Instructions for Policyholder
Accelerated death benefits. Amounts paid as accelerated death benefits are
A payer, such as an insurance company or a viatical settlement provider, must
fully excludable from your income if the insured has been certified by a
give this form to you for payments made under a long-term care insurance
physician as terminally ill. Accelerated death benefits paid on behalf of
contract or for accelerated death benefits. Payments include those made
individuals who are certified as chronically ill are excludable from income to the
directly to you (or to the insured) and those made to third parties.
same extent they would be if paid under a qualified long-term care insurance
A long-term care insurance contract provides coverage of expenses for long-
contract.
term care services for an individual who has been certified by a licensed health
Account number. May show an account or other unique number the payer
care practitioner as chronically ill. A life insurance company or viatical settlement
assigned to distinguish your account.
provider may pay accelerated death benefits if the insured has been certified by
Box 1. Shows the gross benefits paid under a long-term care insurance contract
either a physician as terminally ill or by a licensed health care practitioner as
during the year.
chronically ill.
Box 2. Shows the gross accelerated death benefits paid during the year.
Long-term care insurance contract. Generally, amounts received under a
qualified long-term care insurance contract are excluded from your income.
Box 3. Shows if the amount in box 1 or 2 was paid on a per diem basis or was
However, if payments are made on a per diem basis, the amount you may
reimbursement of actual long-term care expenses. If the insured was terminally
exclude is limited. The per diem exclusion limit must be allocated among all
ill, this box may not be checked.
policyholders who own qualified long-term care insurance contracts for the
Box 4. May show if the benefits were from a qualified long-term care insurance
same insured. See Pub. 525 and Form 8853, and its instructions for more
contract.
information.
Box 5. May show if the insured was certified chronically ill or terminally ill, and
Per diem basis. This means the payments were made on any periodic basis
the latest date certified.
without regard to the actual expenses incurred during the period to which the
Future developments. For the latest developments related to Form 1099-LTC
payments relate.
and its instructions, such as legislation enacted after they were published, go to
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