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What is the name of the insurance company for "your (1st, 2nd, 3rd)" long term care policy? [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 household total expense for this insurance policy? [enter value] ______________
* Enter the actual amount the household paid. Do not include any expenses paid for the household by others
How much was paid this month? [enter value] ______________
* Enter 'C' for a combined expense
What other type of policy is the "long term care insurance" combined with?
* Enter all that apply, separate with commas
Which property (ies) does this policy cover? [enter text] ______________
Do you or any members of your household have any or make payments for any other "long term care insurance" policy?
End of Section 13B Long Term Care Insurance
Go to Section 13 Part B - Life/Disability Insurance - FOR NEW HOUSEHOLDS ONLY »
Go to Section 14 Part A.1 - Hospitalization and Health Insurance »
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Last Modified Date: April 7,2016