Summary Sheet on Your Long Term Care Insurance Plan

Once you purchase a long term care insurance policy, you should prepare an
information sheet that gives basic information about the policy. This sheet should be kept with
your other important papers in a place readily accessible to you and at least one other person.

If you buy your policy when you are young, you may go for years just pay the premium without
thinking about the policy. If you buy it when you are older, you may find it increasingly
difficult to remember things. In either situation, you should have an easy to find information
sheet that will provide you, or someone you trust, with basic information about your long term
care policy.

The following sample form shows the kind of information that should be recorded on your
information sheet. You may wish to modify the form to suit your specific needs.

Long Term Care Insurance Policy Information Sheet

(You may wish to give a copy of your completed sheet to someone you trust.)

  1. Insurance Policy Data

    1. Policy Number___________________________________________
    2. Policy Form Number ______________________________________
      (found in lower left corner of any policy page)
    3. Policy Effective Date ______________________________________

    4. Total Annual Premium $___________________________________
    5. Total Monthly Premium $__________________________________

  2. Insurance Company Information
    1. Name of Company ________________________________________

    2. Address _________________________________________________


      _________________________________________________

      _________________________________________________
    3. Phone Number
      ___________________________________________
    4. E-mail __________________________________________________

  3. Insurance Agent Information
    1. Name of Agent ___________________________________________
    2. Address ________________________________________________


      ________________________________________________


      ________________________________________________
    3. Phone Number
      ___________________________________________
    4. E-mail
      _________________________________________________

  4. Type of Long Term Care Insurance Policy

    1. ______ Nursing Home

    2. ______ Assisted Living

    3. ______ Home Care

    4. ______ Comprehensive (Nursing Home, Assisted Living Facility, Home
      and Community Care, Adult Day Care, etc.)
    5. ______
      Other (describe) ___________________________________
    6. ______ Tax Qualified

  5. Waiting Period

    1. Length of waiting period before benefits begin? ____________
  6. How do I file a claim? (check all that apply)
    1. ______ Need prior approval
    2. ______ Contact the company
    3. ______ Fill out a claim form
    4. ______ Submit a plan of care
    5. ______ Doctor notifies the company
    6. ______ Assessment by the company
    7. ______ Assessment by a care manager

  7. How often do I pay premiums? (check one)

    1. ______ Lump Sum One Time Payment (already paid)
    2. ______
      Annually
    3. ______
      Semi-annually
    4. ______ Quarterly
    5. ______ Monthly


  8. The person to be notified if I forget to pay the premium
    1. Name __________________________________________________
    2. Address

      ________________________________________________

      ________________________________________________