877-727-9582 Scott@LTCShop.com

Lapse Protection Forms

Owning long-term care insurance is important.  Keeping it in-force is even more important.  The last thing you want is for your policy to lapse just before you need to make a claim.  Fortunately, federal regulations can help protect you from losing your long-term care insurance by mistake.   

You can designate up to 3 people to be notified in case your long-term care premium is overdue.  Family, friends, and trusted advisers are good choices.  Even if your policy lapses, it can be reinstated after it has lapsed (up to 6 months after the premium was due) if you were cognitively-impaired or functionally-impaired when your policy lapsed.  No other insurance product has this kind of consumer protection.  

To make it easy for you we’ve provided the forms below.  Choose your long-term care insurance company by clicking the red plus sign and follow the directions for designating which person(s) you want your insurance company to notify in case your policy is in danger of lapsing.

Allianz Life Insurance Company

With this form, you’ll be able to add up to three unintentional lapse designees, or third parties, to receive notice should your policy lapse because the premium was not paid when due. Please click the image below to download or print this form.

  1. Make sure you complete the third party’s full name, address and phone number.
  2. Sign and date the form. 
  3. Make sure you include your policy number and full name as it appears on your policy.
  4. Email completed forms to: FixedAnnuity@send.allianzlife.com OR
    Mail:
    Allianz Life Insurance Company of
    North America
    PO BOX 59060
    Minneapolis, MN 55459-0060Overnight Mail:
    Allianz Life Insurance Company of
    North America
    5701 Golden Hill Dr
    Minneapolis, MN 55416-1297Fax: 763-582-6002

Allianz Third Party Designation Form

Genworth Life Insurance Company
With this form, you’ll be able to add, replace or deleting existing third parties. Please click the image below to download or print this form.

  1. Make sure that you complete the top portion of the form with your name and policy number.
  2. Complete the section entitled “Change third party”. You will need the complete name, address and phone number of the person you are adding.
  3. Make sure you sign and date the form. 
  4. Mail or fax the request to the information listed at the top of the form.

Genworth third party notification form

John Hancock Life Insurance Company

With this form, you’ll be able to a third party billing designation. Please click the image below to download or print this form.

  1. Make sure you complete the third party’s full name, address and phone number.
  2. Make sure you include your policy number and full name as it appears on your policy.
  3. Sign and date the form. 
  4. Mail the form to the address listed.

John Hancock third party notification form

LifeSecure Insurance Company
With this form, you’ll be able to add or change a third party lapse designee. Please click the image below to download or print this form.

  1. Make sure that you complete the top portion of the form with your name, address, policy number, social security number, date of birth, phone numbers and your email address.
  2. Complete the section under Miscellaneous Long Term Care Policy Changes.  Make sure to check “Lapse Designee” and “Change” or “Addition”. You will need the complete name, address and phone number of the person you are adding.
  3. You will notice on page 2 of this form that you may request reinstatement of your long term care policy if you were critically ill before the grace period. Federal regulations allow for reinstatement within 5 months of the termination date due to critical illness. (For this, you will need documentation from your physician.)
  4. Make sure you sign and date the form on page 3. 
  5. Mail or fax the request to the information listed under your signature on page 3.

LifeSecure Policy change form

Massachusetts Mutual Insurance Company
MassMutual does not have a generic form to use to add an Authorized Designee or Third Party to receive notice of unintentional lapse. Their instructions are to call their customer service number at 888-505-8952 so that they can generate a personalized form for you to use. Before you call, please be sure to have your policy number and the full name, address and phone numbers of the parties that you would like to add as Authorized Designees.
MedAmerica Insurance Company
With this form, you’ll be able to add or change a third party lapse designee. Please click the image below to download or print this form.

  1. Make sure that you complete the top portion of the form with your name, address, billing account number and the date.
  2. Complete the section entitled “Lapse Designee”. You will need the complete name, address and phone number of the person you are adding.
  3. Make sure you sign and date the form. 
  4. Mail the request to the information listed at the top of the form.

MedAmerica Administrative Change Form

MetLife Insurance Company

With this form, you’ll be able to add, change or update an unintentional lapse designee, or third party, to receive notice should your policy lapse because the premium was not paid when due. Please click the image below to download or print this form.

  1. Make sure you include your policy number and full name as it appears on your policy.
  2. Check the appropriate box indicating if you are adding, updating or removing a Lapse Designee.
  3. Make sure you complete the third party’s full name, address and phone number.
  4. Sign and date the form. 
  5. Fax or mail the form to the address listed at the bottom of the form.

Met Life Authorized Designee Form

 

Mutual of Omaha Insurance Company
With this form, you’ll be able to add an authorized designee or third party to receive notice in the event of lapse. Please click the image below to download or print this form.

  1. You will need the complete name, address and phone number of the person you are adding as an authorized designee.
  2. Make sure you print your name, sign and date the form.
  3. Make sure you complete the section for your policy number.
  4. Mail the request to the information listed at the bottom of the form.

Mutual of Omaha Lapse Protection Form

Prudential Insurance Company

With this form, you’ll be able to add an unintentional lapse designee, or third party, to receive notice should your policy lapse because the premium was not paid when due. Please click the image below to download or print this form.

  1. Make sure you include your policy number and full name as it appears on your policy.
  2. Make sure you complete the third party’s full name, address and phone number.
  3. Sign and date the form. 
  4. You may fax this form to 877-773-9515 or mail the form to the address listed at the top.

Prudential Unintentional Lapse Designee Form

TransAmerica Life Insurance Company
TransAmerica does not have a generic form to use, but simply states that all requests be made in writing. LTCShop has created a generic form for your convenience. With this form, you’ll be able to add an authorized designee or third party to receive notices in the event of a lapse in coverage due to non-payment. Please click the image below to download or print this form.

  1. Make sure that you complete the top portion of the form with your full name as it appears on your policy. You may also include your telephone numbers.
  2. You will need the complete name, address and phone number of the person you are adding.
  3. Be sure to include your policy number.
  4. Make sure you sign and date the form. 
  5. Fax the request to the information listed at the top of the form. Or, you may mail the form to:

LTC Customer Service P.O. Box 869090 Plano, TX 75086-9090

TransAmerica Lapse Protection Form

If you do not see your insurance company listed above, please email us and we will find it for you.