Cash Indemnity Long-Term Care Claim Form
1. Personal Information
Name of Insured
Policy Number
Date of Birth
Contact Number
Address
2. Claim Information
Date of Injury/Illness
Description of Condition
Date Care Commenced
Name and Address of Care Facility or Provider
3. Activities of Daily Living (ADLs)
Please indicate which ADLs require assistance:
Bathing
Dressing
Eating
Toileting
Transferring
Continence
Details of Assistance Needed
4. Attending Physician Information
Physician Name
Contact Number
Address
5. Signature
Signature of Insured/Authorized Representative
Date