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Underwritten by WHOLESALE CORPORATION Unum Life Insurance Co of America LTC Department 2211 Congress Street Portland Maine 04122 Your Name Last Name First Middle Initial EMPLOYEE SPOUSE OR DOMESTIC PARTNER Group 5 Benefit Election Form Long Term Care Policy 543523-002 Social Security Number - - Gender Male Female Home Telephone Street Address City State Zip Code Complete the following only if applicant is not the employee Employee s Name Employee Social Security No. Date of Birth MM/DD/YYYY / / Date of Hire MM/DD/YYYY Work Telephone Employee Date of Birth Applicant Is This Benefit Election Form must be completed for any selection Employee Employee s Spouse Employee s Domestic Partner You may choose any of the plans listed below. The Long Term Care Application medical questionnaire the Benefit Election form and a signed Authorization to Request Medical Information Form 6720-03 located in the enrollment kit must be completed and you must be approved for coverage in order to enroll in the Long Term Care plan* Plans Check one Plan 1 Plan 2 Long Term Care Facility Simple Inflation Professional Home Care Total Home Care Facility Monthly Benefit Amount Facility Benefit Duration Duration of benefits may vary depending on where benefits are received* 3 Years Calculate your Premium Bi-Weekly Rate for Plan Chosen X Your Bi-Weekly Premium If you are an Active Employee Spouse or Domestic Partner your premium will be paid through the employee s payroll deduction please sign below. Employee must sign below to authorize the employer to make the payroll deduction* Caution if your answers on this Enrollment Form are incorrect or untrue we may have the right to deny benefits or rescind your insurance. By signing below you signify that you have read and understand that loss of Activities of Daily Living ADL or Severe Cognitive Impairment must occur after your effective date of coverage under this Long Term Care plan in order to be covered and that certain limitations and exclusions apply to your coverage. This information is contained in your kit. Applicant s Signature Date Employee s Signature Required for Spouse/Domestic Partner Coverage Please sign and mail all required signature forms to your employer. Retain a copy for your records. M5 If you have questions about Long Term Care coverage please call Unum s toll-free number 1-877-403-9348. The Long Term Care Application medical questionnaire the Benefit Election form and a signed Authorization to Request Medical Information Form 6720-03 located in the enrollment kit must be completed and you must be approved for coverage in order to enroll in the Long Term Care plan* Plans Check one Plan 1 Plan 2 Long Term Care Facility Simple Inflation Professional Home Care Total Home Care Facility Monthly Benefit Amount Facility Benefit Duration Duration of benefits may vary depending on where benefits are received* 3 Years Calculate your Premium Bi-Weekly Rate for Plan Chosen X Your Bi-Weekly Premium If you are an Active Employee Spouse or Domestic Partner your premium will be paid through the employee s payroll deduction please sign below. Employee must sign below to authorize the employer to make the payroll deduction* Caution if your answers on this Enrollment Form are incorrect or untrue we may have the right to deny benefits or rescind your insurance.