Instructions Billing Change Form 1. You may use this form to change your billing option for your coverage under the Federal Long Term Care Insurance Program (FLTCIP). First, fill in your name and Social Security number below and any personal information that has changed since your original application. Then, continue on to select the billing option of your choice. 2. You may also use this form to consolidate your direct billing with another enrollee or have your premiums deducted from another employee’s or annuitant’s pay. Simply provide the information in the appropriate section on the reverse side of this form. If someone else will be paying your premiums through payroll or annuity/pension deduction, that person must also sign the authorization in the payroll or annuity/pension deduction section of this form. 3. BENEFEDS administers the premium payment processes on behalf of the FLTCIP. To find a payroll/annuity office identifier, visit our website at www.LTCFEDS.com/payroll. For questions regarding your premiums, please contact our Customer Service Center at 1-877-888-FEDS (1-877-888-3337) TTY 1-877-889-5680. When completed, please return the form in the provided envelope or mail it to the following address: Long Term Care Partners, LLC, P.O. Box 797, Greenland, NH 03840-0797. Or, you can fax the form to 603-430-6479. First name M.I. Personal information Last name – – Social Security number Street address CityState/territory Country Zip/foreign postal code Check here if this is a foreign address Home phone Work phone Email Automatic bank withdrawal I authorize Long Term Care Partners (LTCP) to initiate automatic bank withdrawals from the account number provided below. Withdrawals will begin the month after LTCP receives this form and will continue on the third business day of every month. I understand that any past due premium will be collected by withdrawing up to two months of premium from my account until current. This authorization will remain in effect until I, my bank, or LTCP terminate(s) it by a 30-day written notice to the others. I understand that I will not receive any bills or other notices of the withdrawals from LTCP. I agree that if the automatic bank withdrawal is not honored by my bank, for whatever reason, LTCP will have no liability for the payments. I understand that my insurance coverage may be terminated because of non-payment of premiums. I also understand that I will receive notice of such non-payment from LTCP before my coverage is terminated. Routing number Account number Below is a sample check detailing where to find the information necessary to complete this section. Please take the time to verify that the information you are providing is correct in order to avoid a delay in the implementation of this billing method on your account. Check # (not needed for billing change) Checking account # (always between these 2 marks) Routing/transit # (a 9-digit number always between these 2 marks) The signature of depositor(s) as shown on bank records for this account is required. If this is a joint account, both depositors must sign. Depositor’s signature Account type (choose one): LTCPBCF v. 2 0314 (Required) Checking (we do not accept money market accounts) Date signed Savings / / (Required: mm/dd/yy) Check here if you wish to pay through payroll or annuity/pension deduction. You must provide a payroll or annuity office identifier and the other information required below. Visit our website at www.LTCFEDS.com/payroll or call 1-877-888-FEDS (1-877-888-3337) TTY 1-877-889-5680 to find a payroll or annuity office identifier. The person from whose pay or annuity deductions will be taken must also sign the authorization below. Due to timing issues, please be aware that there is usually a short delay before your payroll or annuity/pension deductions begin. You may receive a direct bill for any outstanding premiums resulting from a delay. Please provide the payroll or annuity office identifier for the payroll or annuity office from which deductions will be made. Payroll or annuity office identifier: (5–8 digits/characters) If deductions will be made from a Federal or civilian annuity and there is an annuity claim number, please provide it: Annuity claim number: C S Payroll, or annuity/pension deduction Insert A or F above and fill in the remaining 8 characters of your annuity/pension claim number. If you are requesting that deductions be taken from someone else’s pay or annuity/pension, that person must complete this section and the information above, and sign the authorization below. Payor’s first name M.I. Last name – – Payor’s Social Security number Street address CityState/territory Country Zip/foreign postal code Check here if this is a foreign address Home phone Payor’s signature (Required) Date signed Work phone / / (Required: mm/dd/yy) Direct bill I authorize LTCP to deduct from my pay or annuity/pension the amount necessary to pay the premiums for the FLTCIP coverage for this applicant. This authorization may be canceled only upon written notification to LTCP from me or my qualified relative. Please send me a direct bill monthly to the address I provided on the reverse side of this form. If you want to consolidate direct billing with another enrollee, please provide his or her name and Social Security number. First name M.I. Last name – – Social Security number If this person is the payor, please check here. The Federal Long Term Care Insurance Program is sponsored by the U.S. Office of Personnel Management, offered by John Hancock Life & Health Insurance Company, and administered by Long Term Care Partners, LLC.
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