Field Name | Size | Type | Description | Notes |
See Form Filer Common Fields |
|
| Filer fields common to all form types. |
|
See Recipient Common Fields |
|
| Recipient fields common to all form types. |
|
Box 1 Amount | 12 | Amount | Box 1: Gross long-term care benefits paid |
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Box 2 Amount | 12 | Amount | Box 2: Accelerated death benefits paid |
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Box 3 Checkbox 1 | 1 | Checkbox | Box 3: Per diem | X / Y / T / 1 = Checked |
Box 3 Checkbox 2 | 1 | Checkbox | Box 3: Reimbursed amount | X / Y / T / 1 = Checked |
Box INS SSN | 9 | Numeric | INSURED'S social security no. |
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Box INS Name | 40 | Text | INSURED'S name |
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Box INS Address | 40 | Text | Street address (including apt. no) |
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Box INS City | 18 | Text | City of Insured |
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Box INS State | 2 | Text | State of Insured | Use state abbreviation |
Box INS Zip | 9 | Numeric | ZIP/Postal of Insured |
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Box 4 Checkbox | 1 | Checkbox | Box 4: Qualified contract (optional) |
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Box 5 Checkbox 1 | 1 | Checkbox | Box 5: Chronically ill | X / Y / T / 1 = Checked |
Box 5 Checkbox 2 | 1 | Checkbox | Box 5: Terminally ill | X / Y / T / 1 = Checked |
Box 5 Date | 8 | Date | Box 5: Date Certified | MM/DD/YYYY or M/D/YYYY |