Long-Term Care Insurance Claim Forms Library
To file your long-term care insurance claim, the proper claim form from your carrier must be used. For your convenience, we have provided claim forms from the most popular carriers.
Note that some long-term care insurance providers require that claims be submitted online.
Please fill out this form to gain access the Claim Forms Library.
Then check your email for a link to the full library of insurance claim forms.Allianz Claim Form
Bankers Life Claim Initiation Forms
Bankers Life Long Term Care Form
CalPERS
California Public Employees’ Retirement System manages pensions and health insurance for 1.9 million current and retired California public employees and their families. It’s the largest such fund in the U.S. with $389 billion in assets at the end of June 2020.
CalPERS’ Long-term care insurance helps pay the long-term care costs for beneficiaries who need help with their activities of daily living. This is an optional, employee-paid benefit.
Effective June 17, 2020, CalPERS temporarily suspended open enrollment for the LTC program because of uncertainty in the LTC market. Until further notice, CalPERS LTC isn’t accepting new applications, and applications still in underwriting won’t be processed.
CalPERs Filing a Claim—What Is Needed?
CalPERs Agency Provider Form
CalPERs Agency Statement
CalPERs Appeal Form
Assignment of Benefits Independent Provider
Assignment of Benefits
Assignment of Benefits Service Provider
Authorization to Release Individual Personal Representative Form
Authorization Disclose Health
How to File a Claim
Independent Provider Packet
Independent Provider Weekly Time Sheet
CalPERs Online Claim Form
CalPERs PHI Form
CalPERs Reconsideration Form
CNA
CNA stands for Continental National American Group, better known as CNA Financial Corporation. Continental Casualty Company underwrites CNA’s long-term insurance policies, which is the 8th largest commercial insurance company in the U.S.
Continental’s long-term care insurance policies offer customizable coverage. Benefits pay nursing home expenses, up to the policy’s daily maximum. Non-nursing care pay-outs are 50% or 100%. The policy benefit period ranges from 3 – 5 years.
CNA Authorization To Release Info Disclosure Form
CNA Claim Form
CNA Claimants Statement
Conseco
Conseco Health Insurance Co. is a subsidiary of CNO Financial Group, one of the 10 largest public companies in Indiana. Conseco has assets of nearly $2.5 billion as of the end of March 2020.
Conseco Claim Form
Genworth
Formerly the largest provider of long-term care insurance, the company no longer sells stand-alone coverage for individuals through brokerages and agents. Instead, it markets LTC coverage direct-to-consumers or through group coverage options. The move does not affect the firm’s 1.2 million current policyholders.
Coverage, subject to the Elimination Period, specific other requirements, and policy limitations, pays necessary, medically or otherwise, costs of medical and personal care services at home, or in residential or nursing facilities.
Long Term Care Insurance Form
John Hancock
In 2004, the Canadian Manulife Financial acquired John Hancock. John Hancock Life & Health Insurance Company offers life, health, and other long-term care insurance to U.S. residents.
John Hancock offers LTC insurance for care options that include skilled nursing, intermediate and custodial care, whether at home or in assisted living or nursing facilities.
Lincoln Financial
Lincoln National Corporation is a Fortune 250 American holding company. The company’s hybrid LTC insurance is a market leader. A hybrid policy, also known as asset-based, benefits policyholders by providing life insurance coverage while providing long-term care insurance options. The policy reimburses qualified LTC expenses.
Lincoln Financial Group Assignment Of Benefits
Lincoln Fnancial Group Care Provider Assessment
Lincoln Financial Group HIPAA
Lincoln Financial Group Insureds Statement Of Loss
Lincoln Financial Group POA
MetLife
MetLife, Inc. is the holding corporation for the Metropolitan Life Insurance Company, which includes several options for long-term care coverage. MetLife is one of the largest insurance providers worldwide.
Long-term care coverage options include facility-only, home or community-based care, residential, and facility insurance policies. All options offer options that offer a choice of the Elimination Period duration, caregiver training, respite care, supportive services payments, and a transition expense allowance.
Metlife Guide To Service Provider Payment Home Care
Metlife Guide To Service Provider Payment Informal
Metlife Intake Packet Careworks As Future Provider
Metlife LTC
Metlife Privacy Authorization Release Group-IB
Mutual of Omaha
Mutual of Omaha is a Fortune 500 mutual insurance and financial services. It offers a range of individual and group health and life insurance plans, including supplemental Medicare and long-term care insurance plans.
Benefits can include home health care, care coordination, as well as respite care and hospice care.
Mutual of Omaha Authorization for Disclosure Release of Info
Mutual of Omaha Application for Long Term Care Benefits
Mutual of Omaha Disability Form
Northwestern Mutual
Northwestern Mutual is a financial services mutual organization rather than a traditional insurance company. It offers products that include life insurance, permanent life insurance, disability income, long-term care insurance, and annuities. Northwestern Long Term Care Insurance Company is the subsidiary company that provides long-term care insurance.
The company offers a basic policy and other policies that cover 100% of home health care and cover assisted living and nursing facilities, hospice care, adult day care centers, and home health care. The company’s Elimination Period is based on actual days of paid-for service days. It may take longer than a specified number of calendar days.
Northwestern Mutual Claim Form
New York Life
New York Life is the largest mutual insurance company in the U.S.; it offers long-term care insurance.
The company offers 2 traditional LTC policies: LTCSelect Premier and My Care, as well as an asset-based flex policy.
LTCSelect Premier pays for in-home care and assisted living facility, short-term or long-term nursing facility qualified expenses according to chosen policy options and restrictions. My Care Long-Term Care offers more affordable choices of 4 plans with lifetime maximum benefits and deductibles.
New York Life HIPAA
Penn Treaty
The Penn Treaty (2009 rehabilitation) is expected to become the most expensive LTC liquidation with $3 million covered by a guarantee association.
Penn Treaty Assignment of Benefits
Penn Treaty Attending Physicians Statement
Penn Treaty Facility Certification of Care For Initial Claim
Penn Treaty HIPPA
Penn Treaty Policyholder Authorization to Release Information
SHIP
The Senior Health Insurance Company of Pennsylvania’s policies are held in trust by the Commonwealth of Pennsylvania. SHIP previously operated as Conseco Senior Health Insurance Company.
From 1997 to 2000, several other LTC insurance companies merged into or were acquired by Conseco Senior Health Insurance Company. As a result, SHIP is obligated for the LTC policies of the following companies: • Transport Life Insurance Company • American Travelers Life Insurance Company • United General Life Insurance Company • Continental Life Insurance Company.
SHIP Assignment of Benefits Direction to Pay
SHIP Authorization Form
SHIP Claim Information Package
SHIP HIPAA Claims Processing
SHIP Senior Health Insurance Pennsylvania Claim Form
SHIP Claims Form
State Farm
The company is the largest U.S. property and casualty insurance provider and the largest auto insurance company. The firm discontinued LTC insurance sales in May 2018 but still provides claims on existing policies.
Its LTC policies are guaranteed renewable; the company cannot cancel a policy as long as premiums are paid. Benefits include home health and homemaker coverage for assisted living and nursing home facility costs.
Thrivent
Thrivent is a Fortune 500, not-for-profit financial services company that is a member-based fraternal organization.
Policy coverage includes nursing and assisted living facilities, adult day care and hospice care, in-home care, equipment, and home modifications for qualified care services.
Thrivent Long Term Care
TransAmerica LTCI Claim
Unum
Formerly known as UnumProvident, Unum Group is a Fortune 500 insurance company made up of Unum U.S., Unum U.K., and Colonial Life. Unum has discontinued sales of new LTC policies; however, current policyholders continue to receive policy benefits, service, and support. The company accepts new enrollees on active group plans.
Benefits include community-based and nursing facility care, and hospice care.
UNUM Claim Form
Washington National
Washington National is a subsidiary of Conseco, itself a subsidiary of CNO Financial.
Washington National Claim Form
