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.
3. Employee, Spouse/Civil Union Partner/Domestic Partner Enrollment
You will enroll yourself, Spouse/Civil Union Partner/Domestic Partner for Long Term Care coverage on the MyOEBB website. There you will choose your plan options and submit your enrollment request.
If you enroll after the Guarantee Issue enrollment period, or choose benefits over the Guarantee Issue limits, you will be required to fill out Unum's
Long Term Care Insurance Application (medical questionnaire) which will be provided on the MyOEBB site as well. Please fill Group Policy No. with �148198�. You will print off this form complete it and return it directly to Unum at the address listed on the form.
All spouse/domestic partner coverage is medically underwritten. The
Long Term Care Insurance Application (medical questionnaire) must be completed, which will be provided on the MyOEBB site as well. Please fill Group Policy No. with �148198�. You will print off this form complete it and return it directly to Unum at the address listed on the form.
4. Family Enrollment
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 mail 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 (7040-04-OR) with HIPAA Authorization (6720-03)
(Evidence of Insurability - Medical Questionnaire)
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)
3rd Party Notice of Prem Lapse (7606-04)
Authorization & Agreement for Auto Payments (7713-04)
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.
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