Unum Long Term Care #lapse #in #coverage


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1. Review Your Plan Details

Thank you for your interest in enrolling for Unum long term care benefits. In order to provide you with electronic enrollment materials and information, Unum must obtain your consent as illustrated below. If you do not wish to receive these documents electronically, please contact your employer or Unum at 1-800-227-4165.

Consent to use Electronic Records and Electronic Signature

By clicking “Yes, I agree” or by clicking any box acknowledging an associated document or statement, I am providing my agreement for all purposes. This agreement shall have the same force and effect as if I signed a paper copy of the document or statement.

By clicking on “Yes, I agree”, I agree to conduct this transaction and all future transactions concerning this coverage and any other coverage with Unum. This includes the receipt of legally required disclosures or notices I receive electronically.

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. To receive electronic communications from Unum, you must also have an e-mail account.

You may contact Unum at any time later to:

  • Withdraw your consent to conduct transactions by electronic means; or
  • Request a paper copy of any electronic document, or
  • Update your account information

Yes, I agree

No, I don’t agree

Unum Contact Information: 1-800-227-4165

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.

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 (7040-04-OR) with HIPAA Authorization (6720-03)
(Evidence of Insurability – Medical Questionnaire)
Required if you enroll after the Guarantee Issue enrollment period.

Request to Change Coverage (AE-1181)
Required if you are currently enrolled and would like to change your coverage.

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

All spouse/retiree /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.

Domestic Partner Statement Form (1434-97)
Domestic Partner is REQUIRED to sign return form to plan administrator.

Request to Change Coverage (AE-1181)
Required if you are currently enrolled and would like to change your coverage.

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.

Be sure to read the documents in section two above.

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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