• Sullivan & Ward, P.C. Unum LTC Plan

    112525

  • Note the Group Policy and Division Numbers

    Group Policy Number

    • 112525

    Division Numbers 

    • 001

  • All Full-Time Active Shareholders, Attorneys and of Counsel Employees and Their Family Members who have active coverage in the plan prior to 01-01-2020

  • Step 1. Review Your Plan Details 

    Familiarize yourself with the details of your plan.

    • Plan Highlights
    • Outline Of Coverage
    • Rates

    If you resided in a state listed below when you initially purchased your coverage, or you are purchasing new coverage and you reside in a state listed below, then use the link for that state to determine your rate. Otherwise, use the rates in Section 1 above.

    • Connecticut Rates

    Step 2. Important Information About Your Enrollment 

    Please read and print the following documents for your records. These are state required documents to assist with long term care insurance decisions. Nothing in this section needs to be returned in order to apply during your initial enrollment, unless it is also specified as a required form for enrollment in your section below.

    1. Potential Rate Increase Disclosure Form (1151-02)
    2. Things You Should Know About LTC (7608-04-2)
    3. Replacement Notice (1638-94)
    4. Personal Worksheet (AE-7009)
    5. Shoppers Guide (1605-90)
    6. Guide to Health Insur. for People with Medicare (LTC-164)
    7. Life & Health Guaranty Association Notice (1218-IA)
    8. Election to Continue Your LTC Insurance Coverage (7712-04)
    9. Connecticut Resident Identification Form (AE-7018)

  • Should you wish to complete forms in paper versus electronically, please contact LTC Solutions, Inc. at LTCiBenefitsTeam@ltc-solutions.com or 877-286-2852.

    Step 3. Employee Enrollment

    Employee Enrollment Form
    Choose your plan options and submit the form.

    Long Term Care Insurance Application (7014-04) with HIPPA Authorization (6720-03)
    (Evidence of Insurability - Medical Questionnaire)
    Required if you enroll after the Guarantee Issue enrollment period, or choose benefits over the Guarantee Issue limits.

    Request to Change Coverage (AE-1181)
    Required if you are currently enrolled and would like to change your coverage.

    Step 4. Spouse Enrollment

    All spouse/registered domestic partner/domestic partner coverage is medically underwritten. The Long Term Care Insurance Application must be completed along with the Enrollment Form.

    Spouse Enrollment Form
    Choose your plan options and submit the form.

    Long Term Care Insurance Application (7014-04) with HIPPA Authorization (6720-03)
    (Evidence of Insurability Medical Questionnaire)
    Required by Insurer

    Request to Change Coverage (AE-1181)
    Required if you are currently enrolled and would like to change your coverage.

    Step 5. Family Enrollment

    Family coverage is medically underwritten. The Long Term Care Insurance Application must be completed along with the Enrollment Form. To apply for coverage, complete these forms.

    Family Enrollment Form
    Choose your plan options and submit the form.

    Long Term Care Insurance Application (7014-04) with HIPPA Authorization (6720-03)
    (Evidence of Insurability Medical Questionnaire)
    Required by Insurer

    Request to Change Coverage (AE-1181)
    Required if you are currently enrolled and would like to change your coverage.

    Be sure to read the documents in section two above.

    Eligible family members who would like to apply for coverage require these additional form(s):

    LTC Personal Worksheet (AE-7009)

    3rd Party Notice of Prem Lapse (7606-04)

    Authorization & Agreement for Auto Payments (7713-04)

  • All Full-Time Active Shareholders, Attorneys and of Counsel Employees and Their Family Members who are not covered and are applying as a new enrollee

  • Step 1. Review Your Plan Details 

    Familiarize yourself with the details of your plan.

    • Plan Highlights
    • Outline Of Coverage
    • Rates

    If you resided in a state listed below when you initially purchased your coverage, or you are purchasing new coverage and you reside in a state listed below, then use the link for that state to determine your rate. Otherwise, use the rates in Section 1 above.

    • Connecticut Rates

    Step 2. Important Information About Your Enrollment 

    Please read and print the following documents for your records. These are state required documents to assist with long term care insurance decisions. Nothing in this section needs to be returned in order to apply during your initial enrollment, unless it is also specified as a required form for enrollment in your section below.

    1. Potential Rate Increase Disclosure Form (1151-02)
    2. Things You Should Know About LTC (7608-04-2)
    3. Replacement Notice (1638-94)
    4. Personal Worksheet (AE-7009)
    5. Shoppers Guide (1605-90)
    6. Guide to Health Insur. for People with Medicare (LTC-164)
    7. Life & Health Guaranty Association Notice (1218-IA)
    8. Election to Continue Your LTC Insurance Coverage (7712-04)
    9. Connecticut Resident Identification Form (AE-7018)

  • Should you wish to complete forms in paper versus electronically, please contact LTC Solutions, Inc. at LTCiBenefitsTeam@ltc-solutions.com or 877-286-2852.

    Step 3. Employee Enrollment

    Employee Enrollment Form
    Choose your plan options and submit the form.

    Long Term Care Insurance Application (7014-04) with HIPPA Authorization (6720-03)
    (Evidence of Insurability - Medical Questionnaire)
    Required if you enroll after the Guarantee Issue enrollment period, or choose benefits over the Guarantee Issue limits.

    Request to Change Coverage (AE-1181)
    Required if you are currently enrolled and would like to change your coverage.

    Step 4. Spouse Enrollment

    All spouse/registered domestic partner/domestic partner coverage is medically underwritten. The Long Term Care Insurance Application must be completed along with the Enrollment Form.

    Spouse Enrollment Form
    Choose your plan options and submit the form.

    Long Term Care Insurance Application (7014-04) with HIPPA Authorization (6720-03)
    (Evidence of Insurability Medical Questionnaire)
    Required by Insurer

    Request to Change Coverage (AE-1181)
    Required if you are currently enrolled and would like to change your coverage.

    Step 5. Family Enrollment

    Family coverage is medically underwritten. The Long Term Care Insurance Application must be completed along with the Enrollment Form. To apply for coverage, complete these forms.

    Family Enrollment Form
    Choose your plan options and submit the form.

    Long Term Care Insurance Application (7014-04) with HIPPA Authorization (6720-03)
    (Evidence of Insurability Medical Questionnaire)
    Required by Insurer

    Request to Change Coverage (AE-1181)
    Required if you are currently enrolled and would like to change your coverage.

    Be sure to read the documents in section two above.

    Eligible family members who would like to apply for coverage require these additional form(s):

    LTC Personal Worksheet (AE-7009)

    3rd Party Notice of Prem Lapse (7606-04)

    Authorization & Agreement for Auto Payments (7713-04)

  • All other Full-Time Active Employees and Their Family Members who have active coverage in the plan prior to 01-01-2020

  • Step 1. Review Your Plan Details 

    Familiarize yourself with the details of your plan.

    • Plan Highlights
    • Outline Of Coverage
    • Rates

    If you resided in a state listed below when you initially purchased your coverage, or you are purchasing new coverage and you reside in a state listed below, then use the link for that state to determine your rate. Otherwise, use the rates in Section 1 above.

    • Connecticut Rates

    Step 2. Important Information About Your Enrollment 

    Please read and print the following documents for your records. These are state required documents to assist with long term care insurance decisions. Nothing in this section needs to be returned in order to apply during your initial enrollment, unless it is also specified as a required form for enrollment in your section below.

    1. Potential Rate Increase Disclosure Form (1151-02)
    2. Things You Should Know About LTC (7608-04-2)
    3. Replacement Notice (1638-94)
    4. Personal Worksheet (AE-7009)
    5. Shoppers Guide (1605-90)
    6. Guide to Health Insur. for People with Medicare (LTC-164)
    7. Life & Health Guaranty Association Notice (1218-IA)
    8. Election to Continue Your LTC Insurance Coverage (7712-04)
    9. Connecticut Resident Identification Form (AE-7018)

  • Should you wish to complete forms in paper versus electronically, please contact LTC Solutions, Inc. at LTCiBenefitsTeam@ltc-solutions.com or 877-286-2852.

    Step 3. Employee Enrollment

    Employee Enrollment Form
    Choose your plan options and submit the form.

    Long Term Care Insurance Application (7014-04) with HIPPA Authorization (6720-03)
    (Evidence of Insurability - Medical Questionnaire)
    Required if you enroll after the Guarantee Issue enrollment period, or choose benefits over the Guarantee Issue limits.

    Request to Change Coverage (AE-1181)
    Required if you are currently enrolled and would like to change your coverage.

    Step 4. Spouse Enrollment

    All spouse/registered domestic partner/domestic partner coverage is medically underwritten. The Long Term Care Insurance Application must be completed along with the Enrollment Form.

    Spouse Enrollment Form
    Choose your plan options and submit the form.

    Long Term Care Insurance Application (7014-04) with HIPPA Authorization (6720-03)
    (Evidence of Insurability Medical Questionnaire)
    Required by Insurer

    Request to Change Coverage (AE-1181)
    Required if you are currently enrolled and would like to change your coverage.

    Step 5. Family Enrollment

    Family coverage is medically underwritten. The Long Term Care Insurance Application must be completed along with the Enrollment Form. To apply for coverage, complete these forms.

    Family Enrollment Form
    Choose your plan options and submit the form.

    Long Term Care Insurance Application (7014-04) with HIPPA Authorization (6720-03)
    (Evidence of Insurability Medical Questionnaire)
    Required by Insurer

    Request to Change Coverage (AE-1181)
    Required if you are currently enrolled and would like to change your coverage.

    Be sure to read the documents in section two above.

    Eligible family members who would like to apply for coverage require these additional form(s):

    LTC Personal Worksheet (AE-7009)

    3rd Party Notice of Prem Lapse (7606-04)

    Authorization & Agreement for Auto Payments (7713-04)

  • All other Full-Time Active Employees and Their Family Members who are not covered and are applying as a new enrollee

  • Step 1. Review Your Plan Details 

    Familiarize yourself with the details of your plan.

    • Plan Highlights
    • Outline Of Coverage
    • Rates

    If you resided in a state listed below when you initially purchased your coverage, or you are purchasing new coverage and you reside in a state listed below, then use the link for that state to determine your rate. Otherwise, use the rates in Section 1 above.

    • Connecticut Rates

    Step 2. Important Information About Your Enrollment 

    Please read and print the following documents for your records. These are state required documents to assist with long term care insurance decisions. Nothing in this section needs to be returned in order to apply during your initial enrollment, unless it is also specified as a required form for enrollment in your section below.

    1. Potential Rate Increase Disclosure Form (1151-02)
    2. Things You Should Know About LTC (7608-04-2)
    3. Replacement Notice (1638-94)
    4. Personal Worksheet (AE-7009)
    5. Shoppers Guide (1605-90)
    6. Guide to Health Insur. for People with Medicare (LTC-164)
    7. Life & Health Guaranty Association Notice (1218-IA)
    8. Election to Continue Your LTC Insurance Coverage (7712-04)
    9. Connecticut Resident Identification Form (AE-7018)

  • Should you wish to complete forms in paper versus electronically, please contact LTC Solutions, Inc. at LTCiBenefitsTeam@ltc-solutions.com or 877-286-2852.

    Step 3. Employee Enrollment

    Employee Enrollment Form
    Choose your plan options and submit the form.

    Long Term Care Insurance Application (7014-04) with HIPPA Authorization (6720-03)
    (Evidence of Insurability - Medical Questionnaire)
    Required if you enroll after the Guarantee Issue enrollment period, or choose benefits over the Guarantee Issue limits.

    Request to Change Coverage (AE-1181)
    Required if you are currently enrolled and would like to change your coverage.

    Step 4. Spouse Enrollment

    All spouse/registered domestic partner/domestic partner coverage is medically underwritten. The Long Term Care Insurance Application must be completed along with the Enrollment Form.

    Spouse Enrollment Form
    Choose your plan options and submit the form.

    Long Term Care Insurance Application (7014-04) with HIPPA Authorization (6720-03)
    (Evidence of Insurability Medical Questionnaire)
    Required by Insurer

    Request to Change Coverage (AE-1181)
    Required if you are currently enrolled and would like to change your coverage.

    Step 5. Family Enrollment

    Family coverage is medically underwritten. The Long Term Care Insurance Application must be completed along with the Enrollment Form. To apply for coverage, complete these forms.

    Family Enrollment Form
    Choose your plan options and submit the form.

    Long Term Care Insurance Application (7014-04) with HIPPA Authorization (6720-03)
    (Evidence of Insurability Medical Questionnaire)
    Required by Insurer

    Request to Change Coverage (AE-1181)
    Required if you are currently enrolled and would like to change your coverage.

    Be sure to read the documents in section two above.

    Eligible family members who would like to apply for coverage require these additional form(s):

    LTC Personal Worksheet (AE-7009)

    3rd Party Notice of Prem Lapse (7606-04)

    Authorization & Agreement for Auto Payments (7713-04)

  • I have left employment and would like to continue my coverage

  • You may have enrolled in the Unum Long-Term Care (LTC) insurance plan offered through through your employer, which helps protect you, your independence, and your future. If you have left employment, you can continue your plan by being directly billed by Unum.

     To continue your Unum LTC insurance plan, the following is required:  

    1. Complete this Election to Continue Your LTC Insurance Coverage (7712-04) form within 60 days from when your group coverage ended. 
      1. Policy Number: 112525

    2. Receive your initial Unum billing statement when it arrives (within 30 days) or check for your electronic funds transfer. If you do not receive a bill or statement from Unum within 30 days, please call LTC Solutions at (877) 286-2852 and Unum at (866) 679-3054.

    3. Pay your initial Unum billing statement when it arrives or check for your electronic funds
      transfer.

    Verify your payment was deducted from your bank account. If your bank account does not show your payment, then you have not continued your Unum LTC plan. This means you do not have LTC insurance.  It is your responsibility to verify payments are being processed with Unum.

  • Should be Empty: