Affidavit and Indemnity Agreement
This form is required to recognize and work with deponents as the sole, legal, equitable, and unrestricted heirs to the deceased’s estate. 

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Authorization for Disclosure of Health-Related Information
Due to HIPAA regulations, we are unable to release personal information without the insured’s authorization. If you would like to grant access to your policy information to someone else, please print, complete, and mail the attached form to the address listed on the form. 

 

Bank Draft
The option is available to have long-term care policy premiums deducted directly from your checking or savings account. Please follow the instructions on the form to have policy premiums deducted automatically.

 

Claim Form
To submit a request for an eligibility determination, a claim form and additional information is required to initiate this process. Please read the "To File a Claim" instructions included in the Claim Information Package.

 

Claim Information Package
The claim information package contains the documents to explain the claim filing process and the forms that may be needed when filing a new claim.

 

Direction to Pay
The Direction to Pay form is provided as a convenience to our policyholders and their care providers to assign benefits to the care provider. 

 

Authorization for Use of Health-Related Information
Additional information may be necessary to reach an eligibility determination. Completing and submitting this form provides authorization to obtain personal information, including health information from physicians, medical practitioners, hospitals, clinics, etc. If this form is not submitted with the claim form it may delay handling of the claim.

 

Caregiver Weekly Timesheet
This form is provided as a convenience in the event the home health care provider does not have their own daily progress notes or billing forms.​