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1. Review Your Plan Details

Familiarize yourself with the details of your plan.

2. Important Information About Your Enrollment

Read and print for your records. These are for information only. Nothing in this section needs to be completed and sent into Unum.
  1. LTC Personal Worksheet (7625-04)
  2. Potential Rate Increase Disclosure Form (7718-04)
  3. Things You Should Know About LTC (7608-04)
  4. Medicare Disclosure (1504-95)
  5. MassHealth Minimum Coverage Requirements (7650-04)
  6. Replacement Notice (1638-94)
  7. Shoppers Guide (1605-90)
  8. Guide to Health Insur. for People with Medicare (LTC-164)

3. Retiree and Family Enrollment

Retiree and 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.

Retiree and Family Enrollment Form
Choose your plan options and submit the form.

Long Term Care Insurance Application (7040-04)
Required to be returned to insurer.

Be sure to read the documents in section two above.

Eligible retiree and family 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)

Questions? Contact Unum toll-free at 1-800-227-4165 for more information.

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