 |
|
1. Review Your Plan Details
Familiarize yourself with the details of your plan.2. Important Information About Your Enrollment
Read and print for your records. These are for information only. Nothing in this section needs to be completed and sent into Unum.- LTC Personal Worksheet (7625-04)
- Potential Rate Increase Disclosure Form (7718-04)
- Things You Should Know About LTC (7608-04-2)
- Medicare Disclosure (1504-95)
- MassHealth Minimum Coverage Requirements (7650-04)
- Replacement Notice (1638-94)
- Shoppers Guide (1605-90)
- Guide to Health Insur. for People with Medicare (LTC-164)
3. Employee Enrollment
Print out the forms below. Complete, save a copy for your records, and submit these forms to: Your Employer. Please note, the Long Term Care Insurance Application (medical questionnaire) can be returned directly to Unum at the address listed on the form.For detailed instructions on how to enroll, please review the LTC Insurance Enrollment Instructions.
Employee Enrollment Form
Choose your plan options and submit the form.
Long Term Care Insurance Application (7040-04-OR)
(medical questionnaire)
If you enroll after the Guarantee Issue enrollment period, or choose benefits over the Guarantee Issue limits, you will be required to fill out Unum's Long Term Care Insurance Application (medical questionnaire).
Acknowledgement of Disclosure of Rating Practices (7604-04)
REQUIRED to be returned to insurer.
4. Spouse/Domestic Partner Enrollment
All spouse coverage is medically underwritten. The Long Term Care Insurance Application must be completed along with the Enrollment Form. To apply for coverage, print and complete these forms, and mail to: The Employer. Please note, the Long Term Care Insurance Application (medical questionnaire) can be returned directly to Unum at the address listed on the form.Spouse Enrollment Form
Choose your plan options and submit the form.
Long Term Care Insurance Application (7040-04-OR)
Required to be returned to insurer.
Acknowledgement of Disclosure of Rating Practices (7604-04)
REQUIRED to be returned to insurer.
Domestic Partner Statement Form (1434-97)
Domestic Partner is REQUIRED to sign & return form to plan administrator.
5. Family Enrollment
Family coverage is medically underwritten. The Long Term Care Insurance Application must be completed along with the Enrollment Form. To apply for coverage, print and complete these forms, and mail to: Group Long Term Care, Unum Life Insurance Company of America, 2211 Congress Street, Portland, ME 04122.Family Enrollment Form
Choose your plan options and submit the form.
Long Term Care Insurance Application (7040-04-OR)
Required to be returned to insurer.
Be sure to read the documents in section two above.
Eligible family members who would like to apply for coverage require these additional form(s):
LTC Personal Worksheet (7625-04)
3rd Party Notice of Prem Lapse (7606-04)
