Ltc Short Form Application For Current - University Of Texas System Page 2
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1
2
3SECTION 3 – EMPLOYEE INFORMATION
I certify that I am:
An employee
The spouse of an employee
Employee Name: First, Middle, Last
Employee’s Social Security Number:
Employee Benefit ID:
Date of Hire:
SECTION 4 – PAYMENT METHOD
I authorize my employer to make payroll deductions for the above-specified coverage and release other
necessary information to the administrators of this program.
Employee’s Signature
Date
/
/
SECTION 5 – STATEMENT OF INSURABILITY
1. Height
ft.
in.
Weight
lbs.
2. During the last seven (7) years have you been diagnosed or treated by a member of the
YES
NO
medical profession for Acquired Immune Deficiency Syndrome (AIDS) or other immune system
disorder?
3. During the last seven (7) years have you been diagnosed, received medical advice or
treatment by a member of the medical profession for any of the following:
a. Alzheimer’s Disease, Dementia or change in cognitive functioning.
b. Multiple Sclerosis, Huntington’s Disease, Parkinson’s Disease or Amyotrophic Lateral
Sclerosis.
c. Emphysema, Chronic Bronchitis or Asthma.
d. Internal Lupus Erythematosus or any other connective tissue disease or disorder.
e. Cancer which has spread or metastasized.
f.
Heart Disorder.
g. Diabetes Mellitus, Glucose Intolerance or Hyperglycemia.
h. Cerebral Vascular Accident, Stroke or Transient Ischemic Attack.
i.
Alcoholism or Substance Abuse.
j.
Bone or Joint disease or disorder requiring prescription medication or surgery.
k. Mental, Emotional or Nervous disease or disorder, Depression, or Chemical Imbalance.
4. Have you used any tobacco products more than once a month at any time during the last three
years?
5. At any time during the last two years have you needed assistance or supervision or were you
limited in any way physically or cognitively from performing any of the daily activities of bathing,
dressing, toileting, mobility, eating or managing medications?
6
At any time in the last seven years have you applied for or received Social Security
disability benefits or Medicaid?
7. Do you currently have or have you had in the past 12 months any long-term care insurance in
force other than Group Long-Term Care Insurance from Continental Casualty Company or
have you applied for such insurance? If yes, what company and if the policy has lapsed, when
did it lapse?
8. Do you intend to replace any medical or health insurance coverage including a health care
service contract or health maintenance organization with insurance applied for with this
application other than with Group Long-Term Care from Continental Casualty Company?
NEXT PAGE, PLEASE
ZG-119896-A-42
2
AG-140590-D
6/2013 Printed in the USA
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