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What is the name of the insurance company for "your (1st, 2nd, 3rd)" long term care policy listed? [enter text] __________________
* Enter name of insurance company, not the insurance agent.
Briefly describe the policy. [enter text] ______________
Are the policy premiums paid -
Are any premiums paid through payroll deductions?
Since the first of the reference month, what was your or your CU total expense for this insurance policy? [enter value] ______________
* Enter the actual amount the CU paid. Do not include any expenses paid for the CU by others
How much was paid this month? [enter value] ______________
End of Section 13B Long Term Care Insurance
Go to Section 13 Part B - Life/Disability Insurance »
Go to Section 14 Part A.1 - Hospitalization and Health Insurance »
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Last Modified Date: September 4, 2008