Resources

Download important information and forms from our library of resources. You can filter by topic to quickly find what you're looking for. Or, you can request an application kit to be sent to you.

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Book One:
Program Details and Rates
Most Downloaded Application Kit

This book provides a detailed overview of what's covered under the FLTCIP and includes the FLTCIP 3.0 Outline of Coverage and FLTCIP Privacy Notice.

Book Two:
Additional Information
Most Downloaded Application Kit

This book answers common questions about the FLTCIP. It includes a worksheet to compare the FLTCIP with other plans and a glossary of terms.

Premium Rate Increase
and Lapse History
Application Kit

This is an important notice that details the FLTCIP's and John Hancock's premium rate increase and lapse history.

NAIC: A Shopper's Guide to
Long-Term Care Insurance
Most Downloaded Application Kit

The National Association of Insurance Commissioners (NAIC) created this guide to help educate and protect consumers thinking of purchasing long term care insurance.

FLTCIP 3.0 Full
Underwriting Application
Most Downloaded Application Kit

The full application is for all applicants except newly eligible employees and spouses. Full underwriting means we ask comprehensive questions about your health.

FLTCIP 3.0 Abbreviated
Underwriting Application
Application Kit

The abbreviated application is for newly eligible employees and spouses applying within 60 days of becoming eligible. Abbreviated underwriting means we ask fewer questions about your health.

Supplemental Answers for
FLTCIP 3.0 Full Application
Application Kit

If your answers to Part C-Medical Information and Part D-Lifestyle Information on the full application are longer than what can fit on the application, use this form to provide additional information.

FLTCIP 3.0
Benefit Booklet
Most Downloaded Brochures

The FLTCIP 3.0 Benefit Booklet is the governing contractual document for enrollees who have coverage under the FLTCIP 3.0 group policy.

FLTCIP
Program Overview
Brochures

This brochure explains what long term care is and the value of long term care insurance. It also provides an overview of coverage under the FLTCIP and who's eligible.

Choosing a
Medigap Policy
Brochures

This guide was developed jointly by the Centers for Medicare and Medicaid Services (CMS) and the NAIC. It describes ways to help you cover health care costs and explains what a Medigap policy is.

Authorization for
Disclosure of Information
Forms and Worksheets Claims

Use this form to authorize us to speak with a designated person about your coverage.

If a legal representative is authorized to make decisions on your behalf, we require a legal copy of your durable power of attorney or guardianship papers.

Billing
Change Form
Forms and Worksheets

Use this form to change your billing method. The FLTCIP offers payroll or retirement pay deductions, automatic bank withdrawals, and direct billing as options to pay for your coverage.

Agency
Search Tool
Tools

Use this tool to search for your agency's or branch of service's office identifier. It will also tell you if payroll or retirement pay deduction is an available billing option.

Beneficiary
Change Form
Forms and Worksheets

FLTCIP 3.0 coverage includes a refund of premium at death benefit. The amount that may be available is variable. Use this form to update existing or designate new beneficiaries for your FLTCIP plan.

Declaration of
Domestic Partnership
Forms and Worksheets

Domestic partners must submit this form to the employee's or retiree's agency, annuity office, or branch of service before you apply.

Benefits and Features
Comparison Worksheet
Most Downloaded Forms and Worksheets

Use this worksheet to compare long term care insurance policies you may be considering side-by-side.

Beginning the
Claims Process
Claims

This brochure explains the key steps in the claims process, such as determining if you're eligible for benefits and educating you on what to expect if you are approved.

Claims
Initiation Kit
Claims

This kit contains the required forms you, or your legal representative, must complete and return to us before we can process your claim.

Claims
Initiation Form
Claims

Use this form to initiate the claims process. Completing the form does not guarantee a claim approval and/or benefit reimbursement.

Medical
Release
Claims

This authorization permits a licensed health care practitioner, medical facility, or other entity that has health documentation, to disclose information about you that we need to determine if you're eligible for benefits.

IRS Form
W-9
Claims

By completing this form, you are certifying that the Tax Identification Number (TIN) provided is correct. This TIN is used in our required reporting to you and the IRS for benefits paid during the year.

Using Your
FLTCIP 1.0 Benefits
Claims

This brochure is for claimants who have FLTCIP 1.0 coverage. It includes important forms and instructions to assist you in the reimbursement of approved care expenses.

Using Your
FLTCIP 2.0 Benefits
Claims

This brochure is for claimants who have FLTCIP 2.0 coverage. It includes important forms and instructions to assist you in the reimbursement of approved care expenses.

Using Your
FLTCIP 3.0 Benefits
Claims

This brochure is for claimants who have FLTCIP 3.0 coverage. It includes important forms and instructions to assist you in the reimbursement of approved care expenses.

Informal Caregiver
Invoice
Claims

If you use an informal caregiver, you must submit this form along with proof of payment. The payment must be made after the services are rendered. Payments made by cash or checks made out to cash are not reimbursable.

Assignment of
Benefits Form
Claims

You have the option to request direct payment to certain home care agencies or facilities. This form is used to assign benefits directly to your provider. It also includes an IRS Form W-9 that your provider must complete.

Claimant Authorization of
Claims Payments via EFT
Claims

This form is for claimants to authorize direct deposit of claims payments via electronic funds transfer (EFT) to a bank account or to change bank account information for an existing authorization.

Provider Authorization of
Claims Payments via EFT
Claims

This form is for providers to authorize direct deposit of claims payments via electronic funds transfer (EFT) to a bank account or to change bank account information for an existing authorization. You must assign benefits to the provider first.