Unum Long Term Care

Underwritten by:
Unum Life Insurance
Company of America

Home | Overview | Calculator | Enrollment

1. Review Your Plan Details

Familiarize yourself with the details of your plan.

Plan Highlights
Outline of Coverage
Rates

If you resided in a state listed below when you initially purchased your coverage, or you are purchasing new coverage and you reside in a state listed below, then use the link for that state to determine your rate. Otherwise, use the rates in Section 1 above.

Connecticut Rates

Thank you for your interest in Unum long term care benefits. You may obtain electronic enrollment materials and information by choosing NEXT below.

If you do not wish to receive these documents electronically, please contact your employer or Unum at 1-800-227-4165.

System requirements

To retrieve documents provided here or on Unum's website, you must have access to a computer with the following: Microsoft Internet Explorer version 6.0 or higher; Adobe Acrobat Reader; and an Internet connection.

You may contact Unum at any time later to update your information.
NEXT

2. Important Information About Your Enrollment

Please read and print the following documents for your records. These are state required documents to assist with long term care insurance decisions. Nothing in this section needs to be returned in order to apply during your initial enrollment, unless it is also specified as a required form for enrollment in your section below.

Notice of Information Practice Disclosure (1125-01)
Things You Should Know About LTC (1375-96)
LTC Personal Worksheet (7625-04-CA)
Medicare Disclosure (1504-95)
Notice to Employees regarding Consumer Guide (7640-04)
Check List of Delivered Forms (7600-04)
Replacement Notice (1444-95-CA)
A Consumer's Guide to Long Term Care (AE-1255)
Guide to Health Insur. for People with Medicare (LTC-164)
Life & Health Guaranty Association Notice (1046-92)
Election to Continue Your LTC Insurance Coverage (7712-04)
Connecticut Resident Identification Form (AE-7018)
Application Endorsement: Fraud Warning (AE-AMD-CA-UA)

Before you can access the enrollment forms(s) you must first indicate with the checkbox that you have received the Outline of Coverage and other required documents listed above in sections 1 and 2.

3. Employee Enrollment Yes, I agree that I have received the Outline of Coverage and other documents listed above.

Print out the forms below. Complete, save a copy for your records, and submit these forms to: Your Employer. Please note, the Long Term Care Insurance Application (medical questionnaire) can be returned directly to Unum at the address listed on the form.

Employee Enrollment Form
Choose your plan options and submit the form.

Long Term Care Insurance Application (1116-01) with HIPAA Authorization (6720-03-CA)
(Evidence of Insurability - Medical Questionnaire)
Required if you enroll after the Guarantee Issue enrollment period.

Check List of Delivered Forms (7600-04)
Required to be returned to insurer.

Request to Change Coverage (AE-1181)
Required if you would like to decrease, cancel, or change billing method. Please note this is not to be used for request to increase coverage- Please use above enrollment and EOI for these circumstances.

4. Spouse/Domestic Partner Enrollment Yes, I agree that I have received the Outline of Coverage and other documents listed above.

All spouse/domestic partner coverage is medically underwritten. The Long Term Care Insurance Application must be completed along with the Enrollment Form. To apply for coverage, print and complete these forms, and submit them to: The Employer. Please note, the Long Term Care Insurance Application (medical questionnaire) can be returned directly to Unum at the address listed on the form.

Spouse/Domestic Partner Enrollment Form
Choose your plan options and submit the form.

Long Term Care Insurance Application (1116-01) with HIPAA Authorization (6720-03-CA)
(Evidence of Insurability - Medical Questionnaire)
Required to be returned to insurer.

Check List of Delivered Forms (7600-04)
Required to be returned to insurer.

5. Family Enrollment Yes, I agree that I have received the Outline of Coverage and other documents listed above.

Family coverage is medically underwritten. The Long Term Care Insurance Application must be completed along with the Enrollment Form. To apply for coverage, print and complete these forms, and submit them to: Group Long Term Care, Unum Life Insurance Company of America, 2211 Congress Street, Portland, ME 04122.

Family Enrollment Form
Choose your plan options and submit the form.

Long Term Care Insurance Application (1116-01) with HIPAA Authorization (6720-03-CA)
(Evidence of Insurability - Medical Questionnaire)
Required to be returned to insurer.

Check List of Delivered Forms (7600-04)
Required to be returned to insurer.

Be sure to read the documents in section two above.

Eligible family members who would like to apply for coverage require these additional form(s):
LTC Personal Worksheet (7625-04-CA)
3rd Party Notice of Prem Lapse (7606-04)

Authorization & Agreement for Auto Payments (7713-04)

Required for eligible family members who are currently enrolled and would like to change their coverage:
Request to Change Coverage (AE-1181)

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