Life & Health

Long Term Care Forms & Reports

Long Term Care Forms (14 VAC 5-200)

Rescission Reporting Form, Form A (used by insurers only)
Long-Term Care Insurance Personal Worksheet, Form B (Rev. 04/15; Mod. 05/19)
Things You Should Know Before You Buy Long-Term Care Insurance, Form C (Rev. 09/07)
Long-Term Care Insurance Suitability Letter, Form D (Rev. 02/02; Mod. 05/19)
Claim Denial Reporting Form, Form E (Rev. 04/15)
Potential Rate Increase Disclosure Form, Form F (Rev. 09/07)
Long-Term Care Insurance Replacement and Lapse Reporting Form, Form G (Rev. 09/07; Mod. 05/19)
Partnership Program Notice, Form 200-A (effective 9/07)
Partnership Disclosure Notice, Form 200-B (effective 9/07)
Long-Term Care Partnership Certification, Form 200-C (Rev. 04/15; Mod 05/19)
Long Term Care Insurance Rate Request Summary