For use after you buy a long-term care policy. Complete this form and put it with your important papers. You may want to make a copy for a friend or a relative.

1. Insurance Policy Date
Policy Number ________________________________________________
Date Purchased ________________________________________________
Annual Premium ________________________________________________
2. Insurance Company Information
Name of Company ________________________________________________
Address ________________________________________________
Phone Number ________________________________________________
3. Agent Information
Agent's Name ________________________________________________
Phone Number ________________________________________________
Address ________________________________________________
4. Type of Long-Term Care Policy
_____ Tax-qualified_____ MassHealth (Medicaid)
_____ Nursing home only_____ Home health care only
_____ Comprehensive (nursing home, assisted living, home and community care)
5. How long is the waiting period before benefits begin? _____________
How do I file a claim? (Check all that apply)
_____ I need prior approval_____ Contact the company
_____ Fill out a claim form_____ Submit a plan of care
_____ Doctor notifies the company_____ Assessment by company
_____ Assessment by care manager
7. How often do I pay premiums? _____Annually _____Semi-annually _____Other
8. The person to be notified if I forget to pay the premium:
Address _________________________________________
Phone number _______________
9. Are my premiums deducted from my bank account? _____Yes _____No
Name and address of my bank: _______________________________________
Bank account number: ________________________________
10. Where do I keep this long-term care policy?
Other information _________________________________________________
11. Friend or relative who knows where my policy is:
Address ____________________________________________________________
Phone number ____________________________________