Follow the steps to complete your application effectively.

1. Press the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Section 1 – Applicant Information. Fill in your full name, gender, date of birth, and address. Ensure that the Social Security Number, daytime, and evening phone numbers are accurately provided.
3. Move to Section 2 – Benefit Selections. Choose one daily benefit and lifetime maximum option, a home-based care benefit, and an inflation option. Make sure to read the descriptions provided in the enrollment brochure for complete details.
4. In Section 3 – Eligibility, check the appropriate box indicating your relationship to the employee or retiree referenced. Provide their name and ID or Social Security Number.
5. Proceed to Section 4 – Statement of Insurability. Complete the fields regarding your height, weight, and respond to the medical questions carefully. Provide details where necessary, especially if any condition applies to you.
6. Move to Section 5 – Payment Method. Indicate your preferred billing cycle by selecting either direct bill options or monthly electronic funds transfer.
7. In Section 6 – Alternate Billing Designee, designate at least one individual to receive notice before coverage terminates due to nonpayment. Fill in their name and address details or elect not to designate anyone.
8. Complete Section 7 – Authorization. Sign and date the document, ensuring all information is complete and true. Understand that this signature grants permission to obtain relevant information necessary for your application.
9. After completing all sections, review your form thoroughly. Ensure all fields are filled out accurately and any necessary attachments are included.
10. Finally, save your changes, and choose to download, print, or share your completed form as needed.

Begin your application process online today and secure your long-term care insurance.