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Would You Like to Submit a Claim?


Call Us to Get Started

If you would like to submit a claim for long-term care insurance benefits, please call our Policyholder Services Department at 1-800-362-0700. Our representatives will send you an information packet containing instructions and required forms for you to complete and mail or fax to us.

 

You can also download and print forms using the links below. If you need a form that is not listed below, please call 1-800-362-0700 to request that it be mailed or faxed to you.

Forms

If you need a form that is not listed below, please call 1-800-362-0700 to request that it be mailed or faxed to you.
 TitleDescription
1- Address Change Form Use this form to let us know when you change your address and/or phone number.
2- Affidavit - EstateThis form is required to issue any unearned premium refund or benefit payment check to a deceased policyholder’s authorized recipient.
3- Affidavit - TrustThis form is required to issue any unearned premium refund or benefit payment check to a deceased policyholder’s authorized recipient.
4- Assignment of Benefits formThis form authorizes Penn Treaty to pay your home health care agency directly.
5- HIPAA Compliant Authorization to Release InformationPolicyholders must sign this form to give providers permission to release your information to Penn Treaty.
6- Home Health Care Documentation form instructionsA Home Health Care Documentation form must be completed for each day that services are provided. Call 1-800-362-0700 to request these forms.
7- Request for Duplicate PolicyUse this form to request a duplicate policy if your original policy has been lost or destroyed. A $25 fee is charged for duplicate policies.
8- Policyholder Authorization to Release Information FormThis form authorizes Penn Treaty to release information about your insurance policy and claim to your representatives.