Billing Change Form

Billing Change Form
Personal information
Instructions
1. You may use this form to change your payment option for your coverage under the Federal Long Term Care Insurance Program
(FLTCIP). First, provide your name, Social Security number, and any personal information that has changed since your original
application. Then, continue to the payment section 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. If you have questions about your premium
payments, please call our Customer Service Center at 1-877-888-FEDS (1-877-888-3337) TTY 1-877-889-5680 go to
www.BENEFEDS.com/more/email.
Note: You may also change your payment option online. If you have been approved for coverage and you receive a direct bill, you
may change your payment option to automatic bank withdrawal by visiting www.BENEFEDS.com and logging into your My BENEFEDS
account.
First name
–
M.I.
Last name
–
Social Security number
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
it is 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 payment 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:
Date signed
(Required)
Checking (we do not accept money market accounts)
Savings
/
/
(Required: mm/dd/yy)
Check here if you wish to pay through payroll or annuity/pension deduction. To find a payroll or annuity office identifier, visit
our website at www.LTCFEDS.com/payroll. 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.
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

Insert A or F above and fill in the remaining 8 characters of your annuity/pension claim number.
Payroll or annuity/pension deduction
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
Address
CityState/territory
Country
Zip/foreign postal code
Check here if this is a foreign address
Home phone
Work phone
Payor’s signature
(Required)
Date signed
/
/
(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 monthly direct bill 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, check here.
The completed form may be submitted by mail to Long Term Care Partners, LLC, P.O. Box 797, Greenland, NH 03840-0797,
or by fax to 603-430-6479.
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.
LTCPBCF v. 6 0915