Forms
Bank Draft
The option is available to have your Long Term Care policy premiums deducted directly from your checking account. Please follow the instructions on the form if you would like your policy premiums deducted automatically.
Authorization to release medical information
Due to HIPAA regulations we are unable to release your personal information without your authorization. If there is someone that you would like to have access to your policy information, please print, complete and mail the attached form to our office.
Claim Form (formerly Conseco Senior Health Insurance Company, American Travelers Life Insurance Company)
To submit a request for an eligibility determination, a claim form and additional information is required to initiate this process.
Claim Form (formerly Conseco Senior Health Insurance Company, Transport Life Insurance Company and Continental Life Insurance Company)
To submit a request for an eligibility determination, a claim form and additional information is required to initiate this process.
HIPAA Claims Processing
It may be required to have additional information in order to complete an eligibility determination. By completing and submitting this form you give us authorization to obtain personal information, including health information, from your physicians, medical practitioners, hospitals, clinics, etc.