Forms

Long-Term Care Insurance


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Agent Change Form
Agent Change

Use this form to change the agent of record for a policy.

Download Agent Change Form (PDF)
Automatic Deduction Plan Form - Fortis
Automatic Deduction Plan for Fortis Long Term Care Insurance Premium

Use this form to authorize withdrawals from your checking/savings account to pay your Fortis Long Term Care insurance premium.

Download Automatic Deduction Plan Form - Fortis (PDF)
Automatic Deduction Plan for Insurance Premium for Custom Care III
Automatic Deduction Plan for Insurance Premium for Custom Care III featuring Benefit Builder

Use this form to authorize withdrawals from your checking/savings account to pay your Custom Care III featuring Benefit Builder insurance premium.

Download Automatic Deduction Plan for Insurance Premium for Custom Care III Form (PDF)
Automatic Deduction Plan for Insurance Premium
Automatic Deduction Plan for Insurance Premium

Use this form to authorize withdrawals from your checking/savings account to pay your insurance premium.

Download Automatic Deduction Plan for Insurance Premium Form (PDF)
Automatic Deduction Plan for Insurance Premium - Group
Automatic Deduction Plan for Insurance Premium - Group

Use this form to authorize withdrawals from your checking/savings account if you bought your insurance through your employer.

Download Automatic Deduction Plan for Insurance Premium - Group (PDF)
Third Party Billing Designation
Third Party Billing Designation

Use this form to designate another person to be notified in the event that your policy is in danger of lapsing.

Download Third Party Billing Designation Form (PDF)
Address Change Form
Address Change Form

Use this form to update your address.

Download Address Change Form (PDF)