Unum Long Term Care

1. Enter your age as of the effective date:

2. Plan Options (Select one)

Plan 1A: Nursing Home Facility / $3,000 Monthly Benefit Professional Home Care	Plan 2A: Nursing Home Facility / $3,000 Monthly Benefit Professional Home Care Total Home Care	Plan 3A: Nursing Home Facility / $3,000 Monthly Benefit Professional Home Care Simple Inflation	Plan 4A: Nursing Home Facility / $3,000 Monthly Benefit Professional Home Care Total Home Care Simple Inflation
Plan 1B: Nursing Home Facility / $3,000 Monthly Benefit Paid Up Benefit Professional Home Care	Plan 2B: Nursing Home Facility / $3,000 Monthly Benefit Paid Up Benefit Professional Home Care Total Home Care	Plan 3B: Nursing Home Facility / $3,000 Monthly Benefit Paid Up Benefit Professional Home Care Simple Inflation	Plan 4B: Nursing Home Facility / $3,000 Monthly Benefit Paid Up Benefit Professional Home Care Total Home Care Simple Inflation

3. Duration. How long are monthly benefit payments needed?

3 Years

5 Years

Your Monthly Premium:

For more detailed plan feature descriptions, see the Outline of Coverage on the Enrollment page.

*Requires the Long Term Care Insurance Application for employee coverage. All spouse/family selections require this form.