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Claims Initiation Kit

Thank you for your participation in the Federal Long Term Care Insurance Program (FLTCIP). Long Term Care Partners, LLC, administers the FLTCIP. This Claims Initiation Kit contains the forms you, the insured, or your legal representative, must complete and return to us before we can process your claim. It accompanies the Beginning the Claims Processbrochure, which explains the key steps in the claims process, such as determining your eligibility for benefits and educating you on what to expect if you are approved.

The Federal Long Term Care Insurance Program

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For assistance, call 1-800-LTC-FEDS (1-800-582-3337) TTY 1-800-843-3557.

FLTCIP Claims Initiation Form

This form is used to initiate the claims process. Please provide accurate and complete information to the best of your knowledge and ability. Any failure to do so could jeopardize your claim. Note: Form completion does not guarantee claim approval and/or benefit reimbursement.

Personal informationMr. Mrs. Ms.

First name M.I. Last name

Address line 1

Address line 2

City State/Territory

Country Zip/Foreign postal code

Gender

Male Female

Date of birth

/ / Month Day Year

Home phone

– –

Work phone

– –Extension

Email

Social Security number

– –

Please call us at the number below if you do not have a Social Security number (SSN). We use SSNs to obtain health information during the claims process.

Select your current status:

Assistance is needed

Receiving support services for activities of daily living (ADL)

Recovered; received ADL support services prior to recovery

Deceased; received ADL support services prior to death

Date of death

/ / Month Day Year

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Personal information

Select your living accommodations:

Home Assisted living facility Nursing home

Facility’s name (if applicable)

Address line 1

Address line 2



Married?Yes No

Is your spouse in claim or opening a claim?Yes No

Who is the contact for this claim? Insured Other

If you selected “insured,” where should we send claims correspondence? Primary address Facility address

If you selected “other,” please complete the contact information below:

Contact’s name


Relationship to the insured

Contact’s street address

City State Zip code

Contact’s preferred phone

– –

You, the insured, are required to complete and sign all claims forms. However, if you wish to authorize someone to make decisions on your behalf, the designated person must be named on a copy of your durable financial power of attorney or guardianship papers. Once we process this legal documentation, your representative will then have the right to complete forms related to your claim.

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Claim information1. Briefly explain why a claim is being filed.

2. Are you currently in need of assistance with at least two of the following activities: bathing, continence, dressing, eating, toileting, or transferring? Yes No

If yes, what is the approximate date the assistance began? / /Month Day Year

If yes, what type of assistance do you need?

getting into or out of a tub or shower washing your body or hair

putting on and taking off all clothing items and any necessary braces, fasteners, or artificial limbs

getting into and out of bed getting into or out of chair getting into or out of wheelchair

getting on and off the toilet performing the associated personal hygiene

maintaining control of bladder function maintaining control of bowel

when unable to control bowel or bladder, performing associated personal hygiene, including caring for a catheter or colostomy bag

feeding yourself by getting food into your mouth from a container (such as a plate or cup) or by a feeding tube or intravenously

3. Is this claim being opened because you need substantial supervision due to a severe cognitive impairment, such as Alzheimer’s disease or dementia? Yes No

If yes, what is the approximate date assistance began? / /Month Day Year

Please note that in this case a legal representative will be required.

4. Is this claim being opened for any of the following reasons:

Result of injuries sustained due to a motor vehicle accident? Yes No

Result of a work-related injury? Yes No

Hospice services? Yes No

(If you receive hospice services, please list this information in the Provider Information section.)

5. If you are currently in a skilled nursing facility, please provide the expected discharge date (if known):

/ /Month Day Year

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Insurance informationPlease provide the name of any medical insurance you have, including Medicare or TRICARE For Life:

Medical insurance carrier’s name

If you are covered by another long term care insurance policy, please provide the following information:

Long term care insurance carrier’s name

Phone– –

Policy ID number Individual policy Group policy

Policy effective date / /Month Day Year

Residence informationWho is currently living with you in your home?

Name

Relationship

How long have they been living with you?

Name

Relationship


Name

Relationship


Medical informationPlease provide the requested information for all physicians (including your primary care physician) that you may have seen in the last 12 months, as well as any hospitals or rehabilitation facilities you may have visited that relate to your need for long term care assistance.

Name

Street address

City State Zip code

Phone Fax

Start of care date / /Month Day Year

Date of last visit / /Month Day Year

Reason for last visit

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Medical information

Name

Street address

City State Zip code

Phone Fax




Name

Street address

City State Zip code

Phone Fax




Name

Street address

City State Zip code

Phone Fax




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Provider informationPlease share information regarding any care you have received in the past 12 months. The provider may be an individual or an organization. Be sure that information for each provider is complete and accurate in order to help avoid processing delays.

Name

Street address

City State Zip code

Phone Fax


End of care date (if applicable)

/ /Month Day Year

Are you currently receiving services? Yes No If yes, are hospice services included? Yes No

Type of provider

In your home

Informal caregivers

Friend

Family member

Private caregiver

Formal caregivers

Home care agency

Home health agency

Visiting nurse association

Hospice agency

In a facility

Adult day care center

Assisted living facility

Nursing home

Name

Street address

City State Zip code

Phone Fax



/ /Month Day Year


Type of provider

In your home

Informal caregivers

Friend

Family member

Private caregiver

Formal caregivers

Home care agency

Home health agency


Hospice agency

In a facility



Nursing home

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Provider information

Name

Street address

City State Zip code

Phone Fax



/ /Month Day Year


Type of provider

In your home

Informal caregivers

Friend

Family member

Private caregiver

Formal caregivers

Home care agency

Home health agency


Hospice agency

In a facility



Nursing home

Name

Street address

City State Zip code

Phone Fax



/ /Month Day Year


Type of provider

In your home

Informal caregivers

Friend

Family member

Private caregiver

Formal caregivers

Home care agency

Home health agency


Hospice agency

In a facility



Nursing home

If you need additional space, please enclose a separate list.

Enclosed list Physician Provider


Agreement and Acknowledgment

I am requesting a determination for benefit eligibility under the FLTCIP. All of the answers and explanations I have provided are accurate and complete to the best of my knowledge and ability. I understand that medical records or answers to any questions that a care coordinator may have will also be considered.

If there are any changes to my health, treatment, or provider, I agree to immediately notify Long Term Care Partners, LLC, P.O. Box 797, Greenland, NH 03840-0797, in writing.

Caution: If you are approved for benefit eligibility, but you should not have been because one or more of your answers or explanations are incorrect or untrue, or fails to include all material information requested, we may have the right to deny a claim. Any person who, with an intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application, or files a claim containing a false or deceptive statement is guilty of insurance fraud and may be subject to criminal and civil penalties.

Before we can process your claim, you must certify by signing below that the information you have provided on this form is accurate and complete to the best of your knowledge and ability.

I wish to open a claim for FLTCIP benefits.

Signature (insured or legal representative)

Date signed / /(Required: mm/dd/yy)

Print name

Note: If any form is signed by the durable power of attorney designee, guardian, or executor, please submit the appropriate documents with this claims initiation form. If the Medical Release is signed by someone other than the insured, a copy of the durable financial power of attorney, or guardianship papers, may be required.

Remember to complete and sign: f Medical Release

f Form W-9 Request for Taxpayer Identification Number and Certificate

These forms are required to process this claims initiation. In order for us to discuss your coverage with another person designated by you (including your spouse), who is not your durable power of attorney designee or guardian, please complete the Authorization for Disclosure attached at the end of this form.

Please return your completed form by fax to 1-866-513-2674 or by mail to Long Term Care Partners, LLC,P.O. Box 797, Greenland, NH 03840-0797.

The Federal Long Term Care Insurance Program is sponsored by the U.S. Office of Personnel Management, insured by John Hancock Life & Health Insurance Company, under a group long term care insurance policy, and administered by Long Term Care Partners, LLC.

FLTCIP10066 v. 2 1020

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Medical Release

Insured’s name


Date of birth / /

Month Day Year

For claims-related purposes of the Federal Long Term Care Insurance Program, including determining eligibility for benefits, care coordination, claims decision-making, coordinating benefits with other insurance companies or payers, claims payment, claims appeals, and claims management activities, I authorize any licensed health care practitioner, medical facility, employer, insurance company, or any other entity or person that has any health information about me to give that health information to Long Term Care Partners (LTCP), LLC, John Hancock Life & Health Insurance Company (John Hancock), their reinsurers, and their subcontractors who need to know health information to provide contracted services.

The health information I am permitting to be disclosed and used for the Federal Long Term Care Insurance Program includes any information on my medical history, and the diagnosis, prognosis, and treatment of any physical or mental condition, whether such history is in electronic or paper form. It includes the disclosure of any medical care or surgery, psychiatric or psychological care or examinations, and information about alcohol or drug use (including any information otherwise protected by Federal Regulations 42 CFR Part 2 or other applicable laws). I understand that this authorization includes my consent to use and disclose medical information that relates to mental illness, HIV, AIDS, HIV-related illness, and sexually transmitted diseases or other serious communicable diseases, but only in accordance with any law or regulation that applies to any such disclosure of this information about me.

I understand that:f If I do not sign this authorization, any claim for long term care insurance benefits may be denied.f I may revoke this authorization at any time, except to the extent that action has already been taken in reliance on it

before my revocation.f To revoke this authorization, I must notify Long Term Care Partners, LLC, P.O. Box 797, Greenland, NH 03840-0797,

in writing.f If I do revoke this authorization, I understand that my application for long term care insurance may not be

processed and any claim for long term care insurance benefits may be denied. LTCP or John Hancock has a right tocontest my long term care insurance claim or coverage.

f If I do not revoke this authorization, it will be valid until the coverage terminates.f My health information may be redisclosed and no longer protected by applicable law, including federal health

information privacy regulations. This can occur only if such redisclosure is required or allowed by law (e.g., inresponse to a subpoena).

f A copy of this authorization is as valid as the original.

Insured’s signature (Required)


If the insured is unable to sign for him- or herself, please include a copy of the durable financial power of attorney or guardianship papers, if not already submitted.

Legal representative’s signature (Required)


Note: Handwritten signatures are required.

Please return your completed form by fax to 1-866-513-2674 or by mail to Long Term Care Partners, LLC, P.O. Box 797, Greenland, NH 03840-0797.


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Cat. No. 10231X Form W-9 (Rev. 10-2018)

Form W-9(Rev. October 2018)Department of the TreasuryInternal Revenue Service

Request for Taxpayer Identification Number and Certification

Go to www.irs.gov/FormW9 for instructions and the latest information.

Give Form to the requester. Do not send to the IRS.

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1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.

Individual/sole proprietor or single-member LLC

C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.

Other (see instructions)

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting

code (if any)

(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.) See instructions.

6 City, state, and ZIP code

7 List account number(s) here (optional)

Requester’s name and address (optional)

Part I Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.

Social security number

– –

orEmployer identification number

–

Part II CertificationUnder penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue

Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I amno longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

Sign Here

Signature of U.S. person Date

General InstructionsSection references are to the Internal Revenue Code unless otherwise noted.

Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9.

Purpose of FormAn individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following.

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutualfunds)

• Form 1099-MISC (various types of income, prizes, awards, or grossproceeds)

• Form 1099-B (stock or mutual fund sales and certain othertransactions by brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest),1098-T (tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a residentalien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later.

FLTCIP Authorization for Disclosure of InformationInsured’s name


Address



Date of birth / /Month Day Year

I, the insured named above, authorize Long Term Care Partners, LLC (LTCP), to disclose information about my insurance coverage and benefits under the Federal Long Term Care Insurance Program (FLTCIP), including demographic information, billing and payment information, claim and related medical information, and other information related to the FLTCIP, to the person(s) listed below. This will allow that person(s) to assist me in matters related to my coverage under the FLTCIP.

Name Relationship Phone number

– –

Name Relationship Phone number

– –

I understand that this authorization is voluntary. Unless I revoke the authorization, I understand that it is valid until the later of 1) one year from the date this form is signed (if I do not yet have coverage nor become insured) or 2) one year from the date I no longer have coverage under the applicable account (if I am insured or become insured),at which time it will expire. I understand that I may revoke this authorization at any time by notifying LTCP in writingat: Long Term Care Partners, LLC, Attn: HIPAA Privacy Office, P.O. Box 797, Greenland, NH 03840-0797. Revoking thisauthorization will have no effect on any information released in reliance on this authorization before LTCP received therevocation. I further understand that LTCP will not condition treatment, payment, enrollment, or eligibility for benefitson whether I sign this authorization.

I understand that the individual(s) listed above may redisclose any information received. Once information is disclosed to the individual(s), I understand that the information may no longer be protected by the Health Insurance Portability and Accountability Act (HIPAA) regulations and other applicable privacy laws.

Signature (insured or legal representative)


Note: A handwritten signature is required. If signed by a personal representative of the insured, please describe the authority under which the personal representative is authorized to act and enclose any related documentation (e.g., copy of your durable financial power of attorney):

Please return your completed form by fax to 1-866-513-2674 or by mail to Long Term Care Partners, LLC,P.O. Box 797, Greenland, NH 03840-0797.


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FLTCIP10162 v. 3 1020

Claims Initiation KitFLTCIP Claims Initiation FormPersonal informationClaim informationInsurance informationResidence informationMedical informationProvider informationAgreement and Acknowledgment

Medical ReleaseRequest for Taxpayer Identification Number and CertificationFLTCIP Authorization for Disclosure of Information

First name: MI: Last name: Address line 1: Address line 2: City: StateTerritory: Country: ZipForeign postal code: Gender: OffMonth: Day: Year: Email: Assistance is needed: OffReceiving support services for activities of: OffRecovered received ADL support services prior: OffDeceased received ADL support services: OffMonth_2: Day_2: Year_2: Home: OffAssisted living facility: OffNursing home: OffFacilitys name if applicable: Address line 1_2: Address line 2_2: City_2: StateTerritory_2: Country_2: ZipForeign postal code_2: Married: OffInsured: OffOther: OffPrimary address: OffFacility address: OffFirst name_2: MI_2: Last name_2: Relationship to the insured: Contacts street address: City_3: State: Zip code: Month_3: Day_3: Year_3: washing your body or hair: Offgetting into or out of a tub or shower: Offputting on and taking off all clothing items and any necessary braces fasteners or artificial limbs: Offgetting into and out of bed: Offgetting on and off the toilet: Offmaintaining control of bladder function: Offwhen unable to control bowel or bladder performing associated personal hygiene including caring for a: Offfeeding yourself by getting food into your mouth from a container such as a plate or cup or by a feeding: Offgetting into or out of chair: Offgetting into or out of wheelchair: Offperforming the associated personal hygiene: Offmaintaining control of bowel: OffMonth_4: Day_4: Year_4: Month_5: Day_5: Year_5: Medical insurance carriers name: Long term care insurance carriers name: Policy ID number: Individual policy: OffGroup policy: OffName: Relationship: How long have they been living with you 1: Relationship_2: How long have they been living with you 1_2: Relationship_3: How long have they been living with you: Name_2: Street address: City_4: State_2: Zip code_2: Phone_2: Fax: Start of care date: Date of last visit: Reason for last visit: Name_3: Street address_2: City_5: State_3: Zip code_3: Phone_3: Fax_2: Month_7: Day_7: Year_7: Reason for last visit_2: Name_4: Street address_3: City_6: State_4: Zip code_4: Phone_4: Fax_3: Month_8: Day_8: Year_8: Month_9: Day_9: Year_9: Reason for last visit_3: Name_5: Street address_4: City_7: State_5: Zip code_5: Phone_5: Fax_4: Month_10: Day_10: Year_10: Month_11: Day_11: Year_11: Reason for last visit_4: Name_6: City_8: State_6: Zip code_6: Phone_6: Fax_5: Month_12: Day_12: Year_12: Month_13: Day_13: Year_13: Friend: OffFamily member: OffPrivate caregiver: OffHome care agency: OffHome health agency: OffVisiting nurse association: OffHospice agency: OffAdult day care center: OffAssisted living facility_2: OffNursing home_2: OffName_7: City_9: State_7: Zip code_7: Phone_7: Fax_6: Month_14: Day_14: Year_14: Month_15: Day_15: Year_15: Are you currently receiving services_2: OffFriend_2: OffFamily member_2: OffPrivate caregiver_2: OffHome care agency_2: OffHome health agency_2: OffVisiting nurse association_2: OffHospice agency_2: OffAdult day care center_2: OffAssisted living facility_3: OffNursing home_3: OffI wish to open a claim for FLTCIP benefits: OffPrint name: First name_3: MI_3: Last name_3: Month_20: Day_20: Year_20: 1 Name as shown on your income tax return Name is required on this line do not leave this line blank: 2 Business namedisregarded entity name if different from above: C Corporation: OffS Corporation: OffPartnership: OffTrustestate: OffIndividualsole proprietor or: OffOther see instructions: OffExempt payee code if any: Limited liability company Enter the tax classification CC corporation SS corporation PPartnership: code if any: 6 City state and ZIP code: Requesters name and address optional: 7 List account numbers here optional: First name_4: MI_4: Last name_4: Address: City_12: StateTerritory_3: Country_3: ZipForeign postal code_3: Month_21: Day_21: Year_21: matters related to my coverage under the FLTCIP: Name_10: Relationship_4: Employer identification number: Name_8: City_10: State_8: Zip code_8: Phone_8: Fax_7: Month_16: Day_16: Year_16: Month_17: Day_17: Year_17: Are you currently receiving services_3: OffFriend_3: OffFamily member_3: OffPrivate caregiver_3: OffHome care agency_3: OffHome health agency_3: OffVisiting nurse association_3: OffHospice agency_3: OffAdult day care center_3: OffAssisted living facility_4: OffNursing home_4: OffName_9: City_11: State_9: Zip code_9: Phone_9: Fax_8: Month_18: Day_18: Year_18: Month_19: Day_19: Year_19: Are you currently receiving services_4: OffFriend_4: OffFamily member_4: OffPrivate caregiver_4: OffHome care agency_4: OffHome health agency_4: OffVisiting nurse association_4: OffHospice agency_4: OffAdult day care center_4: OffAssisted living facility_5: OffNursing home_5: OffPhysician: OffProvider: OffSelect a prefix: OffHome1-1: Home1-2: Home1-3: Work1-1: Work1-2: Work1-3: Extension1: SSN1-1: SSN1-2: SSN1-3: Is your spouse in claim or opening a claim?: OffContact1-2: Contact1-3: Contact1-1: Briefly explain why a claim is being filed: Are you currently in need of assistance with at least two of the following activities: bathing, continence, dressing, eating, toileting, or transferring?: OffIs this claim being opened because you need substantial supervision due to a severe cognitive impairment such as Alzheimers disease or dementia?: OffIs this claim being opened for any of the following reasons: Result of injuries sustained due to a motor vehicle accident?: OffResult of a work-related injury?: OffHospice services?: OffPhone1-1: Phone1-2: Phone1-3: Month_6: Day_6: Year_6: PolicyMonth: PolicyDay: PolicyYear: Name2: Name3: Start of care date2: Start of care date3: Date of last visit2: Date of last visit3: Are you currently receiving services?: OffIf yes, are hospice services included?: OffStreet Address_6: If yes, are hospice services included? 1: OffStreet Address_5: Street Address_7: Street Address_8: If yes, are hospice services included? 2: OffIf yes, are hospice services included? 3: OffDate signed1-1: Date signed1-2: Date signed1-3: Date signed2-1: Date signed2-2: Date signed2-3: Date signed3-1: Date signed3-2: Date signed3-3: LLC: OffOther-explain: Address number street and apt or suite no See instructions: SSN2-1: SSN2-2: SSN2-3: Employer identification number1: SigDate: FLTCIP-Relationship: Phone2-1: Phone2-2: Phone2-3: Phone3-1: Phone3-2: Phone3-3: DateSigned1-3: HandwrittenSig: DateSigned1-2: DateSigned1-1:

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