Ltc Short Form Application For Current - University Of Texas System printable pdf download

Continental Casualty Company

THE UNIVERSITY OF TEXAS SYSTEM

Policy Number: 0010025-IS

Group Long-Term Care

Short Form Application

SECTION 1 – APPLICANT INFORMATION

Applicant’s Name: First, Middle Initial, Last

Sex: (M or F)

Date of Birth:

Applicant’s Address: Number and Street

Social Security Number:

City:

State:

Zip Code:

Daytime Phone Number:

Evening Phone Number:

Select ONE Payroll Mode:

 Weekly

 Bi-Weekly

 Semi-Monthly

 Monthly

I am employed or the spouse of an employee employed by the Component stated below (Select ONE):

 University of Texas System Administration

 University of Texas at San Antonio

 University of Texas at Arlington

 University of Texas at Tyler

 University of Texas at Austin

 University of Texas Health Science Center at Houston

 University of Texas at Brownsville

 University of Texas Health Science Center at San Antonio

 University of Texas at Dallas

 University of Texas Health Science Center at Tyler

 University of Texas M.D. Anderson Cancer Center

 University of Texas at El Paso

 University of Texas Medical Branch at Galveston

 University of Texas-Pan American



 University of Texas-Permian Basin

University of Texas Southwestern Medical Center at Dallas

SECTION 2 – BENEFIT SELECTIONS

Select ONE Daily Maximum Benefit:



$100 Daily Maximum Benefit



$125 Daily Maximum Benefit



$150 Daily Maximum Benefit



$200 Daily Maximum Benefit



$250 Daily Maximum Benefit

Select ONE Choice for Inflation Protection:



Choice #1 - with Guaranteed Benefit Increase Option (Standard Inflation Protection)



Choice #2 - with Automatic Benefit Increase Option (Optional Inflation Protection)

If you select Choice #1, read and sign the Automation Inflation Protection Rejection below.

Automatic Inflation Protection Rejection: I have reviewed the Outline of Coverage and the graphs that compare

the benefits and premiums of this insurance with the Guaranteed Benefit Increase Option and with the Automatic

Benefit Increase Option. I realize that based on current health care cost trends, the benefits provided by a long-term

care plan without meaningful inflation protection may be significantly diminished in terms of real value to me,

depending on the amount of time which elapses between the date I purchase this coverage and the date on which I

first become eligible for benefits. I have reviewed the coverage and I reject the Automatic Benefit Increase Option.

Applicant’s Signature

Date

OVER, PLEASE

ZG-119896-A-42

AG-140590-D

6/2013 Printed in the USA

Ltc Short Form Application For Current - University Of Texas System

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