprospectivepaymentsystem.Ifthissystem isnotused, then20%ofeligibleexpenseswill be paid.
Excess Benefits – Your bill for Part B services and supplies may exceed the Medicare eligible expense. When that occurs, Stonebridge Standard Plans F andGpays100%uptothechargelimitationestablished by Medicare.
Benefit for Blood –StonebridgeStandardPlansA,F,G&N payexpensesforthefirstthreepintsofblood.
additional Benefits**
Emergency Care received outside the U.S. After youpaya$250calendar-yeardeductible,StonebridgeStandardPlansF,G&Npayyou80%ofeligibleexpensesforcarewhichbeginsduringthefirst60daysofatripuptoalifetimemaximumof$50,000.Benefitsarepayablefor health care you needbecauseof a covered injury or illness.
Covered Benefits
78965MS_OR 1113
PREMIUM INFORMATION Youcannotbesingledoutforarateincrease,nomatterhowmanytimesyoureceivebenefits.Yourpremiumchangeswhenthesamepremiumchangeismadeonallin-forceMedicareSupplementpoliciesofthesameformissuedtopersonsofyourclassificationinthesamegeographicareaofyourstate.
DISCLOSURESUsethisoutlinetocomparebenefitsandpremiumsamongpolicies.
READ YOUR POLICY VERY CAREFULLYThis isonlyanoutlinedescribingyourPolicy’smost important features.ThePolicy is the insurancecontract. You must read the Policy itself to understand all of the rights and duties of both you and Stonebridge Life Insurance Company.
RIGHT TO RETURN POLICYIfyoufindthatyouarenotsatisfiedwithyourPolicy,youmayreturnittoStonebridgeLifeInsuranceCompany,4333EdgewoodRoad,CedarRapids,Iowa52499.
IfyousendthePolicybacktouswithin30daysafteryoureceiveit,wewilltreatthePolicyasifithadnever been issued and return all of your payments.
POLICY REPLACEMENTIfyouarereplacinganotherhealthinsurancePolicy,doNOTcancelituntilyouhaveactuallyreceivedyournewPolicyandaresureyouwanttokeepit.
NOTICE• ThisPolicymaynotfullycoverallofyourmedicalcosts.• NeitherStonebridgeLifeInsuranceCompanynoritsagentsareconnectedwithMedicare.• ThisoutlineofcoveragedoesnotgiveallthedetailsofMedicarecoverage.Contactyourlocal SocialSecurityOfficeorconsultMedicare and You for details. COMPLETE ANSWERS ARE VERY IMPORTANTWhenyoufillout theapplication for thenewPolicy,besure toanswer truthfullyandcompletelyallquestionsaboutyourmedicalandhealthhistory.ThecompanymaycancelyourPolicyandrefusetopay any claims if you leave out or falsify important medical information.
stoneBridge life insuranCe CoMpanYAdministrativeOffice:4333EdgewoodRd.NE,CedarRapids,IA52499
HomeOffice:Rutland,VT
78965MS_OR 1113
MSH
1O
STO
NEB
RID
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LIFE
INSU
RA
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OM
PAN
Y O
UTL
INE
OF
MED
ICA
RE
SUPP
LEM
ENT
CO
VER
AG
E –
CO
VER
PA
GE
BEN
EFIT
PLA
NS
A, F
, G A
ND
N
The
se c
harts
sho
w th
e be
nefit
s in
clud
ed in
eac
h of
the
stan
dard
Med
icar
e su
pple
men
t pla
ns.
Eve
ry c
ompa
ny m
ust m
ake
avai
labl
e P
lan
“A”.
Som
e
p
lans
may
not
be
avai
labl
e in
you
r sta
te.
See
Out
lines
of C
over
age
sect
ions
for d
etai
ls a
bout
ALL
pla
ns.
Bas
ic B
enef
its:
Hos
pita
lizat
ion:
Par
t A c
oins
uran
ce p
lus
cove
rage
for 3
65 a
dditi
onal
day
s af
ter M
edic
are
bene
fits
end.
M
edic
al E
xpen
ses:
Par
t B c
oins
uran
ce (g
ener
ally
20%
of M
edic
are-
appr
oved
exp
ense
s) o
r cop
aym
ents
for h
ospi
tal o
utpa
tient
ser
vice
s.
P
lans
K, L
and
N re
quire
insu
red’
s to
pay
a p
ortio
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Par
t B c
oins
uran
ce o
r cop
aym
ents
.
B
lood
:
Fi
rst 3
pin
ts o
f blo
od e
ach
year
.
H
ospi
ce:
Par
t A c
oins
uran
ce.
*Pla
n F
also
has
an
optio
n ca
lled
a hi
gh d
educ
tible
Pla
n F.
Thi
s hi
gh d
educ
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pla
n pa
ys th
e sa
me
bene
fits
as P
lan
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ter o
ne h
as p
aid
aca
lend
ar y
ear $
2,07
0 de
duct
ible
. Be
nefit
s fro
m h
igh
dedu
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le P
lan
F w
ill n
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ense
s ex
ceed
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070.
Out
-of p
ocke
t ex
pens
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r thi
s de
duct
ible
are
exp
ense
s th
at w
ould
ord
inar
ily b
e pa
id b
y th
e po
licy.
The
se e
xpen
ses
incl
ude
the
Med
icar
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duct
ible
s fo
r Par
t A
and
Par
t B, b
ut d
o no
t inc
lude
the
plan
’s s
epar
ate
fore
ign
trave
l em
erge
ncy
dedu
ctib
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Ple
ase
note
: Hig
h de
duct
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Pla
n F
is c
urre
ntly
not
av
aila
ble
as p
art o
f thi
s pr
ogra
m.
A B
CD
F
F*
G
KL
MN
Bas
ic,
includ
ing
100%
Par
t B
Co-in
sura
nce
Basic
, Inc
luding
10
0% Pa
rt B
Co-ins
urance
Basic
, inc
luding
10
0% Pa
rt B
Co-ins
urance
Basic
, inc
luding
10
0% Pa
rt B
Co-ins
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Basic
, inc
luding
10
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art B
Co
-insu
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Basic
, inc
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10
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art B
Co
-insu
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Hospi
talizatio
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d prev
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car
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at 10
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other b
asic b
enefit
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Hospi
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d prev
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car
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at 10
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other
basic
bene
fits pa
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%
Basic
, inc
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10
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rt B
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urance
Basic
, inclu
ding 1
00%
Par
t B
Co-in
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exce
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ymen
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ffice
visit,
and u
p to $
50 co
-pa
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t for E
R Sk
illed
Nursin
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cility
Co-ins
urance
Skilled
Nu
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Facilit
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-insura
nce
Skille
d Nu
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Fa
cility
Co
-insu
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Skille
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cility
Co
-insu
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50%
Skilled
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-insura
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75%
Skilled
Nu
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Facilit
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-insura
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Skilled
Nu
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Facilit
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-insura
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Skille
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Fa
cility
Co
-insu
ranc
e Pa
rt A
Dedu
ctible
Part A
De
ductib
le Pa
rt A
Dedu
ctible
Part A
De
ducti
ble
Part A
De
ducti
ble
50%
Part A
De
ductib
le 75
% Pa
rt A
Dedu
ctible
50%
Part A
De
ductib
le Pa
rt A
Dedu
ctible
Pa
rt BDe
ductib
le Pa
rt B
Dedu
ctible
Part B
Exc
ess
(100%
) Pa
rt B E
xces
s (10
0%)
Foreig
n Tra
vel
Emerg
ency
Foreig
n Tra
vel
Emerg
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Fore
ign
Trav
el Em
erge
ncy
Fore
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Trav
el Em
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Foreig
nTra
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Emerg
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Fore
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Trav
el Em
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ncy
Out-of
-pocke
t limit $
4,660
; pa
id at 10
0% aft
er limi
t rea
ched
Out-of
-pocke
t limit
$2,33
0; paid
at 10
0%
after lim
it reach
ed
25525085-OR
No
n-T
ob
ac
co
Ra
tes
To
ba
cc
o R
ate
s
Pla
n A
Pla
n F
Pla
n G
Pla
n N
Att
ain
ed
Ag
e
Pla
n A
Pla
n F
Pla
n G
Pla
n N
Fe
ma
leM
ale
Fe
ma
leM
ale
Fe
ma
leM
ale
Fe
ma
leM
ale
Fe
ma
leM
ale
Fe
ma
leM
ale
Fe
ma
leM
ale
Fe
ma
leM
ale
62.02
66.27
104.80
111.98
96.64
103.26
80.76
86.29
Un
de
r 65
68.22
72.90
115.28
123.18
106.30
113.59
88.84
94.92
62.02
66.27
104.80
111.98
96.64
103.26
80.76
86.29
65
68.22
72.90
115.28
123.18
106.30
113.59
88.84
94.92
62.95
67.36
106.37
113.83
98.08
104.96
81.97
87.72
66
69.25
74.10
117.01
125.21
107.89
115.46
90.17
96.49
63.88
68.39
107.94
115.57
99.53
106.57
83.18
89.06
67
70.27
75.23
118.73
127.13
109.48
117.23
91.50
97.97
66.00
70.79
111.53
119.62
102.84
110.30
85.95
92.18
68
72.60
77.87
122.68
131.58
113.12
121.33
94.55
101.40
68.04
72.81
114.97
123.04
106.01
113.46
88.60
94.82
69
74.84
80.09
126.47
135.34
116.61
124.81
97.46
104.30
69.99
74.89
118.28
126.56
109.07
116.70
91.15
97.53
70
76.99
82.38
130.11
139.22
119.98
128.37
100.27
107.28
71.98
77.55
121.64
131.05
112.16
120.84
93.74
100.99
71
79.18
85.31
133.80
144.16
123.38
132.92
103.11
111.09
74.21
80.65
125.41
136.28
115.64
125.66
96.64
105.02
72
81.63
88.72
137.95
149.91
127.20
138.23
106.30
115.52
76.58
84.02
129.41
141.99
119.33
130.93
99.72
109.42
73
84.24
92.42
142.35
156.19
131.26
144.02
109.69
120.36
78.89
87.48
133.32
147.83
122.93
136.31
102.74
113.92
74
86.78
96.23
146.65
162.61
135.22
149.94
113.01
125.31
80.98
90.79
136.85
153.43
126.19
141.48
105.46
118.23
75
89.08
99.87
150.54
168.77
138.81
155.63
116.01
130.05
82.78
93.84
139.88
158.57
128.98
146.22
107.79
122.20
76
91.06
103.22
153.87
174.43
141.88
160.84
118.57
134.42
84.31
96.56
142.48
163.17
131.38
150.46
109.80
125.74
77
92.74
106.22
156.73
179.49
144.52
165.51
120.78
138.31
85.92
99.25
145.20
167.72
133.89
154.65
111.89
129.25
78
94.51
109.18
159.72
184.49
147.28
170.12
123.08
142.18
87.55
101.77
147.94
171.97
136.42
158.57
114.00
132.52
79
96.31
111.95
162.73
189.17
150.06
174.43
125.40
145.77
89.94
104.93
151.98
177.31
140.14
163.50
117.12
136.64
80
98.93
115.42
167.18
195.04
154.15
179.85
128.83
150.30
92.55
108.07
156.39
182.63
144.21
168.40
120.52
140.74
81
101.81
118.88
172.03
200.89
158.63
185.24
132.57
154.81
95.33
111.20
161.10
187.92
148.55
173.28
124.15
144.81
82
104.86
122.32
177.21
206.71
163.41
190.61
136.57
159.29
98.26
114.29
166.05
193.14
153.11
178.09
127.96
148.84
83
108.09
125.72
182.66
212.45
168.42
195.90
140.76
163.72
101.24
117.32
171.08
198.26
157.75
182.82
131.84
152.78
84
111.36
129.05
188.19
218.09
173.53
201.10
145.02
168.06
104.23
120.29
176.13
203.28
162.41
187.44
135.73
156.65
85
114.65
132.32
193.74
223.61
178.65
206.18
149.30
172.32
107.24
123.23
181.22
208.24
167.10
192.02
139.65
160.47
86
117.96
135.55
199.34
229.06
183.81
211.22
153.62
176.52
110.34
126.22
186.46
213.29
171.93
196.67
143.69
164.36
87
121.37
138.84
205.11
234.62
189.12
216.34
158.06
180.80
113.55
129.30
191.89
218.50
176.94
201.48
147.87
168.38
88
124.91
142.23
211.08
240.35
194.63
221.63
162.66
185.22
116.74
132.42
197.28
223.77
181.91
206.34
152.03
172.44
89
128.41
145.66
217.01
246.15
200.10
226.97
167.23
189.68
119.54
135.32
202.01
228.68
186.27
210.87
155.67
176.22
90
131.49
148.85
222.21
251.55
204.90
231.96
171.24
193.84
120.68
136.90
203.93
231.35
188.04
213.33
157.15
178.28
91
132.75
150.59
224.32
254.49
206.84
234.66
172.87
196.11
121.92
138.79
206.03
234.53
189.98
216.26
158.77
180.73
92
134.11
152.67
226.63
257.98
208.98
237.89
174.65
198.80
123.25
140.83
208.27
237.99
192.05
219.45
160.50
183.40
93
135.58
154.91
229.10
261.79
211.26
241.40
176.55
201.74
124.66
143.06
210.66
241.75
194.25
222.92
162.34
186.30
94
137.13
157.37
231.73
265.93
213.68
245.21
178.57
204.93
126.17
145.47
213.21
245.82
196.60
226.67
164.30
189.43
95+
138.79
160.02
234.53
270.40
216.26
249.34
180.73
208.37
For Q
uart
erly,
Sem
i-Ann
ual a
nd A
nnua
l Pre
miu
m M
odes
, mul
tiply
mon
thly
rate
s by
3, 6
and
12
resp
ectiv
ely
For T
ier 1
rate
s m
ultip
ly b
y 1.
1 an
d fo
r Tie
r 2 ra
tes
mul
tiply
by
1.2
Rate
s qu
oted
abo
ve a
re p
er p
erso
n an
d ba
sed
upon
indi
vidu
al a
ge. R
ates
incr
ease
eve
ry y
ear o
n th
e an
nive
rsar
y da
te o
f you
r po
licy/
cert
ifica
te, a
s yo
u gr
ow o
lder
. Nei
ther
Sto
nebr
idge
Life
nor
its
agen
ts a
re c
onne
cted
with
Med
icar
e. F
OR A
GENT
USE
ONL
Y.
NOT
FOR
PUBL
IC D
ISSE
MIN
ATIO
N. R
ates
effe
ctiv
e as
of 1
0/01
/13.
Mon
thly
Rat
es b
y Pl
an -
Ore
gon
Hom
e O
ffice
: R
utla
nd, V
T
a Tr
ansa
mer
ica
Com
pan
y
MSH
1O
Ston
ebrid
ge L
ife In
sura
nce C
ompa
ny
Adm
inis
trativ
e O
ffice
: 43
33 E
dgew
ood
Rd.
NE
Ced
ar R
apid
s, Io
wa
5249
9 PR
EMIU
M IN
FOR
MA
TIO
N
RIG
HT
TO R
ETU
RN
PO
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Y
Th
is o
utlin
e of
cov
erag
e do
es n
ot
W
e, S
tone
brid
ge L
ife In
sura
nce
Com
pany
, can
I
f you
find
that
you
are
not
sat
isfie
d w
ith y
our
gi
ve a
ll th
e de
tails
of M
edic
are
onl
y ra
ise
your
pre
miu
m if
we
rais
e th
e pr
emiu
m
Pol
icy,
you
may
retu
rn it
to S
tone
brid
ge L
ife
co
vera
ge.
Con
tact
you
r loc
al S
ocia
l
for a
ll po
licie
s lik
e yo
urs
in th
is s
tate
.
I
nsur
ance
Com
pany
, 433
3 E
dgew
ood
Roa
d,
Sec
urity
Offi
ce o
r con
sult
Med
icar
e
C
edar
Rap
ids,
Iow
a 52
499.
and
You
for d
etai
ls.
H
owev
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ecau
se th
e pr
emiu
m ra
te is
bas
ed u
pon
y
our a
ttain
ed a
ge, t
he p
rem
ium
will
incr
ease
as
you
If
you
send
the
Pol
icy
back
to u
s w
ithin
30
C
OM
PLET
E A
NSW
ERS
AR
E
a
ge fr
om a
ge 6
5 th
roug
h ag
e 95
. Thi
s an
nual
cha
nge
days
afte
r you
rece
ive
it, w
e w
ill tr
eat t
he
V
ERY
IMPO
RTA
NT
w
ill o
ccur
on
each
Pol
icy
Ren
ewal
Dat
e.
Pol
icy
as if
it h
ad n
ever
bee
n is
sued
and
W
hen
you
fill o
ut th
e ap
plic
atio
n fo
r
re
turn
all
of y
our p
aym
ents
.
the
new
Pol
icy,
be
sure
to a
nsw
er
T
here
will
be
a on
e-tim
e en
rollm
ent f
ee o
f $25
.00
t
ruth
fully
and
com
plet
ely
all
a
dded
to th
e fir
st p
rem
ium
.
POLI
CY
REP
LAC
EMEN
T
ques
tions
abo
ut y
our m
edic
al a
nd
If
you
are
repl
acin
g an
othe
r hea
lth
hea
lth h
isto
ry.
The
com
pany
may
DIS
CLO
SUR
ES
in
sura
nce
Pol
icy,
do
NO
T ca
ncel
it u
ntil
you
ca
ncel
you
r Pol
icy
and
refu
se to
Use
this
out
line
to c
ompa
re b
enef
its a
nd p
rem
ium
s
have
act
ually
rece
ived
you
r new
Pol
icy
and
p
ay a
ny c
laim
s if
you
leav
e ou
t or
a
mon
g po
licie
s.
ar
e su
re y
ou w
ant t
o ke
ep it
.
fal
sify
impo
rtant
med
ical
inf
orm
atio
n.
R
EAD
YO
UR
PO
LIC
Y VE
RY
CA
REF
ULL
Y
NO
TIC
E
R
evie
w th
e ap
plic
atio
n ca
refu
lly
Th
is is
onl
y an
out
line
desc
ribin
g yo
ur P
olic
y’s
mos
t
Thi
s P
olic
y m
ay n
ot fu
lly c
over
all
of y
our
bef
ore
you
sign
it.
Be
certa
in th
at
im
porta
nt fe
atur
es.
The
Pol
icy
is th
e in
sura
nce
med
ical
cos
ts.
all
info
rmat
ion
has
been
pro
perly
con
tract
. Y
ou m
ust r
ead
the
Pol
icy
itsel
f to
unde
rsta
nd
reco
rded
.
all
of th
e rig
hts
and
dutie
s of
bot
h yo
u an
d S
tone
brid
ge
Life
Insu
ranc
e C
ompa
ny.
Nei
ther
Sto
nebr
idge
Life
Insu
ranc
e C
ompa
ny
n
or it
s ag
ents
are
con
nect
ed w
ith M
edic
are.
MSH
1O
PLAN
A
MED
ICA
RE
(PA
RT
A) –
HO
SPIT
AL
SER
VIC
ES –
PER
BEN
EFIT
PER
IOD
*
A b
enef
it pe
riod
begi
ns o
n th
e fir
st d
ay y
ou re
ceiv
e se
rvic
e as
an
inpa
tient
in a
hos
pita
l and
end
s af
ter y
ou h
ave
been
out
of t
he h
ospi
tal a
nd h
ave
no
t rec
eive
d sk
illed
car
e in
any
oth
er fa
cilit
y fo
r 60
days
in a
row
.
Serv
ices
Medi
care
Pay
s Pl
an A
Pay
s Yo
u Pa
y HO
SPITA
LIZAT
ION*
Se
mipri
vate
room
and b
oard,
gene
ral nu
rsing
and m
iscella
neou
s serv
ices a
nd su
pplies
F
irst 6
0 day
s
All
but $
1,216
$0
$1
,216 (
Part A
Ded
uctib
le)
61st th
rough
90th d
ay
All bu
t $30
4 a da
y $3
04 a
day
$0
91st d
ay an
d afte
r:
W
hile us
ing 60
lifetim
e res
erve d
ays
All
but $
608 a
day
$6
08 a
day
$0
O
nce l
ifetim
e res
erve d
ays a
re us
ed:
Addit
ional
365 d
ays
$0
100%
of M
edica
re Eli
gible
Expe
nses
$0
**
Beyo
nd th
e add
itiona
l 365
days
$0
$0
All
costs
SK
ILLE
D NU
RSIN
G FA
CILI
TY C
ARE*
Yo
u mus
t mee
t Med
icare
’s re
quire
ments
, inclu
ding h
aving
been
in a
hosp
ital fo
r at
least
3 day
s and
enter
ed a
Medic
are a
ppro
ved f
acilit
y with
in 30
days
after
leav
ing th
e ho
spita
l
Fi
rst 20
days
All ap
prove
d amo
unts
$0
$0
21st t
hrou
gh 10
0th day
All
but $
152 a
day
$0
Up to
$152
a da
y
10
1st day
and a
fter
$0
$0
All co
sts
BLOO
D
Fi
rst 3
pints
$0
3 p
ints
$0
A
dditio
nal a
moun
ts 10
0%
$0
$0
HOSP
ICE C
ARE
You m
ust m
eet M
edica
re’s
requ
ireme
nts, in
cludin
g a do
ctor’s
certif
icatio
n of te
rmina
l illn
ess.
All
but v
ery lim
ited
copa
ymen
t/coin
suran
ce fo
r ou
tpatie
nt dru
gs an
d inp
atien
t res
pite c
are
Me
dicare
copa
ymen
t/ co
insura
nce
$0
*
*NO
TIC
E: W
hen
your
Med
icar
e P
art A
hos
pita
l ben
efits
are
exh
aust
ed, t
he in
sure
r sta
nds
in th
e pl
ace
of M
edic
are
and
will
pay
wha
teve
r am
ount
M
edic
are
wou
ld h
ave
paid
for u
p to
an
addi
tiona
l 365
day
s as
pro
vide
d in
the
polic
y’s
“Cor
e B
enef
its.”
Dur
ing
this
tim
e th
e ho
spita
l is
proh
ibite
d
f
rom
bill
ing
you
for t
he b
alan
ce b
ased
on
any
diffe
renc
e be
twee
n its
bille
d ch
arge
s an
d th
e am
ount
Med
icar
e w
ould
hav
e pa
id.
MSH
1O
PL
AN A
M
EDIC
AR
E (P
AR
T B
) – M
EDIC
AL
SER
VIC
ES –
PER
CA
LEN
DA
R Y
EAR
*Onc
e yo
u ha
ve b
een
bille
d $1
47 o
f Med
icar
e A
ppro
ved
amou
nts
for c
over
ed s
ervi
ces
(whi
ch a
re n
oted
with
an
aste
risk)
, you
r Med
icar
e P
art B
Ded
uctib
le w
ill h
ave
been
met
for t
he c
alen
dar y
ear.
Se
rvice
s Me
dica
re P
ays
Plan
A P
ays
You
Pay
MEDI
CAL
EXPE
NSES
– IN
OR
OUT
OF T
HE H
OSPI
TAL A
ND
OUTP
ATIE
NT H
OSPI
TAL T
REAT
MENT
, suc
h as p
hysic
ian’s
servi
ces,
inpati
ent
and o
utpati
ent m
edica
l and
surg
ical s
ervic
es an
d sup
plies
, phy
sical
and s
peec
h the
rapy
, diag
nosti
c tes
ts, du
rable
med
ical e
quipm
ent
Firs
t $14
7 of M
edica
re A
ppro
ved A
moun
ts*
$0
$0
$147
(Par
t B D
educ
tible)
R
emain
der o
f Med
icare
App
rove
d Amo
unts
Gene
rally
80%
Ge
nera
lly 20
%
$0
Part
B Ex
cess
Cha
rges
(abo
ve M
edica
re A
ppro
ved A
moun
ts)
$0
$0
All c
osts
BLOO
D
Fi
rst 3
pints
$0
All c
osts
$0
Nex
t $14
7 of M
edica
re A
ppro
ved A
moun
ts*
$0
$0
$147
(Par
t B D
educ
tible)
R
emain
der o
f Med
icare
App
rove
d Amo
unts
80%
20
%
$0
CLIN
ICAL
LAB
ORAT
ORY
SERV
ICES
- TE
STS
FOR
DIAG
NOST
IC
SERV
ICES
10
0%
$0
$0
PAR
TS A
& B
HO
ME H
EALT
H CA
RE –
MEDI
CARE
APP
ROVE
D SE
RVIC
ES
Medic
ally n
eces
sary
skille
d car
e ser
vices
and m
edica
l sup
plies
10
0%
$0
$0
Dura
ble m
edica
l equ
ipmen
t
F
irst $
147 o
f Med
icare
App
rove
d Amo
unts*
$0
$0
$1
47 (P
art B
Ded
uctib
le)
R
emain
der o
f Med
icare
App
rove
d Amo
unts
80%
20
%
$0
MSH
1O
PL
ANS
F AN
D G
MED
ICA
RE
(PA
RT
A) –
HO
SPIT
AL
SER
VIC
ES –
PER
BEN
EFIT
PER
IOD
* A b
enef
it pe
riod
begi
ns o
n th
e fir
st d
ay y
ou re
ceiv
e se
rvic
e as
an
inpa
tient
in a
hos
pita
l and
end
s af
ter y
ou h
ave
been
out
of t
he h
ospi
tal a
nd
h
ave
not r
ecei
ved
skille
d ca
re in
any
oth
er fa
cilit
y fo
r 60
days
in a
row
.
Serv
ices
Medi
care
Pay
s Pl
an F
Pay
s Yo
u Pa
y Pl
an G
Pay
s Yo
u Pa
y HO
SPITA
LIZAT
ION*
Se
mipri
vate
room
and b
oard,
gene
ral nu
rsing
and m
iscella
neou
s se
rvice
s and
supp
lies
Firs
t 60 d
ays
All
but $
1,216
$1
,216 (
Part A
De
ductib
le)
$0
$1
,216 (
Part A
De
ductib
le)
$0
61st th
rough
90th d
ay
All bu
t $30
4 a da
y $3
04 a
day
$0
$304
a da
y $0
91
st day
and a
fter:
W
hile u
sing 6
0 life
time r
eser
ve da
ys
All
but $
608 a
day
$6
08 a
day
$0
$608
a da
y $0
O
nce l
ifetim
e res
erve d
ays a
re us
ed:
A
dditio
nal 3
65 da
ys
$0
100%
of M
edica
re Eli
gible
Expe
nses
$0
**
10
0% of
Med
icare
Eligib
le Ex
pens
es
$0
**
Beyo
nd th
e add
itiona
l 365
days
$0
$0
All
costs
$0
All
costs
SK
ILLED
NUR
SING
FACI
LITY C
ARE*
Yo
u mus
t mee
t Med
icare
’s re
quire
ments
, inclu
ding h
aving
be
en in
a ho
spita
l for a
t leas
t 3 da
ys an
d ente
red a
Me
dicar
e app
rove
d fac
ility w
ithin
30 da
ys af
ter le
aving
the
hosp
ital
Fir
st 20
days
All
appro
ved a
moun
ts
$0
$0
$0
$0
21
st throu
gh10
0th da
y All
but $
152 a
day
Up to
$152
a da
y $0
Up
to $1
52 a
day
$0
1
01st d
ay an
d afte
r $0
$0
All
costs
$0
All
cos
ts BL
OOD
F
irst 3
pints
$0
3 p
ints
$0
3 pint
s
$0
A
dditio
nal a
moun
ts 10
0%
$0
$0
$0
$0
HOSP
ICE C
ARE
You m
ust m
eet M
edica
re’s
requ
ireme
nts, in
cludin
g a
docto
r’s ce
rtifica
tion o
f term
inal il
lness
.
All bu
t very
limite
d co
paym
ent/c
oinsu
rance
for
outpa
tient
drugs
and
inpati
ent re
spite
care
Medic
are co
paym
ent/
coins
uranc
e $0
Me
dicare
copa
ymen
t/ co
insura
nce
$0
**N
OTI
CE
: Whe
n yo
ur M
edic
are
Par
t A h
ospi
tal b
enef
its a
re e
xhau
sted
, the
insu
rer s
tand
s in
the
plac
e of
Med
icar
e an
d w
ill p
ay w
hate
ver a
mou
nt
Med
icar
e w
ould
hav
e pa
id fo
r up
to a
n ad
ditio
nal 3
65 d
ays
as p
rovi
ded
in th
e po
licy’
s “C
ore
Ben
efits
.” D
urin
g th
is ti
me
the
hosp
ital i
s pr
ohib
ited
fro
m b
illin
g yo
u fo
r the
bal
ance
bas
ed o
n an
y di
ffere
nce
betw
een
its b
illed
char
ges
and
the
amou
nt M
edic
are
wou
ld h
ave
paid
.
MSH
1O
PL
ANS
F AN
D G
MED
ICA
RE
(PA
RT
B) –
MED
ICA
L SE
RVI
CES
– P
ER C
ALE
ND
AR
YEA
R
*O
nce
you
have
bee
n bi
lled
$147
of M
edic
are
App
rove
d A
mou
nts
for c
over
ed s
ervi
ces
(whi
ch a
re n
oted
with
an
aste
risk)
, you
r Par
t B D
educ
tible
will
hav
e be
en m
et fo
r the
cal
enda
r yea
r.
Serv
ices
Medi
care
Pay
s Pl
an F
Pay
s Yo
u Pa
y Pl
an G
Pay
s Yo
u Pa
y ME
DICA
L EXP
ENSE
S---IN
OR
OUT O
F THE
HOS
PITAL
AND
OU
TPAT
IENT H
OSPIT
AL TR
EATM
ENT,
such
as ph
ysicia
n’s
servi
ces,
inpati
ent a
nd ou
tpatie
nt me
dical
and s
urgica
l servi
ces
and m
edica
l equ
ipmen
t
Firs
t $14
7 of M
edica
re Ap
prove
d Amo
unts*
$0
$147
(Part
B De
ductib
le)
$0
$0
$147
(Part
B De
ductib
le)
Rem
ainde
r of M
edica
re A
ppro
ved A
moun
ts Ge
neral
ly 80%
Ge
neral
ly 20%
$0
Ge
neral
ly 20%
$0
Pa
rt B Ex
cess
Cha
rges
(abo
ve M
edica
re Ap
prove
d Amo
unts)
$0
10
0%
$0
100%
$0
BL
OOD
Fi
rst 3
pints
$0
All
costs
$0
All co
sts
$0
N
ext $
147 o
f Med
icare
App
rove
d Amo
unts*
$0
$147
(Part
B De
ductib
le)
$0
$0
$147
(Part
B De
ductib
le)
Rem
ainde
r of M
edica
re A
ppro
ved A
moun
ts 80
% 20
% $0
20
% $0
CL
INIC
AL L
ABOR
ATOR
Y SE
RVIC
ES---T
ESTS
FOR
DIAG
NOST
IC SE
RVIC
ES
10
0%
$0
$0
$0
$0
PAR
TS A
& B
HO
ME H
EALT
H CA
RE---M
EDIC
ARE A
PPRO
VED
SERV
ICES
Me
dically
nece
ssary
skille
d care
servi
ces a
n d m
edica
l supp
lies
100%
$0
$0
$0
$0
Dura
ble m
edica
l equ
ipmen
t
Firs
t $14
7 of M
edica
re A
ppro
ved A
moun
ts*
$0
$147
(Par
t B
Dedu
ctible
)
$0
$0
$147
(Par
t B
Dedu
ctible
)
Rem
ainde
r of M
edica
re A
ppro
ved A
moun
ts 80
%
20%
$0
20
%
$0
OTH
ER B
ENEF
ITS
- NO
T C
OVE
RED
BY
MED
ICA
RE
FORE
IGN
TRAV
EL---N
OT C
OVER
ED BY
MED
ICAR
E Me
dically
nece
ssary
emerg
ency
care
servi
ces b
eginn
ing du
ring
the fir
st 60
days
of ea
ch tri
p outs
ide th
e USA
F
irst $
250 e
ach c
alend
ar ye
ar
$0
$0
$250
$0
$250
Re
maind
er of
char
ges
$0
80%
to a
lifetim
e Ma
ximum
Ben
efit
of $5
0,000
20%
and a
moun
ts ov
er th
e $50
,000
lifetim
e Max
imum
Be
nefit
80%
to a
lifetim
e Ma
ximum
Ben
efit o
f $5
0,000
20%
and a
moun
ts ov
er th
e $50
,000
lifetim
e Max
imum
Be
nefit
MSH
1O
PL
AN N
M
EDIC
AR
E (P
AR
T A
) – H
OSP
ITA
L SE
RVI
CES
– P
ER B
ENEF
IT P
ERIO
D
*A
ben
efit
perio
d be
gins
on
the
first
day
you
rece
ive
serv
ice
as a
n in
patie
nt in
a h
ospi
tal a
nd e
nds
afte
r you
hav
e be
en o
ut o
f the
hos
pita
l and
hav
e no
t rec
eive
d sk
illed
care
in a
ny o
ther
faci
lity
for 6
0 da
ys in
a ro
w.
Se
rvice
s Me
dica
re P
ays
Plan
N P
ays
You
Pay
HOSP
ITALIZ
ATIO
N*
Semi
priva
te roo
m an
d boa
rd, ge
neral
nursi
ng an
d misc
ellane
ous s
ervice
s and
supp
lies
F
irst 6
0 day
s
All
but $
1,216
$1,21
6 (Pa
rt A D
educ
tible)
$0
6
1st throu
gh 90
th day
s All
but $
304 a
day
$304
a da
y $0
91st d
ay an
d afte
r:
W
hile us
ing 60
lifetim
e res
erve d
ays
All bu
t $60
8 a da
y
$608
a da
y $0
Onc
e life
time r
eserv
e day
s are
used
:
Addit
ional
365 d
ays
$0
100%
of M
edica
re
Eligib
le Ex
pens
es
$0**
Be
yond
the a
dditio
nal 3
65 da
ys
$0
$0
All co
sts
SKILL
ED N
URSIN
G FA
CILIT
Y CAR
E*
You m
ust m
eet M
edica
re’s r
equir
emen
ts, in
cludin
g hav
ing be
en in
a ho
spita
l for a
t leas
t 3
days
and e
ntered
a Me
dicare
appro
ved f
acility
with
in 30
days
after
leav
ing th
e hos
pital.
Firs
t 20 d
ays
All ap
prove
d amo
unts
$0
$0
2
1st throu
gh 10
0th day
All
but $
152 a
day
Up to
$152
a da
y $0
101st d
ay an
d afte
r $0
$0
All
costs
BL
OOD
F
irst 3
pints
$0
3 p
ints
$0
A
dditio
nal a
moun
ts 10
0%
$0
$0
HOSP
ICE C
ARE
You m
ust m
eet M
edica
re’s r
equir
emen
ts, in
cludin
g a do
ctor’s
certif
icatio
n of te
rmina
l illne
ss.
All bu
t very
limite
d co
paym
ent/c
oinsu
rance
for
outpa
tient
drugs
and
inpati
ent re
spite
care
Medic
are co
paym
ent/c
oinsu
rance
$0
**N
OTI
CE
: Whe
n yo
ur M
edic
are
Par
t A h
ospi
tal b
enef
its a
re e
xhau
sted
, the
insu
rer s
tand
s in
the
plac
e of
Med
icar
e an
d w
ill p
ay w
hate
ver a
mou
nt
Med
icar
e w
ould
hav
e pa
id fo
r up
to a
n ad
ditio
nal 3
65 d
ays
as p
rovi
ded
in th
e po
licy’
s “C
ore
Ben
efits
.” D
urin
g th
is ti
me
the
hosp
ital i
s pr
ohib
ited
fro
m b
illin
g yo
u fo
r the
bal
ance
bas
ed o
n an
y di
ffere
nce
betw
een
its b
illed
char
ges
and
the
amou
nt M
edic
are
wou
ld h
ave
paid
.
MSH
1O
PLAN
N
MED
ICA
RE
(PA
RT
B) –
MED
ICA
L SE
RVI
CES
– P
ER C
ALE
ND
AR
YEA
R
*O
nce
you
have
bee
n bi
lled
$147
of M
edic
are
App
rove
d A
mou
nts
for c
over
ed s
ervi
ces
(whi
ch a
re n
oted
with
an
aste
risk)
, you
r Par
t B
Ded
uctib
le w
ill h
ave
been
met
for t
he c
alen
dar y
ear.
Serv
ices
Medi
care
Pay
s Pl
an N
Pay
s Yo
u Pa
y ME
DICA
L EXP
ENSE
S---IN
OR
OUT O
F THE
HOS
PITAL
AND
OUTP
ATIEN
T HOS
PITAL
TR
EATM
ENT,
such
as ph
ysicia
n’s se
rvice
s, inp
atien
t and
outpa
tient
medic
al an
d surg
ical
servi
ces a
nd su
pplies
, phy
sical
and s
peec
h the
rapy,
diagn
ostic
tests,
durab
le me
dical
equip
ment
First
$147
of M
edica
re Ap
prove
d Amo
unts*
$0
$0
$1
47 (P
art B
Dedu
ctible)
Rem
ainde
r of M
edica
re Ap
prove
d Amo
unts
Gene
rally 8
0%
Balan
ce, o
ther th
an up
to $2
0 per
office
visit a
nd up
to $5
0 per
emerg
ency
room
visit.
The
copa
ymen
t of u
p to $
50 is
waive
d if
the in
sured
is ad
mitte
d to a
ny ho
spita
l an
d the
emerg
ency
visit is
cove
red as
a M
edica
re Pa
rt A ex
pens
e.
Up to
$20 p
er off
ice vis
it and
up
to $5
0 per
emerg
ency
room
vis
it. Th
e cop
ayme
nt of
up to
$5
0 is w
aived
if the
insu
red is
admi
tted t
o any
hosp
ital a
nd
the em
ergen
cy vis
it is co
vered
as
a Me
dicare
Part A
expe
nse.
Part B
Exce
ss C
harg
es (a
bove
Med
icare
Appro
ved A
moun
ts)
$0
$0
All co
sts
BLOO
D
Firs
t 3 pi
nts
$0
All co
sts
$0
Nex
t $14
7 of M
edica
re Ap
prove
d Amo
unts*
$0
$0
$1
47 (P
art B
Dedu
ctible)
Rem
ainde
r of M
edica
re Ap
prove
d Amo
unts
80%
20%
$0
CLIN
ICAL
LAB
ORAT
ORY
SERV
ICES
---TES
TS FO
R DI
AGNO
STIC
SERV
ICES
10
0%
$0
$0
PAR
TS A
& B
HO
ME H
EALT
H CA
RE---M
EDIC
ARE A
PPRO
VED
SERV
ICES
Me
dically
nece
ssary
skille
d care
servi
ces a
nd m
edica
l supp
lies
100%
$0
$0
Du
rable
med
ical e
quipm
ent
Firs
t $14
7 of M
edica
re A
ppro
ved A
moun
ts*
$0
$0
$147
(Part
B De
ductib
le)
Rem
ainde
r of M
edica
re A
ppro
ved A
moun
ts 80
% 20
% $0
OTH
ER B
ENEF
ITS
– N
OT
CO
VER
ED B
Y M
EDIC
AR
E FO
REIG
N TR
AVEL
---NOT
COV
ERED
BY M
EDIC
ARE
Medic
ally ne
cess
ary em
ergen
cy ca
re se
rvice
s beg
inning
durin
g the
first
60 da
ys of
each
trip
outsid
e the
USA
F
irst $
250 e
ach c
alend
ar ye
ar
$0
$0
$250
Re
maind
er of
char
ges
$0
80%
to a
lifetim
e Max
imum
Be
nefit
of $5
0,000
20
% an
d amo
unts
over
the
$50,0
00 lif
etime
Max
imum
Be
nefit
AtStonebridgeLifeInsuranceCompanywetakeveryseriouslythetrustourcustomersplaceinustohelpensuretheirfinancialsecurity.Forover100years,wehavenavigated throughgoodtimesandtoughtimes.Throughoutourhistory,ourcompanyhasremainedresilient,stronganddedicated to delivering on our long-term commitments to our customers.Weunderstandthatnow,morethanever,youneedtofeelconfidentaboutyourfinancial future.Despitehistoricalchanges inthefinancialmarkets,ourgoalhasremainedthesame:tohelpourcustomersprotecttheirfinancialfuturebyofferingawiderangeofcompetitiveandinnovativeproducts and services.
Weaccomplishthisby:•Deliveringonourlong-termcommitments,•Maintainingaprudentriskmanagementculture,•Implementingeffectivecapitalandliquiditystrategies,and•Adheringtoasoundanddisciplinedinvestmentphilosophy.
StonebridgeLifeInsuranceCompanyisaTransamericacompany.TheTransamericacompaniesofferawidearrayofinnovativefinancialservicesandproductswithacommonpurpose:tohelpindividuals,families,andbusinessesbuild,protectandpreservetheirhard-earnedassets.Withmorethanacenturyofexperience,wehavebuiltasolidreputationonsolidmanagement,sounddecisionsandconsumerconfidence.
MSH1A,F,G,NOR(EXISTINGBUSINESS)MSH2A,F,G,NOR(NEWBUSINESS)
78965MS_OR 0413LL #26068891_OR
Home office: Rutland, Vt